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Pease M, Gupta K, Moshé SL, Correa DJ, Galanopoulou AS, Okonkwo DO, Gonzalez-Martinez J, Shutter L, Diaz-Arrastia R, Castellano JF. Insights into epileptogenesis from post-traumatic epilepsy. Nat Rev Neurol 2024; 20:298-312. [PMID: 38570704 DOI: 10.1038/s41582-024-00954-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
Post-traumatic epilepsy (PTE) accounts for 5% of all epilepsies. The incidence of PTE after traumatic brain injury (TBI) depends on the severity of injury, approaching one in three in groups with the most severe injuries. The repeated seizures that characterize PTE impair neurological recovery and increase the risk of poor outcomes after TBI. Given this high risk of recurrent seizures and the relatively short latency period for their development after injury, PTE serves as a model disease to understand human epileptogenesis and trial novel anti-epileptogenic therapies. Epileptogenesis is the process whereby previously normal brain tissue becomes prone to recurrent abnormal electrical activity, ultimately resulting in seizures. In this Review, we describe the clinical course of PTE and highlight promising research into epileptogenesis and treatment using animal models of PTE. Clinical, imaging, EEG and fluid biomarkers are being developed to aid the identification of patients at high risk of PTE who might benefit from anti-epileptogenic therapies. Studies in preclinical models of PTE have identified tractable pathways and novel therapeutic strategies that can potentially prevent epilepsy, which remain to be validated in humans. In addition to improving outcomes after TBI, advances in PTE research are likely to provide therapeutic insights that are relevant to all epilepsies.
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Affiliation(s)
- Matthew Pease
- Department of Neurosurgery, Indiana University, Bloomington, IN, USA.
| | - Kunal Gupta
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Solomon L Moshé
- The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
- Department of Neuroscience, Albert Einstein College of Medicine, New York, NY, USA
- Department of Paediatrics, Albert Einstein College of Medicine, New York, NY, USA
| | - Daniel J Correa
- The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
| | - Aristea S Galanopoulou
- The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
- Department of Neuroscience, Albert Einstein College of Medicine, New York, NY, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Lori Shutter
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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Neth BJ, Mustafa R. Bihemispheric Seizure Without Generalization. Neurohospitalist 2024; 14:220-221. [PMID: 38666266 PMCID: PMC11040619 DOI: 10.1177/19418744231210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
A 70-year-old male without prior psychiatric history presented with recurrent episodes (<60 seconds each, every 5-10 minutes) of left hemibody and right lower extremity jerking movements concerning for seizure with preserved awareness (Video). Examination showed left hemiparesis (leg > arm) in addition to right lower extremity weakness. Computed tomography showed a right parafalcine acute subdural hematoma (SDH). Clinical events did not recur after intravenous lorazepam (4 mg) and levetiracetam load (3500 mg), and his weakness improved. He was continued on levetiracetam and has since remained seizure free for 16 months. A 60-minute awake/sleep electroencephalogram (EEG) obtained 12 hours after administration of antiseizure medications showed low amplitude theta slowing (posterior predominant) in the range of 5-7 Hz. There was no apparent epileptiform activity or other abnormalities during the awake and sleep recording or photic stimulation. Focal seizures originate from pathologic disruption of neuronal activity within an isolated brain region, almost exclusively from a single hemisphere. Focal seizures may generalize bilaterally with associated impaired awareness. This is the first visual report demonstrating focal, bihemispheric clinical seizures, without generalization or impaired awareness. Rarely patients with generalized motor involvement from seizures have had retained consciousness and memory. The parafalcine SDH likely promoted epileptogenicity of the bilateral hemispheres. Acute and chronic SDH commonly present with seizures. Although there were no supportive electrographic findings, parasagittal epileptogenic lesions may be difficult for both clinical and electrographic localization. Post-event paresis with clinical improvement in the hours after event cessation supports clinical seizure.
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Affiliation(s)
- Bryan J. Neth
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Rafid Mustafa
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Won SY, Freiman TM, Lee-Müller SS, Dubinski D, Willems LM, Reif PS, Hattingen E, Ullmann J, Herrmann E, Melzer N, Seifert V, Gessler F, Rosenow F, Konczalla J, Strzelczyk A. The Long-Term Use of Diagnostic Subdural Electroencephalogram Electrodes and Subdural Hematoma: A Prospective Cohort Study. Crit Care Med 2023; 51:1754-1765. [PMID: 37638780 DOI: 10.1097/ccm.0000000000006033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVES Seizures and status epilepticus (SE) are frequent complications of acute subdural hematoma (aSDH) associated with increased morbidity and mortality. Therefore, we aimed to evaluate whether invasive subdural electroencephalogram recording leads to earlier seizure detection and treatment initiation in patients with aSDH. DESIGN Prospective, single-center, cohort trial. SETTING Neurologic and neurosurgical ICUs of one academic hospital in Germany. PATIENTS Patients with aSDH undergoing surgical treatment. In total, 76 patients were enrolled in this study, 31 patients (40.8%) were assigned to the invasive electroencephalogram (iEEG) monitoring group and 45 patients (59.2%) to control group. INTERVENTIONS The electrode group was implanted with a subdural strip electrode providing up to 7 days of real-time electroencephalogram recording in the neurointensive care unit, whereas the control group received regular normal surface electroencephalograms during the 7-day period. The primary outcomes were the prevalence and time to seizures and SE occurrence. Secondary outcomes included neurologic outcomes assessed using the Glasgow Outcome Scale (GOS) at discharge and 6-month follow-up and the prevalence of focal structural epilepsy within 2 years after discharge. MEASUREMENTS AND MAIN RESULTS The trial was stopped after a study committee meeting when the prespecified criteria were met. The iEEG and control groups were well-matched for clinical characteristics at admission. Frequencies of seizures and SE detection were significantly higher in the iEEG group than in the control group (61% vs 15.6%; p < 0.001 and 38.7% vs 11.1%; p = 0.005). Time to seizure and SE detection was significantly earlier (median 29.2 vs 83.8 hr; p = 0.018 and 17.2 vs 83.8 hr; p = 0.033) in the iEEG group than in the control group. Favorable outcomes (GOS 4-5) were more frequently achieved in the iEEG group than in the control group (58% vs 31%; p = 0.065). No significant differences were detected in long-term mortality or post-traumatic epilepsy. CONCLUSIONS Invasive subdural electroencephalogram monitoring is valuable and safe for early seizure/SE detection and treatment and might improve outcomes in the neurocritical care of patients with aSDH.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
- Department of Neurosurgery, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Sara Sujin Lee-Müller
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Joana Ullmann
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Nico Melzer
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Germany
| | - Volker Seifert
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Florian Gessler
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
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Vespa P. Seizures After Acute Subdural Hemorrhage: Call for More Monitoring. Crit Care Med 2023; 51:1839-1840. [PMID: 37971343 DOI: 10.1097/ccm.0000000000006047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Paul Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, CA
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Wu L, Guo X, Ou Y, Yu X, Zhu B, Li Y, Liu W. Seizure after chronic subdural hematoma evacuation: associated factors and effect on clinical outcome. Front Neurol 2023; 14:1190878. [PMID: 37228408 PMCID: PMC10203208 DOI: 10.3389/fneur.2023.1190878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/25/2023] [Indexed: 05/27/2023] Open
Abstract
Objective Chronic subdural hematoma (CSDH) is a common disease in neurosurgery, which usually occurs in the elderly. Seizure is one of the postoperative complications in CSDH patients and can affect patient outcomes. There is currently no consensus on whether antiepileptic drugs should be prescribed prophylactically. The aim of this study was to evaluate independent risk factors for postoperative seizures and unfavorable outcomes in CSDH patients. Methods We reviewed 1,244 CSDH patients who had undergone burr-hole craniotomy in this study. Patient clinical data, CT scan results, recurrence and outcome data were collected. We divided the patients into two groups based on whether they had a postoperative seizure. Percentages and χ2 tests were applied for categorical variables. Standard deviations and two-sided unpaired t-tests were applied for continuous variables. Stepwise logistic regression analyses were performed to identify the independent factors of postoperative seizures and unfavorable outcomes. Results The incidence of seizures after CSDH surgery was 4.2% in this study. There was no significant difference in recurrence rate between seizure and non-seizure patients (p = 0.948), and the outcome of seizure patients was significantly poor (p < 0.001). There are more postoperative complications in seizure patients (p < 0.001). Logistic regression analysis showed that the independent risk factors for postoperative seizures included drinking history (p = 0.031), cardiac disease (p = 0.037), brain infarction (p = 0.001) and trabecular hematoma (p < 0.001). The use of urokinase is a protective factor for postoperative seizures (p = 0.028). Hypertension is an independent risk factor for unfavorable outcome in seizure patients (p = 0.038). Conclusion Seizures after CSDH surgery were associated with postoperative complications, higher mortality and poorer clinical outcomes at follow-up. We believe that alcohol consumption, cardiac disease, brain infarction and trabecular hematoma are independent risk factors for seizures. The use of urokinase is a protective factor against seizures. Patients with postoperative seizures need more stringent management of their blood pressure. A prospective randomized study is necessary to determine which subgroups of CSDH patients would benefit from antiepileptic drugs prophylaxis.
