Long-term seizure outcome and risk factors for recurrence after extratemporal epilepsy surgery

Purpose: We aimed to assess long‐term seizure outcome and risk factors for seizure recurrence in a cohort of patients who have undergone extratemporal resection for management of refractory seizures. Methods: Eighty‐one patients underwent extratemporal resection at Austin Health, Melbourne, Australia (1991–2004). Seizure recurrence was any postoperative disabling seizure (complex partial seizure [CPS] ± secondary generalization). Multivariate Cox proportional hazards regression models examined potential preoperative and perioperative risk factors and the risk associated with early postoperative seizures (≤28 days postsurgery). The change between preoperative and postoperative seizure frequency was also measured. Key Findings: Median follow‐up was 10.3 years (range 1–17.7). The probabilities of freedom from disabling seizures (on or off antiepileptic medication) were 40.7% (95% confidence interval [CI] 30–51) at 1 month, 23.5% (95% CI 15–33) at 1 year, and 14.7% (95% CI 8–23) at 5 years postoperative. Reduction of disabling seizures to at least 20% of preoperative frequency was attained by 57% of patients at 5 postoperative years. Of the preoperative/perioperative factors, focal cortical dysplasia (FCD) type 1 (hazard ratio [HR] 1.90, 95% CI 1.08–3.34, p = 0.025) and incomplete resection (HR 1.71, 95% CI 1.06–2.76, p = 0.028) were independent recurrence risks. After surgery, an early postoperative seizure was the only factor associated with higher risk (HR 4.28 [2.42–7.57], p = 0.00). Significance: Distinction between subtypes of focal cortical dysplasia, which can be made using magnetic resonance imaging (MRI) criteria, may be useful for preoperative prognostication. Early seizures after surgery are not benign and may be markers of factors that contribute to seizure recurrence. Most patients achieve substantial reduction in seizure frequency. Further study of the significance of this reduction in terms of surgical “success” or otherwise is required.     

微创穿刺术治疗脑出血后颅内血肿临床分析

目的分析微创穿刺术治疗脑出血颅内血肿的临床疗效。方法脑出血患者128例随机分为对照组和观察组各64例,对照组实施内科保守治疗,观察组采用颅内血肿微创穿刺清除术。观察比较2组疗效、并发症发生率。结果术后2周观察组总有效率81.3%,大于对照组的46.9%,差异有统计学意义(P0.05);2组消化道出血、肺部感染、尿路感染、脑疝形成并发症发生率差异无统计学意义(P0.05),观察组再出血、肾衰竭、电解质紊乱发生率低于对照组,差异有统计学意义(P0.05)。结论微创穿刺术对比传统内科保守治疗疗效较好,可有效降低患者病死率、减少并发症的发生,且操作简单值得推广。     

颅内动脉瘤介入术后预后不良的危险因素分析

目的分析颅内动脉瘤介入术后预后不良的危险因素。方法回顾性分析2017年1月—2019年1月于我院接受介入栓塞术的304例颅内动脉瘤患者临床资料,整理其性别、年龄、既往病史、动脉瘤情况(大小、形态、位置、数量)、术前Hunt-Hess分级、Fisher分级、手术时机、手术并发症等资料,随访至术后6个月,采用格拉斯哥预后量表(GOS)分为预后不良组与预后良好组,采用Logistic回归分析颅内动脉瘤介入术后预后不良的影响因素。结果术后6个月,预后良好224例(73.7%),预后不良80例(26.3%)。单因素分析显示,预后不良组在手术时机、术前Hunt-Hess分级、Fisher分级、AR值、并发症发生率方面与预后良好组差异有统计学意义(P0.05),性别、年龄、合并高血压、糖尿病、动脉瘤数量、位置和直径方面与预后良好组差异无统计学意义(P0.05);多因素Logistic回归分析显示,手术时机(■=1.301)、术前Hunt-Hess分级(■=1.328)、Fisher分级(■=1.868)、AR值(■=1.910)、合并并发症(■=2.083)是介入术预后的危险因素(P0.05)。结论手术时机、术前Hunt-Hess分级、Fisher分级、AR值、合并并发症是介入术预后的危险因素,针对有手术指征的动脉瘤患者尽早进行手术、积极防治并发症是改善预后、提高生活质量的有效措施。     

Incidence, risk factors, and outcome of venous infarction after meningioma surgery in 705 patients

