Intraindividual comparison of histopathological diagnosis obtained by stereotactic serial biopsy to open surgical resection specimen in patients with intracranial tumours

Background

There are concerns in the literature about the accuracy of histopathological diagnosis obtained by stereotactic biopsy in patients with brain tumours. The aim of this study was to analyse intraindividually the histopathological accuracy of stereotactic biopsies of intracerebral lesions in comparison to open surgical resection.

Materials and methods

Between 2007 and 2011 a total of 635 patients underwent stereotactic serial biopsy in our department. Among these patients we identified 51 patients, who underwent magnetic resonance (MR) based stereotactic biopsy and subsequent open resection within 30 days. Mortality and morbidity data as well as final histopathological diagnoses of both procedures were compared with regard to tumour grade and tumour cell type. Patients with discrepancies between the histological diagnosis obtained by biopsy and open resection were classified into three subgroups (same cell type but different grading; same grading but different cell type and different grading as well as different cell type).

Results

The mean number of tissue samples taken by stereotactic serial biopsy from each patient was 12 (range 7–21). Minor morbidity was 6% and major morbidity was 14% after open surgery compared to no morbidity after stereotactic biopsy. Mortality was 2% after stereotactic biopsy (one patient died after stereotactic biopsy as a result of a fatal bleeding) compared to 0% in the resection group. Silent bleeding rate without any clinical symptoms was 8% in the biopsy group. A complete correlation of histopathological findings between the biopsy group and the resection group was achieved in 76% and was increased to 90% by analyzing clinical and neuroradiological information. In patients with recurrence the correlation was higher (94%) than for patients with primary brain lesions (67%). The discrepancies between the open resection group and biopsy group were analysed.

Conclusion

Stereotactic MR guided serial biopsy is a minimal invasive procedure with low morbidity and high diagnostic accuracy for diagnosis and grading of brain tumours. Diagnostic accuracy of stereotactic biopsy can be enhanced further by careful interpretation of neuroradiological and clinical information.     

Influenza outbreaks management in a French psychiatric hospital from 2004 to 2012

Objective

Influenza epidemics can have consequences in terms of morbidity and mortality for the patients. This work assesses influenza outbreaks in order to validate and optimize alert and control measures in a psychiatric hospital.

Method

The prospective monitoring of influenza episodes was conducted for 8 years in 19 units of a mental health hospital. Rapid influenza diagnostic tests were used. The study of the episodes with confirmed influenza cases was carried out.

Results

Influenza monitoring and alert were essential with information and laboratory-confirmed cases. Influenza was common with a total of 20 episodes for the studied period. A maximum of 25% (5/20) of the units were affected in 2008–2009. Rapid influenza diagnostic tests allowed a quick identification with an average time of 1.5 days. Mainly, control measures limited the spread of the influenza virus in units with patient not at high risk of complications. On the other hand, antiviral curative treatment and chemoprophylaxis are essential in units with patients at high risk of complications.

Conclusion

In a psychiatric hospital, influenza management has to take into account the exposed patient's risks for influenza complications and to adapt the strategy according to the risks identified.     

Risk factors and short-term outcome in patients with angiographically negative subarachnoid hemorrhage

Objectives

The objective of this study was to identify prognostic factors for clinical outcome in patients with non-traumatic, angiographically negative subarachnoid hemorrhage. Furthermore, the aim was to investigate if patients on anticoagulant therapy may have a more unfavorable outcome than patients not receiving anticoagulant therapy.

Materials and methods

This study contains a retrospective analysis of 95 patients with non-traumatic, non-aneurysmal subarachnoid hemorrhage who were admitted to our institution in the period 2000–2011. The patients were classified according to risk factors, clinical presentation at admission, anticoagulant therapy at the time of hemorrhage and complications. The outcome was assessed with modified Rankin Score at discharge.

Results

Patients who were exposed to risk factors combined with a higher WFNS score at admission had an unfavorable outcome according to the modified Rankin Score at discharge. Unfavorable outcome was evaluated in relation to sex, anticoagulant therapy, hypertension, smoking and alcohol abuse. A strong correlation with anticoagulant therapy, smoking and alcohol abuse was found. None of the patients who developed vasospasms in this study were receiving anticoagulant therapy.

Conclusion

There is a correlation between antithrombotic state at admission and unfavorable outcome for patients with non-traumatic, non-aneurysmal subarachnoid hemorrhage. The results from this study indicate that patients on anticoagulant therapy have a higher risk of developing complications after non-aneurysmal angiographically negative subarachnoid hemorrhage compared to patients who were not receiving anticoagulant therapy.     

