Neurosurgery Blog: January 2015

Thursday, January 15, 2015

Warfarin and OTCs: An Unrecognized Risky Combination

Medscape Today- Medscape

What common over-the-counter medication is causing this previously stable patient's increase in INR?
Medscape Internal Medicine

Original Article: http://www.medscape.com/viewarticle/838026?src=rss

Sunday, January 11, 2015

hemorrhagic stroke - Head CT

Check out this video on YouTube:

http://youtu.be/9s4EYHZOVcA

Neurosurgery App

Neurosurgery App - www.weneuro.com
https://appsto.re/br/w_jbJ.i

Criminal behavior and dementing disease association examined

Neurology News & Neuroscience News from Medical News Today

Researchers have examined criminal behavior in patients with dementing neurodegenerative diseases and found that some increase risk for individuals committing certain crimes.

Original Article: http://www.medicalnewstoday.com/articles/287581.php

Is prolonged rest the best medicine for concussion?

Neurology News & Neuroscience News from Medical News Today

Although strict rest - sometimes for several days, in a darkened room - is standard care for concussed patients, a new study suggests it may actually impede recovery.

Original Article: http://www.medicalnewstoday.com/articles/287585.php

Neuro-ICUs: A Cost Effective Option? (CME/CE)

MedPage Today Neurology

(MedPage Today) -- Early data suggest money spent to transfer ICH patients is money well spent.

Original Article: http://www.medpagetoday.com/Cardiology/Strokes/49404

[Articles] Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis

The Lancet Neurology

Our results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain. Inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Modest efficacy, large placebo responses, heterogeneous diagnostic criteria, and poor phenotypic profiling probably account for moderate trial outcomes and should be taken into account in future studies.

Original Article: http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(14)70251-0/fulltext?rss=yes

Strict Rest After Concussion Offers No Additional Benefit

Medscape NeurologyHeadlines

A randomized trial shows 5 days of strict rest is no better than 1 or 2 days followed by gradual resumption of physical and mental activities.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/837710?src=rss

New Cancer Diagnosis Linked to Increased Stroke Risk

Medscape NeurologyHeadlines

A diagnosis of cancer -- particularly lung, pancreatic, or colorectal cancer -- is associated with an increased short-term risk for stroke, a new study suggests.
Medscape Medical News

Original Article: http://www.medscape.com/viewarticle/837807?src=rss

Patients experience high levels of anxiety two years following aneurysmal subarachnoid hemorrhage

Neurosurgery News

World Neurosurgery

Original Article: http://www.mdlinx.com/neurology/news-article.cfm/5830388/?xml

Some emotional responses to music are universal, study finds

Neurology News & Neuroscience News from Medical News Today

By comparing reactions to musical extracts among Canadians and Mbenzélé Pygmies from the Congo, researchers found some emotional responses to music are universal.

Original Article: http://www.medicalnewstoday.com/articles/287680.php

Networks of the brain reflect the individual gender identity

Neurology News & Neuroscience News from Medical News Today

Our sense of belonging to the male or female gender is an inherent component of the human identity perception. As a general rule, gender identity and physical sex coincide.

Original Article: http://www.medicalnewstoday.com/releases/287767.php

Brazil Water Supply, Crops Still at Risk a Year after Epic Drought

Scientific American: Mind and Brain

By Anna Flávia Rochas and Roberto Samora SAO PAULO, Jan 9 (Reuters) - Southeastern Brazil is getting some rainfall a year after a record drought started, but not enough to eliminate worries...

-- Read more on ScientificAmerican.com

Original Article: http://www.scientificamerican.com/article/brazil-water-supply-crops-still-at-risk-a-year-after-epic-drought/

Biological and clinical characteristics of the European Friedreich's Ataxia Consortium for Translational Studies (EFACTS) cohort: a cross-sectional analysis of baseline data.

Unbound MEDLINE | Lancet journal articles

Reetz K, Dogan I, Costa AS, et al.
Biological and clinical characteristics of the European Friedreich's Ataxia Consortium for Translational Studies (EFACTS) cohort: a cross-sectional analysis of baseline data. [JOURNAL ARTICLE]
Lancet Neurol 2015 Jan 2.

