Factors predicting the development of new onset post-operative Hydrocephalus following trans-sphenoidal surgery for pituitary adenoma

Background

The aim of this retrospective study was to identify the factors which can predict the development of new onset post-operative Hydrocephalus following transsphenoidal surgery for pituitary adenomas.

Methods

A total of 224 patients with the diagnosis of pituitary adenoma and without preoperative Hydrocephalus were identified from 1995 to 2012. Age, gender, tumor volumes, prior craniotomy and irradiation, outcome, hospital stay, CSF leak, infection and functional status of the tumor were included in the model for analysis.

Results

A total of 13 patients (5.8%) developed new onset post-operative Hydrocephalus. Intraoperative and post-operative CSF leaks were noted in 19 (8.5%) and 17 (7.6%) patients respectively. CSF infection was seen in only 7 (3.1%) patients. Age of the patient (p = 0.010), length of hospital stay (p = 0.012), intraoperative CSF leak (p = 0.000), post-operative CSF leak (p = 0.000) and CSF infection (p = 0.000) had shown significant correlation with the de novo onset of postoperative HC. The independent predictors of post-operative HC were post-operative CSF leak [p = 0.002, OR 27.898, 95% CI 3.350–232.311] and intra-operative CSF leak [p = 0.050, OR 7.687, 95% CI 1.003–58.924].

Conclusion

Age of the patient, intra-operative and post-operative CSF leak, CSF infection and duration of hospital stay were correlated with the development of HC. Post-operative and intra-operative CSF leaks were the independent predictors of new onset HC.     

No cerebrocervical venous congestion in patients with multiple sclerosis

Objective:

Multiple sclerosis (MS) is characterized by demyelination centered around cerebral veins. Recent studies suggested this topographic pattern may be caused by venous congestion, a condition termed chronic cerebrospinal venous insufficiency (CCSVI). Published sonographic criteria of CCSVI include reflux in the deep cerebral veins and/or the internal jugular and vertebral veins (IJVs and VVs), stenosis of the IJVs, missing flow in IJVs and VVs, and inverse postural response of the cerebral venous drainage.

Methods:

We performed an extended extra‐ and transcranial color‐coded sonography study including analysis of extracranial venous blood volume flow (BVF), cross‐sectional areas, IJV flow analysis during Valsalva maneuver (VM), and CCSVI criteria. Fifty‐six MS patients and 20 controls were studied.

Results:

Except for 1 patient, blood flow direction in the IJVs and VVs was normal in all subjects. In none of the subjects was IJV stenosis detected. IJV and VV BVF in both groups was equal in the supine body position. The decrease of total jugular BVF on turning into the upright position was less pronounced in patients (173 ± 235 vs 362 ± 150ml/min, p < 0.001), leading to higher BVF in the latter position (318ml/min ± 242 vs 123 ± 109ml/min; p < 0.001). No differences between groups were seen in intracranial veins and during VM. None of the subjects investigated in this study fulfilled >1 criterion for CCSVI.

Interpretation:

Our results challenge the hypothesis that cerebral venous congestion plays a significant role in the pathogenesis of MS. Future studies should elucidate the difference between patients and healthy subjects in BVF regulation. ANN NEUROL 2010;68:173–183

     

Patterns of retinal nerve fiber layer loss in multiple sclerosis patients with or without optic neuritis and glaucoma patients

Objective

Optical coherence tomography (OCT) has gained increasing attention in multiple sclerosis (MS) research and has been suggested as outcome measure for neuroprotective therapies. However, to date it is not clear whether patterns of retinal nerve fiber layer thickness (RNFLT) loss are different in MS compared to other diseases such as glaucoma and data on RNFLT loss in MS patients with or without optic neuritis (ON/NON) have remained inconsistent or even contradictory.