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Affiliation(s)
- Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunfei Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Neurological Center, People’s Hospital of Ningxia Hui Autonomous Region (The Third Clinical Medical College, Ningxia Medical University), Yinchuan, China
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A Predictive Model for Chronic Hydrocephalus After Clipping Aneurysmal Subarachnoid Hemorrhage. J Craniofac Surg 2023; 34:680-683. [PMID: 36168119 DOI: 10.1097/scs.0000000000009036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Chronic hydrocephalus after clipping aneurysmal subarachnoid hemorrhage (aSAH) often results in poor outcomes. This study was to establish and validate model to predict chronic hydrocephalus after aSAH by least absolute shrinkage and selection operator logistic regression. The model was constructed from a retrospectively analyzed. Two hundred forty-eight patients of aSAH were analyzed retrospectively in our hospital from January 2019 to December 2021, and the patients were divided into chronic hydrocephalus (CH) group (n=55) and non-CH group (n=193) according to whether occurred CH within 3 months. In summary, 16 candidate risk factors related to chronic hydrocephalus after aSAH were analyzed. Univariate analysis was performed to judging the risk factors for CH. The least absolute shrinkage and selection operator regression was used to filter risk factors. Subsequently, the nomogram was designed by the above variables. And area under the curve and calibration chart were used to detect the discrimination and goodness of fit of the nomogram, respectively. Finally, decision curve analysis was constructed to assess the practicability of the risk of chronic hydrocephalus by calculating the net benefits. Univariate analysis showed that age (60 y or older), aneurysm location, modified Fisher grade, Hunt-Hess grade, and the method for cerebrospinal fluid drainage, intracranial infections, and decompressive craniectomy were significantly related to CH ( P <0.05). Whereas 5 variables [age (60 y or older), posterior aneurysm, modified Fisher grade, Hunt-Hess grade, decompression craniectomy] from 16 candidate factors were filtered by LASSO logistic regression for further research. Area under the curve of this model was 0.892 (95% confidence interval: 0.799-0.981), indicating a good discrimination ability. Meanwhile, the result of calibration indicated a good fitting between the prediction probability and the actual probability. Finally, decision curve analysis showed a good clinical efficacy. In summary, this model could conveniently predict the occurrence of chronic hydrocephalus after aSAH. Meanwhile, it could help physicians to develop personalized treatment and close follow-up for these patients.
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Hamou H, Alzaiyani M, Rossmann T, Pjontek R, Kremer B, Zaytoun H, Ridwan H, Clusmann H, Hoellig A, Veldeman M. Seizure after surgical treatment of chronic subdural hematoma—Associated factors and effect on outcome. Front Neurol 2022; 13:977329. [PMID: 36158969 PMCID: PMC9493299 DOI: 10.3389/fneur.2022.977329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionChronic subdural hematoma (cSDH) is becoming more prevalent due to population aging and the increasing use of antithrombotic drugs. Postoperative seizure in cSDH have a negative effect on outcome, and there currently no consensus regarding prophylactic anti-epileptic drug (AED) treatment. The objective of this study was to evaluate predisposing and triggering factors associated with postoperative epileptic seizure in patients with cSDH.MethodsAll patients, who were surgically treated for cSDH in a single tertiary care center between 2015 and 2019, were considered for inclusion. Relevant patient- and hematoma-specific characteristics were retrospectively extracted from hospital records. Paroxysmal events categorized by the treating physician as suspected postoperative seizures were noted. The clinical outcome was extracted from the last available follow-up visit and classified according to the Glasgow outcome scale (GOS).ResultsOf the included 349 patients, 54 (15.5%) developed suspected postoperative epileptic complications in the form of early seizure (≤ 7 days) in 11 patients (3.2%) and late seizure (>7 days) in 43 patients (12.3%). In the logistic regression analysis, solely depressed brain volume (supratentorial volume (ml) not filled with re-expanded brain) was independently associated with postoperative seizure (odds ratio [OR] 1.006, 95% CI: 1.001–1.011; p = 0.034). The occurrence of postoperative seizure (OR 6.210, 95% CI: 2.704–14.258; p < 0.001) and preoperative Markwalder grading (OR 2.919, 95% CI: 1.538–5.543; p = 0.001) were independently associated with unfavorable (GOS1−3) outcome.ConclusionLarger postoperative depressed brain volume was the only factor independently associated with suspected postoperative seizure, and it could help identify a subgroup of patients with higher susceptibility to epileptic events. Based on our data, no formal recommendation can be made regarding the prophylactic use of anti-epileptic drugs. Nevertheless, the relative safety of new generation AEDs and the detrimental effect of postoperative seizure on outcome may justify its use in a selected patient population.
