Symptomatic Moyamoya disease: Clinical features and outcome after indirect bypass surgery in four French adults

BackgroundThere are a few reports of moyamoya disease (MMD) in the European Caucasian adult population. We present the clinical manifestations, the neuroradiological aspects, the treatment, and the outcome after surgical revascularization of four French patients with MMD.Patients and methodsWe identified four adults (age >18 years; three women and one man) with MMD who underwent digital subtraction catheter angiography at our institution from 1997 through 2006. The median age at symptom onset was 35 years (range, 22 to 41 years). The initial clinical presentation was intracerebral hemorrhage in three patients and ischemic stroke in one patient.ResultsThree patients underwent bilateral surgical revascularization and one patient underwent unilateral surgical revascularization. All patients underwent the same surgical revascularization procedure (encephalo-duro-arterio-myo-synangiosis). The mean (+/? SD) period of follow-up after diagnosis of MMD was 6 years and 9 months (+/? 3 years and 5 months). No patient experienced any recurrent hemorrhagic or ischemic stroke. No perioperative stroke occurred. No patient was severely disabled or unable to walk. Three patients out of four were employed.ConclusionOur data suggest safety and a potential benefit of surgical revascularization (indirect bypass surgery) in European adult patients with symptomatic MMD. Further long-term prospective multicenter studies are needed. The establishment of a registry would be useful in order to accumulate data in large numbers of European patients with this uncommon disease.     

The natural history of Moyamoya in a North American adult cohort

Moyamoya disease and moyamoya syndrome (MMD/S) are a considerable source of neurologic morbidity in adults as a result of both ischemic and hemorrhagic events. Unfortunately, there is a paucity of literature detailing the natural course of MMD/S in the USA. To elucidate epidemiological information, stroke rates, hemorrhage rates, and risk factors for these events in patients with MMD/S, we reviewed our own institutional cohort of 42 North American adults with MMD/S. The mean patient age was 38.8 (standard deviation [SD] 12.7) with a 5:1 female-to-male predominance. About 74% of patients had an ischemic presentation while only 17% presented with hemorrhage. The mean Suzuki grade was higher in patients presenting with hemorrhage (3.7 compared to 2.9, p = 0.03) but similar in those who presented with a stroke as compared to those who did not (3.00 compared to 3.05, p = 0.88). The overall annual stroke and hemorrhage rates were 13.3% and 1.7%, respectively. Statistically significant risk factors for stroke or hemorrhage were female sex (p = 0.031) and stroke presentation within 3 years (hazard ratio [HR] = 4.08, p = 0.035). Smoking was another risk factor, but it did not meet statistical significance (HR = 1.56, p = 0.38). We conclude that these results favor intervention for MMD/S to mitigate the high annual stroke risk. This particularly applies to females and/or those presenting with a recent stroke/hemorrhage. Our results also serve as a baseline for comparison of hemorrhage rates after intervention.     

Five-year experience of 101 adult patients with moyamoya disease at a single institution in Eastern China

This retrospective study included 101 adult moyamoya disease (MMD) patients of whom 58 were females and 43 were males in Wenzhou, China. Clinical and diagnostic features, surgical treatment, follow-up information and outcomes constitute this review. The modified Rankin Scale (mRS) was used to determine the neurological functional outcome. The Kaplan–Meier method was used to estimate recurrent stroke and mortality risk based on drug treatment alone or in combination with revascularization. The mean age at symptom onset was 43.3 (range, 18–64) years. The initial symptom was either hemorrhage, ischemia or transient ischemic attack (TIA) in 90, 6 and 5 patients, respectively. The median follow-up time in 84 patients was 26.5 (range, 6–62) months. Ten patients were treated with revascularization. In the remaining drug-treated group, the 5-year risk of recurrent stroke and death was 8% following onset of initial symptoms, while it was 25% in the revascularization group. However, the difference between these two groups was not significant (p > 0.05). There was also no difference in mRS between these two groups upon patient discharge, but in the revascularization group was lower than that in the drug-treated group at their last follow-up (p < 0.05). Adult MMD patients were most ikely to present with hemorrhage and had a better neurological functional outcome after revascularization than from medical therapy. However, revascularization did not decrease the recurrent stroke incidence or mortality risk. These results are different from those reported by other Chinese and foreign institutions.     