Surgery for carpal tunnel syndrome under antiplatelet therapy

Objective

Antiplatelet therapy is often instituted after cardiovascular or neurological ischemic events. In general, discontinuation of the antiplatelet medication for several days is warranted previous to surgery. However, discontinuation can lead to ischemic events. For some forms of surgery, the risks of an ischemic event, and especially, its consequences do not outweigh the benefit of discontinuation of the antiplatelet therapy. Retrospective analysis was done of a cohort of patients treated for carpal tunnel syndrome with special emphasis on postoperative hemorrhage in combination with antiplatelet medication.

Methods

Retrospective analysis of cohort consisting of 362 consecutive patients treated for carpal tunnel syndrome in the Neurosurgical Centre, Nijmegen was done.

Results

In 362 patients 423 operations on carpal tunnel release were done. Thirty-one patients were on antiplatelet therapy, of which 6 did not discontinue the medication before surgery. The remaining patients stopped at least seven days before surgery. A postoperative hemorrhage did not occur in any of the 423 operations.

Conclusion

There seems no reasonable evidence that discontinuation of aspirin for carpal tunnel syndrome is justified. Bleeding complications are considered rare, moreover the impact of an ischemic cardiovascular or a cerebral event would be far more severe than that of postoperative hemorrhage in the wrist.     

Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit

Objective

To compare cumulative complication rates of peripherally (PICC) and centrally (CICVC) inserted central venous catheters, including catheter-related large vein thrombosis (CRLVT), central line-associated bloodstream infection (CLABSI), and line insertion-related complications in neurological intensive care patients.

Methods

Retrospective cohort study and detailed chart review for 431 consecutive PICCs and 141 CICVCs placed in patients under neurological intensive care from March 2008 through February 2010. Cumulative incidence of CRLVT, CLABSI, and line insertion-related complications were compared between PICC and CICVC groups. Risk factors for CRLVT including mannitol therapy during dwell time, previous history of venous thromboembolism, surgery longer than 1 h during dwell time, and line placement in a paretic arm were also compared between groups.

Results

During the study period, 431 unique PICCs were placed with cumulative incidence of symptomatic thrombosis of 8.4%, CLABSI 2.8%, and line insertion-related complications 0.0%. During the same period, 141 unique CICVCs were placed with cumulative incidence of symptomatic thrombosis of 1.4%, CLABSI 1.4%, and line insertion-related complications 0.7%. There was a statistically significant difference in CRLVT with no difference in CLABSI or line insertion-related complications.

Conclusions

In neurological critical care patients, CICVCs appear to have a better risk profile compared to PICCs, with a decreased risk of CRLVT. As use of PICCs in critical care patients increases, a prospective randomized trial comparing PICCs and CICVCs in neurological critical care patients is necessary to assist in choosing the appropriate catheter and to minimize risks of morbidity and mortality associated with central venous access.     

Elderly patients are at increased risk for mortality undergoing surgical repair of dens fractures

Objective

Dens fractures are common cervical injuries in advanced aged patients. The presented study was undertaken to analyze the clinical results and risks of surgically treated patients with dens fractures over 70 years.

Methods

Data of 28 patients (17 female, 11 male) over 70 years treated from September 2004 to October 2009 were recorded. Clinical and radiological parameters were obtained including type of fracture, associated cervical and/or other injuries, comorbidities, symptoms, neurological condition, surgical strategy, postoperative course and complications.

Results

89% were in a good neurological condition before surgery (ASIA E or D). In most cases, surgery was performed at an early stage after trauma (21 patients within 5 days). Ventral screw fixation was the preferred surgical strategy (64%). A slight worsening of neurological functions immediately after operation was only seen in one patient. Five patients died in the early and 2 in the late postoperative course which means a treatment mortality of 25%. Among the surviving patients two had general medical complications.

Conclusion

Type II dens fractures are a common fracture of elderly patients. Our results are good concerning the neurological functions. Surgical and general medical complications were acceptable. However, the study also underlines that mortality rate is high and therefore treatment options should be well-considered in this high risk group.     

Significance of the T2*-weighted gradient echo brain imaging in patients with infective endocarditis

Background

Although aneurysm formation accompanying parenchymal hemorrhage is one of devastating complications in the central nerves system (CNS), imaging studies of the brain are not routinely warranted in patients with infective endocarditis (IE). To assess the clinical importance for detecting silent lesions in the central nervous system, we investigated hypointense signal spots detected on the brain T2*-weighted MR imaging in patients with IE.