Central to safe and effective surgical resection of meningiomas is consideration of the venous anatomy both near and intrinsic to the tumor. The exact incidence of venous infarction following meningioma surgery has not been established. To determine this incidence, we present a large multivariate analysis of 705 patients undergoing craniotomy for resection of a histologically proven meningioma at our institution between 1991 and 2007. Clinical information was retrospectively reconstructed using patient medical records and radiologic data. Venous infarctions were identified by postoperative CT scans or MRI that demonstrated the typical imaging findings. Stepwise multivariate logistic regression analysis was performed to test the association with approach used and the rate of venous infarction, controlling for multiple independent variables. The overall rate of venous infarction (n = 705) was 2.0% of all patients (95% confidence interval [CI], 0.9-3.0%). Interestingly, on multivariate logistic regression analysis, we found the use of a bifrontal craniotomy was the sole independent predictor of venous infarction in this regression model (odds ratio, 3.18; 95% CI, 1.03-9.77; p < 0.05). We found that the rate of venous infarction was significantly reduced in the extended bifrontal group compared to the group not receiving biorbital osteotomies (0% versus 8.9%, ??²p < 0.05). We demonstrated that the most important factor determining the risk of venous infarction is the approach used to access the tumor.     

急性外伤性颅内血肿开颅血肿清除术后迟发血肿相关因素分析

目的 分析颅内血肿开颅血肿清除术患者的临床特征及术后出现迟发血肿的危险因素.方法 以我院2009-03-2013-03收治的68例急性外伤性颅内血肿开颅手术治疗患者为研究对象,根据是否发生迟发血肿进行分组,采用Logistic回归模型分析术后迟发血肿危险因素.结果 多因素Logistic回归分析结果显示血浆凝血酶时间、手术时机、颅骨骨折为发生迟发血肿的危险因素.结论 急性外伤性颅内血肿患者多伴有重型颅脑损伤和颅内占位,术后迟发血肿一般发生于术后12 h内,以脑内血肿、硬膜外血肿、硬膜下血肿为常见,血浆凝血酶时间延长、手术时机短、合并颅骨骨折为高危因素,应引起高度关注.     

Recurrent intracranial and spinal meningiomas: clinical and histological features

The clinical records and histopathological features of 424 patients treated surgically for meningioma over a 20-year period were reviewed. Forty-nine patients (11.5%) required a second operation and in 8 other cases (1.8%) there was clinical evidence of recurrence but further surgery was contra-indicated. The two independent factors associated with recurrence were incomplete surgical resection at the first operation and angioblastic histology. In contrast, recurrences were uncommon in the very elderly, in spinal lesions and fibroblastic tumors. Transitional and meningocytic meningiomas were equally represented in each group, and there was no individual intracranial site where meningiomas were especially likely to recur.     

颅骨成形术后颅内出血的相关危险因素分析

目的分析颅骨成形术后颅内出血的相关危险因素。 方法回顾性分析解放军总医院第三医学中心神经创伤外科自2010年11月至2018年11月收治的278例行颅骨成形术患者的临床资料，按照术后颅内是否出血将患者分为出血组和未出血组。采用单因素分析和多因素Logistic回归分析确定颅骨成形术后颅内出血的独立影响因素。 结果278例患者颅骨成形术后颅内出血12例，颅内出血发生率为4.3%。单因素分析显示：缺损面积及颅骨缺损时间与颅内出血发生相关，差异有统计学意义（P<0.05），Logistic多因素回归分析显示：颅内缺损面积（≥100 cm²）是颅骨成形术后颅内出血的独立危险因素（P<0.05）。 结论颅骨缺损面积是影响颅骨成形术后颅内出血的临床危险因素，评估上述指标对颅骨成形术后颅内出血有重要的临床意义。     

Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome.

OBJECTIVES: To clarify whether different causative events (trauma, stroke, intracranial surgery), time of intervention, and treatment mode influence outcome, patients with fixed and dilated pupils (FDPs) in a prospective neurosurgical series were evaluated. METHODS: Ninety nine consecutive patients who presented with or developed one or two FDPs, were split into three groups according to the respective aetiology: 46 patients had a trauma, 41 patients a stroke (subarachnoid or intracerebral haemorrhage), and 12 patients had undergone previous elective intracranial surgery. Appropriate therapy was performed depending on the CT findings. Outcome was classified according to the Glasgow outcome scale (GOS). RESULTS: Overall mortality was 75%. In 15% outcome was unfavourable (GOS 2 and 3), and in 10% favourable (GOS 4, 5) at 24 month follow up. No differences in outcome were found between trauma, stroke, and postelective surgery groups. Unilaterally FDP was associated with a better chance of survival (46% v 13%; p<0.01). Age did not correlate with survival, but younger survivors had a significantly better outcome. Patients in whom an intracranial mass was removed surgically had a 42% survival rate, compared with 8% with conservative treatment (p<0.01). Patients with a shorter delay from FDPs to intervention had a better chance of recovery after trauma and previous intracranial surgery (p<0.05). No patient survived better than a vegetative state, if previous FDPs did not become reactive shortly after therapy. If both pupils became reactive on therapy, the chance of survival was 62%. Of these survivors 42% had a favourable outcome. CONCLUSION: Bilateral restoration of pupillary reactivity shortly after therapy is crucial for survival. Surgical evacuation of an intracranial mass, unilateral FDPs, early intervention, and younger age are related to better chances of survival or recovery. The prognosis of patients with FDPs after trauma, stroke, and previous elective intracranial surgery is similar.     

