Monday, July 30, 2012

Characteristics and Sequelae of Intracranial Hypertension After Intracerebral Hemorrhage

Abstract
Introduction  
The characteristics and sequelae of intracranial hypertension after ICH are unclear.
Methods  
In a cohort of patients with spontaneous ICH, we obtained ICP values from nursing documentation of hourly vital signs and reviewed charts to rule out spurious ICP recordings. We used multiple logistic regression to explore factors associated with intracranial hypertension, and ordinal logistic regression controlling for the ICH score to examine the relationship between intracranial hypertension and the mRS score at 12 months.
Results  
Among 243 patients, 57 (24 %) underwent ICP monitoring, of whom 40 (70 %; 95 % CI 57–82 %) had an episode of ICP > 20 mmHg. Intracranial hypertension was less likely in older patients (OR per decade 0.6, 95 % CI 0.3–0.9) and after infratentorial hemorrhage (OR 0.1, 95 % CI 0–0.7). Intracranial hypertension was not independently associated with mRS scores (OR 0.8, 95 % CI 0.3–2.3); this remained true for a threshold of >25 mmHg (OR 0.5, 95 % CI 0.2–1.5), number of elevations (OR 0.98 per elevation, 95 % CI 0.96–1.00), or area under the curve (OR 1.00 per mmHg × h, 95 % CI 0.99–1.01). Among patients with intracranial hypertension, seven (18 %) were functionally independent (mRS 0–2) at 12 months. Our results were not significantly changed after excluding patients with early DNR orders.
Conclusion  
Intracranial hypertension is common after ICH, especially in younger patients with supratentorial hemorrhage. Given active treatment of elevated ICP, intracranial hypertension does not appear associated with long-term outcomes, suggesting that ICP elevations should not necessarily be taken to signify a poor prognosis.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-5
  • DOI 10.1007/s12028-012-9744-7
  • Authors
    • Hooman Kamel, Department of Neurology and Neuroscience, Weill Cornell Medical College, 525 East 68th St, F610, New York, NY 10065, USA
    • J. Claude Hemphill III, Department of Neurology, University of California, San Francisco, USA





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Emergency Neurological Life Support (ENLS): What to Do in the First Hour of a Neurological Emergency

Abstract  
Emergency Neurological Life Support (ENLS) is a series of protocols, generated by experienced neurocritical care and emergency physicians that describe key steps when managing a patient within the first hours of a neurological emergency. The protocols are designed to help standardize these important early steps for several reasons: (1) patients will likely experience better outcomes, (2) they provide the essential elements to communicate to receiving physicians a patient's diagnosis and emergency treatment, (3) this approach forms the foundation for eventual consensus on neurological emergency decisions, and (4) this consensus can inform researchers about the important clinical questions that need resolution to enhance patient care. ENLS is online and free to use. Certification and training in ENLS is hosted by the Neurocritical Care Society. This document introduces the concept of ENLS, reviews the history of its creation, and enumerates future goals as ENLS becomes adopted more widely.

  • Content Type Journal Article
  • Category Editorial
  • Pages 1-3
  • DOI 10.1007/s12028-012-9741-x
  • Authors
    • Wade S. Smith, Department of Neurology, University of California, San Francisco, CA, USA
    • Scott Weingart, Division of Emergency Critical Care, Mount Sinai School of Medicine, New York, NY, USA





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Saturday, July 28, 2012

Neurosurgical management of frontal lobe epilepsy in children

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-11, Ahead of Print.
Object Pediatric frontal lobe epilepsy (FLE) remains a challenging condition for neurosurgeons and epileptologists to manage. Postoperative seizure outcomes remain far inferior to those observed in temporal lobe epilepsies, possibly due to inherent difficulties in delineating and subsequently completely resecting responsible epileptogenic regions. In this study, the authors review their institutional experience with the surgical management of FLE and attempt to find predictors that may help to improve seizure outcome in this population. Methods All surgically treated cases of intractable FLE from 1990 to 2008 were reviewed. Demographic information, preoperative and intraoperative imaging and electrophysiological investigations, and follow-up seizure outcome were assessed. Inferential statistics were performed to look for potential predictors of seizure outcome. Results Forty patients (20 male, 20 female) underwent surgical management of FLE during the study period. Patients were an average of 5.6 years old at the time of FLE onset and 11.7 years at the time of surgery; patients were followed for a mean of 40.25 months. Most patients displayed typical FLE semiology. Twenty-eight patients had discrete lesions identified on MRI. Eight patients underwent 2 operations. Cortical dysplasia was the most common pathological diagnosis. Engel Class I outcome was obtained in 25 patients (62.5%), while Engel Class II outcome was observed in 5 patients (12.5%). No statistically significant predictors of outcome were found. Conclusions Control of FLE remains a challenging problem. Favorable seizure outcome, obtained in 62% of patients in this series, is still not as easily obtained in FLE as it is in temporal lobe epilepsy. While no statistically significant predictors of seizure outcome were revealed in this study, patients with FLE continue to require extensive workup and investigation to arrive at a logical and comprehensive neurosurgical treatment plan. Future studies with improved neuroimaging and advanced invasive monitoring strategies may well help define factors for success in this form of epilepsy that is difficult to control.





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Neurosurgical management of frontal lobe epilepsy in children

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-11, Ahead of Print.
Object Pediatric frontal lobe epilepsy (FLE) remains a challenging condition for neurosurgeons and epileptologists to manage. Postoperative seizure outcomes remain far inferior to those observed in temporal lobe epilepsies, possibly due to inherent difficulties in delineating and subsequently completely resecting responsible epileptogenic regions. In this study, the authors review their institutional experience with the surgical management of FLE and attempt to find predictors that may help to improve seizure outcome in this population. Methods All surgically treated cases of intractable FLE from 1990 to 2008 were reviewed. Demographic information, preoperative and intraoperative imaging and electrophysiological investigations, and follow-up seizure outcome were assessed. Inferential statistics were performed to look for potential predictors of seizure outcome. Results Forty patients (20 male, 20 female) underwent surgical management of FLE during the study period. Patients were an average of 5.6 years old at the time of FLE onset and 11.7 years at the time of surgery; patients were followed for a mean of 40.25 months. Most patients displayed typical FLE semiology. Twenty-eight patients had discrete lesions identified on MRI. Eight patients underwent 2 operations. Cortical dysplasia was the most common pathological diagnosis. Engel Class I outcome was obtained in 25 patients (62.5%), while Engel Class II outcome was observed in 5 patients (12.5%). No statistically significant predictors of outcome were found. Conclusions Control of FLE remains a challenging problem. Favorable seizure outcome, obtained in 62% of patients in this series, is still not as easily obtained in FLE as it is in temporal lobe epilepsy. While no statistically significant predictors of seizure outcome were revealed in this study, patients with FLE continue to require extensive workup and investigation to arrive at a logical and comprehensive neurosurgical treatment plan. Future studies with improved neuroimaging and advanced invasive monitoring strategies may well help define factors for success in this form of epilepsy that is difficult to control.