Methods and results

Eleven patients with IE were retrospectively reviewed. Seven patients (63.6%) showed hypointense signal spots on T2*-weighted MR images. The number of hypointense signal spots increased within only a few weeks in five patients.

Conclusion

The brain T2*-weighted MR imaging in patients with IE may have a potential role to detect CNS lesions with clinical significance of potentially high risk of intracranial hemorrhage. T2*-weighted hypointense signal spots may be specific to brain involvement, and be quite useful in monitoring CNS lesions associated with IE, even if they are asymptomatic.     

Muscle and nerve biopsies: Techniques for the neurologist and neurosurgeon

Objective

Muscle and nerve biopsies are commonly performed procedures for the diagnosis of neuromuscular disorders. Neurologists and neurosurgeons are often consulted to perform these procedures in clinical practice. We provide guidelines in the performance of muscle and nerve biopsies.

Methods

We describe the technique for performance of muscle and nerve biopsy, and review the relevant literature.

Results

The quadriceps muscle is the most typical biopsy site for most myopathies, whereas the sural nerve is the most common nerve biopsy site for most peripheral neuropathies. Other sites may be utilized depending upon the pattern of symptoms or the differential diagnosis. Motor nerves may be sampled in the setting of motor neuron disease, for example. We advocate the use of conduit repair to allow for sensory or motor recovery to occur following nerve biopsy.

Conclusion

The muscle biopsy and nerve biopsy may be performed with high yield, low morbidity, and rare complications.     

Thrombomodulin alfa treatment in patients with acute promyelocytic leukemia and disseminated intravascular coagulation: A retrospective analysis of an open-label,multicenter, post-marketing surveillance study cohort

Introduction

Patients with acute promyelocytic leukemia (APL) can develop disseminated intravascular coagulation (DIC) that results in life-threatening hemorrhagic complications. Studies regarding the safety and efficacy of thrombomodulin alfa (TM-α; recombinant human soluble thrombomodulin) in patients with APL and DIC are limited.

Materials and methods

A retrospective evaluation was performed on a cohort of 172 patients with APL from an open-label, multicenter, post-marketing surveillance study of TM-α.

Results

Of the 172 patients, 31 were relapse/refractory APL patients, and 141 were newly diagnosed APL patients. Within the first 30 days, 24 patients (14.0%) died, and six of those deaths (3.5%) were due to hemorrhage. In total, 12 patients (7.0%) had severe hemorrhagic complications. Both the early death rate due to hemorrhage as well as the severe hemorrhage rate did not exceed those in some recent population-based studies of patients with APL. Forty-nine patients received TM-α prior to the initiation of antileukemic treatment, and one patient experienced hemorrhagic early death (ED), suggesting that early TM-α treatment appeared to result in a reduction in the hemorrhagic ED rate. Moreover, TM-α improved coagulopathy regardless of concomitant all-trans retinoic acid treatment.

Conclusions

This study confirmed the safety and efficacy of TM-α in daily clinical practice for patients with APL and DIC. TM-α appeared to reduce hemorrhagic early deaths due to DIC in patients with APL who were receiving antileukemic treatment.     

Increased ventriculostomy infection rate with use of intraventricular tissue plasminogen activator: A single-center observation

Objective

Intraventricular tissue plasminogen activator (alteplase) has been advocated for prevention of vasospasm in aneurysmal subarachnoid hemorrhage and treatment of traumatic or spontaneous intraventricular hemorrhage. External ventricular drain (EVD) insertion is often performed to manage increased intracranial pressure and hydrocephalus associated with these disease states. EVD-related ventriculitis is a serious infection with an up to 50% mortality rate.

Methods

We assessed the EVD infection rate in patients receiving intraventricular alteplase over a 12-month period. Patients were divided into intraventricular alteplase and non-intraventricular alteplase groups; ventriculitis rates were compared.

Results

EVDs were placed in 93 patients. Six of 7 (86%) patients who received intraventricular alteplase developed ventriculitis versus 4 of 86 (5%) patients in the non-intraventricular alteplase group (p < 0.0001).

Conclusion

Intraventricular alteplase use may increase ventriculitis risk. Currently, we reserve intraventricular alteplase for patients with EVDs obstructed by hematoma accompanied by increased intracranial pressure.     