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Affiliation(s)
- Hussam Hamou
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Mohammed Alzaiyani
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Tobias Rossmann
- Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Rastislav Pjontek
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Benedikt Kremer
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Hasan Zaytoun
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
- *Correspondence: Michael Veldeman
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Kong WY, Marawar R. Acute symptomatic seizures and status epilepticus in older adults: A narrative review focusing on management and outcomes. Front Neurol 2022; 13:954986. [PMID: 36090864 PMCID: PMC9458973 DOI: 10.3389/fneur.2022.954986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022] Open
Abstract
A clear narrative of acute symptomatic seizures (ASyS) in older adults is lacking. Older adults (≥60 years) have the highest incidence of seizures of all age groups and necessitate a tailored approach. ASyS has a bimodal peak in infancy and old age (82.3–123.2/100,000/year after 65 years of age). ASyS can represent half of the new-onset seizures in older adults and can progress to acute symptomatic status epilepticus (ASySE) in 52–72% of the patients. Common etiologies for ASyS in older adults include acute stroke and metabolic disturbances. For ASySE, common etiologies are acute stroke and anoxic brain injury (ABI). Initial testing for ASyS should be consistent with the most common and urgent etiologies. A 20-min electroencephalogram (EEG) is less sensitive in older adults than in younger adults and might not help predict chronic epilepsy. The prolonged postictal phase is an additional challenge for acute management. Studies note that 30% of older adults with ASyS subsequently develop epilepsy. The risk of wrongly equating ASyS as the first seizure of epilepsy is higher in older adults due to the increased long-term challenges with chronic anti-seizure medication (ASM) treatment. Specific challenges to managing ASyS in older adults are related to their chronic comorbidities and polypharmacy. It is unclear if the prognosis of ASyS is dependent on the underlying etiology. Short-term mortality is 1.6 to 3.6 times higher than younger adults. ASySE has high short-term mortality, especially when it is secondary to acute stroke. An acute symptomatic etiology of ASySE had five times increased risk of short-term mortality compared to other types of etiology.
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Blaauw J, Zundert JMV, Hertog HM, Gaag NA, Jellema K, Dammers R, Groen RJM, Lingsma HF, Naalt J, Jacobs B. Pathophysiology of transient neurological deficit in patients with chronic subdural hematoma: A systematic review. Acta Neurol Scand 2022; 145:649-657. [PMID: 35355247 DOI: 10.1111/ane.13617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/01/2022] [Accepted: 03/19/2022] [Indexed: 11/29/2022]
Abstract
Patients with chronic subdural hematoma (CSDH) can have transient neurological deficits deficit (TND) mimicking transient ischemic attacks. The prevalence of TNDs in CSDH varies between 1%-24%, depending on TND definition. Despite this high prevalence the pathophysiology of TND in CSDH is not clear in many cases. In this systematic review, we aim to unravel the responsible mechanism. Pubmed and Embase were searched for all articles concerning the pathophysiology of TND as a presenting symptom in patients with CSDH. There were no publication date restrictions for the articles in the search. Two reviewers independently selected studies for inclusion and subsequently extracted the necessary data. Out of 316 identified references, 15 met the inclusion criteria. Several articles mentioned multiple pathophysiological mechanisms. One of the proposed etiologies of TND was epileptic activity, stated by three articles. In contrast, three different studies stated that seizures are unlikely to cause TND. Five papers suggested that obstruction of blood flow, caused by the hematoma or subsequent swelling, might be the cause. Six articles made no definite statement on the responsible pathophysiological mechanism of TND. Different mechanisms have been proposed to be the cause of TNDs in patients with CSDH. Based on this review, the exact pathophysiology of TND remains unclear. We suggest that future studies on this topic should incorporate MRI of the brain (with diffusion-weighted imaging) and EEG, to provide better insight into TND pathophysiology. The knowledge resulting from future studies might contribute to better understanding of TND and optimal treatment in CSDH.
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Affiliation(s)
- Jurre Blaauw
- Department of Neurology University of Groningen University Medical Center Groningen Groningen The Netherlands
- Department of Public Health Center for Medical Decision Sciences Erasmus Medical Center Rotterdam The Netherlands
| | - Josje M. van Zundert
- Department of Neurology University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Heleen M. Hertog
- Department of Neurology Isala Hospital Zwolle Zwolle The Netherlands
| | - Niels A. Gaag
- Leiden University Medical Center University Neurosurgical Center Holland (UNCH) Leiden The Netherlands
- Haaglanden Medical Center & Haga teaching hospital The Hague The Netherlands
| | - Korné Jellema
- Department of Neurology Haaglanden Medical Centre The Hague The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery Erasmus MC Stroke Center Erasmus Medical Center Rotterdam The Netherlands
| | - Rob J. M. Groen
- Department of Neurosurgery University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Hester F. Lingsma
- Department of Public Health Center for Medical Decision Sciences Erasmus Medical Center Rotterdam The Netherlands
| | - Joukje Naalt
- Department of Neurology University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Bram Jacobs
- Department of Neurology University of Groningen University Medical Center Groningen Groningen The Netherlands
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Zawar I, Briskin I, Hantus S. Risk factors that predict delayed seizure detection on continuous electroencephalogram (cEEG) in a large sample size of critically ill patients. Epilepsia Open 2022; 7:131-143. [PMID: 34913615 PMCID: PMC8886063 DOI: 10.1002/epi4.12572] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Majority of seizures are detected within 24 hours on continuous EEG (cEEG). Some patients have delayed seizure detection after 24 hours. The purpose of this research was to identify risk factors that predict delayed seizure detection and to determine optimal cEEG duration for various patient subpopulations. METHODS We retrospectively identified all patients ≥18 years of age who underwent cEEG at Cleveland clinic during calendar year 2016. Clinical and EEG data for all patients and time to seizure detection for seizure patients were collected. RESULTS Twenty-four hundred and two patients met inclusion criteria. Of these, 316 (13.2%) had subclinical seizures. Sixty-five (20.6%) patients had delayed seizures detection after 24 hours. Seizure detection increased linearly till 36 hours of monitoring, and odds of seizure detection increased by 46% for every additional day of monitoring. Delayed seizure risk factors included stupor (13.2% after 48 hours, P = .031), lethargy (25.9%, P = .013), lateralized (LPDs) (27.7%, P = .029) or generalized periodic discharges (GPDs) (33.3%, P = .022), acute brain insults (25.5%, P = .036), brain bleeds (32.8%, P = .014), especially multiple concomitant bleeds (61.1%, P < .001), altered mental status (34.7%, P = .001) as primary cEEG indication, and use of antiseizure medications (27.8%, P < .001) at cEEG initiation. SIGNIFICANCE Given the linear seizure detection trend, 36 hours of standard monitoring appears more optimal than 24 hours especially for high-risk patients. For awake patients without epileptiform discharges, <24 hours of monitoring appears sufficient. Previous studies have shown that coma and LPDs predict delayed seizure detection. We found that stupor and lethargy were also associated with delayed seizure detection. LPDs and GPDs were associated with delayed seizures. Other delayed seizure risk factors included acute brain insults, brain bleeds especially multiple concomitant bleeds, altered mental status as primary cEEG indication, and use of ASMs at cEEG initiation. Longer cEEG (≥48 hours) is suggested for these high-risk patients.