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Stent-assisted coil emboilization of ruptured intracranial aneurysms: A retrospective multicenter review

Stent-assisted coil emboilization of ruptured intracranial aneurysms: A retrospective multicenter review 

by Gavin W Britz

Kiarash Golshani, Andrew Ferrel, Mark Lessne, Pratish Shah, Abhineet Chowdhary, Armen Choulakian, Michael J Alexander, Tony P Smith, David S Enterline, Ali R Zomorodi, Gavin W Britz
Surgical Neurology International 2012 3(1):84-84

Background: The purpose of this study is to retrospectively review our experience with stent-assisted embolization of patients with an acutely ruptured cerebral aneurysm. Methods: Medical records and imaging were reviewed for 36 patients who underwent stent-assisted embolization of a ruptured cerebral aneurysm. Results: Seventeen patients (47%) received a preprocedural loading dose of clopidogrel and five patients (14%) received an intraprocedural dose of clopidogrel. The remaining 14 patients (36%) were treated with antiplatelet therapy following the procedure. Six (17%) stent related intraprocedural thromboembolic complications were encountered; four of these resolved (one partial, three complete) following treatment with abciximab and/or heparin during the procedure. Five of the six thromboembolic events occurred in patients who were not pretreated with clopidogrel (P = 0.043). Two patients in this series (6%) had a permanent thrombotic complication resulting in mild hemiparesis in one patient, and hemianopsia in the second. No procedure related hemorrhagic complications occurred in any patient. One patient had a spontaneous parenchymal hemorrhage contralateral to the treated aneurysm discovered 10 days after treatment. Twenty-eight patients (78%) had a Glasgow Outcome Score of 4 or better at discharge. Seven of 21 patients (33%) with angiographic follow-up required further treatment of the coiled aneurysm. Conclusion: Stent-assisted coil embolization is an option for treatment of ruptured wide neck ruptured aneurysms and for salvage treatment during unassisted embolization of ruptured aneurysms but complications and retreatment rates are higher than for routine clipping or coiling of cerebral aneurysms. Pretreatment with clopidogrel appears effective in reducing thrombotic complications without significant increasing risk of hemorrhagic complications.
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3T magnetic resonance imaging testing of externally programmable shunt valves

Joseph M Zabramski, Mark C Preul, Josef Debbins, Daniel J McCusker

Surgical Neurology International 2012 3(1):81-81

Background: Exposure of externally programmable shunt-valves (EPS-valves) to magnetic resonance imaging (MRI) may lead to unexpected changes in shunt settings, or affect the ability to reprogram the valve. We undertook this study to examine the effect of exposure to a 3T MRI on a group of widely used EPS-valves. Methods: Evaluations were performed on first generation EPS-valves (those without a locking mechanism to prevent changes in shunt settings by external magnets other than the programmer) and second generation EPS-valves (those with a locking mechanisms). Fifteen new shunt-valves were divided into five groups of three identical valves each, and then exposed to a series of six simulated MRI scans. After each of the exposures, the valves were evaluated to determine if the valve settings had changed, and whether the valves could be reprogrammed. The study produced 18 evaluations for each line of shunt-valves. Results: Exposure of the first generation EPS-valves to a 3T magnetic field resulted in frequent changes in the valve settings; however, all valves retained their ability to be reprogrammed. Repeated exposure of the second generation EPS-valves has no effect on shunt valve settings, and all valves retained their ability to be interrogated and reprogrammed. Conclusions: Second generation EPS-valves with locking mechanisms can be safely exposed to repeated 3T MRI systems, without evidence that shunt settings will change. The exposure of the first generation EPS-valves to 3T MRI results in frequent changes in shunt settings that necessitate re-evaluation soon after MRI to avoid complications.





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Stent-assisted coil emboilization of ruptured intracranial aneurysms: A retrospective multicenter re

Kiarash Golshani, Andrew Ferrel, Mark Lessne, Pratish Shah, Abhineet Chowdhary, Armen Choulakian, Michael J Alexander, Tony P Smith, David S Enterline, Ali R Zomorodi, Gavin W Britz

Surgical Neurology International 2012 3(1):84-84

Background: The purpose of this study is to retrospectively review our experience with stent-assisted embolization of patients with an acutely ruptured cerebral aneurysm. Methods: Medical records and imaging were reviewed for 36 patients who underwent stent-assisted embolization of a ruptured cerebral aneurysm. Results: Seventeen patients (47%) received a preprocedural loading dose of clopidogrel and five patients (14%) received an intraprocedural dose of clopidogrel. The remaining 14 patients (36%) were treated with antiplatelet therapy following the procedure. Six (17%) stent related intraprocedural thromboembolic complications were encountered; four of these resolved (one partial, three complete) following treatment with abciximab and/or heparin during the procedure. Five of the six thromboembolic events occurred in patients who were not pretreated with clopidogrel (P = 0.043). Two patients in this series (6%) had a permanent thrombotic complication resulting in mild hemiparesis in one patient, and hemianopsia in the second. No procedure related hemorrhagic complications occurred in any patient. One patient had a spontaneous parenchymal hemorrhage contralateral to the treated aneurysm discovered 10 days after treatment. Twenty-eight patients (78%) had a Glasgow Outcome Score of 4 or better at discharge. Seven of 21 patients (33%) with angiographic follow-up required further treatment of the coiled aneurysm. Conclusion: Stent-assisted coil embolization is an option for treatment of ruptured wide neck ruptured aneurysms and for salvage treatment during unassisted embolization of ruptured aneurysms but complications and retreatment rates are higher than for routine clipping or coiling of cerebral aneurysms. Pretreatment with clopidogrel appears effective in reducing thrombotic complications without significant increasing risk of hemorrhagic complications.







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Clinical Outcome after Vertebral Artery Injury following Blunt Cervical Spine Trauma

Publication year: 2012
Source:World Neurosurgery
Alim P. Mitha, Samuel Kalb, Juan C. Ribas-Nijkerk, Juan Solano, Cameron G. McDougall, Felipe C. Albuquerque, Robert F. Spetzler, Nicholas Theodore
Objective Imaging after blunt cervical trauma is being used increasingly to screen patients for injury of the vertebral artery (VA). There are no guidelines for imaging of the VA for nonpenetrating cervical trauma. The purpose of this study was to determine the effect of VA injury on clinical outcome after blunt cervical trauma. Methods Sixty-six patients who underwent computed tomography angiography (CTA) and magnetic resonance angiography (MRA) after blunt cervical trauma were reviewed. Medical records were reviewed for clinical status, including the presence of a neurologic deficit or pain related to spine or vascular injury. Any suggested brain injury was evaluated with diffusion-weighted MR imaging. Both clinical and radiographic data were analyzed to determine the incidence of VA abnormalities and their association with clinical outcome. Results VA abnormalities were present in 19.7% of cases. Two patients had symptomatic brain sequelae from VA injury. There was no significant association between VA abnormalities and the presence of symptoms and/or cervical spine fractures at presentation. The presence of a fracture and neurological symptoms at presentation predicted a significantly worse outcome at a mean follow-up of 5 months. However, the presence of VA abnormalities did not predict a worse clinical outcome. Conclusions The clinical outcome of patients with blunt cervical trauma was not associated with the presence of VA abnormalities. Given the rare but potentially devastating consequences of a VA injury, however, screening may still be worthwhile.