Evaluation of brain biopsy in the diagnosis of severe neurologic disease of unknown etiology

Objective

To determine the value of non-stereotactic brain biopsies in patients with severe neurologic disease of unknown etiology and indeterminate brain imaging.

Methods

We reviewed 42 consecutive patients who underwent non-stereotactic brain biopsy at a single institution for evaluation of severe neurologic disease of unknown etiology. All patients had indeterminate or normal imaging results. Seventy-nine percent had been symptomatic for less than a year. Exclusion criteria were immunocompromise or a preoperative diagnosis of intracranial neoplasm. Diagnostic yield and surgical complication rate were calculated. We performed exploratory univariate analysis aimed at identifying clinical features possibly predictive of diagnostic biopsies.

Results

A histologic diagnosis was achieved in 12 of 42 biopsies (29%). Three patients experienced minor transient complications from the procedure (7%). There were no permanent deficits or deaths. Treatment was altered based on biopsy result in five patients (12%). A more precise prognosis was obtained in eight patients (19%). In total, 11 different patients (26%) benefited from biopsy. Exploratory univariate analysis showed a possible inverse relationship between age and the likelihood of a diagnostic biopsy (OR = 0.929; 95% CI = 0.864–0.998).

Conclusions

Our data suggest that the value of non-stereotactic brain biopsy is sufficiently high and the morbidity sufficiently low to justify its use in carefully selected patients with severe neurologic disease that remains undiagnosed despite thorough less invasive evaluation.     

Gamma Knife radiosurgery in the management of brainstem metastases

Background

Metastases to the brainstem portend a poor prognosis and present a challenge in clinical management. Surgical resection is rarely a viable option.

Methods

Post-treatment MRI scans of patients with brainstem metastases treated with radiosurgery were used to determine local control and disease progression. Median survival was calculated using Kaplan–Meier analysis. Univariate and multivariate analyses were performed using log-rank test and Cox proportional hazards model, respectively.

Results

Thirty-two consecutive patients with brainstem metastasis underwent Gamma Knife radiosurgery. Median age was 50 years. Median tumor volume was 0.71 cm³ and median tumor margin dose was 13 Gy. Seventeen of 32 patients received WBRT prior to stereotactic radiosurgery. Median survival was 5.2 months. There was a statistically significant difference in survival based on RTOG recursive partition analysis (RPA) class. Median survival of patients categorized as RPA class I was 19.2 months, RPA class II was 8.4 months, and RPA class III was 1.9 months. The overall local tumor control rate was 87.5%. There were no acute complications following stereotactic radiosurgery and no evidence of radiation necrosis noted on post-treatment MRI scans.

Conclusion

Stereotactic radiosurgery is an effective treatment for brainstem metastases and should be considered especially for patients with good performance status.     

Spectroscopy-supported frame-based image-guided stereotactic biopsy of parenchymal brain lesions: Comparative evaluation of diagnostic yield and diagnostic accuracy

Objective

Comparative evaluation of diagnostic efficacy of stereotactic brain biopsy performed with and without additional use of spectroscopic imaging (¹H-MRS) for target selection was done.

Methods

From 2002 to 2006, 30 patients with parenchymal brain lesions underwent ¹H-MRS-supported frame-based stereotactic biopsy, whereas in 39 others MRI-guided technique was used. Comparison of diagnostic yield of the procedure in these two groups was performed. Additionally, the diagnostic accuracy was evaluated in 37 lesions, which were surgically resected within 1 month thereafter.

Results

Stereotactic biopsy permitted establishment of a definitive histopathological diagnosis in 57 cases and diagnosis of low-grade glioma without specific tumor typing in 8 cases. In 4 cases tissue sampling was non-diagnostic. In 5 out of 8 cases with incomplete diagnosis and in all non-diagnostic cases target selection was performed without the use of ¹H-MRS (P = 0.2073). The diagnostic yields of ¹H-MRS-supported and MRI-guided procedures were 100% and 90%, respectively (P = 0.1268). Comparison of the histopathological diagnoses after stereotactic biopsy and surgical resection revealed complete diagnostic agreement in 13 cases, minor disagreement in 14 cases, and major disagreement in 10 cases. Among these last 10 cases, initial undergrading of non-enhancing WHO grade III gliomas was the most common (7 cases). The diagnostic accuracy of ¹H-MRS-supported and MRI-guided procedures was 67% and 79%, respectively (P = 0.4756).