Methods

In this large cross-sectional study we analyzed the patterns of axonal loss of retinal ganglion cells in MS eyes (n = 262) with and without history of ON (MS/ON: 73 eyes; MS/NON: 189 eyes) and patients eyes with glaucomatous optic disc atrophy (GA: n = 22; 39 eyes) in comparison to healthy control eyes (HC: n = 406 eyes).

Results

We found that significant average and quadrant RNFLT loss is detectable by OCT in both MS and GA patients compared to healthy controls (p < 0.01). The age- and gender adjusted average and quadrant RNFLT did not differ significantly between MS and GA patients (p > 0.05). Average (p < 0.0001) and quadrant (p < 0.05) RNFL thinning is significantly more severe in MS/ON versus MS/NON eyes, and the extent of RNFL thinning varies across quadrants in MS/ON eyes with the highest degree of RNFLT loss in the temporal quadrant (p < 0.001).

Conclusion

RNFLT reduction across all four quadrants in MS patients as a whole as well as in MS/NON eyes argues for a diffuse neurodegenerative process. Superimposed inflammatory attacks to the optic nerve may cause additional axonal damage with a temporal preponderance. Future studies are necessary to further evaluate the capacity of OCT to depict disease specific damage patterns.     

Treatment of sleep disorders may improve fatigue in multiple sclerosis

Objective

In a previous polysomnographic cross-sectional study we found a significant relationship between sleep disorders and multiple sclerosis (MS) related fatigue. The purpose of this open follow-up observation was to compare the impact of treatment of sleep disorders on MS related fatigue measured with the Modified Fatigue Impact Scale (MFIS).

Methods

Non-randomized follow-up observation: treated versus untreated patients, subgroups according to compliance with sleep medical treatment recommendations (univariate, multivariate analysis, multiple logistic regression). 66 MS patients were followed after polysomnography, 49 patients with relevant sleep disorders and 17 without.

Results

Mean MFIS scores decreased from 41.2 to 26.2 (p = 0.025) in patients with good compliance (GC; n = 18), from 42.4 to 32.1 (p = 0.12) in patients with moderate compliance (MC; n = 12), and from 41.6 to 35.5 (p = 0.17) in non-compliant patients (NC; n = 17). Mean MFIS values increased in patients without sleep disorders from 22.9 to 25.4 (NSD; n = 12, p = 0.56). In multiple logistic regression, treatment of sleep disorders predicted decrease of MFIS-values (GC versus NSD odds ratio 13.4; p = 0.015; 95% confidence interval (CI) 1.7–107.2, MC versus NSD odds ratio 13.8; p = 0.028; 95% CI 1.3–143.3).

Conclusions

Sleep medical treatment may improve MS related fatigue when patients adhere to treatment recommendations.     

Who are at risk for thromboembolism after arthroplasty? A systematic review and meta-analysis

Background

Thromboembolism, including deep venous thrombosis and pulmonary embolism, is a grave threat to patients undergoing total joint replacement. Using a systematic review and meta-analysis we asked whether gene mutations or polymorphisms could be risk factors for thrombosis after arthroplasty.

Methods

We performed a comprehensive search of Medline, PubMed, Embase, Cochrane databases, China National Knowledge Infrastructure (CNKI), and Google Scholar, and identified 19 studies detailing genetic investigations of patients with thromboembolism following joint replacement.

Results

Our meta-analyses included 5149 patients who underwent arthroplasty surgery. Significant associations with venous thromboembolism were identified for factor G1691A (odds ratio (OR) 1.41, 95% confidence interval (CI) 1.03 - 1.94, p = 0.03), prothrombin G20210A (OR 2.16, 95% CI, 1.27- 3.69, p = 0.005), and MTHFR/C677T/TT (OR 2.36, 95% CI 1.03 - 5.42, p = 0.04) in Caucasian populations. No significant gene mutation was identified in Asian populations.

Conclusion

This study suggests a way to identify patients scheduled for arthroplasty who are at higher risk of thrombosis, enabling individualized treatment.     