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Affiliation(s)
- Ifrah Zawar
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
- University of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Isaac Briskin
- Department of Quantitative Health SciencesLerner Research InstituteCleveland ClinicClevelandOhioUSA
| | - Stephen Hantus
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhioUSA
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Lane JR, Ssentongo P, Peterson MR, Harper JR, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Onen J, Donnelly R, Levenbach J, Cherukuri V, Monga V, Kulkarni AV, Warf BC, Schiff SJ. Preoperative risk and postoperative outcome from subdural fluid collections in African infants with postinfectious hydrocephalus. J Neurosurg Pediatr 2022; 29:31-39. [PMID: 34598146 PMCID: PMC9078082 DOI: 10.3171/2021.7.peds21209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study investigated the incidence of postoperative subdural collections in a cohort of African infants with postinfectious hydrocephalus. The authors sought to identify preoperative factors associated with increased risk of development of subdural collections and to characterize associations between subdural collections and postoperative outcomes. METHODS The study was a post hoc analysis of a randomized controlled trial at a single center in Mbale, Uganda, involving infants (age < 180 days) with postinfectious hydrocephalus randomized to receive either an endoscopic third ventriculostomy plus choroid plexus cauterization or a ventriculoperitoneal shunt. Patients underwent assessment with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III; sometimes referred to as BSID-III) and CT scans preoperatively and then at 6, 12, and 24 months postoperatively. Volumes of brain, CSF, and subdural fluid were calculated, and z-scores from the median were determined from normative curves for CSF accumulation and brain growth. Linear and logistic regression models were used to characterize the association between preoperative CSF volume and the postoperative presence and size of subdural collection 6 and 12 months after surgery. Linear regression and smoothing spline ANOVA were used to describe the relationship between subdural fluid volume and cognitive scores. Causal mediation analysis distinguished between the direct and indirect effects of the presence of a subdural collection on cognitive scores. RESULTS Subdural collections were more common in shunt-treated patients and those with larger preoperative CSF volumes. Subdural fluid volumes were linearly related to preoperative CSF volumes. In terms of outcomes, the Bayley-III cognitive score was linearly related to subdural fluid volume. The distribution of cognitive scores was significantly different for patients with and those without subdural collections from 11 to 24 months of age. The presence of a subdural collection was associated with lower cognitive scores and smaller brain volume 12 months after surgery. Causal mediation analysis demonstrated evidence supporting both a direct (76%) and indirect (24%) effect (through brain volume) of subdural collections on cognitive scores. CONCLUSIONS Larger preoperative CSF volume and shunt surgery were found to be risk factors for postoperative subdural collection. The size and presence of a subdural collection were negatively associated with cognitive outcomes and brain volume 12 months after surgery. These results have suggested that preoperative CSF volumes could be used for risk stratification for treatment decision-making and that future clinical trials of alternative shunt technologies to reduce overdrainage should be considered.
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Affiliation(s)
- Jessica R. Lane
- Department of Neurosurgery, Penn State College of Medicine, Hershey
| | - Paddy Ssentongo
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park,Department of Public Health Sciences, Penn State College of Medicine, Hershey
| | - Mallory R. Peterson
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park
| | - Joshua R. Harper
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park
| | | | | | - Peter Ssenyonga
- CURE Children’s Hospital of Uganda, Mbale,Mulago National Referral Hospital, Kampala, Uganda
| | - Justin Onen
- CURE Children’s Hospital of Uganda, Mbale,Mulago National Referral Hospital, Kampala, Uganda
| | - Ruth Donnelly
- Division of Neurosurgery, University of Toronto, Hospital for Sick Children, Toronto
| | - Jody Levenbach
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Venkateswararao Cherukuri
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park
| | - Vishal Monga
- School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, University of Toronto, Hospital for Sick Children, Toronto
| | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children’s Hospital and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Schiff
- Department of Neurosurgery, Penn State College of Medicine, Hershey,Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park,Department of Physics, The Pennsylvania State University, University Park, Pennsylvania
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Zöllner JP, Schmitt FC, Rosenow F, Kohlhase K, Seiler A, Strzelczyk A, Stefan H. Seizures and epilepsy in patients with ischaemic stroke. Neurol Res Pract 2021; 3:63. [PMID: 34865660 PMCID: PMC8647498 DOI: 10.1186/s42466-021-00161-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy. CONCLUSION PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.
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Affiliation(s)
- Johann Philipp Zöllner
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | | | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Konstantin Kohlhase
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Seiler
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Hermann Stefan
- Department of Neurology - Biomagnetism, University Hospital Erlangen, Erlangen, Germany
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Chihi M, Darkwah Oppong M, Quesada CM, Dinger TF, Gembruch O, Pierscianek D, Ahmadipour Y, Uerschels AK, Wrede KH, Sure U, Jabbarli R. Role of Brain Natriuretic Peptide in the Prediction of Early Postoperative Seizures Following Surgery for Traumatic Acute Subdural Hematoma: A Prospective Study. Neurol Ther 2021; 10:847-863. [PMID: 34342872 PMCID: PMC8571437 DOI: 10.1007/s40120-021-00269-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Brain natriuretic peptide (BNP) is a reliable biomarker in the acute phase of traumatic brain injury. However, the relationship between BNP and traumatic acute subdural hematoma (aSDH) has not yet been addressed. This study aimed to analyze BNP levels on admission in surgically treated patients and assess their relationship with early postoperative seizures (EPS) and functional outcomes. METHODS Patients with unilateral traumatic aSDH who were surgically treated in our department between July 2017 and May 2020 were included in the study. BNP was preoperatively measured. Patients' neurologic condition, radiographic variables on initial cranial computed tomography, sodium serum levels on admission, and occurrence of EPS were prospectively assessed. Functional outcome was assessed using the modified Rankin Scale (mRS) at discharge and follow-up (at 2-3 months). A poor outcome was defined by a mRS score > 3. RESULTS EPS occurred in 20 (19.6%) of 102 surgically treated patients in the final cohort on the median day 3. A significant association between EPS and a poor Glasgow Coma Scale score at the 7th postoperative day was found, which in turn independently predicted a poor functional outcome at discharge and follow-up. Nonetheless, EPS were not associated with poor functional outcomes. The multivariate analysis revealed BNP > 95.4 pg/ml (aOR = 5.7, p = 0.003), sodium < 137.5 mmol/l (aOR = 4.6, p = 0.009), and left-sided aSDH (aOR = 4.4, p = 0.020) as independent predictors of EPS. CONCLUSION In the early postoperative phase of traumatic aSDH, EPS were associated with worse neurologic conditions, which in turn independently predicted poor outcomes at discharge and follow-up. Although several EPS risk factors have already been elucidated, this study presents BNP as a novel reliable predictor of EPS. Further larger studies are needed to determine whether a more precise estimate of EPS risk using BNP levels can be reached.
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Affiliation(s)
- Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Carlos M Quesada
- Department of Neurology, Center of Epileptology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Wasfie T, Fitzpatrick N, Niasan M, Hille JL, Yapchai R, Hella J, Barber K, Brimmier A, Shapiro B. Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly. Am Surg 2021; 88:372-375. [PMID: 34794326 DOI: 10.1177/00031348211056279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. METHODS A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. RESULTS There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). CONCLUSION Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.