Conclusion

While in the present study the diagnostic yield of ¹H-MRS-supported frame-based stereotactic brain biopsy was 100%, its statistically significant diagnostic advantages over MRI-guided technique were not proved. Optimal selection of the spectroscopic target for tissue sampling remains unclear.     

Local intraarterial tirofiban after formation of anterograde flow in patients with acute ischemic stroke: Preliminary experience and short term follow-up results

Objective

Despite the risk of intracranial hemorrhage, combination therapy with intravenous recombinant tissue plasminogen activator and intraarterial mechanical thrombolysis can be effective for treatment of acute ischemic stroke. We investigated the feasibility and safety of intraarterial tirofiban following formation of anterograde flow after mechanical thrombolysis in acute ischemic stroke.

Methods

We analyzed data from consecutive patients with acute ischemic stroke, who underwent treatment with intraarterial thrombolysis. All patients were evaluated immediately and 7 days later by computed tomography scanning and magnetic resonance imaging scanning with magnetic resonance angiography. For clinical outcome analysis, we followed up the NIHSS score and modified Rankin Scale score during a period of 3 months.

Results

Sixteen patients underwent treatment. The mean baseline NIHSS score was 16.1 ± 4.4 points. 75.1% of patients showed angiographic improvement; 43.8% and 31.3% had complete and partial recanalization, respectively. 53.3% and 56.3% showed clinical improvement and favorable outcome at 24 h and 3 months, respectively. One patient had symptomatic intracranial hemorrhage.

Conclusions

Our results suggest that administration of local intraarterial tirofiban after anterograde flow formation is a viable treatment strategy for patients of acute ischemic stroke for reducing the risk of reocclusion after intraarterial thrombolysis.     

Management and treatment of eating disorders with severe medical complications on a psychiatric ward: a study of 9 inpatients in Japan

Objective

To describe eating disorders inpatients with severe medical complications and elucidate the problems in managing them on a psychiatric ward.

Method

Of the 111 eating disorders patients hospitalized on our psychiatric ward from January 2005 to December 2012, 9 had eating disorders with severe medical complications. Through chart review and computerized data collection, we retrospectively evaluated patient clinical data.

Result

All 9 patients were women, with a mean age of 22.4±5.7 years, mean body weight of 26.2±3.0 kg, and mean body mass index of 10.5±1.5 on admission. Severe medical complications commonly seen were severe hypoglycemia, refeeding syndrome, coagulation abnormality, and severe liver dysfunction. Three patients died during hospitalization. All patients were managed mainly on the psychiatric ward despite their abnormally low body weight and severe medical complications.

Conclusions

Patients with eating disorders, although physically serious, often need to be managed on a psychiatric ward, even at the risk of providing less than ideal care for their physical complications. It is important to assess patient status both physically and psychologically and to select an appropriate therapeutic environment for safe and effective treatment.     

Bleeding complications in patients with coronary stents during non-cardiac surgery

Introduction

Patients with coronary stents often undergo non-cardiac invasive procedures. These are often associated with thrombotic and/or hemorrhagic complications. The type of procedure, perioperative antiplatelet therapy, and other patient-related factors influence the risk of postoperative haemorrhage. Our objective was to analyze the postoperative risk factors for hemorrhagic complications and to determine the impact of antiplatelet and anticoagulant therapy strategies on postoperative bleeding risk in patients with coronary stents undergoing non-cardiac surgery.

Patients and Methods

Prospective, multicentre observational cohort study of 1134 consecutive patients with coronary stents undergoing non-cardiac surgery between April 2007 and April 2009. The primary outcome measure was the occurrence of an hemorrhagic complication during the first 30 days following the surgery or intervention.

Results

Among the 1134 patients evaluated, 108 (9.5%) experienced a postoperative hemorrhagic complication (with a median time to occurrence of 5.3 days). These complications were considered major, involved the operative site, and required reoperation in 92 (85.2%), 92 (85.2%), and 20 (18.5%) of patients, respectively. Mortality in patients with a haemorrhagic complication was 12% (n = 13). Independent postoperative factors associated with haemorrhagic complications were identified as a high and intermediate bleeding risk procedure and the use and dose of anticoagulants. When interrupted before the procedure, resumption of antiplatelet treatment was delayed in patients developing early postoperative hemorrhagic complications.

Conclusion

Patients with coronary stents who undergo surgery are at high risk for hemorrhagic complications.     

Vascular complications of stereotactic radiosurgery for arteriovenous malformations

Objective

Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience.