Association of methylenetetrahydrofolate reductase A1298C polymorphism but not of C677T with multiple sclerosis in Tunisian patients

Background and objective

Multiple sclerosis (MS) is a chronic neurological disease characterized by central nervous system (CNS) inflammation and demyelination of nerve axons. The aim of this study was to investigate a possible association between the methylenetetrahydrofolate reductase (MTHFR) gene and multiple sclerosis in Tunisian patients.

Patients and methods

The genotyping of two missense variants of the methylenetetrahydrofolate reductase (MTHFR) gene, C677T and A1298C was performed in 80 multiple sclerosis patients and 200 healthy controls.

Results

No significant differences were found in the frequency of the MTHFR C677T polymorphism between MS patients and healthy controls. However, the genotype prevalence of the missense variant MTHFR A1298C was significantly different between patients and controls (A/C: 55% versus 7%, p < 10⁻³; C/C: 13.75% versus 0%, p < 10⁻³, respectively).

Conclusion

Although our preliminary findings suggest no association between the MTHFR C677T variants and MS, there is evidence to suggest a significant association between the MTHFR A1298C polymorphisms and MS.     

Exercise training improves depressive symptoms in people with multiple sclerosis: Results of a meta-analysis

Objective

There is a high prevalence, yet under-treatment of depressive disorder and symptoms by conventional therapy in people with multiple sclerosis (MS). We conducted a meta-analysis examining the overall effect of exercise training on depressive symptoms in MS.

Methods

We searched PubMed for randomized controlled trials (RCT) of exercise training and depression as an outcome in samples with MS. There were 13 RCTs that met inclusion criteria and yielded data for effect size (ES) generation (Cohen's d). An overall ES was calculated using a random effects model and expressed as Hedge's g.

Results

The weighted mean ES was small, but statistically significant (Hedge's g = 0.36, SE = 0.09, 95% CI = 0.18–0.54, z = 3.92, p < .001) indicating the exercise training resulted in an improvement in depressive symptoms compared to control. The overall effect was not heterogeneous (Q = 16.46, df = 12, p = 0.17, I² = 27.08); and post-hoc, exploratory analyses only identified depression symptom scale as a potential moderator variable (p = 0.04).

Conclusion

The cumulative evidence indicates that exercise training can yield a small, yet statistically significant and reliable reduction in depressive symptoms for people with MS.     

HLA class II alleles and multiple sclerosis in Tunisian patients

Objective

The aim of our study was to investigate the association of HLA-DRB1 and -DQB1 alleles with multiple sclerosis (MS) in a Tunisian population and their effect on age at onset and disease severity.

Methods

58 MS patients and 105 healthy controls were genotyped for HLA class II alleles by PCR-SSP technique.

Results

An association of MS with HLA-DRB1*15 was found (14.7% vs 3.8%, OR (95% CI) = 4.34 (1.69–11.39), p_c = 2.5 × 10⁻³) after Bonferroni's correction. Moreover, the DRB1*15–DQB1*06 (13.8% vs 2.8%, OR (95% CI) = 5.44 (1.92–17.41), p_c = 1.1 × 10⁻³) and DRB1*04–DQB1*04 (8.6% vs 1.9%, OR (95% CI) = 4.86 (1.36–21.62), p_c = 0.028) haplotypes were found to confer a susceptibility to multiple sclerosis.

Conclusion

To our knowledge, this is the first study performed to analyze the association of HLA-DRB1/DQB1 alleles on MS susceptibility in Tunisia. The modern Tunisian gene pool shows some degree of heterogeneity and reflects a significant gene flow from Mediterranean regions.     

Influence of coronary artery disease-associated genetic variants on risk of venous thromboembolism

Introduction

We investigated whether genetic variations robustly associated with coronary artery disease are also associated with risk of venous thromboembolism in a well-defined, female case–control study (n = 2753) from Sweden.

