Next Event April 26Th-Webinar Evaluation of Pediatric Patients in Neurosurgery
Webinar # 13 Topic: Evaluation of Pediatric Patients in Neurosurgery Time: Apr 26, 2020 12:00 PM Greenwich Mean Time Join Zoom Meeting https://zoom.us/j/94642500378 Meeting ID: 946 4250 0378
Aneurysmal Subarachnoid Hemorrhage Outcome in Elderly Patients
Aneurysmal subarachnoid hemorrhage outcome in elderly patients are at high risk for poor functional outcomes. However, among those presenting with good Hunt and Hess Stroke Scale scores, younger-elderly patients (ages 60-65 years) tend to fare better than older-elderly patients (ages >65 years). Elderly patients presenting with high-grade aSAH fare poorly regardless of age, which can inform clinical decision-making and prognostication 1).
They performed a retrospective analysis of the Bernese SAH database for poor-grade (World Federation of Neurosurgical Societies grade IV and V) elderly patients (age ≥60 years) suffering from aSAH admitted to the institution from 2005 to 2017. Patients were divided into 3 age groups (60-69, 70-79, and 80-90 years).
Survival analysis was performed to estimate mean survival and hazard ratios for death. Binary logarithmic regression was used to estimate the odds ratio for favorable (modified Rankin Scale score of 0-3) and unfavorable (modified Rankin Scale score of 4-6) outcome. Results- Increasing age was associated with an increased risk of death after aSAH. The hazard ratio increased by 6% per year of age ( P<0.001; hazard ratio, 1.06; 95% CI, 1.03-1.09) and 76% per decade ( P<0.001; hazard ratio, 1.76; 95% CI, 1.35-2.29). Mean survival was 56.3±8 months (patients aged 60-69 years), 31.6±7.6 months (70-79 years), and 7.6±5.8 months (80-90 years). Unfavorable outcomes 6 to 12 months after aSAH were strongly related to an older age. The odds ratio increased by 11% per year of age ( P<0.001; odds ratio, 1.11; 95% CI, 1.05-1.18) and 192% per decade ( P<0.001; odds ratio, 2.92; 95% CI, 1.63-5.26). Conclusions- Risk for death and unfavorable outcome increases markedly with older age in elderly patients with poor-grade aSAH. Despite high initial mortality, treatment resulted in a reasonable proportion of favorable outcomes up to 79 years of age and only a small number of patients who were moderately or severely disabled 6 to 12 months after aSAH. Mean survival and proportion of favorable outcomes decreased markedly in patients older than 80 years 2).
It is also important to investigate the critical age for defining a higher risk population among elderly patients and the clinical grade at admission in order to provide a prognostic description and help guide the management of patients aged ≥ 70 years.
A retrospective study included 165 patients aged 70-90 years who underwent surgical or endovascular treatment for a ruptured aneurysm. In addition to medical and radiological data, telephone interviews were used to obtain the 1-year functional outcome.
Multivariate analysis revealed age (p = 0.001) and the World Federation of Neurological Surgeons (WFNS) grade (p = 0.001), regardless of the treatment modalities (surgical versus endovascular), as significant risk factors for a poor outcome, while a receiver operating characteristic analysis revealed 75 years as an appropriate cutoff value for the patient age to predict a poor 1-year functional outcome (area under the curve: 0.683). For the patients aged 70-75 years with good (1-3) and poor (4-5) WFNS grades, 81.9 % and 42.9 % achieved a favorable outcome (modified Rankin Scale 0-3), respectively, whereas for the patients over the critical age (> 75 years) with good and poor WFNS grades, 54.8 % and 5.9 % achieved a favorable outcome, respectively.
The long-term outcome for elderly patients with an aneurysmal SAH is affected primarily by the clinical condition at admission and the patient’s age in relation to the critical age (> 75 years), regardless of the treatment modalities, including surgical clipping and endovascular coiling 3).
Medical Management of Neurosurgical Patients
by Rene Daniel and Catriona M Harrop
List Price: $74.95
Emerging as a new sub-specialization within the hospitalist community, the neurosurgery hospitalist provides preoperative risk stratification, advises on managing pre- and postoperative complications, and helps doctors make decisions about when to involve specialists other than neurosurgeons. This collaborative approach to the neurosurgery patient has been shown to offer effective care since hospitalists can be better attuned than specialists to multiple medical problems that most patients have.
