Month: June 2016

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Predictors of aneurysmal rebleed before definitive surgical or endovascular management

A Simple and Quantitative Method to Predict Symptomatic Vasospasm After Subarachnoid Hemorrhage Based on Computed Tomography- Beyond the Fisher Scale

Acta Neurochir (2016) 158:1037–1044

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

Method: A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

Results: Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p=0.023), diastolic blood pressure of >90 mmHg on admission (p=0.008); presence of loss of consciousness (p= 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p=0.005); higher Fisher grade (p<0.001); presence of multiple aneurysms (p= 0.021); irregular aneurysm surface (0.002).

Conclusions: Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

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Anterior Nucleus Deep Brain Stimulation for Refractory Epilepsy

Anterior Nucleus Deep Brain Stimulation for Refractory Epilepsy

Neurosurgery 78:802–811, 2016

Anterior nucleus (AN) deep brain stimulation (DBS) is a palliative treatment for medically refractory epilepsy. The long-term efficacy and the optimal target localization for AN DBS are not well understood.

OBJECTIVE: To analyze the long-term efficacy of AN DBS and its predictors.

METHODS: We performed a retrospective review of 16 patients who underwent AN DBS. We selected only patients with reliable seizure frequency data and at least a 1-year follow-up. We studied the duration of the seizure reduction after DBS insertion and before stimulation (the insertional effect) and its association with long-term outcome. We modeled the volume of activation using the active contacts, stimulation parameters, and postoperative imaging. The overlap of this volume was plotted in Montreal Neurological Institute 152 space in 7 patients with significant clinical efficacy.

RESULTS: Nine patients reported a decrease in seizure frequency immediately after electrode insertion (insertional or microthalamotomy effect). The duration of insertional effect varied from 2 to 4 months. However, 1 patient had a long-term insertional effect of 36 months. Altogether, 11 patients reported .50% decrease in seizure frequency with long-term stimulation. The most common pattern of seizure control was immediate and sustained stimulation benefit (n = 8). In patients with long-term stimulation benefit, the efficacious target was localized in the anteroventral AN in close proximity to the mammillothalamic tract.

CONCLUSION: AN DBS is efficacious in the control of seizure frequency in selected patients. An insertional effect is commonly observed (56%). The most efficacious site of stimulation appears to be the anteroventral AN.

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