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Tuesday, July 24, 2012

Career Satisfaction and Burnout Among U.S. Neurosurgeons: A Feasibility and Pilot Study

INTRODUCTION: Neurosurgery is a challenging and stressful field. Excessive stress and professional dissatisfaction can lead to medical errors, negatively impact patient care, and cause physician burnout. Our objective is to develop and critically evaluate a survey measuring professional stress and satisfaction and to obtain preliminary data on sources and degree of stress and the prevalence of burnout among American neurosurgeons. METHODS: A 107-item questionnaire was developed and sent to 169 American neurosurgeons to evaluate career satisfaction and stressors, quality of professional life, and burnout. Participants were also asked about the survey itself. Most variables were evaluated using the Likert scale. Burnout was measured using the validated Maslach Burnout Inventory (MBI). RESULTS: The 85 (50%) respondents were typically male, full-time, board-certified neurosurgeons. Ninety-five percent were satisfied as neurosurgeons (73% very satisfied). Most (88%) would choose neurosurgery again as a career, but only 55% would recommend it to a child. Low salary/income, low collections/billing, and uncertainty regarding future earnings/health care reform were reported as stressful factors by the majority of participants. Compared with published norms, the median scores were lower for emotional exhaustion and depersonalization and higher for personal accomplishment. The burnout rate was 27%. CONCLUSION: Our survey was well-received and, according to respondents, encompassed the major issues associated with career stress, satisfaction, and burnout, but needs to be shortened. Respondents were generally satisfied with their career but identified several major stressors. A larger study to identify predictors of career satisfaction/dissatisfaction will help generate dialogue on improving the quality of professional life for neurosurgeons. Copyright (C) by the Congress of Neurological Surgeons





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Rate of Pediatric Ventriculo-peritoneal Shunt Infection After Prophylactic Administration of Int

INTRODUCTION: Postoperative ventriculo-peritoneal shunt infection rates range from 5 to 15% and are highest in the 30-day period immediately following implantation. Pediatric patients experience higher rates of infection due to immature immune resistance. Intrathecal antibiotics such as vancomycin have been used to treat post-operative shunt infections resistant to intravenous administration. Although these infections are common in every pediatric practice, no study has addressed whether intraoperative intraventricular antibiotics administered prophylactically impact postoperative shunt infection rates. METHODS: From 2004 to 2011, 652 consecutive pediatric patients at a single institution underwent ventriculo-peritoneal shunt insertion using standard techniques. Prior to connecting the ventricular catheter to the valve, 2.5 milliliters of intrathecal vancomycin were injected through the ventricular catheter and 2.5 milliters were irrigated topically within the subgaleal pocket surrounding the valve and distal catheter (10 mg total). RESULTS: Seven shunt infections were recorded out of a total of 307 patients undergoing intrathecal vancomycin administration (2.2%) as described in the methods. In contrast, ten shunt infections were recorded over the same time period out of a total of 335 patients who did not receive intraoperative intrathecal vancomycin (2.9%). This result did not reach statistical significance, however, the percentage of cases including intrathecal vancomycin administration increased over this time period from 0 to 94.5% and during the same time period the ventriculo-peritoneal shunt infection rate decreased from 8% to 2%. CONCLUSION: Intraventricular vancomycin administration and topical irrigation of the ventriculo-peritoneal shunt apparatus was well tolerated in a population of 307 pediatric patients undergoing shunt insertion. The infection rates between those patients with and without intrathecal vancomycin administration were not statistically different, though a trend toward a significant reduction in ventriculo-peritoneal shunt infection rates has been observed. This trend is underscored by the significant impact that reduction of each shunt infection carries in this population. Copyright (C) by the Congress of Neurological Surgeons





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International Variations in the Clinical Presentation and Management of Cervical Spondylotic Mye

INTRODUCTION: While cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord impairment worldwide, little is known regarding international variations in clinical presentation, management and outcomes of this condition. To address this key issue, we undertook a prospective multicenter study of CSM patients undergoing surgical treatment. METHODS: 486 patients with clinically symptomatic CSM were enrolled in 16 sites in Europe, Asia, North and South America. The following outcomes were assessed: modified Japanese Orthopaedic Assessment scale (mJOA), Nurick Score, Neck Disability Index (NDI), short form 36v2, and complications. Data were analyzed using multivariate techniques (SAS 9.2) adjusting for baseline differences in patient populations (age, gender, surgical approach, number of spinal levels and baseline outcome parameter value). RESULTS: To date, 389 patients have completed the 1-year follow-up. Thirty-five percent were females with an average age of 56.2 yrs (SD 12.4). Patients underwent anterior (58%), posterior (40%) or circumferential (2%) surgery. There were significant differences in the age at presentation and baseline neurological status among the regions, with Asian and Latin American patients being significantly younger and with less neurological impairment. With surgical treatment, there was a significant (P < 0.001) improvement from baseline values to 12 months in all outcome parameters assessed. The amount of improvement varied across the international regions with patients from Asia-Pacific and Latin America reporting comparatively better SF36 PCS and MCS scores for comparatively similar outcomes on the Nurick and mJOA assessments. CONCLUSION: This large prospective global clinical study shows that surgical treatment for CSM is associated with significant improvements in generic and patient-specific outcome measures at one-year. Interestingly, there are significant variations in clinical presentation and in patient perceptions of the impact of these improvements on their perceptions of quality of life. Copyright (C) by the Congress of Neurological Surgeons





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Comparison Between Patient and Surgeon Perception of Outcomes of Operations for Degenerative Spi

INTRODUCTION: Patient-filled questionnaires, such as Oswestry Disability Index (ODI) or Neck Disability Index (NDI) have become the mainstay in the evaluation of treatment outcomes in degenerative spine disease (DSD), replacing result-reporting by surgeons. In this study we set to compare patients' and surgeons' assessment of spine treatment outcome in a prospective blinded patient-driven spine surgery outcomes registry. METHODS: Patients referred to the neurosurgery clinic between 9/8/09 and 11/1/2011 filled out surveys at baseline, at recruitment preoperatively, and at 3- and 6- months postoperatively. The surgeons were blinded to the survey content. Pain was rated on a Visual Analog Scale (VAS) from 0 to 10, while NDI was scored for cervical spine patients and ODI for lumbar patients. At 3- and 6- months postoperatively, outcome was rated independently by patients and surgeons on a 7-point Likert-type scale RESULTS: 337 patients prospectively enrolled in the database with intention to treat; 134 (40%) had cervical spine disease, 195 (58%) had lumbar spine disease and 8 patients (2%) had both. 109 (32%) had outcome ratings from both the patient and the surgeon in corresponding time frames. We found that surgeons' and patients' ratings correlated strongly (Spearman rho = 0.4, ***P < 0.0001); with 44.6% identical and 86.7% within +/- 1 grade of each other. Patient rating correlated better with most recent NDI/ODI and pain score than with the incremental change from the baseline. In a multivariate analysis, the age of the patient and identity of the surgeon were the only variables that had significant impact on the ratings' discrepancy (*P = 0.02 and *P = 0.04, respectively). CONCLUSION: We show that patients' and surgeons' global outcome ratings for spinal disease correlate highly with each other. Also, patients' ratings correlate better with their most recent functional scores rather than the incremental change from their baseline. Copyright (C) by the Congress of Neurological Surgeons





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Ruptured Basilar Apex Aneurysms: Current Outcomes at a Tertiary High Volume Center

INTRODUCTION: A paucity of patients with ruptured basilar apex aneurysms have been analyzed with long-term clinical results. METHODS: Sixty-one consecutive ruptured basilar apex aneurysms from 2005 to 2011 were retrospectively reviewed. A team-oriented approach was used to decide treatment. Clipping was typically used in younger patients, those with a complex neck anatomy, or when the origin of PCA was from the aneurysmal sac. RESULTS: Demograhics and Outcome: Coiling Group (n = 39 or 64%): The average age was 57 with a Hunt and Hess grade (HH) 3.3. At discharge 10% had died, 33% had a poor outcome (mRS3-5) and 57% had a good outcome (mRS0-2). Analyzing survivors, drastic long term improvement was noted. At three months, 78% of these patients were a mRS 0-2 which improved to 87% by one year. Clipping group (n = 22 or 36%): The average age was 49 with a HH grade of 2.6. At discharge 14% had died, 27% had a poor outcome and 59% had a good outcome. Analyzing the survivors, dramatic improvement was seen. At three months, 82% of these patients were a mRS 0-2 which improved to 86% at one year. Eight out of 22 (37%) patients had post-operative 3rd nerve palsies. All but one resolved at longest follow up. Radiographic outcome: After initial coiling, 59% achieved a Raymond 1, 36% Raymond 2, and 2.5% Raymond 3. 11/15 Raymond 2 or 3 patients had long term follow up. In this group, 46% had stable disease that did not require treatment, 27% spontaneously resolved, and 27% required re-treatment. One patient (4.5%) in the Clipping group had a residual stable lesion at one year. CONCLUSION: By using a team-oriented approach, both clipping and coiling of ruptured basilar apex aneurysms provided excellent long term outcomes with >85% of survivors reaching a good outcome by one year. Copyright (C) by the Congress of Neurological Surgeons