Materials and Methods

39 single nucleotide polymorphisms in 32 loci associated with coronary artery disease in genome-wide association studies were identified in a literature search and genotyped in the ThromboEmbolism Hormone Study (TEHS). Association with venous thromboembolism was assessed by logistic regression.

Results

Only rs579459 in the ABO locus demonstrated a significant association with VTE. A tentative association between ANRIL and VTE in the discovery analysis failed to replicate in a meta-analysis of 4 independent cohorts (total n = 7181).

Conclusions

It appears that only the ABO locus is a shared risk factor for coronary artery disease and VTE.     

Influence of sports climbing and yoga on spasticity,cognitive function,mood and fatigue in patients with multiple sclerosis

Objectives

Spasticity, cognitive impairment, depression and fatigue significantly reduce the quality of life in multiple sclerosis (MS) patients. To find out whether nonpharmalogical treatment approaches can reduce these symptoms we investigated effects of sports climbing (SC) and yoga on spasticity, cognitive impairment, mood change and fatigue in MS patients. Sports climbing (SC) and yoga are aerobic physical activities comprised a series of stretching techniques, implementation of which demands body control and planning of complex movements.

Materials and methods

20 subjects with relapsing–remitting or progressive MS, 26–50 years of age, with EDSS ≤ 6 and EDSS pyramidal functions score (EDSSpyr) > 2 were enrolled in a randomized prospective study. The participants were randomly divided into SC and yoga group. We evaluated spasticity, cognitive function, mood and fatigue before and after both programs, that lasted 10 weeks, with standardized assessment methods.

Results

There were no significant improvements in spasticity after SC and yoga. In the SC group we found a 25% reduction (p = 0.046) in EDSSpyr. There were no differences in executive function after the completion of both programs. There was a 17% increase in selective attention performance after yoga (p = 0.005). SC reduced fatigue for 32.5% (p = 0.015), while yoga had no effect. We found no significant impact of SC and yoga on mood.

Conclusions

Yoga and SC might improve some of the MS symptoms and should be considered in the future as possible complementary treatments.     

Prevalence and risk factors for suicidal ideation in a multiple sclerosis population

Objective

To estimate the prevalence, incidence and determinants of suicidal ideation in the multiple sclerosis (MS) population.

Methods

A sample of 188 subjects were randomly selected from a community-based MS clinic registry and participated in as many as 13 interviews over 6 months. Thoughts of “being better off dead” or of “harming oneself” were assessed using item 9 on the Patient Health Questionnaire, Brief (PHQ-9).

Results

At baseline, the 2-week period prevalence of suicidal ideation was 8.3%. Over the course of 6 months, 22.1% of respondents reported having such thoughts at least once. Survival analysis incorporating baseline PHQ-8 scores as a covariate confirmed that being age 65 and over (HR = 4.3, 95% CI 1.7–11.3) and having lower quartile self-efficacy ratings (HR = 3.5, 95% CI 1.5–8.2) predicted suicidal ideation. Lower levels of task-oriented coping (treated as a continuous variable) also predicted suicidal ideation after adjustment for depressive symptoms (p = 0.015), as did self-reported bladder or bowel symptoms (HR = 2.6, 95% CI 1.1–6.0) and difficulties with speaking and swallowing (HR = 2.9, 95% CI 1.3–6.8). Associations with MS symptoms were not confounded by depressive symptoms.

Conclusion

This study identified several potentially modifiable factors that may be useful for preventing suicide in people with MS.     

Motor and cognitive slowing in multiple sclerosis: An attentional deficit?

Background

Action slowing is frequently observed in multiple sclerosis (MS) patients. Several factors may account for response slowing: motor, perceptual, cognitive deficits, global mental slowing. Our objective was to examine mechanisms accounting for action slowing in MS patients.

Methods

Twenty MS patients, free of visual impairment and of upper limbs sensory–motor deficit underwent previously validated reaction time (RT) tests using visual stimuli. Three tasks were used: (1) motor tapping, (2) simple reaction time (SRT) in a simple and dual task condition, and (3) choice RT (CRT) with varying response probabilities. Results were compared to those of 20 healthy matched subjects.