Outcome of psychogenic nonepileptic seizures (PNES) in children: A 2-year follow-up study

ObjectiveThe objective of this study was to determine the outcome of psychogenic nonepileptic seizures (PNES) in children seen at a level 4 epilepsy center.MethodsWe retrospectively analyzed patients under the age of 18 years who were diagnosed with PNES based on evaluation in the epilepsy monitoring unit and had a follow-up of at least 2 years postdiagnosis. Remission of events was noted at 6 months, 12 months, and 24 months of follow-up, and patient and disease variables affecting outcome were studied.ResultsNinety patients met inclusion criteria (58 females; mean age: 14.03 ± 3.3 years). Thirty-two out of ninety (36%) patients had early (within 6 months) and sustained remission (until 2 years of follow-up) of their events (“favorable outcome”), while 30/90 patients (33%) never achieved remission during the study period (“unfavorable outcome”). The factors that were associated with “unfavorable outcome” included the presence of comorbid epilepsy [12/30 (40%) vs 0/32, p < 0.0001] and prolonged duration of symptoms before establishment of the diagnosis (median 365 days vs 60 days, p < 0.0001). Patient's age, gender, frequency of events, the presence of major psychosocial stressors, and comorbid psychiatric conditions had no significant impact on the disease outcome.ConclusionsAbout a third of children with PNES achieve early and sustained remission of symptoms, while another third continue to manifest seizure-like events until at least two years after the diagnosis. The presence of comorbid epilepsy and prolonged duration of PNES are associated with a poor two-year outcome. Early suspicion and diagnosis of PNES, especially in patients with epilepsy, is essential.     

Evaluation of frequency-selective non-linear blending technique on brain CT in postoperative children with Moyamoya disease

ObjectiveTo evaluate whether a frequency-selective non-linear blending (BC) technique can improve tissue contrast and infarct detection on non-enhanced brain CT (NECT) in postoperative Moyamoya (MMD) patients.Materials and methodsFrom January 2010 to December 2017, 33 children (13 boys and 20 girls; mean age 9.1 ± 3.4 years) with MMD postoperatively underwent NECT followed by diffusion MRI. We compared the contrast-to-noise ratio (CNR) between gray matter (GM) and white matter (WM) in NECT and BC images and the CNR between the infarct lesion and adjacent normal-appearing brain in NECT and BC images using a paired t-test. We assessed image noise, GM-WM differentiation, artifacts, and overall quality using a Wilcoxon signed rank test. A McNemar two-tailed test was conducted to compare the diagnostic accuracy of infarct detection.ResultsThe CNR between GM and WM and the CNR of the infarct was better in BC images than in NECT images (3.9 ± 1.0 vs. 1.8 ± 0.6, P < 0.001 and 3.6 ± 0.3 vs. 1.9 ± 0.2, P < 0.001), with no difference in overall image quality observed. The sensitivity and specificity of infarct detection were 55.0% and 76.9% using NECT, and 70.0% and 69.2% using BC technique. The diagnostic accuracy of NECT and BC technique was 63.6% (21/33) and 69.7% (23/33), respectively.ConclusionThis study showed that the BC technique improved CNR and maintained image quality. This technique may also be used to identify ischemic brain changes in postoperative MMD patients by improving the CNR of the infarct lesion.     

Long-term outcome and predictors of resective surgery prognosis in patients with refractory extratemporal epilepsy