Friedreich's ataxia is a rare autosomal recessive neurodegenerative disorder. Here we report cross-sectional baseline data to establish the biological and clinical characteristics for a prospective, international, European Friedreich's ataxia database registry.Within the European Friedreich's Ataxia Consortium for Translational Studies (EFACTS) framework, we assessed a cohort of patients with genetically confirmed Friedreich's ataxia. The primary outcome measure was the Scale for the Assessment and Rating of Ataxia (SARA) and secondary outcome measures were the Inventory of Non-Ataxia Signs (INAS), the performance-based coordination test Spinocerebellar Ataxia Functional Index (SCAFI), the neurocognitive phonemic verbal fluency test, and two quality-of-life measures: the activities of daily living (ADL) part of the Friedreich's Ataxia Rating Scale and EQ-5D. The Friedreich's ataxia cohort was subdivided into three groups: early disease onset (≤14 years), intermediate onset (15-24 years), and late onset (≥25 years), which were compared for clinical characteristics and outcome measures. We used linear regression analysis to estimate the annual decline of clinical outcome measures based on disease duration. This study is registered with ClinicalTrials.gov, number NCT02069509.We enrolled 592 patients with genetically confirmed Friedreich's ataxia between Sept 15, 2010, and April 30, 2013, at 11 sites in seven European countries. Age of disease onset was inversely correlated with the number of GAA repeats in the frataxin (FXN) gene: every 100 GAA repeats on the smaller repeat allele was associated with a 2·3 year (SE 0·2) earlier onset. Regression analyses showed significant estimated annual worsening of SARA (regression coefficient 0·86 points [SE 0·05], INAS (0·14 points [0·01]), SCAFI Z scores (-0·09 [0·01]), verbal fluency (-0·34 words [0·07]), and ADL (0·64 points [0·04]) during the first 25 years of disease; the regression slope for health-related quality-of-life state from EQ-5D was not significant (-0·33 points [0·18]). For SARA, the predicted annual rate of worsening was significantly higher in early-onset patients (n=354; 1·04 points [0·13]) and intermediate-onset patients (n=137; 1·17 points [0·22]) than in late-onset patients (n=100; 0·56 points [0·10]).The results of this cross-sectional baseline analysis of the EFACTS cohort suggest that earlier disease onset is associated with larger numbers of GAA repeats and more rapid disease progression. The differential estimated progression of ataxia symptoms related to age of onset have implications for the design of clinical trials in Friedreich's ataxia, for which SARA might be the most suitable measure to monitor disease progression.European Commission.

Original Article: http://www.unboundmedicine.com/medline/citation/25566998/Biological_and_clinical_characteristics_of_the_European_Friedreich's_Ataxia_Consortium_for_Translational_Studies__EFACTS__cohort:_a_cross_sectional_analysis_of_baseline_data_

Saturday, January 3, 2015

Rational and Irrational Thought: The Thinking that IQ Tests Miss

Scientific American: Mind and Brain

Why smart people sometimes do dumb things

-- Read more on ScientificAmerican.com

Original Article: http://www.scientificamerican.com/article/rational-and-irrational-thought-the-thinking-that-iq-tests-miss/

Learning a musical instrument boosts kids' brains

Neurology News & Neuroscience News from Medical News Today

A child psychiatry team suggests that musical training for children can help them attain greater emotional control, focus their attention and reduce feelings of anxiety.

Original Article: http://www.medicalnewstoday.com/articles/287458.php

What Does A Smart Brain Look Like?

Scientific American: Mind and Brain

A new neuroscience of intelligence is revealing that not all brains work in the same way

-- Read more on ScientificAmerican.com

Original Article: http://www.scientificamerican.com/article/what-does-a-smart-brain-look-like1/

Tools for readers: Getting the most from the Neurology electronic platforms

Neurology recent issues

Increasingly, readers of journals are accessing content online and on mobile devices as publishers enhance the features of their electronic versions and device ownership is growing. The Neurology® Web sites and mobile platforms have tools and features that can help you easily discover and use the information in the journal. Besides the usual enhancements offered by online versions (easy-to-use interface, efficient search through nearly 65 years of archived issues, links to MEDLINE and other content, availability of supplemental data), we describe some of the special features currently available or that will appear soon.