Results

MS patients had: (1) lower motor tapping frequency (p = 0.02); (2) SRT lengthening (p = 0.001) related to a lower proportion of fast responses (p = 0.001) indicating attentional deficit whereas perceptuomotor index was spared (p = 0.5), without higher sensitivity to dual task (p = 0.9); and (3) CRT lengthening (p = 0.001) with spared decision time (p = 0.7).

Conclusions

This study showed that action slowing of MS patient is mainly related to (1) attentional deficit resulting in inability to maintain high level of rapid actions, and (2) subtle motor slowing even in patients without motor deficit on clinical examination, whereas (3) divided attention and decisional process are preserved.     

Homocysteine,vitamin B12 and folate levels in Iranian patients with Multiple Sclerosis: A case control study

Background

Recently, homocysteine (Hcy), folate, and vitamin B12 have been proposed to have several roles on MS pathogenesis.

Objective

We performed this study to determine the role of serum levels of Hcy, vitamin B12, and folate in patients with relapsing remitting MS (RRMS) and compared them with healthy controls.

Methods

We recruited 75 RRMS patients and 75 subjects as controls with the same age and sex. Homocysteine was measured using fluorimetric high-performance liquid chromatography. Plasma folate and vitamin B12 levels were measured through ion-capture method.

Results

Mean plasma levels of vitamin B12, folate, and Hcy in cases were 342.64 ± 210.66 pg/ml, 9.74 ± 4.77 ng/ml, and 22.73 ± 11.63 μM/L, respectively, which showed significant difference in comparison with the controls. In addition, there were significant correlations between mean serum Hcy levels and duration of disease (r = 0.2, p = 0.05) and treatment with interferon (r = 0.21, p = 0.01). In cases, Hcy level was higher among those on β interferon (24.56 ± 11.87 vs. 19.71 ± 10.75, p = 0.01).

Conclusions

We concluded that serum levels of vitamin B12 and folate decreased in RRMS patients, but Hcy levels increased significantly. It seems necessary to conduct prospective trials to determine whether the treatment with supplements and correct biomarker levels in the early stage of the disease can change the course of the disease. We recommend regular checking of the serum level of Hcy in patients who use disease-modifying drugs.     

Population-based epidemiology of postoperative venous thromboembolism in Taiwanese patients receiving hip or knee arthroplasty without pharmacological thromboprophylaxis

Introduction

Population-based evaluation on the incidence of postoperative venous thromboembolism (VTE) has not yet been reported for Asians receiving arthroplasty. In Taiwan, thromboprophylaxis was not commonly applied for patients. The population-based cohort study aimed to investigate the epidemiology, and to determine the risk factors VTE for patients receiving hip or knee replacement without pharmacological thromboprophylaxis in Taiwan.

Materials and Methods

We retrospectively acquired patients’ data from National Health Insurance databases representing more than 99% of about 23 million Taiwanese citizens. The primary outcome was the incidence of composite symptomatic VTE within 28 days after receiving hip or knee replacement surgery.

Results

During 2002 to 2006, there were 114,026 patients undergoing hip (n = 61,460) or knee (n = 52,566) replacement surgery. The occurrence rate of overall postoperative VTE was 0.44%. The incidence of pulmonary embolism was four in 10,000 patients receiving hip replacement or seven in 10,000 individuals undergoing knee replacement. The weekly cumulative incidence of VTE was persistently rising up to 28 days after surgery. Dramatic increase in risk of post-surgical VTE was associated with prior disease history of PE (p < 0.001 for hip replacement, p = 0.01 for knee replacement) or DVT (p = 0.004 for hip replacement, p < 0.001 for knee replacement). Prior claim of congestive heart failure was an independent risk factor associated with patients receiving knee arthroplasty (p = 0.01).