PurposeWe analyzed the long-term postoperative outcome and possible predictive factors of the outcome in surgically treated patients with refractory extratemporal epilepsy.MethodsWe retrospectively analyzed 73 patients who had undergone resective surgery at the Epilepsy Center Brno between 1995 and 2010 and who had reached at least 1 year outcome after the surgery. The average age at surgery was 28.3 ± 11.4 years. Magnetic resonance imaging (MRI) did not reveal any lesion in 24 patients (32.9%). Surgical outcome was assessed annually using Engel's modified classification until 5 years after surgery and at the latest follow-up visit.ResultsFollowing the surgery, Engel Class I outcome was found in 52.1% of patients after 1 year, in 55.0% after 5 years, and in 50.7% at the last follow-up visit (average 6.15 ± 3.84 years). Of the patients who reached the 5-year follow-up visit (average of the last follow-up 9.23 years), 37.5% were classified as Engel IA at each follow-up visit. Tumorous etiology and lesions seen in preoperative MRI were associated with significantly better outcome (p = 0.035; p < 0.01). Postoperatively, 9.6% patients had permanent neurological deficits.ConclusionSurgical treatment of refractory extratemporal epilepsy is an effective procedure. The presence of a visible MRI-detected lesion and tumorous etiology is associated with significantly better outcome than the absence of MRI-detected lesion or other etiology.     

IV t-PA therapy in acute stroke patients with atrial fibrillation

Background and purposeAtrial fibrillation (AF) is a predictor for severe stroke. Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcomes in patients with acute ischemic stroke. We investigated clinical characteristics and patient outcome in patients with and without AF after t-PA therapy.MethodsConsecutive ischemic stroke patients treated with t-PA within 3 h of stroke onset were studied prospectively. MRI examinations, including diffusion weighted imaging and MRA, were performed before t-PA thrombolysis. NIHSS scores were obtained before and 7 days after t-PA infusion. The patients were divided into two groups (AF group and Non-AF group). Their clinical characteristics and outcome 7 days and 3 months after t-PA therapy were compared.Results85 patients (56 males, mean age, 73.4 ± 11.5 years) were enrolled in the present study. The AF-group had 44 patients, and the Non-AF group had 41 patients. Fewer patients with AF had dramatic improvement at 7 days and favorable outcome (mRS 0–1) at 3 months after t-PA therapy than patients without AF (31.8% vs. 61.0%, P = 0.007, and 15.9% vs. 46.3%, P = 0.002). On the other hand, worsening at 7 days and poor outcome (mRS > 3 and death) at 3 months after t-PA therapy were more frequently observed in AF group than Non-AF group (22.7% vs. 9.8%, P = 0.107, and 70.5% vs. 41.5%, P = 0.007). After adjusting age and gender, patients with AF more frequently had worsening and poor outcome than those without AF (adjusted OR; 4.54, 95% CI 1.04–19.75, P = 0.044, and adjusted OR; 2.8, 95% CI 1.10–7.28, P = 0.032).ConclusionThe present study found that acute ischemic stroke patients with AF more frequently had poor outcome after IV-t-PA therapy compared with those without AF.     

General anesthesia or conscious sedation for endovascular therapy of basilar artery occlusions: ETIS registry results

Background and purposeAcute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.MethodsData from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0–3 at 90 days.ResultsAmong the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR = 0.90 [95%CI 0.46–1.77] P = 0.769) or mortality (OR = 0.75 [0.37–1.49] P = 0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR = 0.43 [0.16–1.16] P = 0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR = 1.08 [0.62–1.88] P = 0.767).ConclusionsSafety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.     

Traumatic interhemispheric subdural haematoma: Study of 35 cases

The clinical and radiological findings, management, and outcomes in 35 patients with traumatic interhemispheric subdural haematoma (ISH) were reviewed retrospectively. Twenty-five patients had favourable outcomes and 10 had poor outcomes. All patients were treated conservatively for ISH. Univariate analysis found that the Glasgow Coma Scale (GCS) score (p < 0.001), hypovolemic shock (p = 0.018), skull fracture (p = 0.008), convexity or posterior fossa subdural haematoma (p = 0.008), and subarachnoid haemorrhage (SAH) were correlated with outcome (p < 0.001). Multivariate analysis showed that GCS score (p = 0.031; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3–0.9) and the presence of SAH (p = 0.023; OR, 14.2; 95% CI, 1.5–138.2) were significantly related to poor outcome. This study provides important information on the clinicoradiological findings and prognoses in patients with traumatic ISH.     