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Affiliation(s)
- Tarik Wasfie
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Nicholas Fitzpatrick
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Mursal Niasan
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Jennifer L Hille
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Raquel Yapchai
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Jennifer Hella
- Department of Academic Research, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Kimberly Barber
- Department of Academic Research, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Alexis Brimmier
- School of Osteopathic Medicine, 12266Michigan State University, Lansing, MI, USA
| | - Brian Shapiro
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
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Abstract
PURPOSE OF REVIEW This article discusses neurologic complications encountered in the postoperative care of neurosurgical patients that are common or key to recognize in the immediate postoperative period. The major neurosurgical subspecialty procedures (cerebrovascular neurosurgery, neuro-oncology, epilepsy neurosurgery, functional neurosurgery, CSF diversion, endovascular neurosurgery, and spinal surgery) are broadly included under craniotomy procedures, endovascular/vascular procedures, and spinal procedures. This article focuses on the range of complications inherent in these approaches with specific scenarios addressed as applicable. RECENT FINDINGS The morbidity and mortality related to neurosurgical procedures remains high, necessitating ongoing research and quality improvement efforts in perioperative screening, intraoperative management, surgical approaches, and postoperative care of these patients. Emerging research continues to investigate safer and newer options for routine neurosurgical approaches, such as coiling over clipping for amenable aneurysms, endoscopic techniques for transsphenoidal hypophysectomy, and minimally invasive spinal procedures; postoperative monitoring and care of patients after these procedures continues to be a key component in the continuum of care for improving outcomes. SUMMARY Postoperative care of patients undergoing major neurosurgical procedures is an integral part of many neurocritical care practices. Neurosurgeons often enlist help from neurologists to assist with evaluation, interpretation, and management of complications in routine inpatient settings. Awareness of the common neurologic complications of various neurosurgical procedures can help guide appropriate clinical monitoring algorithms and quality improvement processes for timely evaluation and management of these patients.
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Deep Versus Lobar Intraparenchymal Hemorrhage: Seizures, Hyperexcitable Patterns, and Clinical Outcomes. Crit Care Med 2021; 48:e505-e513. [PMID: 32301843 DOI: 10.1097/ccm.0000000000004317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare electrographic seizures, hyperexcitable patterns, and clinical outcomes in lobar and deep intraparenchymal hemorrhage. Additionally, to characterize electrographic seizure and hyperexcitable pattern predictors in each group and determine seizure risk with thalamic involvement. DESIGN Retrospective cohort study. SETTING Tertiary academic medical center. PATIENTS Consecutive adult patients with nontraumatic intraparenchymal hemorrhage undergoing continuous electroencephalography at our center between January 2013 and December 2016. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Based on head CT closest to the initial continuous electroencephalography session, we classified intraparenchymal hemorrhage as isolated deep (no insular, subarachnoid, subdural extension) or lobar. Hyperexcitable patterns included the following: periodic discharges, spike-wave complexes, any rhythmic delta other than generalized. We used Fisher exact test for categorical and Mann-Whitney U test for continuous variables. Multivariable regression identified predictors of electrographic seizures, hyperexcitable patterns, and poor outcomes (score of 1-2 on Glasgow Outcome Scale) in lobar intraparenchymal hemorrhage. The cohort comprised of 128 patients, 88 lobar, and 40 deep intraparenchymal hemorrhage. Electrographic seizures occurred in 17% of lobar and 5% of deep intraparenchymal hemorrhage (p = 0.09). Hyperexcitable patterns were more frequent in the lobar group (44.3% vs 17.5%; p = 0.005). In multivariable analyses in the lobar group, lateralized rhythmic delta activity predicted electrographic seizures (odds ratio, 6.24; CI, 1.49-26.08; p = 0.012); insular involvement predicted hyperexcitable patterns (odds ratio, 4.88; CI, 1.36-17.57; p = 0.015); coma, temporal lobe involvement, intraparenchymal hemorrhage volume, and electrographic seizures predicted poor outcome. Thalamic involvement did not affect electrographic seizures or hyperexcitable patterns in either group. CONCLUSIONS Electrographic seizures are frequent in lobar intraparenchymal hemorrhage, occurring in one in six monitored patients, as opposed to only 5% in isolated deep intraparenchymal hemorrhage not extending to cortex/insula, subarachnoid, or subdural spaces. Patients with lobar intraparenchymal hemorrhage and lateralized rhythmic delta activity were six times as likely to have electrographic seizures, which were associated with 5.47 higher odds of a poor outcome. Coma, temporal lobe involvement, hematoma volume, and electrographic seizures predicted poor outcome in lobar intraparenchymal hemorrhage.
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Won SY, Freiman TM, Reif PS, Dubinski D, Hattingen E, Herrmann E, Seifert V, Rosenow F, Strzelczyk A, Konczalla J. DIagnostic Subdural EEG electrodes And Subdural hEmatoma (DISEASE): a study protocol for a prospective nonrandomized controlled trial. Neurol Res Pract 2020; 2:50. [PMID: 33344885 PMCID: PMC7737265 DOI: 10.1186/s42466-020-00096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background Epileptic seizures are common clinical features in patients with acute subdural hematoma (aSDH); however, diagnostic feasibility and therapeutic monitoring remain limited. Surface electroencephalography (EEG) is the major diagnostic tool for the detection of seizures but it might be not sensitive enough to detect all subclinical or nonconvulsive seizures or status epilepticus. Therefore, we have planned a clinical trial to evaluate a novel treatment modality by perioperatively implanting subdural EEG electrodes to diagnose seizures; we will then treat the seizures under therapeutic monitoring and analyze the clinical benefit. Methods In a prospective nonrandomized trial, we aim to include 110 patients with aSDH. Only patients undergoing surgical removal of aSDH will be included; one arm will be treated according to the guidelines of the Brain Trauma Foundation, while the other arm will additionally receive a subdural grid electrode. The study’s primary outcome is the comparison of incidence of seizures and time-to-seizure between the interventional and control arms. Invasive therapeutic monitoring will guide treatment with antiseizure drugs (ASDs). The secondary outcome will be the functional outcome for both groups as assessed via the Glasgow Outcome Scale and modified Rankin Scale both at discharge and during 6 months of follow-up. The tertiary outcome will be the evaluation of chronic epilepsy within 2–4 years of follow-up. Discussion The implantation of a subdural EEG grid electrode in patients with aSDH is expected to be effective in diagnosing seizures in a timely manner, facilitating treatment with ASDs and monitoring of treatment success. Moreover, the occurrence of epileptiform discharges prior to the manifestation of seizure patterns could be evaluated in order to identify high-risk patients who might benefit from prophylactic treatment with ASDs. Trial registration ClinicalTrials.gov identifier no. NCT04211233.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Philipp S Reif
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Elke Hattingen
- Institutes of Neuroradiology, Goethe University, Frankfurt, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
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Hammer D, Scheuer M, Fong-Isariyawongse J. Pearls & Oy-sters: Cyclic Seizures and Heart Rate Variability. Neurology 2020; 96:e1694-e1696. [PMID: 33277425 DOI: 10.1212/wnl.0000000000011317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Hammer
- From the Department of Neurology (D.H., J.F.-I.), University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), University of Pittsburgh Medical Center, PA; and Persyst Development Corporation (M.S.), Solana Beach, CA
| | - Mark Scheuer
- From the Department of Neurology (D.H., J.F.-I.), University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), University of Pittsburgh Medical Center, PA; and Persyst Development Corporation (M.S.), Solana Beach, CA
| | - Joanna Fong-Isariyawongse
- From the Department of Neurology (D.H., J.F.-I.), University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), University of Pittsburgh Medical Center, PA; and Persyst Development Corporation (M.S.), Solana Beach, CA.