Conclusion

Life-threatening PE occurred and increased cumulatively up to 28 days after hip or knee arthroplasty in Asians. Proper prophylaxis for patients with the exposure of high risks needs to be scrutinized.     

Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer

Backgrounds

Enoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery.

Study design

A retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n = 228) and an enoxaparin (+) group (n = 53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared.

Results

In the enoxaparin (+) group, the patients’ age (65 vs. 69 years; p = 0.01) and BMI (22.9 vs. 24.4; p < 0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p = 0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p = 0.04). The independent risk factors for PVT were an operation time ≥ 300 minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49).

Conclusions

Postoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.     

Prehospital transfer medicalization increases thrombolysis rate in acute ischemic stroke. A French stroke unit experience

Objectives

Narrow therapeutic window is a major cause of thrombolysis exclusion in acute ischemic stroke. Whether prehospital medicalization increases t-PA treatment rate is investigated in the present study.

Patients and methods

Intrahospital processing times and t-PA treatment were analyzed in stroke patients calling within 6 h and admitted in our stoke unit. Patients transferred by our mobile medical team (SAMU) and by Fire Department (FD) paramedics were compared.

Results

193 (61.6%) SAMU patients and 120 (38.4%) FD patients were included within 30 months. Clinical characteristics and onset-to-call intervals were similar in the two groups. Mean door-to-imaging delay was deeply reduced in the SAMU group (52 vs. 159 min, p < 0.0001) and was <25 min in 50% of SAMU patients and 14% of FD patients (p < 0.0001). SAMU management was the only independent factor of early imaging (p = 0.0006). t-PA administration rate was higher in SAMU group than in FD group (42% vs. 28%, p = 0.04). Proportion of patients with delayed therapeutic window was higher in FD group than in SAMU group (38% vs. 26%, p < 0.0001).

Conclusion

Prehospital transfer medicalization promotes emergency room bypass, direct radiology room admission and high thrombolysis rate in acute ischemic stroke.     

Month of birth and risk of multiple sclerosis in a Portuguese population

Background

Several studies analyzing the month of birth (MOB) of multiple sclerosis (MS) patients and the risk of the disease have been published; as a whole, MS patients were found to be predominantly born in spring months, leading to the current assumption that MOB is somewhat related to the risk of MS.

Objective

Estimate the risk of MS by MOB in a Portuguese population.

Methods

MS patients sample was obtained from the database of patients attended at our MS clinic and born in the districts of Porto, Braga and Viana do Castelo. The control sample was composed of the live births records in the same time period and geographical area. We applied the Hewitt test for seasonality.

Results

We found 421 patients that satisfied the conditions to enter the study. The rank-sums for successive 6-month segments indicate the July–December period as of higher incidence; however, the corresponding rank-sum (48) was not statistically significant according to the Hewitt test (p > 0.05).

Conclusion

Our data does not support the seasonality hypothesis of MOB as risk factor for MS in Portugal. However we are aware that the analysis of a larger MS sample could shed more light in this issue.     

CT perfusion-guided versus time-guided mechanical recanalization in acute ischemic stroke patients

Objective

Perfusion studies are increasingly used to triage acute stroke patients for endovascular recanalization therapies. We compare the safety and efficacy of CT perfusion (CTP)-guided to time-guided mechanical recanalization in acute ischemic stroke (AIS) patients.

Methods

A review was conducted on 132 patients, 94 undergoing CTP-guided and 38 undergoing time-guided (maximum 8 h from symptom onset) mechanical recanalization at our institution.

Results

The rate of partial-to-complete recanalization did not differ between the CTP and the non-CTP group (78.7% vs. 81.6%, respectively, p = 0.71). ICH occurred respectively in 18.1% in the CTP group versus 31.6% in the non-CTP group (p = 0.06). The overall in-hospital mortality rate was significantly lower in the CTP group (15.9% vs. 36.8%, p = 0.04). In multivariable analysis, CTP-guided patient selection was an independent negative predictor of in-hospital mortality (OR = 3.2; p = 0.01). CTP-guided patient selection, however, was not a predictor of favorable outcome (Modified Rankin Scale 0–2 or 0–3).