High glycemic variability: An underestimated determinant of stroke functional outcome following large vessel occlusion

Background and purposeEarly glycemic variability (GV) in diabetic patients is a poor prognosis factor following cardiovascular events. However, its influence on the course of acute ischemic stroke (AIS) with large vessel occlusion remains unclear. We investigated the relationship between high GV during acute stroke and three-month functional outcome among patients treated with combined intravenous thrombolysis and endovascular therapy for large vessel occlusion.MethodsA single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent thrombolysis and mechanical thrombectomy between January 2015 and May 2017. Early GV was assessed using standard deviation (SD) of blood glucose levels for the first 24 hours. The main outcome was functional status at three months as defined by the modified Rankin scale (mRS). Secondary outcomes were change in NIHSS score from baseline to 24 hours and occurrence of severe hemorrhagic transformation. Multivariate logistic regression analyses including GV, admission glycemia and mean glycemia were performed.ResultsAmong the 93 patients evaluated, 26 had early high GV (≥ 20.9 mg/dl). High GV was associated with poor functional outcome (OR = 8.00; 95%CI [1.34–47.89]; P = 0.02) unlike admission glycemia and mean glycemia (OR = 2.92; 95%CI [0.51–16.60]; P = 0.23 and OR = 0.36; 95%CI [0.05-2.6]; p = 0.31, respectively). High GV was not associated with NIHSS at 24 hours or hemorrhagic transformation.ConclusionAcute high GV contributes to poorer functional outcome following AIS related to large vessel occlusion and should be considered as a new target in acute stroke management.     

Long-term outcome of psychogenic nonepileptic seizures: The role of induction by suggestion

PurposeThe aims of our retrospective observational study were to evaluate the long-term outcome of PNESs after communication of the diagnosis and to define predictors of good outcome.MethodTwenty-seven consecutive patients with a certain diagnosis of psychogenic nonepileptic seizures (PNESs) were included in the study. Follow-up information was obtained from each participant through a questionnaire designed for the study. Regarding seizure frequency, the patients were asked to report how many seizures they had experienced on average every month before the communication of the diagnosis and after it.ResultsAfter the communication of the diagnosis, the median seizure frequency had dropped to 4 every month (p < 0.001). Seventeen participants (63%) were seizure-free at follow-up, and a further five (18.5%) showed a greater than 50% improvement in seizure frequency. Regarding the predictive value of clinical and sociodemographic variables for PNES global outcome, the factors gender, education, economic status, interval of time from onset, comorbidity with epilepsy, psychiatric history, mental retardation, psychological therapy, psychiatric therapy, and the presence of stressful and traumatic events were not related to prognosis; the only factor associated with a better outcome was the diagnosis made after the induction of PNESs by suggestion (p = 0.000, χ² = 4.654).ConclusionA substantial majority of our patients became seizure-free with communication of the diagnosis as the only intervention. The use of the induction by suggestion test was an important predictor of good outcome.     

Clinical predictors of depression treatment outcomes in patients with coronary heart disease

ObjectivesPatients with coronary heart disease (CHD) who respond to treatment for depression are at lower risk of mortality than are nonresponders. This study sought to determine whether variables that have been shown to predict both depression treatment outcomes in psychiatric patients and cardiac events in patients with CHD, also predict poor response to depression treatment in patients with CHD.MethodsOne hundred fifty-seven patients with stable CHD who met the DSM-IV criteria for a major depressive episode were treated with cognitive behavior therapy (CBT) for 16 weeks, either alone or in combination with an antidepressant.ResultsThe mean Beck Depression Inventory (BDI-II) score was 30.2 ± 8.5 at baseline and 8.5 ± 7.8 at 16 weeks. Over 50% of the participants were in remission (HAM-D-17 score ≤ 7) at the end of treatment. Of the hypothesized predictors, severe depression at baseline (p = 0.02), stressful life events during the first (p = 0.03) and last (p < 0.0001) 8 weeks of treatment, and the completion of CBT homework assignments (p = 0.001) predicted depression outcomes. History of prior episodes, anxiety symptoms, antidepressant therapy at study enrollment, and medical hospitalizations or emergency department visits during treatment did not predict treatment outcome.ConclusionsPatients who are under considerable stress do not respond as well to evidence-based treatments for depression as do patients with less stress. If future studies support these findings, more work will be needed to better address stressful life events in patients who may otherwise remain at high risk for mortality and medical morbidity following depression treatment.     

