Control of refractory status epilepticus precipitated by anticonvulsant withdrawal using left vagal nerve stimulation: a case report

OBJECTIVE: To describe a case of left vagal nerve stimulation (VNS) resulting in immediate cessation of status epilepticus (SE) with good neurological outcome. CASE DESCRIPTION: A 30-year-old man with medically intractable seizures including episodes of SE was successfully treated using left VNS. After requiring discontinuation of phenytoin, valproic acid, carbamazepine, and topiramate because of severe allergic reactions resembling Stevens-Johnson syndrome, the patient required pentobarbital coma along with phenobarbital, tiagabine, and levetiracetam for seizure frequency reduction. He underwent left vagal nerve stimulator placement after nearly 9 days of barbiturate-induced coma, with stimulation initiated in the operating room. On the following day, electroencephalography revealed resolution of previously observed periodic lateral epileptiform discharges and the patient was free of seizures. Prestimulation seizure frequency was recorded at 59 times a day, with some seizures enduring 45 minutes despite barbiturate coma. Poststimulation, the patient has been free of seizures for 19 days and is presently taking only levetiracetam and phenobarbital, from which he continues to be successfully weaned without seizures. He is awake, alert, and can recall events leading up to his seizures, with good long-term memory and residual left upper extremity and lower extremity weakness. CONCLUSION: This case illustrates the role of left vagal stimulation in the treatment of SE and otherwise medically intractable seizures caused by allergic reactions. To our knowledge, this is the first case in the world literature for adults reporting cessation of SE after VNS. Another case with a similar improvement has been reported in the pediatric population.     

Drug-eluting stents: the beginning of the end of restenosis?

In multiple clinical trials, patients who received drug-eluting stents instead of plain stents during percutaneous coronary interventions had rates of restenosis that were lower by roughly one half to three fourths, depending on how restenosis was defined and on the population studied. These stents will likely be used more and more as their indications evolve.     

Complications of posterior cranial fossa surgery—an institutional experience of 500 patients

BackgroundThe complication of the posterior fossa surgery is seldom described in the literature. The purposes of this retrospective study are to draw attention to the potential complications associated with posterior fossa surgery and to critically review the predisposing factors that might influence the complication rate.MethodsWe undertook a 10-year (1992-2002) retrospective study of all posterior fossa surgery performed at LSUHSC. A total of 500 patients were obtained from the operation database, and they were categorized into 5 groups based on the surgical approaches: (1) cerebellopontine angle lesion, (2) microvascular decompression for facial pain and spasm, (3) cerebellar lesions, (4) Chiari I decompression, and (5) petroclival lesions. Data collected for analysis included patient demographics, pathological characteristics of the lesions, and the postoperative complications that occurred as unexpected and undesirable events that prolonged hospital stay and may require surgical/medical intervention.ResultsOf the 500 patients reviewed, 220 (44%) patients had tumor resections at the cerebellopontine angle; 110 (22%) patients had microvascular decompression for trigeminal neuralgia and hemifacial spasm; 86 (17.2%) patients had cerebellar lesions; 60 (12%) patients had Chiari I decompression; and 24 (4.8%) patients required transpetrosal approaches for petroclival lesions. The overall complication rate in our study was 31.8%, affecting 159 patients. Cerebrospinal fluid leaks were the most frequently encountered, presenting in 65 (13%) patients followed by meningitis in 46 (9.2%) patients, wound infection in 35 (7%) patients, and CN palsies in 24 (4.8%) patients. Other complications that were observed to develop almost exclusively in patients undergoing cerebellar parenchymal tumor resection included cerebellar edema in 25 (5%) patients, hydrocephalus in 23 (4.6%) patients, cerebellar hematoma in 15 (3%) patients, and cerebellar mutism in 6 (1.2%) patients. The overall mortality rate related to surgery was 2.6% occurring in 13 patients.ConclusionPosterior fossa surgery involves greater morbidity and mortality and has a wider variety of complications than surgery in the supratentorial compartment. These complications may be avoided by careful perioperative planning, strict adherence to aseptic technique, meticulous microsurgical dissection, proper wound closure, and the judicious use of prophylactic agent. A thorough understanding of the patient's history, neurological findings, imaging studies, operative anatomy, as well as all potential adverse events associated with the procedure is also essential to minimize complications.     

Emergency redo mitral valve replacement and caesarean section in a patient with previous atrioventricular septal defect repair in childhood

A 19-year-old primigravida, with a history of mechanical mitral prosthesis at the age of six years following previous repair of an atrioventricular septal defect, presented at 26 weeks' gestation with cardiogenic shock secondary to obstruction of the mitral prosthesis. She underwent successful emergency redo mitral valve replacement and caesarean section. At operation the prosthesis was found to be virtually completely obstructed with pannus. Both mother and baby had an excellent outcome following surgery. The case report is presented with a brief review of the literature.     

Assessing the safety of post-exposure rabies immunization in pregnancy

Fourteen pregnant women who received rabies post-exposure prophylaxis (PEP) at the anti-rabies clinic (ARC) of Kempegowda Institute of Medical Sciences (KIMS) were followed up for assessing the safety of modern rabies vaccines and equine rabies immunoglobulin (ERIG) in pregnancy. The women were in the age range of 18-28 years, mostly from urban area (64%) and exposed to suspect rabid dogs (86%). They had received purified vero cell rabies vaccine (Verorab = 8 and Abhayrab = 4), purified chick embryo cell vaccine (Rabipur = 2) by Essen regimen; and equine rabies immunoglobulin (Equirab = 7 and Pasteur anti-rabies serum = 1). None of the pregnant women reported any adverse events to either vaccine or equine rabies immunoglobulin. All had safe vaginal deliveries and in all cases both the mother and the child were found to be healthy and normal.     

Cyclooxygenase-2 expression in brain metastases

BACKGROUND: Elevated Cyclooxygenase-2 (COX-2) expression is thought to increase metastatic potential of many tumors. Furthermore, elevated COX-2 expression correlates with radiation resistance in many tumor types. We evaluated whether: (i) the degree of COX-2 expression correlated with either metastatic tumor type or with the presence of necrosis and whether (ii) radiation-resistant tumors (renal cell and melanoma) had higher expression of COX-2 than did relatively radiation-sensitive tumors (breast and lung). MATERIALS AND METHODS: Specimens from sixteen patients who underwent resection of brain metastases were analyzed for COX-2 expression using a COX-2 antibody-based immunoassay. Specimens consisted of brain metastases from lung tumors, breast adenocarcinomas, melanomas and renal cell carcinomas. All specimens were analyzed for the presence or absence of necrosis. RESULTS: Ten of sixteen brain metastasis specimens had ten percent or less Cox-2 immunostaining. Statistical analyses showed no correlation between Cox-2 immunostaining and metastatic tumor type or between Cox-2 immunostaining and necrosis in this study. Furthermore, renal cell carcinoma and melanoma showed variable Cox-2 immunostaining. CONCLUSION: Cox-2 is not consistently expressed in metastases to the brain. The degree of Cox-2 expression does not correlate with metastatic tumor type or with the presence of necrosis. Radioresistant tumors did not have statistically different expression of Cox-2 than radiosensitive specimens studied in this analysis.