Conclusions

CTP-based patient selection was associated with lower ICH and mortality rates. Favorable outcomes, however, did not differ between the 2 groups. These results may suggest a possible benefit in terms of in-hospital mortality with CTP-guided triage of AIS patients for endovascular treatment.     

Intravenous rt-PA in patients with ischaemic stroke and renal dysfunction

Objective

Renal dysfunction (RD) increases risk for ischaemic stroke (IS). The impact of RD on the effects of iv-thrombolysis in the Caucasian population has not been fully determined.

Aims

To evaluate the associations between RD and the outcome of iv-thrombolysis in Caucasian patients with IS.

Methods

The observational, multicentre study included 404 patients with IS who were treated with iv-thrombolysis. RD was defined as estimated glomerular filtration rate ≤60 ml/min/1.73 m². Outcome was assessed with modified Rankin Score at 3 months after the stroke onset.

Results

Medians baseline NIHSS score did not differ between groups of patients with and without RD (12.0 vs. 11.0 pts, p = 0.33). Unfavourable outcome was found in 52.1% of patients with and in 41.2% of patients without RD (p = 0.05), mortality was higher in patients with RD (29.9% vs. 14.3%, p < 0.001), and the presence of haemorrhagic transformation (HT) did not differ between the groups (17.1% vs. 17.1% respectively, p = 0.996). A multivariate analysis showed no impact of RD on the unfavourable outcome (OR 0.98; 95%CI 0.88–1.10), mortality (OR 0.92; 95%CI 0.81–1.05) or presence of HT (OR 1.03; 95%CI 0.90–1.18).

Conclusions

We found no impact of RD on the safety and efficacy of iv-thrombolysis in Caucasian patients with IS.     

What is the best treatment of drug-resistant trigeminal neuralgia in patients affected by multiple sclerosis? A literature analysis of surgical procedures

Objective

Drug-resistant trigeminal neuralgia (TN) can complicate the clinical course of patients affected by multiple sclerosis (MS). Various surgical procedures have been reported for the treatment of this condition, but there is no agreement on the best management of these patients. To our knowledge, there is no critical literature analysis focusing on this particular topic. The aim of this study was to evaluate the clinical outcome of different surgical procedures utilized for drug-resistant TN in MS patients.

Methods

We reviewed the literature about the studies reporting on surgical treatment of drug-resistant TN in MS patients. Case reports and case series less than 4 patients were excluded from the analysis. Nineteen studies were selected for the statistical analysis. To reduce the variability of the data, the selected studies were evaluated for the following outcome parameters: acute pain relief rate (APR), rate of recurrence (RR), pain free at follow-up rate (PF at FU) and complication rate (CR). For the statistical analysis, chi-square statistic, using the Fisher's exact test was utilized.

Results

There was no procedure statistically superior in terms of APR rate in MS patients following the surgical treatment of TN. The highest RR was observed for percutaneous balloon compression (PBC) (60.2 ± 14.4%). This result was statistically significant when compared to gamma knife surgery (GKS) (p = 0.0129) and microvascular decompression (MVD) (p = 0.0281). MVD together with percutaneous radiofrequency rhizothomy (PRR) was associated with a statistically better PF at FU rate (56.5 ± 16.8% and 73.5 ± 14.2%, respectively). However PBC and MVD showed statistical significant minor CR compared to other techniques (no complications and 18.7 ± 17.4%, respectively).

Conclusion

Our study shows no differences in the short term results among different procedures for TN in MS patients. Each technique demonstrate advantages and limits in terms of long term pain, recurrence rate and complication rate. Each patient should be accurately informed on pros and cons of each procedure in order to be involved in the most appropriate choice.