Efficacy and tolerability of the first antiepileptic drug in children with newly diagnosed idiopathic epilepsy

PurposeLimited data are available for the effectiveness of the antiepileptic drugs in children in daily clinical practice. The aim of this study was to investigate the efficacy and tolerability of the first prescribed old and new antiepileptic drugs in children with newly diagnosed idiopathic epilepsy during a 12-month period.MethodA total of 289 children (141 females and 148 males) who received phenobarbital (n = 33), valproate (n = 142), carbamazepine (n = 42), oxcarbazepine (n = 38), or levetiracetam (n = 34) as the first-line treatment, were enrolled in the study. Seizure control and the occurrence of adverse events were assessed during a treatment period of 12 months.ResultsOverall, 245 (84.8%) patients remained seizure-free during the study period. The rate of seizure control did not differ significantly between the drug groups (p = 0.099). Forty-four (15.2%) patients including 1 (3.0%) treated with phenobarbital, 22 (15.5%) with valproate, 7 (16.7%) with carbamazepine, 10 (26.3%) with oxcarbazepine, and 4 (11.8%) with levetiracetam had treatment failure. There was no significant difference between seizure-free and failure groups in terms of age, gender, seizure type, and drugs used. Overall, 80 (27.7%) patients had adverse events, of those the most common ones were behavioral problems, nausea and/or vomiting, weight gain, and learning difficulties. The reasons for treatment failures were lack of seizure control in 29 (10.0%) patients and intolerable adverse events in 15 (5.2%) patients.ConclusionIt appears that old (phenobarbital, valproate and carbamazepine) and new antiepileptic drugs (oxcarbazepine and levetiracetam) have similar efficacy and tolerability profiles.Institutional ethic number is 28.3.2013/14.     

Factors affecting the outcome of delayed intravenous thrombolysis (> 4.5 hours)

IntroductionEvidence of the intravenous tissue plasminogen activator (tPA) efficacy beyond the 4.5 hours window is emerging. We aim to study the factors affecting the outcome of delayed thrombolysis in patients of clear onset acute ischemic stroke (AIS).MethodsData of patients with AIS who received intravenous thrombolytic after 4.5 hours were reviewed including: demographics, risk factors, clinical, laboratory, investigational and radiological data, evidence of mismatch, treatment type and onset, National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, 7 days after thrombolysis and before discharge, and 3 months follow-up modified Rankin Scale (mRS).ResultsWe report 136 patients treated by intravenous tPA between 4.53 and 19.75 hours with average duration of 5.7 h. The ASPECT score of our patients was ≥ 7. Sixty-four cases showed intracranial arterial occlusion. Perfusion mismatch was detected in 117 (84.6%) patients, while clinical imaging mismatch was detected in 19 (15.4%). Early neurological improvement after 24 hours occurred in 114 (83.8%) patients. At 90 days, 91 patients (67%) achieved good outcome (mRS 0–2), while 45 (33%) had bad outcome (mRS 3–6). Age, endovascular treatment, NIHSS, AF, and HT were significantly higher in the bad outcome group. Age (P = 0.001, OR: 1.099, 95% CI: 1.042–1.160) and baseline NIHSS were predictive of the poor outcome (P = 0.002, OR: 1.151, 95% CI: 1.055–1.256). The best cutoff value of age was 72.5 with AUC of 0.76, sensitivity 73.3% and specificity 60.4%. While for NIHSS at admission, the cutoff value of 7 showed the best results with AUC of 0.73, sensitivity 71.1% and specificity 63.7%. Combination of age and admission NIHSS raised the sensitivity and specificity to 84.4% and 63.7%, respectively.ConclusionIncreased age and admission NIHSS may adversely affect the outcome of delayed thrombolysis and narrow the eligibility criteria. Age and baseline NIHSS based stratification of the patients may provide further evidence as regards the efficacy of the delayed thrombolysis.     