Medical Management of Neurosurgical Patients is a first of its kind textbook providing a standardized source of information for neurosurgery hospitalists in order to establish a common ground and improve their knowledge and training. The work will focus on the management of CNS infections, management of bleeding in the context of CNS surgery (a potentially catastrophic complication), management of sodium and blood glucose levels including steroid-induced hyperglycemia, perioperative pain control, and management of pressure injuries and rehabilitation in the context of CNS injury.
Unruptured posterior communicating artery (PCoA) aneurysms with oculomotor nerve palsy (ONP) have a very high risk of rupture.
ONP can occur with PCOMM aneurysm with or without subarachnoid hemorrhage (SAH) 1).
In many cases, an initially incomplete paresis develops to a complete ocular palsy within eight days. Ptosis is generally the first symptom, and it frequently shows the earliest recovery of all other disturbed oculomotor functions after surgery. Full recovery of oculomotor palsy occurs usually only in those patients who undergo early clipping of an aneurysm, i.e. mainly within 10 days after onset of ocular palsy. Complete restitution after carotid ligation is possible, but rare. In cases with full recovery, restitution occurs mostly within three months, sometimes even within a few weeks. An improvement in oculomotor palsy is still possible after a year, but ultimately in these patients recovery remains always more or less incomplete. Incomplete restitution of a third cranial nerve lesion is very often associated with aberrant regeneration and subsequent synkinetic ocular movement. The restitution of the single ocular muscle functions shows a fairly constant course: the levator palpebrae muscle and the M. rectus medialis show rapid recovery. The parasympathetic fibres follow next, but normal function of elevation and depression of the ocular bulb (M. rectus sup., M. obliquus inf. and M. rectus inf.) is often delayed 3).
Patients with ONP secondary to PCoA aneurysms treated with clipping showed higher rates of full ONP resolution than patients treated with coil embolization. Larger prospective studies are needed to determine the true potential of recovery associated with each treatment 4).
Eleven relevant studies involving a total of 384 patients with third nerve palsy due to PCoA aneurysms at baseline, of whom 257 (67.0%) were treated by clipping and 127 by coiling (33.0%), were included in a meta-analysis. Pooled Odds Ratios of the impact of clipping or coiling on complete ONP recovery, lack of ONP recovery and procedure-related death were calculated. The overall complete ONP recovery rate was 42.5% in the coiling group compared to 83.6% in the clipping group. The increase in complete ONP recovery in the clipping group corresponds to an overall pooled Mantel-Haenzel odds ratio of 4.44 (95% CI 1.66-11.84). Subgroup analysis revealed a clear benefit of clipping over coiling in patients with ruptured aneurysms, but not in unruptured aneurysms. None of the eleven studies reported any procedure-related death.
Surgical clipping of PCoA aneurysms causing third nerve palsy achieves better ONP recovery than endovascular coiling. This result could be particularly true in the case of ruptured aneurysms. In view of the purely observational data, statements about this effect should be made with great caution. A randomized trial would address the therapeutic dilemma involved better, but pending the results of such a trial, we recommend treating PCoA artery aneurysms causing ONP with surgery 5).
Simultaneous elimination of 2 injury mechanisms, compression and pulsation, when treating the oculomotor nerve by surgical clipping may be more advantageous than endovascular embolization 6).
All patients were followed up for more than a year. And 31 patients (56.4%) out of 55 achieved complete recovery, 19 (34.5%) attained partial recovery and 5 (9.1%) had no recovery from ONP. Whereas, 20 patients (71.4%) in the embolization + mecobalamin treatment group achieved complete recovery and 11 (40.7%) in the embolization treatment group achieved partial recovery, and the comparative difference was statistically significant (p < 0.05).
Endovascular is highly efficacious treatment for ONP-inducing PcomA and can promote the recovery of oculomotor nerve palsy after embolism 7).
Nine published reports of eligible studies involving 297 participants met the inclusion criteria. Overall, compared with endovascular coiling, surgical clipping had no statistically significant difference on the complete recovery of ONP, although there was an obvious trend in favor of clipping [RR=1.48, 95%CI (0.95, 2.29), p=0.08]. There was no significant difference in the total efficiency (any degree of change) on ONP [RR=1.08, 95%CI (0.94, 1.25), p>0.05], the overall complications [RR=0.60, 95%CI (0.33, 1.10), p>0.05], the efficacy on the complete recovery of ONP in patients without SAH [RR=0.83, 95%CI (0.53, 1.31), p>0.05], the effect on the complete recovery of ONP in patients with pre-operatively complete or incomplete ONP [RR=1.12, 95%CI (0.68, 1.85), p>0.05], [RR=1.12, 95%CI (0.79, 1.59), p>0.05]. In a comparison of a small cohort of patients that had suffered an SAH (17 vs. 22) there was a significant difference on the effect on complete recovery of ONP between clipping and coiling [RR=1.70, 95%CI (1.08, 2.67), p<0.05].