Original Article: http://www.neurology.org/cgi/content/short/84/1/11?rss=1

Teaching NeuroImages: Posttraumatic lumbar epidural hematoma

Neurology current issue

A 36-year-old man presented with pain radiating from his right hip to the knee, after a heavy fall on his back 2 months earlier. At neurologic examination, bilateral Lasegue's sign (straight leg raise test) was present. MRI revealed a ventral epidural space-occupying lesion at L2-L3 (figure). The differential diagnosis consisted of a sequestered disc, a ventral synovial cyst, and an epidural hematoma.

Original Article: http://www.neurology.org/cgi/content/short/84/1/e7?rss=1

Hyperventilation during routine EEG recording: are “3 minutes” really necessary?

Hyperventilation during routine EEG recording: are "3 minutes" really necessary?

Pediatric Neurology

Hyperventilation induces absence seizures in children with absence epilepsy, and routine electroencephalography studies include 3 minutes of hyperventilation. We aimed at determining the duration of hyperventilation required to provoke a first absence seizure, in order to establish whether 3 minutes of the procedure are indeed necessary.

Original Article: http://www.pedneur.com/article/S0887-8994(14)00760-7/abstract?rss=yes

Evaluation of glycerol-preserved bone allografts in cervical spine fusion: a prospective, randomized controlled trial

Journal of Neurosurgery: Journal of Neurosurgery: Spine: Table of Contents

Journal of Neurosurgery: Spine, Volume 22, Issue 1, Page 1-10, January 2015.
OBJECT Bone allografts used for interbody spinal fusion are often preserved through either freeze drying or lowtemperature freezing, each having disadvantages related to graft preparation time and material properties. In response, a glycerol preservation treatment has been developed to maintain the biomechanical properties of allografts at ambient temperatures, requiring no thawing or rehydration and minimal rinsing prior to implantation. The authors conducted a prospective randomized study to compare the clinical results of glycerol-preserved Cloward dowels and those of freezedried Cloward dowels in anterior cervical discectomy and fusion. The primary outcome measures were evidence of fusion and graft subsidence, and the secondary outcome measures included adverse events, pain, and neck disability scores. METHODS Of 106 patients, 53 (113 levels of surgery) were randomly assigned to the glycerol-preserved graft group and 53 (114 levels of surgery) to the freeze-dried graft group. Subsidence was assessed at 3 and 6 months after implantation. Evidence of fusion was evaluated radiographically at 6 months postimplantation. Subsidence was quantitatively assessed based on physical measurements obtained from radiographs by using calibrated comparators, whereas fusion was also evaluated visually. Surgeons were blinded to treatment type during visual and physical assessments of the patients and the radiographs. RESULTS No one in either group had evidence of complete nonunion according to radiographic evaluation at the 6-month follow-up. Average subsidence for all graft-treated levels was 2.11 mm for the glycerol-preserved group and 2.73 mm for the freeze-dried group at the 3-month follow-up and 2.13 and 2.83 mm at the 6-month follow-up, respectively. The 2 treatment groups were statistically equivalent (p = 0.2127 and 0.1705 for the 3- and 6-month follow-up, respectively). No differences were noted between the graft types in terms of adverse event incidence or severity. CONCLUSIONS Glycerol-preserved bone allografts exhibit fusion results and subsidence values similar to those of their freeze-dried counterparts, potentially more favorable biomechanical properties, and significantly shorter preparation times.

Original Article: http://thejns.org/doi/abs/10.3171/2014.9.SPINE131005?ai=rt&mi=0&af=R

The supracerebellar-transtentorial approach to posteromedial temporal lesions in children with refractory epilepsy

Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 15, Issue 1, Page 45-54, January 2015.
OBJECT Operations on tumors of the posteromedial temporal (PMT) region, that is, on those arising from the posterior parahippocampal, fusiform, and lingual gyri, are challenging to perform because of the deep-seated location of these tumors between critical cisternal neurovascular structures and the adjacent temporal and occipital cortexes. Traditional surgical approaches require temporal or occipital transgression, retraction, or venous sacrifice. These approaches may result in unintended complications that should be avoided. To avoid these complications, the supracerebellar-transtentorial (SCTT) approach to this region has been used as an effective alternative treatment in adult patients. The SCTT approach uses a sitting position that offers a direct route to the posterior fusiform and lingual gyri of the temporal lobe. The authors report the feasibility, safety, and efficacy of this approach, using a modified lateral park-bench position in a small cohort of pediatric patients. METHODS The authors carried out a retrospective case review of 5 consecutive patients undergoing a paramedian SCTT approach between 2009 and 2014 at the authors' institution. RESULTS The SCTT approach in the park-bench position was used in 3 boys and 2 girls with a mean age of 7.8 years (range 13 months to 16 years). All patients presented with a seizure disorder related to a tumor in a PMT region involving the parahippocampal and fusiform gyri of the left (n = 3) or right (n = 2) temporal lobe. No procedure-related complications were observed. Gross-total resection and control of seizures were achieved in all cases. Tumor classes and types included 1 Grade II astrocytoma, 1 pleomorphic xanthoastrocytoma, 1 ganglioglioma, and 2 glioneural tumors. None of the tumors had recurred by the mean follow-up of 22 months (range 1–48 months). Outcomes of epileptic seizures were excellent, with seizure symptoms in all 5 patients scoring in Engel Class IA. CONCLUSIONS The SCTT approach represents a viable option when resecting tumors in this region, providing a reasonable working corridor and low morbidity. The authors' experience in a cohort of pediatric patients demonstrates that complete resection of the lesions in this location is feasible and is safe when involving an approach that involves using a park-bench lateral positioning.

Original Article: http://thejns.org/doi/abs/10.3171/2014.10.PEDS14162?ai=3f6&mi=3ba5z2&af=R

Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience

Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 15, Issue 1, Page 71-77, January 2015.
OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0–2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.

Original Article: http://thejns.org/doi/abs/10.3171/2014.9.PEDS146?ai=3f6&mi=3ba5z2&af=R

Chiari malformation I and autism spectrum disorder: an underrecognized coexistence

Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 15, Issue 1, Page 96-100, January 2015.
OBJECT Patients with symptomatic Chiari malformation Type I (CM-I) frequently present with headaches, neck pain, difficulty swallowing, and balance disturbances. In children with autism spectrum disorder (ASD), diagnosing CM-I can be a challenging task. Moreover, even if symptomatic, some patients do not undergo further evaluation or management, as their presentations are attributed to autism and its myriad symptoms. Therefore, cranial MRI findings were reviewed after evaluating and treating patients with coexisting ASD and CM-I. In this paper, the authors report on 5 children with ASD and symptomatic CM-I, including their clinical presentation, imaging studies, management, and outcomes, and discuss the likely underrecognized coexistence of these conditions. METHODS All pediatric patients with ASD and cranial MRI conducted for any reason in the period from 1999 to 2013 were considered for analysis. All cases with concomitant symptomatic CM-I were eligible for this retrospective analysis. RESULTS One hundred twenty-five pediatric patients diagnosed with ASD had undergone MRI, and 9 of them had evidence of cerebellar tonsillar herniation. Five patients were symptomatic and underwent suboccipital craniectomy, a C-1 or a C-1 and C-2 laminectomy, and duraplasty with bovine pericardium or Type I collagen allograft. There were no intraoperative complications. All patients showed symptom improvement and/or resolution of presenting symptoms, which included headache, dysphasia, speech, and irritability. CONCLUSIONS There is no identified cause of autism. Children with ASD can be difficult to assess specifically in a neurological examination. Thus, cranial MRI considered when completing a comprehensive diagnostic evaluation. While cranial MRI is not a routine part of ASD evaluation, this study demonstrates that CM-I and ASD may coexist and be underrecognized. The study reinforces the importance of a comprehensive medical evaluation designed to elucidate neurological findings in children with impaired communication abilities and suggests the judicious use of neuroimaging.

Original Article: http://thejns.org/doi/abs/10.3171/2014.10.PEDS13562?ai=3f6&mi=3ba5z2&af=R

Smoking is not associated with recurrence and retreatment of intracranial aneurysms after endovascular coiling