Methods

Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies.

Results

After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3 cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage.

Conclusion

While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.     

Anticoagulation duration in heterozygous factor V Leiden: A decision analysis

Background

Current anticoagulation guidelines suggest that optimal anticoagulation duration for unprovoked venous thromboembolism is determined by an individual risk assessment, balancing risks of anticoagulation bleeding with venous thromboembolism recurrence. Among individuals heterozygous for the factor V Leiden mutation, while venous thromboembolism recurrence risk is greater, the risk for bleeding is recognized to be lower, suggesting longer duration anticoagulation could be considered.

Objective

The objective of this study was to compare standard vs. lifelong anticoagulation in 20-year-old factor V Leiden heterozygotes with unprovoked venous thromboembolism.

Methods

A Markov state-transition model was used, incorporating risks of major, minor, and fatal anticoagulation bleeding, bleeding and thromboembolism morbidity and mortality, and quality of life utilities. Model parameter values favoring lifelong anticoagulation in factor V Leiden heterozygotes were determined in sensitivity analyses. Outcomes were in quality-adjusted life years, discounted at 3% per year.

Results

In general population groups with odds ratios for venous thromboembolism recurrence and anticoagulation bleeding of 1.0, a short-term anticoagulation strategy gained 0.09 quality-adjusted life years more than a lifelong anticoagulation strategy. By contrast, in factor V Leiden heterozygotes, lifetime anticoagulation was favored if their relative risk of venous thromboembolism was greater than 1.07 or their relative risk for bleeding was less than 0.91. Results were relatively insensitive to individual variation in other parameter values.

Conclusion

Lifelong anticoagulation may benefit individuals heterozygous for factor V Leiden and previous idiopathic venous thromboembolism. Studies assessing bleeding risk with anticoagulation in factor V Leiden heterozygotes and the costs of indefinite anticoagulation are needed to determine if lifelong anticoagulation is the optimal strategy.     

Hemorrhage rates of external ventricular drain (EVD), intracranial pressure gauge (ICP) or combined EVD and ICP gauge placement within 48 h of endovascular coil embolization of cerebral aneurysms

Object

In single patients with a cerebral aneurysm an external ventricular drain (EVD), an intracranial pressure (ICP) gauge or a combined EVD and ICP gauge placement is necessary after coil embolization and initiation of postprocedural anticoagulation. The aim of this study was to examine the hemorrhage rates of drain placement within 48 h after aneurysm coiling and under anticoagulation or antiplatelet therapy.

Methods

We retrospectively analyzed hemorrhage rates of EVD, ICP gauge or combined EVD and ICP gauge placement in 27 patients within 48 h after coil embolization under different anticoagulation or antiplatelet schemes (heparin, acetylsalicylic acid, clopidogrel). In patients with continuous heparin via perfusor the application was stopped periprocedurally. The results were compared to literature.

Results

Four hemorrhages (14.8%) were observed. Three hemorrhages were petechial and one was by definition a larger hemorrhage with 8 mm × 10 mm in diameter.

Conclusions

EVD, ICP gauge or combined EVD and ICP gauge placements within 48 h after cerebral aneurysm coiling and under different anticoagulation or antiplatelet regimens seem to have no increased risk of hemorrhages compared to literature.     

Association between obstructive sleep apnea and deep vein thrombosis / pulmonary embolism: A population-based retrospective cohort study

Background

Obstructive sleep apnea (OSA) is a major contributor to cardiovascular disease, and may cause severe morbidity and mortality. Recent studies have indicated that OSA patients exhibited elevated platelet activity, fibrinogen levels, and platelet aggregation.

Objectives

We investigated the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients diagnosed with OSA compared with age- and sex-matched unaffected people.

Patients/Methods

This longitudinal, nationwide, population-based cohort study was conducted using data from Taiwan National Health Insurance Research Database (NHIRD) recorded between January 2000 and December 2011. The study consisted of 3511 patients with OSA and 35110 matched comparison individuals. A Cox proportional hazard regression was used to compute the risk of DVT and PE in patients with OSA compared with those without OSA.

Results

The DVT and PE risks were 3.50- and 3.97-fold higher (95% CI = 1.83–6.69 and 1.85–8.51) respectively, in the OSA cohort than in the reference cohort after we adjusted for age, sex, and comorbidities.

Conclusion

This nationwide population-based cohort study indicates that patients with OSA exhibit a higher risk of subsequent DVT and PE.