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Differences in Defensive Practices between Neurosurgeons in Malpractice Crisis vs Non-Crisis Sta

INTRODUCTION: As medical liability and malpractice concerns continue to rise to crisis levels in many parts of the United States, defensive medicine fuels management decisions and drives healthcare expenditures. In this study, we present a 2011 survey of US neurosurgeons' defensive medicine practices in malpractice crisis vs non-crisis states. METHODS: A validated 51-question survey, available through an anonymous online survey instrument, was sent to all 4,672 United States neurosurgeon members of the American Association of Neurological Surgeons (AANS). States were designated malpractice crisis or non-crisis states based upon the American Medical Association's analysis of malpractice lawsuits. The survey was conducted over 6 weeks. Multiple regression analysis was used. RESULTS: A total of 1,028 surveys were completed (31% response rate) by neurosurgeons representing diverse practices. Respondents engaged in defensive medicine practices by ordering additional imaging studies (72%) and laboratory tests (67%), referring patients to consultants (66%), or prescribing medications (40%). There were significant differences between malpractice crisis and non-crisis states, with neurosurgeons in crisis states more likely to acknowledge increased defensive practices, specifically ordering: additional laboratory tests (coeff = .05, CI +/-.016, P = .001), additional imaging (coeff = .04, CI +/-.017, P = .012), and outside consultations (coeff = .03, CI +/-.016, P = .017) relative to neurosurgeons in non-crisis states. Neurosurgeons in crisis states were more likely to view liability insurance premiums as a significant burden (coeff = .08, CI +/-.018, P = 0.0). CONCLUSION: Medical liability concerns have affected practice patterns, and in some areas, these concerns have fueled neurosurgeons' defensive practices. Malpractice fuels increased medical costs and influences clinical decision-making. Copyright (C) by the Congress of Neurological Surgeons





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117 Digital Substraction Angiography in CT Angiography Negative Spontaneous Subarachnoid Hemorrhage:

INTRODUCTION: Recent studies have documented the high sensitivity of CT angiography (CTA) in detecting a ruptured aneurysm in the presence of acute subarachnoid hemorrhage (SAH). The practice of digital subtraction angiography (DSA) when CTA does not reveal an aneurysm has thus been called into question. We examined the efficacy of DSA in CTA negative SAH when balanced with the costs and risks associated with the procedure. METHODS: A decision tree was created using TreeAge Pro Suite 2012; in one arm a CTA negative SAH was followed-up with DSA, in the other arm patients were observed without further imaging. Based on literature review, costs and utilities were assigned to each potential outcome. Base case and sensitivity analysis were performed to determine the cost effectiveness of each strategy. A Monte Carlo simulation was then conducted, by sampling each variable over a plausible distribution, to evaluate the robustness of the model. RESULTS: Using a negative predictive value (NPV) of 95.7% for CTA, observation was found to be the most cost effective strategy ($2031.37/QALY vs $4185.88/QALY), in the base case analysis. One-way sensitivity analysis demonstrated that DSA became the more cost-effective option if the NPV of CTA fell below 92.6%. The Monte Carlo simulation produced an incremental cost-effectiveness ratio of $86 985/QALY. At the conventional willingness to pay threshold of $50 000/QALY, observation was the more cost effective strategy in 91.6% of simulations. CONCLUSION: The results of this analysis support observation as the more cost-effective clinical strategy when a CTA negative SAH is encountered in the majority of real world scenarios. Patients need not be subjected to the costs and risks associated with conventional angiography given the high sensitivity of modern CTA. DSA should be reserved only for patients exhibiting a clinical exam incongruent with perimesencephalic SAH. Copyright (C) by the Congress of Neurological Surgeons





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A prescription for the Epley maneuver: www.youtube.com?

Objectives:

Video-sharing Web sites are being used for information about common conditions including dizziness. The Epley maneuver (EM) is a simple and effective treatment for benign paroxysmal positional vertigo (BPPV) of the posterior canal. However, the maneuver is underused in routine care. In this study, we aimed to describe and analyze the available information about the EM on youtube.com.

Methods:

A YouTube search was performed on August 31, 2011, for videos that demonstrated the entire EM. Detailed data were abstracted from each video and corresponding Web site. Videos were rated on the accuracy of the maneuver by 2 authors, with differences resolved by adjudication. Comments posted by viewers were assessed for themes regarding video use.

Results:

Of the 3,319 videos identified, 33 demonstrated the EM. The total number of hits for all videos was 2,755,607. The video with the most hits (802,471) was produced by the American Academy of Neurology. Five of the videos accounted for 85% of all the hits. The maneuver demonstration was rated as accurate in 64% (21) of the videos. Themes derived from the 424 posted comments included patients self-treating with the maneuver after reviewing the videos, and providers using the videos as a prescribed treatment or for educational purposes.

Conclusion:

Accurate video demonstration of the Epley maneuver is available and widely viewed on YouTube. Video-sharing media may be an important way to disseminate effective interventions such as the EM. The impact of video Web sites on outcomes and costs of care is not known and warrants future study.






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Hematoma growth and outcomes in intracerebral hemorrhage: The INTERACT1 study

Objective:

Uncertainty exists over the size of potential beneficial effects of medical treatments targeting hematoma growth in intracerebral hemorrhage (ICH). We report associations of hematoma growth parameters on clinical outcomes in the pilot phase, Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT1) (ClinicalTrials.gov NCT00226096).

Methods:

In randomized patients with both baseline and 24-hour brain CT (n = 335), associations between measures of absolute and relative hematoma growth and 90-day poor outcomes of death and dependency (modified Rankin Scale score 3–5) were assessed in logistic regression models, with data reported as odds ratios (OR) and 95% confidence intervals (CI).

Results:

A total of 10.7 mL (1 SD) increase in hematoma volume over 24 hours was strongly associated with poor outcome (adjusted OR 1.72, 95% CI 1.19–2.49; p = 0.004). An association was also evident for relative growth (adjusted OR 1.67, 95% 1.22–2.27; p = 0.001 for 1 SD increase). The analyses were adjusted for age, sex, achieved systolic blood pressure, elevated NIH Stroke Scale score (≥14), hematoma location, baseline hematoma volume, intraventricular extension, antithrombotic therapy, baseline glucose, time from ICH to baseline CT scan, and time from baseline to repeat CT scan. A 1 mL increase in hematoma growth was associated with a 5% (95% CI 2%–9%) higher risk of death or dependency.

Conclusion:

Medical treatments, such as rapid intensive blood pressure lowering, could achieve ~2–4 mL absolute attenuation of hematoma growth. There is hope that this could translate into modest but still clinically worthwhile (~10%–20% better chance) outcome from ICH.






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Earlier Blood Pressure-Lowering and Greater Attenuation of Hematoma Growth in Acute Intracerebral He

Background and Purpose—

The INTEnsive blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT) pilot study showed that early intensive blood pressure-lowering can attenuate hematoma growth in acute intracerebral hemorrhage. The present analysis aimed to determine the treatment effects on hematoma growth by time from intracerebral hemorrhage onset to randomization.

Methods—

Patients (N=404) with acute intracerebral hemorrhage and elevated systolic blood pressure were randomly assigned to intensive or guideline-based blood pressure management. Baseline and repeat CT (24 and 72 hours) were performed and changes in hematoma volume were assessed using generalized estimating equations.