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 122, Issue 1, Page 95-100, January 2015.
OBJECT Tobacco smoking is one of the most important risk factors for the formation of intracranial aneurysms and for aneurysmal subarachnoid hemorrhages. Smoking has also been suggested to contribute to the recurrence of aneurysms after endovascular coiling. To improve the understanding of the impact of smoking on long-term outcomes after coil embolization of intracranial aneurysms, the authors studied a consecutive contemporary series of patients treated at their institution. The aims of this study were to determine whether smoking is an independent risk factor for aneurysm recurrence and retreatment after endovascular coiling. METHODS All patients who had received an intrasaccular coil embolization of an intracranial aneurysm, who had undergone a follow-up imaging exam at least 6 months later, and whose smoking history had been recorded from January 2005 through December 2012 were included in this study. Patients were stratified according to smoking status into 3 groups: 1) never a smoker, 2) current smoker (smoked at the time of treatment), and 3) former smoker (quit smoking before treatment). The 2 primary outcomes studied were aneurysm recurrence and aneurysm retreatment after treatment for endovascular aneurysms. Kruskal-Wallis and chi-square tests were used to test statistical significance of differences in the rates of aneurysm recurrence, retreatment, or of both among the 3 groups. A multivariate logistic regression analysis controlling for smoking status and for several characteristics of the aneurysm was also performed. RESULTS In total, 384 patients with a combined total of 411 aneurysms were included in this study. The aneurysm recurrence rate was not significantly associated with smoking: both former smokers (OR 1.00, 95% CI 0.61–1.65; p = 0.99) and current smokers (OR 0.58, 95% CI 0.31–1.09; p = 0.09) had odds of recurrence that were similar to those who were never smokers. Former smokers (OR 0.78, 95% CI 0.46–1.35; p = 0.38) had odds of retreatment similar to those of never smokers, and current smokers had a lower odds of undergoing retreatment (OR 0.44, 95% CI 0.21–0.91; p = 0.03) than never smokers. Moreover, an analysis adjusting for aneurysm rupture, diameter, and initial occlusion showed that former smokers (OR 0.65, 95% CI 0.33–1.28; p = 0.21) and current smokers (OR 1.04, 95% CI 0.60–1.81; p = 0.88) had odds of aneurysm recurrence similar to those who were never smokers. Adjusting the analysis for aneurysm rupture, diameter, and occlusion showed that both former smokers (OR 0.49, 95% CI 0.23–1.05; p = 0.07) and current smokers (OR 0.82, 95% CI 0.46–1.46; p = 0.50) had odds of retreatment similar to those of patients who were never smokers. CONCLUSIONS The results show that smoking was not an independent risk factor for aneurysm recurrence and aneurysm retreatment among patients receiving endovascular treatment for intracranial aneurysms at the authors' institution. Nonetheless, patients with intracranial aneurysms should continue to be counseled about the risks of tobacco smoking.

Original Article: http://thejns.org/doi/abs/10.3171/2014.10.JNS141035?ai=ru&mi=0&af=R

Brainstem arteriovenous malformations: anatomical subtypes, assessment of “occlusion in situ” technique, and microsurgical results

Brainstem arteriovenous malformations: anatomical subtypes, assessment of "occlusion in situ" technique, and microsurgical results

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 122, Issue 1, Page 107-117, January 2015.
OBJECT The surgical management of brainstem arteriovenous malformations (AVMs) might benefit from the definition of anatomical subtypes and refinements of resection techniques. Many brainstem AVMs sit extrinsically on pia mater rather than intrinsically in the parenchyma, allowing treatment by occluding feeding arteries circumferentially, interrupting draining veins after arteriovenous shunting is eliminated, and leaving the obliterated nidus behind. The authors report here the largest series of brainstem AVMs to define 6 subtypes, assess this "occlusion in situ" technique, and analyze the microsurgical results. METHODS Brainstem AVMs were categorized as 1 of 6 types: anterior midbrain, posterior midbrain, anterior pontine, lateral pontine, anterior medullary, and lateral medullary AVMs. Data from a prospectively maintained AVM registry were reviewed to evaluate multidisciplinary treatment results. RESULTS During a 15-year period, the authors treated 29 patients with brainstem AVMs located in the midbrain (1 anterior and 6 posterior), pons (6 anterior and 7 lateral), and medulla (1 anterior and 8 lateral). The nidus was pial in 26 cases and parenchymal in 3 cases. Twenty-three patients (79%) presented with hemorrhage. Brainstem AVMs were either resected (18 patients, 62%) or occluded in situ (11 patients, 38%). All lateral pontine AVMs were resected, and the occlusion in situ rate was highest with anterior pontine AVMs (83%). Angiography confirmed complete obliteration in 26 patients (89.6%). The surgical mortality rate was 6.9%, and the rate of permanent neurological deterioration was 13.8%. At follow-up (mean 1.3 years), good outcomes (modified Rankin Scale [mRS] score ≤ 2) were observed in 18 patients (66.7%) and poor outcomes (mRS score of 3–5) were observed in 9 patients (33.3%). The mRS scores in 21 patients (77.8%) were unchanged or improved. The best outcomes were observed with lateral pontine (100%) and lateral medullary (75%) AVMs, and the rate of worsening/death was greatest with posterior midbrain and anterior pontine AVMs (50% each). CONCLUSIONS Brainstem AVMs can be differentiated by their location in the brainstem (midbrain, pons, or medulla) and the surface on which they are based (anterior, posterior, or lateral). Anatomical subtypes can help the neurosurgeon determine how to advise patients, with lateral subtypes being a favorable surgical indication along with extrinsic pial location and hemorrhagic presentation. Most AVMs are dissected with the intention to resect them, and occlusion in situ is reserved for those AVMs that do not separate cleanly from the brainstem, that penetrate into the parenchyma, or are more anterior in location, where it is difficult to visualize and preserve perforating arteries (anterior pontine and lateral medullary AVMs). Although surgical morbidity is considerable, surgery results in a better obliteration rate than nonoperative management and is indicated in highly selected patients with high rerupture risks.