A superiority of clipping over coiling for the complete recovery of oculomotor nerve palsy in patients that had suffered an SAH from a ruptured aneurysm of the posterior communicating artery was found in the present meta-analysis. Limited by the relatively small sample sizes included, there were no significant differences observed in the clinical outcome between coiling and clipping in the treatment of unruptured PcomAA causing ONP. More evidence from advanced multi-center studies of large scale is needed to provide insight into the optimal treatment for outcome of ONP caused by PcomAAs 8).
The clinical characteristics did not differ among the 3 groups (p > 0.05), whereas the morphological and hemodynamic analyses showed that size, aspect ratio, size ratio, undulation index, nonsphericity index, ellipticity index, normalized wall shear stress (WSS), and percentage of low WSS area differed significantly (p < 0.05) among the 3 groups. Furthermore, multiple comparisons revealed that these parameters differed significantly between the ONP group and the asymptomatic unruptured group and between the ruptured group and the asymptomatic unruptured group, except for size, which differed significantly only between the ONP group and the asymptomatic unruptured group (p = 0.0005). No morphological or hemodynamic parameters differed between the ONP group and the ruptured group.
Unruptured PCoA aneurysms with ONP demonstrated a distinctive morphological-hemodynamic pattern that was significantly different compared with asymptomatic unruptured PCoA aneurysms and was similar to ruptured PCoA aneurysms. The larger size, more irregular shape, and lower WSS might be related to the high rupture risk of PCoA aneurysms 9).
Of the 20 patients, 9 (45%) presented with complete ONP and 11 (55%) with partial ONP. After an average follow-up period of 16 months, all patients achieved oculomotor nerve recovery; 9 (45%) patients had complete recovery and 11 (55%) patients had partial recovery. Of the 9 patients who presented with complete ONP, 5 (56%) patients made a complete recovery and 4 (44%) made a partial recovery. Of the 11 patients who initially presented with partial ONP, 4 (36%) made a complete recovery and 7 (64%) made a partial recovery. 7 (35%) patients also had a SAH, of whom 3 (43%) made a complete recovery with 4 (57%) making a partial recovery10).
A significant difference between normal pressure hydrocephalus (NPH) and controls in the change between baseline and 1 day after spinal tap was only observed in MMSE. In the domains of visuoconstructive function and attention, controls performed slightly better at day one compared to baseline, which could be interpreted as a learning effect, but after adjusting for multiple testing none of the P values were significant. In contrast to other reports, the MMSE seems to provide a sensitive evaluation of the response to spinal tap in NPH patients and might therefore be included into the routine work up of NPH patients. All other neuropsychological (NPSY) tests showed less prominent changes within 1 day after spinal tap 1).
1) Schmidt H, Elster J, Eckert I, Wiefek J, Paulus W, von Steinbuechel N, Abatih EN, Blocher J. Cognitive functions after spinal tap in patients with normal pressure hydrocephalus. J Neurol. 2014 Sep 20. [Epub ahead of print] PubMed PMID: 25239390
Cervical spine decompression and fusion can improve or stabilize myelopathy, and significantly relieve neck pain and radiculopathy in the majority of patients with coexistent CS and MS. Urinary dysfunctions appear unlikely to improve after surgery. The low rate of surgical complications in this cohort demonstrates that cervical spine surgery can be safely performed in carefully selected patients with concomitant CS and MS with a good clinical outcome and also eliminate CS as a confounding factor in the long-term management of MS patients ((Tan LA, Kasliwal MK, Muth CC, Stefoski D, Traynelis VC. Is cervical decompression beneficial in patients with coexistent cervical stenosis and multiple sclerosis? J Clin Neurosci. 2014 Jul 31. pii: S0967-5868(14)00353-1. doi: 10.1016/j.jocn.2014.05.023. [Epub ahead of print] PubMed PMID: 25088960.))
Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.
We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.
Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability [requirement for assistance with most bodily needs]); and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group.
Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs. (Funded by the Deutsche Forschungsgemeinschaft; DESTINY II Current Controlled Trials number, ISRCTN21702227.) ((Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M,
Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger
J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with
extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar
20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PubMed PMID: 24645942.))