Results—

Among 296 patients with all 3 CT scans available for analysis, reductions in proportional hematoma growth produced by randomized intensive blood pressure-lowering treatment over 72 hours decreased progressively with delays in initiation of study treatment: 22%, 17%, 9%, and 3% for quartile groups defined by time from onset to randomization of <2.9, 2.9 to 3.6, 3.7 to 4.8, and ≥4.9 hours, respectively (P trend=0.001). There were also smaller absolute reductions in hematoma growth with delays in initiation of study treatment (6.5 mL, 3.3 mL, 0.9 mL, and 0.6 mL), although the trend did not reach statistical significance (P trend=0.12).

Conclusions—

Earlier initiation of intensive blood pressure-lowering treatment is likely to provide greater protection against hematoma growth in acute intracerebral hemorrhage.

Clinical Trial Registration Information—

http://www.clinicaltrials.gov, NCT002226096.






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Posttraumatic Stress Disorder and Adherence to Medications in Survivors of Strokes and Transient Isc

Background and Purpose—

Posttraumatic stress disorder (PTSD) can be triggered by life-threatening medical events such as strokes and transient ischemic attacks (TIAs). Little is known regarding how PTSD triggered by medical events affects patients' adherence to medications.

Methods—

We surveyed 535 participants, age ≥40 years old, who had at least 1 stroke or TIA in the previous 5 years. PTSD was assessed using the PTSD Checklist-Specific for stroke; a score ≥50 on this scale is highly specific for PTSD diagnosis. Medication adherence was measured using the 8-item Morisky scale. Logistic regression was used to test whether PTSD after stroke/TIA was associated with increased risk of medication nonadherence. Covariates for adjusted analyses included sociodemographics, Charlson comorbidity index, modified Rankin Scale score, years since last stroke/TIA, and depression.

Results—

Eighteen percent of participants had likely PTSD (PTSD Checklist-Specific for stroke ≥50), and 41% were nonadherent to medications according to the Morisky scale. A greater proportion of participants with likely PTSD were nonadherent to medications than other participants (67% versus 35%, P<0.001). In the adjusted model, participants with likely PTSD were nearly 3 times more likely (relative risk, 2.7; 95% CI, 1.7–4.2) to be nonadherent compared with participants without PTSD (PTSD Checklist-Specific for stroke <25) even after controlling for depression, and there was a graded association between PTSD severity and medication nonadherence.

Conclusion—

PTSD is common after stroke/TIA. Patients who have PTSD after stroke or TIA are at increased risk for medication nonadherence.






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Effect of Addition of Clopidogrel to Aspirin on Mortality: Systematic Review of Randomized Trials [O

Background and Purpose—

In the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, addition of clopidogrel to aspirin was associated with an unexpected increase in mortality in patients with lacunar strokes. We assessed the effect of the addition of clopidogrel to aspirin on mortality in a meta-analysis of published randomized trials.

Methods—

Randomized trials in which clopidogrel was added to aspirin in subjects with vascular disease or vascular risk factors were identified. Trials were restricted to those with a mean follow-up of ≥14 days in which both the combination of aspirin and clopidogrel was tested and mortality was reported.

Results—

Twelve trials included 90 934 participants (mean age, 63 years; 70% men; median follow-up, 1 year) with 6849 observed deaths. There was no significant increase in mortality with the combination therapy either in 4 short-term (14 days–3 months; OR, 0.93; 95% CI, 0.87–0.99) or in 7 long-term (>3 months; hazard ratio, 0.97; 95% CI, 0.91–1.04) trials after 1 long-term trial (the SPS3 trial) was excluded because of heterogeneity. Addition of clopidogrel was associated with an increase in fatal hemorrhage (OR, 1.35; 95% CI, 0.97–1.90) and a reduction in myocardial infarction (OR, 0.82; 95% CI, 0.74–0.91).

Conclusions—

The addition of clopidogrel to aspirin has no overall effect on mortality. The SPS3 trial results are outliers, possibly because of a lower prevalence of coronary artery ischemia. Addition of clopidogrel to aspirin increases fatal bleeding and reduces myocardial infarction.

Clinical Trial Registration—

URL: http//www.clinicaltrials.gov. Unique identifier: NCT00059306.






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Statin Therapy and the Risk of Intracerebral Hemorrhage: A Meta-Analysis of 31 Randomized Controlled

Background and Purpose—

Statin therapy decreases the risk of ischemic stroke. An increased risk of intracerebral hemorrhage (ICH) has been observed in some studies. To investigate this issue, we performed a meta-analysis of randomized controlled trials using statins that reported ICH.

Methods—

We performed a literature search of Medline, Web of Science, and The Cochrane Library through January 25, 2012, and identified additional randomized controlled trials by reviewing reference lists of retrieved studies and prior meta-analyses. All randomized controlled trials of statin therapy that reported ICH or hemorrhagic stroke were included. The primary outcome variable was ICH. Thirty-one randomized controlled trials were included. All analyses used random effects models and heterogeneity was not observed in any of the analyses.

Results—

A total of 91 588 subjects were included in the active group and 91 215 in the control group. There was no significant difference in incidence of ICH observed in the active treatment group versus control (OR, 1.08; 95% CI, 0.88–1.32; P=0.47). ICH risk was not related to the degree of low-density lipoprotein reduction or achieved low-density lipoprotein cholesterol. Total stroke (OR, 0.84; 95% CI, 0.78–0.91; P<0.0001) and all-cause mortality (OR, 0.92; CI, 0.87–0.96; P=0.0007) were significantly reduced in the active therapy group. There was no evidence of publication bias.

Conclusions—

Active statin therapy was not associated with significant increase in ICH in this meta-analysis of 31 randomized controlled trials of statin therapy. A significant reduction in all stroke and all-cause mortality was observed with statin therapy.






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Trends in Management and Outcome of Hospitalized Patients With Acute Stroke and Transient Ischemic A

Background and Purpose—

Improving stroke management, guideline adherence, and outcome is a global priority. Our aim was to examine trends in nationwide use of reperfusion therapy, stroke in-hospital management, and outcome.

Methods—

Data were based on the triennial 2-month period of the National Acute Stroke Israeli registry (February to March 2004, March to April 2007, April to May 2010). The registry includes unselected patients admitted to all hospitals nationwide. There were in total 6279 patients: ischemic stroke, 4452 (70.9%); intracerebral hemorrhage, 485 (7.7%); undetermined stroke, 97 (1.6%); and transient ischemic attacks, 1245 (19.8%).

Results—

Overall use of reperfusion therapy for acute ischemic stroke increased from 0.4% in 2004% to 5.9% in 2010 (P<0.001; adjusted OR, 17.0; 95% CI, 7.5–38.7). Use of CT or MR angiography for ischemic events increased from 2.1% in 2004% to 16.6% in 2010 (P<0.001; adjusted OR, 9.7; 95% CI, 6.8–13.9). Overall use of antithrombotics and anticoagulation for atrial fibrillation did not differ between periods, whereas clopidogrel use increased nearly 3-fold to 41% and statin use nearly 2-fold to 68%. The relative odds of providing reperfusion therapy, using CT or MR angiography, and prescribing anticoagulants for atrial fibrillation were higher among hospitals with large as compared with small stroke patient volumes. In-hospital mortality after acute ischemic stroke decreased from 7.2% in 2004 to 3.9% in 2010 (P<0.001; adjusted OR, 0.7; 95% CI, 0.4–1.0), whereas there was no significant change in odds of poor functional outcome.

Conclusions—

Based on a nationwide stroke registry, use of reperfusion therapy, vascular imaging, and statins is steadily increasing, whereas in-hospital mortality is decreasing.