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19
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Moosavi R, Swisher CB. Acute Provoked Seizures-Work-Up and Management in Adults. Semin Neurol 2020; 40:595-605. [PMID: 33155185 DOI: 10.1055/s-0040-1719075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute provoked seizures, also known as acute symptomatic seizures, occur secondary to a neurological or systemic precipitant, commonly presenting as a first-time seizure. In this article, we will discuss etiology, emergent protocols, medical work-up, initial treatment, and management of these seizures. The definitions, classifications, and management of convulsive status epilepticus and nonconvulsive status epilepticus in an acute setting will also be reviewed.
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Affiliation(s)
- Rana Moosavi
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Christa B Swisher
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
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20
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Suresh V, Sharma S. Medical Management of Chronic Subdural Hematoma with Tranexamic Acid. J Stroke Cerebrovasc Dis 2020; 30:105396. [PMID: 33097374 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Varun Suresh
- Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala 695011, India.
| | - Saurabh Sharma
- Department of Neuro-anesthesia and Neuro-critical care, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha 751024, India
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Won SY, Dubinski D, Freiman T, Seifert V, Gessler F, Strzelczyk A, Konczalla J. Acute-on-chronic subdural hematoma: a new entity for prophylactic anti-epileptic treatment? Eur J Trauma Emerg Surg 2020; 48:933-942. [PMID: 32986132 PMCID: PMC9001543 DOI: 10.1007/s00068-020-01508-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
Purpose Acute-on-chronic subdural hematoma (acSDH) describes acute bleeding into a chronic subdural hematoma (SDH), after surgery or second trauma. Because seizures are a well-known complication of SDH, associated with substantial morbidity and mortality, we aimed to analyze the incidence of acute symptomatic seizures (ASz), including status epilepticus, and determine the functional outcomes in this specific cohort of patients. Methods A retrospective analysis was performed, including patients with acSDH who were admitted to our department between 2010 and 2019. The incidence and timely onset of ASz and status epilepticus were evaluated. Functional outcomes at discharge and at 3–6 month follow-up were analyzed based on the modified Rankin scale. Results Of 506 patients with chronic SDH, 29 patients (5.7%) were diagnosed with acSDH. The overall incidence of ASz and status epilepticus were 72.4% and 10.3%, respectively. Favorable outcomes were identified in 11 patients (52.4%) in the ASz group compared with 6 patients (75%) in the non-ASz group. The mortality rate was higher in the ASz group compared with that in the control group (29% vs 0%). At follow-up, favorable outcomes were similar to those observed at discharge (52.4% in the ASz group and 71.4% in the control group). The mortality rate was still higher in the ASz group, at 32% compared with 14% for the control group. Conclusion AcSDH has a high risk for ASz, including status epilepticus, and is associated with unfavorable outcomes and high mortality. Thus, prophylactic treatment with antiepileptic drugs should be considered among this specific cohort of patients.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Thomas Freiman
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.,Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.,Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
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22
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Role of prophylactic antiepileptic drugs in chronic subdural hematoma-a systematic review and meta-analysis. Neurosurg Rev 2020; 44:2069-2077. [PMID: 32910368 DOI: 10.1007/s10143-020-01388-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
Chronic subdural hematoma is a common neurosurgical pathology, which is more commonly seen in the elderly age group. Few patients with chronic subdural hematoma (cSDH) can have seizures-either before or after surgical intervention. Reported incidence of seizures varies from 0.7-18.5% in patients with cSDH. Many factors which have been proposed to increase the risk of seizures in these patients include the presence of encapsulated membranes, occult cortical injury, mass effect, or an acute hemorrhage. The role of prophylactic antiepileptic drugs is not very clear in cSDH. We reviewed the currently available evidence for the use of prophylactic antiepileptic drugs (AEDs) in patients with cSDH. We included 13 studies in the systematic review and 6 studies compared the incidence of seizures in patients who received antiepileptic drugs with those who did not. Our review did not find any significant reduction in the incidence of seizures in patients with cSDH following administration of antiepileptic drugs.
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23
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Brown SC, King ZA, Kuohn L, Kamel H, Gilmore EJ, Frontera JA, Murthy S, Kim JA, Omay SB, Falcone GJ, Sheth KN. Association of race and ethnicity to incident epilepsy, or epileptogenesis, after subdural hematoma. Neurology 2020; 95:e2890-e2899. [PMID: 32907969 DOI: 10.1212/wnl.0000000000010742] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 06/25/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether race is associated with the development of epilepsy after subdural hematoma (SDH), we identified adult survivors of SDH in a statewide administrative dataset and followed them up for at least 1 year for revisits associated with epilepsy. METHODS We performed a retrospective cohort study using claims data on all discharges from emergency departments (EDs) and hospitals in California. We identified adults (age ≥18 years) admitted from 2005 to 2011 with first-time traumatic and nontraumatic SDH. We used validated diagnosis codes to identify a primary outcome of ED or inpatient revisit for epilepsy. We used multivariable Cox regression for survival analysis to identify demographic and medical risk factors for epilepsy. RESULTS We identified 29,342 survivors of SDH (mean age 71.2 [SD 16.4] years, female sex 11,954 [41.1%]). Three thousand two hundred thirty (11.0%) patients had revisits to EDs or hospitals with a diagnosis of epilepsy during the study period. Black patients (n = 1,684 [5.7%]) had significantly increased risk compared to White patients (n = 16,945 [57.7%]; hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.28-1.64, p < 0.001). Status epilepticus during the index SDH admission, although infrequent (n = 94 [0.3%]), was associated with a nearly 4-fold risk of epilepsy (HR 3.75, 95% CI 2.80-5.03, p < 0.001). Alcohol use, drug use, smoking, renal disease, and markers of injury severity (i.e., intubation, surgical intervention, length of stay, disposition other than home) were also associated with epilepsy (all p < 0.05). CONCLUSIONS We found an association between Black race and ED and hospital revisits for epilepsy after SDH, establishing the presence of a racial subgroup that is particularly vulnerable to post-SDH epileptogenesis.
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Affiliation(s)
- Stacy C Brown
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Zachary A King
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Lindsey Kuohn
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Hooman Kamel
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Emily J Gilmore
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Jennifer A Frontera
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Santosh Murthy
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Jennifer A Kim
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Sacit Bulent Omay
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Guido J Falcone
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York
| | - Kevin N Sheth
- From the Division of Neurocritical Care and Emergency Neurology (S.C.B., L.K., E.J.G., J.A.K., G.J.F., K.N.S.), Department of Neurology, and Department of Neurosurgery (S.B.O.), Yale School of Medicine, New Haven, CT; David Geffen School of Medicine at UCLA (Z.A.K.), Los Angeles, CA; Department of Neurology (H.K., S.M.), Weill Cornell Medicine; and Department of Neurology (J.A.F.), New York University School of Medicine, New York.