Successful outcome after evacuation of intracranial hematoma following thrombolysis in acute myocardial infarction

Thrombolytic therapy is the modality of choice for the treatment of life threatening thrombosis in various vascular territories and nowadays, is used extensively in the setting of acute myocardial infarction. There is, however, the omnipresent danger of serious bleeding inherently associated with the use of all thrombolytics which if it occurs in the brain, can lead to potentially serious neurological impairment and even death. In our report, we describe the successful surgical management of a streptokinase-induced intracranial hemorrhage. Timely neurosurgical intervention is advocated as the optimal approach for this particular side effect of thrombolytic agents.     

Hemorrhagic infarction: risk factors, clinical and tomographic features, and outcome A case-control study

A radiological diagnosis of hemorrhagic infarction (HI) was made in 41 of 2726 cases with cerebrovascular lesions (1.9%). The clinical records of the cases and those of 82 age- and gender-matched subjects with ischemic infarction were examined, and notes of the principal risk factors of cerebrovascular disorders, the clinico-radiologic features and the outcome of the disease were taken for comparison. Cardiac sources of emboli (atrial fibrillation, native or prosthetic valve disorders, recent myocardial infarction) were present in 44% of cases and in 24% of controls. Diabetes mellitus was recorded in 31% and 18% respectively. Thirteen percent of cases and 35% of controls gave a history of transient ischemic attacks. Stupor or coma during the acute phase and a more severe course were more common among cases. In general, HIs were significantly larger than ischemic infarcts, with mass-effect, although the size of the lesion did not seem to be related to the presence of cardiogenic embolism.     

颅内血肿体积评估方法的影像和临床进展

颅内血肿的体积是评估患者预后和死亡率的重要指标之一。因此，对于颅内血肿的体积进行正确而严谨的评估具有重要意义。首先，虚假的过大或者过低的血肿体积评估都会影响医师的初始决定和患者的转归；其次，血肿体积的准确评估也是临床和动物试验入选指标的一个结点。不断研究探索适合血肿体积的影像和数学计算方法具有重要意义。     

颅内动脉瘤破裂出血后不同时机手术效果及再出血风险

目的 已破裂颅内动脉瘤手术时机是一个值得关注的重要问题,目前尚存在争论,本文拟探讨动脉瘤出血后不同时机手术效果及再出血风险.方法四川大学华西医院2005年1月～2006年12月所收治首次发生蛛网膜下腔出血动脉瘤患者,共303例,采取手术治疗者279例,分为早期手术组(首次出血后3d内手术),中间期手术组(出血后3d～2W内手术),晚期手术组(出血2W后手术),动脉瘤颈夹闭259例,孤立9例,包裹手术11例.近期手术效果以死亡率进行判断,远期恢复效果按术后3月格拉斯哥结果记分(GOS)评价.结果早期手术者手术死亡率较中间期及晚期手术明显降低,远期恢复效果较后两者为佳,中间期及晚期手术者手术死亡率及恢复良好率无明显差异.56例患者入院后发生再出血,早期再出血患者占再出血患者总数的39.3%,中间期再出血患者占33.9%,晚期再出血患者占26.8%,再出血死亡率60.7%.结论脑血管痉挛不应作为考虑手术时机主要因素,为防止后果严重的再出血,除了早期手术外还应做到及时尽早手术.     

凝血因子ⅩⅢ缺乏导致术后颅内迟发血肿的诊断和治疗

目的 探讨凝血因子ⅩⅢ缺乏症与开颅手术后颅内迟发血肿的关系.方法 分析2例凝血因子ⅩⅢ缺乏症导致手术后颅内迟发血肿患者的临床资料,并与同时期58例非凝血因子ⅩⅢ缺乏症开颅手术后出现颅内迟发血肿患者的病历资料做对照,总结凝血因子ⅩⅢ缺乏症导致手术后颅内迟发血肿病历的临床特点及规律.结果 凝血因子ⅩⅢ缺乏导致手术后颅内迟发血肿的特点是术后迟发血肿位于手术区域,且发病隐匿,病情进展快.结论术后出现迟发血肿病例要警惕凝血因子ⅩⅢ缺乏的可能,如能及时诊治则患者预后良好.