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Timing of Aneurysm Treatment After Subarachnoid Hemorrhage: Relationship With Delayed Cerebral Ische

Background and Purpose—

The ideal timing of coiling or clipping after aneurysmal subarachnoid hemorrhage is unknown. Within the International Subarachnoid Aneurysm Trial we assessed differences in incidence of delayed cerebral ischemia and clinical outcome between different timings of treatment.

Methods—

The treated 2106 patients randomized to coiling or clipping were divided into 4 categories: treatment <2 days, on days 3 to 4, on days 5 to 10, and >10 days after the hemorrhage. ORs with 95% CI were calculated with logistic regression analysis for delayed cerebral ischemia, poor outcome at 2 months, and 1 year for the different timing categories, with treatment <2 days as reference. Analyses were performed for all patients, and for coiled and clipped patients separately, and were adjusted for baseline characteristics.

Results—

Adjusted ORs of delayed cerebral ischemia for treatment on days 5 to 10 were 1.18 (95% CI, 0.91–1.53) for all patients, 1.68 (95% CI, 1.17–2.43) after coiling, and 0.79 (95% CI, 0.54–1.16) after clipping. ORs for poor outcome at 2 months were 1.16 (95% CI, 0.89–1.50) for treatment (clipping and coiling combined) at 3 to 4 days, 1.39 (95% CI, 1.08–1.80) for treatment at 5 to 10 days, and 1.84 (95% CI, 1.36–2.51) for treatment >10 days. ORs for coiled and clipped patients separately were in the same range. Results for outcome at 1 year were similar.

Conclusions—

Our results support the current practice for early aneurysm treatment in subarachnoid hemorrhage patients. The risk for poor outcome was highest when treatment was performed after day 10; postponing treatment in patients who are eligible for treatment between days 5 to 10 after subarachnoid hemorrhage is not recommended.






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Relation Between Change in Blood Pressure in Acute Stroke and Risk of Early Adverse Events and Poor

Background and Purpose—

The Scandinavian Candesartan Acute Stroke Trial (SCAST) found no benefits of candesartan in acute stroke. In the present analysis we aim to investigate the effect of change in blood pressure during the first 2 days of stroke on the risk of early adverse events and poor outcome.

Methods—

SCAST was a multicenter, randomized controlled, double-blind trial of candesartan in acute stroke. The trial recruited 2029 patients presenting within 30 hours of acute stroke and with systolic blood pressure (SBP) ≥140 mm Hg. Treatment was given for 7 days. Change in blood pressure was defined as the difference in SBP between baseline and Day 2 and was used to divide patients into groups with increase/no change, a small decrease, moderate decrease, or large decrease in SBP. The primary effect parameter was early adverse events (recurrent stroke, stroke progression, and symptomatic hypotension) during the first 7 days, analyzed using logistic regression, with the group with a small decrease in SBP as the reference group. Secondary effect parameters were neurological status at 7 days and functional outcome at 6 months.

Results—

Patients with a large decrease or increase/no change in SBP had a significantly increased risk of early adverse events relative to patients with a small decrease (OR, 2.08; 95% CI, 1.19–3.65 and OR, 1.96; 95% CI, 1.13–3.38, respectively). Patients with an increase/no change in SBP had a significantly increased risk of poor neurological outcome as compared with the other groups (P=0.001). No differences were observed in functional outcome at 6 months.

Conclusions—

Our findings support the suggestion from SCAST that blood pressure reduction may be harmful and that routine blood pressure-lowering treatment should probably be avoided in the acute phase.

Clinical Trial Information—

Clinical Trial Registration: www.clinicaltrials.gov. Unique identifier: NCT00120003.






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Long-term Excess Mortality in Pediatric Patients With Cerebral Aneurysms [Original Contributions; Cl

Background and Purpose—

Knowledge of the long-term excess mortality in pediatric aneurysm patients is lacking. The aim of this study was to assess the long-term excess mortality of 102 pediatric patients with cerebral aneurysm treated at the department of neurosurgery at Helsinki University Central Hospital between 1937 and 2009.

Methods—

Patients were followed from diagnosis until death or the end of the year 2010. Relative survival ratio provided the measure of excess mortality in these patients compared with mortality of the general Finnish population matched by age, sex, and calendar time.

Results—

A majority of the patients (n=89) presented with subarachnoid hemorrhage. Aneurysms (n=118) were treated operatively (n=79), endovascularly (n=1), or conservatively (n=36). The mean follow-up time was 26.8 years (range, 0–55.6 years). By the end of follow-up, 34 of the 102 patients had died; 26 of these deaths (76%) were aneurysm-related. There was overall excess mortality of 10% (cumulative relative survival ratio, 0.90; 95% CI, 0.80–0.96) and 19% (cumulative relative survival ratio, 0.81; 95% CI, 0.66–0.91) at 20 and 40 years after the diagnosis among the 1-year subarachnoid hemorrhage survivors, respectively. The excess mortality was particularly high in boys. There was no long-term excess mortality among patients with unruptured aneurysms. Aneurysm-related deaths included rebleedings from open or partially occluded aneurysms, epileptic seizures, de novo and recurrent aneurysms, or sequelae of subarachnoid hemorrhage.

Conclusions—

There is long-term excess mortality in pediatric patients with aneurysm even decades after successful treatment of a ruptured aneurysm, especially among boys. The excess mortality is mainly aneurysm-related.






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Posterior Versus Anterior Circulation Infarction: How Different Are the Neurological Deficits? [Orig

Background and Purpose—

Distinguishing between symptoms of posterior circulation infarction (PCI) and anterior circulation infarction (ACI) can be challenging. This study evaluated the frequency of symptoms/signs in the 2 vascular territories to determine the diagnostic value of particular symptoms/signs for PCI.

Methods—

Neurological deficits were reviewed and compared from 1174 consecutive patients with a diagnosis of PCI or ACI confirmed by magnetic resonance imaging in the Chengdu Stroke Registry. The diagnostic value of specific symptoms/signs for PCI was determined by measuring their sensitivity, specificity, positive predictive value (PPV), and the OR.

Results—

Homolateral hemiplegia (PCI, 53.6% versus ACI, 74.9%; P<0.001), central facial/lingual palsy (PCI, 40.7% versus ACI, 62.2%; P<0.001), and hemisensory deficits (PCI, 36.4% versus ACI, 34.2%; P=0.479) were the 3 most common symptoms/signs in PCI and ACI. The signs with the highest predictive values favoring a diagnosis of PCI were Horner's syndrome (4.0% versus 0%; P<0.001; PPV=100.0%; OR=4.00), crossed sensory deficits (3.0% versus 0%; P<0.001; PPV=100.0%; OR=3.98), quadrantanopia (1.3% versus 0%; P<0.001; PPV=100.0%; OR=3.93), oculomotor nerve palsy (4.0% versus 0%; P<0.001; PPV=100.0%; OR=4.00), and crossed motor deficits (4.0% versus 0.1%; P<0.001; PPV=92.3%; OR=36.04); however, all had a very low sensitivity, ranging from 1.3% to 4.0%.

Conclusions—

This study indicates that the symptoms/signs considered typical of PCI occur far less often than was expected. Inaccurate localization would occur commonly if clinicians relied on the clinical neurological deficits alone to differentiate PCI from ACI. Neuroimaging is vital to ensure accurate localization of cerebral infarction.






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Prediction of Cardioembolic, Arterial, and Lacunar Causes of Cryptogenic Stroke by Gene Expression a

Background and Purpose—

The cause of ischemic stroke remains unclear, or cryptogenic, in as many as 35% of patients with stroke. Not knowing the cause of stroke restricts optimal implementation of prevention therapy and limits stroke research. We demonstrate how gene expression profiles in blood can be used in conjunction with a measure of infarct location on neuroimaging to predict a probable cause in cryptogenic stroke.