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24
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Golub D, Ashayeri K, Dogra S, Lewis A, Pacione D. Benefits of the Subdural Evacuating Port System (SEPS) Procedure Over Traditional Craniotomy for Subdural Hematoma Evacuation. Neurohospitalist 2020; 10:257-265. [PMID: 32983343 DOI: 10.1177/1941874420920520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background There remains no consensus on the optimal primary intervention for subdural hematoma (SDH). Although historically favored, craniotomy carries substantial morbidity and incurs significant costs. Contrastingly, the subdural evacuating port system (SEPS) is a minimally invasive bedside procedure. We assessed the benefits of SEPS over traditional craniotomy for SDH evacuation. Methods A single-center retrospective cohort study of SDH patients receiving craniotomy or SEPS between 2012 and 2017 was performed. Information regarding demographics, medical history, presentation, surgical outcomes, cost, and complications was collected. Pre- and postoperative hematoma volumes were calculated using 3D image segmentation using Vitrea software. Multivariate regression models were employed to assess the influence of intervention choice. Results Of 107 patients, 68 underwent craniotomy and 39 underwent SEPS. There were no differences in age, sex, blood thinner use, platelet count, INR, hematoma lateralization, age, volume, or midline shift at presentation between intervention groups. Although there was no difference in percent residual hematoma volume 24-hour postintervention (44.1% vs 45.1%, P = .894), SEPS was associated with lower hospitalization costs ($108 391 vs $166 318, *P = .002), shorter length of stay (4.0 vs 5.8 days, *P = .0002), and fewer postoperative seizures (2.6% vs 17.7%, *P = .048). Reoperation rate was higher after SEPS overall (33.3% vs 13.2%, *P = .048) but comparable to craniotomy in chronic SDH (12.50% vs 7.69%, P = 1.000). Conclusion In this retrospective cohort, SEPS was noninferior to craniotomy at reducing SDH hematoma volume. The SEPS procedure was also associated with decreased length of stay hospitalization costs, and postoperative seizures and demonstrated a comparable recurrence rate to craniotomy for chronic SDH in particular.
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Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, NYU School of Medicine, NYU Langone Health, New York, NY, USA
| | - Kimberly Ashayeri
- Department of Neurosurgery, NYU School of Medicine, NYU Langone Health, New York, NY, USA
| | - Siddhant Dogra
- Department of Radiology, NYU School of Medicine, NYU Langone Health, New York, NY, USA
| | - Ariane Lewis
- Department of Neurosurgery, NYU School of Medicine, NYU Langone Health, New York, NY, USA.,Department of Neurology, NYU School of Medicine, NYU Langone Health, New York, NY, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU School of Medicine, NYU Langone Health, New York, NY, USA
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25
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Won SY, Dubinski D, Eibach M, Gessler F, Herrmann E, Keil F, Seifert V, Konczalla J, Behmanesh B. External validation and modification of the Oslo grading system for prediction of postoperative recurrence of chronic subdural hematoma. Neurosurg Rev 2020; 44:961-970. [PMID: 32112162 DOI: 10.1007/s10143-020-01271-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/18/2019] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
Recently, Oslo grading system (OGS) for prediction of recurrence in chronic subdural hematoma (cSDH) was introduced. The aim of the study was to validate and if applicable to modify the grading system. Data of all patients admitted to the Goethe University Hospital between 2016 and 2018 with chronic subdural hematoma were prospectively entered into a database. Dataset of patients with uni- (n = 272) and bilateral cSDH (n = 177) were used for the validation of OGS via logistic regression analysis. Additional predictors were identified and integrated to build a modified OGS (mOGS). Internal validation of the modified OGS was performed using same dataset of patients. The OGS showed a significant good predictive value with correlating increase of recurrence rate depending on the level of score in unilateral cSDH (p = 0.002). Regarding bilateral cSDH, there was no significant predictive value found (p = 0.921). By performing uni- and multivariate analysis, additional predictors for recurrence in uni- and bilateral cSDH were identified and integrated into the score system. Accordingly, the mOGS for unilateral cSDH inherited 4 components: previous OGS with 3 components (OR1.6) and seizure (OR2.5) (0 point, 0% recurrence rate; 1-2 points, 17.4%; 3-4 points, 30.6%; ≥ 5 points, 80%). Regarding bilateral cSDH, the mOGS consisted of 4 components as well: hypodense/gradation subtypes (OR3.3), postoperative unilateral volume > 80 mL (OR7.4), postoperative unilateral air trapping > 80 mL (OR15.3), and seizure (OR5.5) (0 point, 3.6% recurrence rate; 1 point, 30.6%; 2 points, 53.5%; 3 points, 58.3%; ≥ 4 points, 100%). Furthermore, the mOGS was internally verified showing high significant predictive power for recurrent hematoma in uni- (p = 0.004) and bilateral cSDH (p < 0.001). External validation of OGS showed accurate risk stratification of recurrence in unilateral cSDH; however, the validation failed for bilateral cSDH. Thus, mOGS was developed to strengthen its clinical utility and applicability.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Michael Eibach
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Frankfurt am Main, Germany
| | - Fee Keil
- Department of Neuroradiology, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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26
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Moffet EW, Subramaniam T, Hirsch LJ, Gilmore EJ, Lee JW, Rodriguez-Ruiz AA, Haider HA, Dhakar MB, Jadeja N, Osman G, Gaspard N, Struck AF. Validation of the 2HELPS2B Seizure Risk Score in Acute Brain Injury Patients. Neurocrit Care 2020; 33:701-707. [PMID: 32107733 DOI: 10.1007/s12028-020-00939-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Seizures are common after traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage (aSAH), subdural hematoma (SDH), and non-traumatic intraparenchymal hemorrhage (IPH)-collectively defined herein as acute brain injury (ABI). Most seizures in ABI are subclinical, meaning that they are only detectable with EEG. A method is required to identify patients at greatest risk of seizures and thereby in need of prolonged continuous EEG monitoring. 2HELPS2B is a simple point system developed to address this need. 2HELPS2B estimates seizure risk for hospitalized patients using five EEG findings and one clinical finding (pre-EEG seizure). The initial 2HELPS2B study did not specifically assess the ABI subpopulation. In this study, we aim to validate the 2HELPS2B score in ABI and determine its relative predictive accuracy compared to a broader set of clinical and electrographic factors. METHODS We queried the Critical Care EEG Monitoring Research Consortium database for ABI patients age ≥ 18 with > 6 h of continuous EEG monitoring; data were collected between February 2013 and November 2018. The primary outcome was electrographic seizure. Clinical factors considered were age, coma, encephalopathy, ABI subtype, and acute suspected or confirmed pre-EEG clinical seizure. Electrographic factors included 18 EEG findings. Predictive accuracy was assessed using a machine-learning paradigm with area under the receiver operator characteristic (ROC) curve as the primary outcome metric. Three models (clinical factors alone, EEG factors alone, EEG and clinical factors combined) were generated using elastic-net logistic regression. Models were compared to each other and to the 2HELPS2B model. All models were evaluated by calculating the area under the curve (AUC) of a ROC analysis and then compared using permutation testing of AUC with bootstrapping to generate confidence intervals. RESULTS A total of 1528 ABI patients were included. Total seizure incidence was 13.9%. Seizure incidence among ABI subtype varied: IPH 17.2%, SDH 19.1%, aSAH 7.6%, TBI 9.2%. Age ≥ 65 (p = 0.015) and pre-cEEG acute clinical seizure (p < 0.001) positively affected seizure incidence. Clinical factors AUC = 0.65 [95% CI 0.60-0.71], EEG factors AUC = 0.82 [95% CI 0.77-0.87], and EEG and clinical factors combined AUC = 0.84 [95% CI 0.80-0.88]. 2HELPS2B AUC = 0.81 [95% CI 0.76-0.85]. The 2HELPS2B AUC did not differ from EEG factors (p = 0.51), or EEG and clinical factors combined (p = 0.23), but was superior to clinical factors alone (p < 0.001). CONCLUSIONS Accurate seizure risk forecasting in ABI requires the assessment of EEG markers of pathologic electro-cerebral activity (e.g., sporadic epileptiform discharges and lateralized periodic discharges). The 2HELPS2B score is a reliable and simple method to quantify these EEG findings and their associated risk of seizure.