Sleep-disordered breathing: Impact on functional outcome of ischemic stroke patients

Background and purposeSleep-disordered breathing (SDB) is more prevalent in stroke patients than age- and sex-matched controls, but the relationship between SDB and functional outcome of stroke patients is unclear. The aim of our study was to determine the prevalence of SDB in ischemic stroke and its influence on functional outcome at 3 and 6 months after stroke onset.MethodsIn a prospective study, 60 patients were selected by polysomnography (PSG). The apnea–hypopnea index (AHI) was determined 6.5 ± 3.2 days after stroke onset. Neurologic severity at admission was assessed by the Scandinavian Stroke Scale (SSS) and outcome by the Barthel Index (BI). Patients were evaluated on admission, 3 and 6 months after stroke onset.ResultsAmong the 60 patients, 39 (65%) patients had SDB (AHI ? 5); of these, 30 patients (50%) had AHI ? 15 and 18 (30%) > 30. On Logistic regression analysis, the BI at 3 months was independently predicted by SSS (OR = 0.74, 95% CI [0.62–0.88], P = 0.001) and AHI (OR = 1.09, 95% CI [1.02–1.17], P < 0.05). At 6 months, the BI was predicted only by SSS (OR = 0.83, 95% CI [0.74–0.92], P = 0.001).ConclusionsSDB is common in patients during acute phase after stroke onset. SDB appears to be associated with a worse functional outcome during the early recovery period following stroke, increasing the likelihood of dependency.     

Long-term outcome and tolerability of the ketogenic diet in drug-resistant childhood epilepsy—The Austrian experience

PurposeTo evaluate the long-term efficacy/tolerability of the ketogenic diet (KD) in paediatric drug-resistant epilepsies.MethodsData from children who were treated between 1999 and 2008 and had continuous follow-up of at least 6 months after initiation of the KD were analysed retrospectively. Response was defined as ≥50% seizure reduction. Treatment effects on EEG, developmental outcome and the “outcome-predictive” value of various clinical factors were also assessed.Results50 children (22 boys; mean age 4.5 years ± 3.55) were included. Mean follow-up was 3.93 ± 2.95. 50% of the patients were responders, 48% of them became seizure free. 50% were non-responders, 20% of them deteriorated. In responders, EEG background activity improved significantly (p = 0.014) and a significantly lower rate of epileptic discharges (p = 0.009) was seen after 6 months. In addition, neurological examination findings demonstrated significant developmental progress (p = 0.038).Favourable treatment outcome was associated with a shorter disease duration (p = 0.025) and generalised tonic clonic seizures (p = 0.059). No further significant outcome predictors were detected. However, response was 44% in patients with infantile spasms, 62.5% in those with Dravet syndrome and 50% in Lennox-Gastaut-syndrome.Side effects occurred in 28%, but discontinuation of the KD was not required in any case. They most often observed with concomitant topiramate (p = 0.001) and valproate (p = 0.046).ConclusionDespite the retrospective nature of the study and the inhomogeneous patient sample, we found good long-term effects of the KD on seizure frequency, EEG and neurological development.     

Clinical features and outcome of super-refractory status epilepticus: A retrospective analysis in West China

PurposeData about super-refractory status epilepticus (SRSE) are scarce. This study aimed to assess the clinical features and outcome of patients with SRSE.MethodClinical features of all SRSE patients admitted to the Neurologic Intensive Care Unit (NICU)/Neurology Department of West China Hospital, Sichuan University, between January 2010 and August 2013, were retrospectively analyzed. Outcome at discharge, at the three-month and long-term follow-ups were evaluated using the Glasgow Outcome Scale (GOS). Possible predictors of mortality and outcome were also evaluated.ResultsThirteen patients with SRSE were included. Young patients with encephalitis accounted for the majority of the series (61.5%). In-hospital mortality was 15.4% (2/13), and the three-month mortality was 36.4% (4/11; two patients ceasing therapy were excluded). At the long-term follow-up, 18.2% of patients improved and 45.5% of patients recovered. Patients of older age and those with multiple complications had higher mortality compared with those of younger age and those with fewer complications. For survivors, functional outcome had significantly improved at three-month follow-up (GOS score = 4.1 ± 1.2) compared to that at discharge (GOS score = 3.1 ± 1.2, P < 0.05). Long duration of anesthesia, etiology of encephalitis and positive neuroimaging findings tended to be associated with poor functional outcome.ConclusionWe conclude that the typical patient susceptible to development of SRSE in West China is a young patient with encephalitis. Older age and multiple complications increase the risk of death. Most patients can survive with aggressive therapy, and their functional outcome improves over time.     