Methods—

The cause of cryptogenic stroke was predicted using previously described profiles of differentially expressed genes characteristic of patients with cardioembolic, arterial, and lacunar stroke. RNA was isolated from peripheral blood of 131 cryptogenic strokes and compared with profiles derived from 149 strokes of known cause. Each sample was run on Affymetrix U133 Plus 2.0 microarrays. Cause of cryptogenic stroke was predicted using gene expression in blood and infarct location.

Results—

Cryptogenic strokes were predicted to be 58% cardioembolic, 18% arterial, 12% lacunar, and 12% unclear etiology. Cryptogenic stroke of predicted cardioembolic etiology had more prior myocardial infarction and higher CHA2DS2-VASc scores compared with stroke of predicted arterial etiology. Predicted lacunar strokes had higher systolic and diastolic blood pressures and lower National Institutes of Health Stroke Scale compared with predicted arterial and cardioembolic strokes. Cryptogenic strokes of unclear predicted etiology were less likely to have a prior transient ischemic attack or ischemic stroke.

Conclusions—

Gene expression in conjunction with a measure of infarct location can predict a probable cause in cryptogenic strokes. Predicted groups require further evaluation to determine whether relevant clinical, imaging, or therapeutic differences exist for each group.






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YouTube Videos May Help Some Vertigo Patients (CME/CE)

(MedPage Today) -- Two-thirds of videos posted to the YouTube website accurately depicted the Epley maneuver (EM) for benign positional vertigo, suggesting that such video sharing might help increase use of the procedure.





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Monday, July 23, 2012

Complications After Treatment With Pipeline Embolization for Giant Distal Intracranial Aneurysms Wit

imageBACKGROUND AND IMPORTANCE: The Pipeline Embolization Device (PED) is a flow diverter designed to treat intracranial aneurysms through endoluminal parent vessel reconstruction. The role of adjunctive coil embolization is unknown. CLINICAL PRESENTATION: This report details the authors' experience with the PED in 2 patients with symptomatic, giant distal intracranial aneurysms (1 basilar artery and 1 M1 segment middle cerebral artery). Both patients had successful parent vessel reconstruction. In the first patient, the basilar artery aneurysm was treated with PEDs alone, and the patient experienced early fatal brainstem hemorrhage from aneurysm rupture. In the second patient, the M1 aneurysm was treated with 2 PEDs along with dense coil embolization, with a good initial angiographic result. This patient experienced acute thrombosis of the PED post-procedure, likely related to mass effect and thrombogenicity of the dense coil mass. CONCLUSION: Flow diversion is an evolutionary step in the treatment of giant intracranial aneurysms. However, complete aneurysm occlusion occurs over a delayed period. The authors recommend placement of coils in addition to PED in the treatment of large or giant distal intracranial aneurysms in an attempt to protect the dome. However, robust packing is to be avoided because it can lead to acute PED thrombotic or compressive occlusion. ABBREVIATION: PED, pipeline embolization device





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The Frontotemporal (Pterional) Approach: An Historical Perspective

imageThe frontotemporal, so-called pterional, approach has evolved with the contribution of many neurosurgeons over the past century. It has stood the test of time and has been the most commonly used transcranial approach in neurosurgery. In its current form, drilling the sphenoid wing as far down as the superior orbital fissure with or without the removal of the anterior clinoid, thinning the orbital roof, and opening the Sylvian fissure and basal cisterns are the hallmarks of this approach. Tumoral and vascular lesions involving the sellar/parasellar area, anterior and anterolateral circle of Willis, middle cerebral artery, anterior brainstem, upper basilar artery, insula, basal ganglia, mesial temporal region, anterior cranial fossa, orbit, and optic nerve are within the reach of the frontotemporal approach. In this article, we review the origins, evolution, and modifications of the frontotemporal approach and update the discussion of some of the related derivative procedures. ABBREVIATIONS: FTS, frontotemporosphenoidal ICA, internal carotid artery MCA, middle cerebral artery





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Efficacy and Safety of Endoscopic Transventricular Lamina Terminalis Fenestration for Hydrocephalus

imageBACKGROUND: Endoscopic third ventriculostomy (ETV) has become the procedure of choice in the treatment of obstructive hydrocephalus. In certain cases, standard ETV might not be technically possible or may engender significant risk. OBJECTIVE: To present an alternative through the lamina terminalis (LT) by a transventricular, transforaminal approach with flexible neuroendoscopy and to discuss the indications, technique, neuroendoscopic findings, and outcomes. METHODS: Between 1994 and 2010, all patients who underwent endoscopic LT fenestration as an alternative to ETV were analyzed and prospectively followed up. The decision to perform an LT fenestration was made intraoperatively. RESULTS: Twenty-five patients, ranging in age from 7 months to 76 years (mean, 28.1 years), underwent endoscopic LT fenestration. Patients had obstructive hydrocephalus secondary to neurocysticercosis (11 patients), neoplasms (6 patients), congenital aqueductal stenosis (3 patients), and other (5 patients). Thirteen patients (52%) had had at least 1 ventriculoperitoneal shunt that malfunctioned; 6 patients (24%) had undergone a previous endoscopic procedure. Intraoperative findings that led to an LT fenestration were the following: ETV not feasible to perform, basal subarachnoid space not sufficient, or adhesions in the third ventricle. No perioperative complications occurred. The mean follow-up period was 63.76 months. Overall, 19 patients (76%) had resolutions of symptoms, had no evidence of ventriculomegaly, and did not require another procedure. Six (24%) required a ventriculoperitoneal shunt. CONCLUSION: Endoscopic transventricular transforaminal LT fenestration with flexible neuroendoscopy is feasible with a low incidence of complications. It is a good alternative to standard ETV. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit. ABBREVIATIONS: ETV, endoscopic third ventriculostomy LT, lamina terminalis VP, ventriculoperitoneal





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A Systematic Review of Nerve Transfer and Nerve Repair for the Treatment of Adult Upper Brachial Ple

imageNerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion. ABBREVIATION: MRC, Medical Research Council





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Reoperative Hemispherectomy for Intractable Epilepsy: A Report of 36 Patients

imageBACKGROUND: In patients with medically intractable epilepsy and diffuse unilateral hemispheric disease, functional or disconnective hemispherectomy is a widely accepted and successful treatment option. If recurrent seizures develop after disconnective hemispherectomy, management options become more complex and include conversion to anatomic hemispherectomy. OBJECTIVE: To present the outcomes of all patients undergoing reoperative hemispherectomy in 1 institution by 1 surgeon since 1998. METHODS: The medical records, operative reports, and imaging studies for 36 patients undergoing reoperative hemispherectomy for continuing medically intractable epilepsy from 1998 to 2011 at Cleveland Clinic were reviewed. Patient characteristics, cause of seizure, imaging findings, surgery-related complications, and long-term seizure outcomes were evaluated. RESULTS: Patients presented with a variety of seizure origins, including Rasmussen encephalitis, perinatal infarction, cortical dysplasia, and hemimegalencephaly. Overall, 19% of patients were seizure free after conversion to anatomic hemispherectomy, and 45% reported a decrease in seizure frequency by ≥ 90%. An additional 36% reported no improvement. Generalized ictal electroencephalography tended to confer a poorer prognosis, as did cortical dysplasia as the underlying diagnosis. CONCLUSION: The possibility that residual epileptogenic tissue in the operated hemisphere remains connected should be considered after failed functional hemispherectomy because our data suggest that improvement in seizure frequency is possible after reoperative hemispherectomy, although the chance of obtaining seizure freedom is relatively low. The decision to proceed with reoperative hemispherectomy should be made after proper discussion with the patient and family and informed consent is given. ABBREVIATION: EEG, electroencephalography