Original Article: http://thejns.org/doi/abs/10.3171/2014.8.JNS1483?ai=ru&mi=0&af=R

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 122, Issue 1, Page 202-210, January 2015.
OBJECT Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. METHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. RESULTS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). CONCLUSIONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.

Original Article: http://thejns.org/doi/abs/10.3171/2014.10.JNS132545?ai=ru&mi=0&af=R

Cost-consequence analysis of antibiotic-impregnated shunts and external ventricular drains in hydrocephalus

Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 122, Issue 1, Page 139-147, January 2015.
OBJECT Despite multiple preventive strategies for reducing infection, up to 15% of patients with shunt catheters and 27% of patients with external ventricular drains (EVDs) may develop an infection. There are few data on the cost-effectiveness of measures to prevent hydrocephalus catheter infection from the hospital perspective. The objective of this study was to perform a cost-consequence analysis to assess the potential clinical and economic value of antibiotic-impregnated catheter (AIC) shunts and EVDs compared with non-AIC shunts and EVDs in the treatment of hydrocephalus from a hospital perspective. METHODS The authors used decision analytical techniques to assess the clinical and economic consequences of using antibiotic-impregnated shunts and EVDs from a hospital perspective. Model inputs were derived from the published, peer-reviewed literature. Clinical studies comparing infection rates and the clinical and economic impact of infections associated with the use of AICs and standard catheters (non-AICs) were evaluated. Outcomes assessed included infections, deaths due to infection, surgeries due to infection, and cost associated with shunt- and EVD-related infection. A subanalysis using only AIC shunt and EVD Level I evidence (randomized controlled trial results) was conducted as an alternate to the cumulative analysis of all of the AIC versus non-AIC studies (13 of the 14 shunt studies and 4 of the 6 EVD studies identified were observational). Sensitivity analyses were conducted to determine how changes in the values of uncertain parameters affected the results of the model. RESULTS In 100 patients requiring shunts, AICs may be associated with 0.5 fewer deaths, 71 fewer hospital days, 11 fewer surgeries, and $128,228 of net savings in hospital costs due to decreased infection. Results of the subanalysis showed that AICs may be associated with 1.9 fewer deaths, 1611 fewer hospital days, 25 fewer surgeries, and $346,616 of net savings in hospital costs due to decreased infection. The rate of decrease in infection with AIC shunts was shown to have the greatest impact on the cost savings realized with use of AIC shunts. In 100 patients requiring EVDs, AICs may be associated with 2.7 fewer deaths and 82 fewer hospital days due to infection. The relative risk of more severe neurological impairment was estimated to be 5.33 times greater with EVD infection. Decreases in infection with AIC EVDs resulted in an estimated $264,069 of net savings per 100 patients treated with AICs. Results of the subanalysis showed that AIC EVDs may be associated with 1.0 fewer deaths, 31 infection-related hospital days averted, and $74,631 saved per 100 patients treated with AIC EVDs. As was seen with AIC shunts, the rate of decrease in infection with AIC EVDs was shown to have the greatest impact on the cost savings realized with use of AIC EVDs. CONCLUSIONS The current value analysis demonstrates that evidence supports the use of AICs as effective and potentially cost-saving treatment.

Original Article: http://thejns.org/doi/abs/10.3171/2014.9.JNS131277?ai=ru&mi=0&af=R