Long-term follow-up analysis of microsurgical clip ligation and endovascular coil embolization for dorsal wall blister aneurysms of the internal carotid artery

Blister aneurysms at non-branching sites of the dorsal internal carotid artery (dICA) are fragile, rare, and often difficult to treat. The purpose of this study is to address the demographics, treatment modalities, and long-term outcome of patients treated for dICA blister aneurysms. A retrospective review of medical records identified all consecutive patients who presented with a blister aneurysm from 2002 to 2011 at our institution. Eighteen patients (M = 7, F = 11; mean age: 48.4 ± 15.1 years; range: 15–65 years) harbored a total of 43 aneurysms, 25 of which were dorsal wall blister aneurysms of the ICA. Eleven (61.1%) patients presented with aneurysmal subarachnoid hemorrhage (aSAH), and 10 (55.6%) patients had multiple aneurysms at admission. Twelve patients had 18 aneurysms that were treated microsurgically. Five (41.7%) of these patients had a single recurrence that was retreated with subsequent repeat clip ligation. Six patients had 7 blister aneurysms that were treated with endovascularly. One (16.7%) of these patients had a single recurrence that was retreated with subsequent coil embolization. Postoperative vasospasm occurred in 8 (44.4%) patients, one of whom suffered from a stroke. This is one of the largest single-institution dICA blister aneurysm studies to date. There was no detected significant difference between microsurgical clip ligation and endovascular coil embolization in terms of surgical outcome. These blister aneurysms demonstrate a propensity to be associated with multiple cerebral aneurysms. Strict clinical and angiographic long-term follow-up may be warranted.Statement of SignificanceBlister aneurysms are focal wall defects covered by a thin layer of fibrous tissue and adventitia, lacking the usual collagenous layer. Due to their pathologically thin vessel wall, blister aneurysms are prone to rupture. The management of these rare and fragile aneurysms presents a number of challenges. Here, we address the long-term outcome of patients treated for blister aneurysms at non-branching sites of the dICA. The presented data and analysis is imperative to determine the necessary strict long-term clinical and angiographic follow-up.     

Prevalence of residual excessive sleepiness during effective oral appliance therapy for sleep-disordered breathing

BackgroundOral appliance therapy with a mandibular advancement device (OA_m) can yield to complete therapeutic response (apnea–hypopnea index [AHI] < 5 events/h), though some patients show little or no improvement in daytime sleepiness. The prevalence of residual excessive sleepiness (RES) despite effective treatment with OA_m therapy is unknown. We aimed to determine the prevalence of RES in patients treated with a titratable custom-made duobloc OA_m.MethodsA prevalence study was performed, collecting data from 185 patients with an established diagnosis of sleep-disordered breathing (SDB) under OA_m therapy with a titratable custom-made duobloc device (baseline data were male:female ratio, 129:56; age, 48 ± 9 years; body mass index [BMI], 27 ± 4 kg/m²; Epworth Sleepiness Scale [ESS] score, 10 ± 5; and AHI, 19 ± 12 events/h). A full-night polysomnography was performed at baseline and after 3 months of OA_m therapy. Daytime sleepiness was assessed using the ESS with RES defined as an ESS score of 11 or higher out of 24, despite complete therapeutic response.ResultsOut of 185 patients, 84 patients (45%) showed a complete therapeutic response with an AHI of <5 events per hour after 3 months of OA_m therapy. Despite this normalization of AHI, 27 out of these 84 patients (32%) showed RES and had a significantly higher baseline ESS (15 ± 4 vs 9 ± 4; P < .001) and were younger (43 ± 9 vs 47 ± 9; P = .028) compared to patients without RES.ConclusionRES under OA_m therapy showed a prevalence of up to 32% in SDB patients effectively treated with respect to AHI. Patients with RES were younger and had higher baseline daytime sleepiness.