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The SILVER (Silver Impregnated Line Versus EVD Randomized Trial): A Double-Blind, Prospective, Rand

imageBACKGROUND: Cerebrospinal fluid (CSF) infections associated with external ventricular drain (EVD) placement attract major consequences. Silver impregnation of catheters attempts to reduce infection. OBJECTIVE: To assess the efficacy of silver catheters against CSF infection. METHODS: We performed a randomized, controlled trial involving 2 neurosurgical centers (June 2005 to September 2009). A total of 356 patients requiring an EVD were assessed for eligibility; 325 patients were enrolled and randomized (167 plain, 158 silver); 278 patients were analyzed (140 plain, 138 silver). The primary outcome measure was CSF infection as defined by organisms seen on Gram stain or isolated by culture. Secondary outcome measures included ventriculoperitoneal (VP) shunting. RESULTS: There was a significant difference in infection risk between the 2 study arms: 21.4% (30/140) for plain catheters vs 12.3% (17/138) for silver catheters (P = .0427; 95% confidence interval [CI]: 1.015-3.713). Patients who had an EVD infection had more than double the risk of requiring a VP shunt compared with patients without an EVD infection (45.7% [21/46] vs 19.7% [45/229], respectively, P = .0002; 95% CI: 1.766-6.682). There was also a significant difference in VP shunt risk with infection: plain (55.2%; 16/29) vs the silver arm (29.4%; 5/17); P = .0244 (95% CI: 1.144-11.695). A multivariate analysis demonstrated that infection risk was increased by duration of EVD placement (odds ratio: 1.160), spontaneous intracranial hemorrhage (odds ratio 4.958) and decreased by silver catheters (odds ratio: 0.423). CONCLUSION: The study provides Class I evidence that silver-impregnated catheters reduce CSF infection. ABBREVIATIONS: CI, confidence interval EVD, external ventricular drain GCS, Glasgow Coma Scale RCT, randomized, controlled trial SILVER, Silver Impregnated Line Versus EVD Randomized VP, ventriculoperitoneal





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Surgical Treatment of Chiari I Malformation—Analysis of Intraoperative Findings, Complications, and

imageBACKGROUND: Foramen magnum decompression is widely accepted as the treatment of choice for Chiari I malformation. However, important surgical details of the procedure are controversial. OBJECTIVE: This study analyzes 371 decompressions focusing on intraoperative findings, analysis of complications, and long-term outcomes. METHODS: Among 644 patients between 1985 and 2010, 359 patients underwent 371 decompressions. Surgery for symptomatic patients consisted of suboccipital craniectomy, C1 laminectomy, arachnoid dissection, and duraplasty. Short-term results were determined after 3 months; long-term outcomes were evaluated with Kaplan-Meier statistics. RESULTS: The mean age was 40 ± 16 years; mean follow-up was 49 ± 56 months; 75.8% demonstrated syringomyelia. The complication rate was 21.8% with permanent surgical morbidity of 3.2% and surgical mortality of 1.3%. Of the patients, 73.6% reported improvement after 3 months; 21% were unchanged. Overall, 14.3% demonstrated a neurological deterioration within 5 years and 15.4% within 10 years. The severity of neurological symptoms correlated with the grade of arachnoid pathology. Outcome data correlated with the number of previous decompressions, severity of arachnoid pathology, handling of the arachnoid, type of duraplasty, and surgical experience. First-time decompressions with arachnoid dissection and an alloplastic duraplasty resulted in surgical morbidity for 2.0%, a 0.9% mortality rate, postoperative improvement after 3 months for 82%, and neurological recurrence rates of 7% after 5 years and 8.7% after 10 years. CONCLUSION: Arachnoid pathology in Chiari I malformation has an impact on clinical symptoms and postoperative results. Decompressions with arachnoid dissection and an alloplastic duraplasty performed by surgeons experienced with this pathology offer a favorable long-term prognosis. ABBREVIATION: UCLA, University of California at Los Angeles





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Hemorrhage From Arteriovenous Malformations During Pregnancy

imageBACKGROUND: Previous hemorrhage, deep venous drainage, and deep location are established risk factors for arteriovenous malformation (AVM) hemorrhage. Although pregnancy is an assumed risk factor, there is a relative paucity of data to support this neurosurgical tenet. OBJECTIVE: To elucidate the hemorrhage rate of AVMs during pregnancy. METHODS: We reviewed the records of 54 women with an angiographic diagnosis of an AVM at our institution. Annual hemorrhage rates were calculated as the ratio of the number of bleeds to total number of patient-years of follow-up. Patient-years of follow-up were tallied assuming lesion presence from birth until AVM obliteration. The Cox proportional hazards model for hemorrhage with pregnancy as the time-dependent variable was used to calculate the hazard ratio. RESULTS: Five hemorrhages in 4 patients occurred over 62 pregnancies, yielding a hemorrhage rate of 8.1% per pregnancy or 10.8% per year. Over the remaining 2461.3 patient-years of follow-up, only 28 hemorrhages occurred, yielding an annual hemorrhage rate of 1.1%. The hazard ratio for hemorrhage during pregnancy was 7.91 (P = 2.23 × 10−4), increasing to 18.12 (P = 7.31 × 10−5) when limiting the analysis to patient follow-up up to age 40. CONCLUSION: Because of the increased risk of hemorrhage from AVMs during pregnancy, we recommend intervention in women who desire to bear children, particularly if the AVM has bled. If the AVM is discovered during pregnancy, we recommend early intervention if it has ruptured; if it is unruptured, we recommend comprehensive counseling, weighing risks of intervention against continuation of pregnancy without intervention. ABBREVIATION: AVM, arteriovenous malformation





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Shorter Disease Duration Correlates With Improved Long-term Deep Brain Stimulation Outcomes in Young

imageBACKGROUND: Treatment with deep brain stimulation (DBS) of the globus pallidus internus in children with DYT1 primary torsion dystonia is highly effective; however, individual response to stimulation is variable, and a greater understanding of predictors of long-term outcome is needed. OBJECTIVE: To report the long-term outcomes of subjects with young-onset DYT1 primary torsion dystonia treated with bilateral globus pallidus DBS. METHODS: Fourteen subjects (7 male, 7 female) treated consecutively from 2000 to 2010 at our center were included in this retrospective study. The Burke-Fahn-Marsden Dystonia Rating Scale was performed at baseline and at 1, 2, and up to 6 years postoperatively. RESULTS: Pallidal DBS was well tolerated and highly effective, with mean Burke-Fahn-Marsden Dystonia Rating Scale movement scores improving from baseline by 61.5% (P < .001) at 1 year, 64.4% (P < .001) at 2 years, and 70.3% (P < .001) at the final follow-up visit (mean, 32 months; range, 7-77 months). Disability scores also improved significantly. Multiple linear regression analysis revealed a significant influence of duration of disease as a predictor of percent improvement in Burke-Fahn-Marsden Dystonia Rating Scale movement score at long-term follow-up (duration of disease, P < .05). Subjects with fixed orthopedic deformities (4) had less improvement in these regions. Location of the active DBS electrode used at final follow-up visit was not predictive of clinical outcome. CONCLUSION: Our findings highlight the sustained benefit from DBS and the importance of early referral for DBS in children with medically refractory DYT1 primary torsion dystonia, which can lead to improved long-term benefits. ABBREVIATIONS: BRMDRS, Burke-Fahn-Marsden Dystonia Rating Scale DBS, deep brain stimulation GPi, globus pallidus internus MS, movement score PTD, primary torsion dystonia





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