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Affiliation(s)
- Eric W Moffet
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, 7131 MFCB, 600 Highland Avenue, Madison, WI, 53705, USA.,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thanujaa Subramaniam
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, 7131 MFCB, 600 Highland Avenue, Madison, WI, 53705, USA
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Hiba A Haider
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Monica B Dhakar
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Neville Jadeja
- Department of Neurology, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gamaledin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Nicolas Gaspard
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.,Département de Neurologie, Université Libre de Bruxelles, Hôspital Erasme, Brussels, Belgium
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, 7131 MFCB, 600 Highland Avenue, Madison, WI, 53705, USA.
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27
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Huang J, Gao C, Dong J, Zhang J, Jiang R. Drug treatment of chronic subdural hematoma. Expert Opin Pharmacother 2020; 21:435-444. [PMID: 31957506 DOI: 10.1080/14656566.2020.1713095] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jingfei Dong
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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28
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Lavergne P, Labidi M, Brunet MC, Lessard Bonaventure P, Zetchi A, Carrondo Cottin S, Simonyan D, Turmel A. Efficacy of antiseizure prophylaxis in chronic subdural hematoma: a cohort study on routinely collected health data. J Neurosurg 2020; 132:284-288. [PMID: 30660118 DOI: 10.3171/2018.9.jns182092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/20/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common neurosurgical condition that can result in significant morbidity. The incidence of epileptic events associated with CSDH reported in the literature varies considerably and could potentially increase morbidity and mortality rates. The effectiveness of antiepileptic prophylaxis for this indication remains unclear. The primary objective of this study was to assess the relevance of anticonvulsant prophylaxis in reducing seizure events in patients with CSDH. METHODS All consecutive cases of CSDH from January 1, 2005, to May 30, 2014, at the Hôpital de l'Enfant-Jésus in Quebec City were retrospectively reviewed. Sociodemographic data, antiepileptic prophylaxis use, incidence of ictal events, and clinical and radiological outcome data were collected. Univariate analyses were done to measure the effect of antiepileptic prophylaxis on ictal events and to identify potential confounding factors. Multivariate logistic regression was performed to evaluate factors associated with epileptic events. RESULTS Antiepileptic prophylaxis was administered in 28% of the patients, and seizures occurred in 11%. Univariate analyses showed an increase in the incidence of ictal events in patients receiving prophylaxis (OR 5.92). Four factors were identified as being associated with seizures: septations inside the hematoma, membranectomy, antiepileptic prophylaxis, and a new deficit postoperatively. Antiepileptic prophylaxis was not associated with seizures in multivariate analyses. CONCLUSIONS Antiepileptic prophylaxis does not seem to be effective in preventing seizures in patients with CSDH. However, due to the design of this study, it is difficult to conclude definitively about the usefulness of this prophylactic therapy that is widely prescribed for this condition.
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Affiliation(s)
- Pascal Lavergne
- 1Department of Surgery, Division of Neurosurgery, CHU de Québec-Université Laval, Quebec City
| | - Moujahed Labidi
- 2Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal
| | - Marie-Christine Brunet
- 1Department of Surgery, Division of Neurosurgery, CHU de Québec-Université Laval, Quebec City
| | | | - Akli Zetchi
- 1Department of Surgery, Division of Neurosurgery, CHU de Québec-Université Laval, Quebec City
| | | | - David Simonyan
- 4Clinical and Evaluative Research Platform, CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada
| | - André Turmel
- 1Department of Surgery, Division of Neurosurgery, CHU de Québec-Université Laval, Quebec City
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Oshida S, Akamatsu Y, Matsumoto Y, Ishigame S, Ogasawara Y, Aso K, Kashimura H. A case of chronic subdural hematoma demonstrating the epileptic focus at the area with sulcal hyperintensity on fluid-attenuated inversion recovery image. Radiol Case Rep 2019; 14:1109-1112. [PMID: 31338136 PMCID: PMC6629924 DOI: 10.1016/j.radcr.2019.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/13/2019] [Accepted: 06/27/2019] [Indexed: 11/20/2022] Open
Abstract
Although the sulcal hyperintensity on fluid-attenuated inversion recovery (FLAIR) images is detected in some chronic subdural hematoma (CSDH) cases, its clinical significance remains determined. A 77-year-old man with symptomatic CSDH presented with generalized tonic-clonic seizures at 9 days after surgery. 123I-iomazenil -single photon emission computed tomography revealed transient reduction in cortical benzodiazepine receptors binding potential at the region corresponding to that of the sulcal hyperintensity on FLAIR images. Findings of sulcal hyperintensity on FLAIR imaging under the CSDH may have a relation with the cause of epileptic seizure.
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Affiliation(s)
- Sotaro Oshida
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate 024-8507, Kitakami, Iwate, Japan
| | - Yosuke Akamatsu
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Yoshiyasu Matsumoto
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate 024-8507, Kitakami, Iwate, Japan
| | - Shinya Ishigame
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate 024-8507, Kitakami, Iwate, Japan
| | - Yasushi Ogasawara
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate 024-8507, Kitakami, Iwate, Japan
| | - Kenta Aso
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate 024-8507, Kitakami, Iwate, Japan
| | - Hiroshi Kashimura
- Department of Neurosurgery, Iwate Prefectural Chubu Hospital, 17-10 Murasakino, Kitakami, Iwate 024-8507, Kitakami, Iwate, Japan
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Won S, Dubinski D, Sautter L, Hattingen E, Seifert V, Rosenow F, Freiman T, Strzelczyk A, Konczalla J. Seizure and status epilepticus in chronic subdural hematoma. Acta Neurol Scand 2019; 140:194-203. [PMID: 31102548 DOI: 10.1111/ane.13131] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute symptomatic seizure (ASz) and status epilepticus (SE) are serious conditions associated with poor quality of life, with unfavorable psychosocial and functional outcome. Chronic subdural hematoma (cSDH) is a common neurosurgical disease related to those complications; therefore, we aimed to evaluate incidence, predictors of ASz/SE, and outcome in this cohort. METHODS We retrospectively analyzed patient diagnosed cSDH between 2010 and 2017. Beside their incidence of ASz/SE, patient characteristics, symptoms at admission, comorbidities, and all previously published relevant parameters were assessed. Recurrence rate and functional outcome were analyzed at hospital discharge and 90-day follow-up. RESULTS A total of 375 patients were included; incidence of ASz was 15.2% and of SE, 1.9%. In the univariate analysis, drainage insertion (P = 0.004; OR = 0.3) was a significant negative predictor for ASz/SE and multivariate analysis, including all significant parameters, designated GCS ≤13 at admission (P = 0.09; OR = 1.9), remote stroke (P = 0.009; OR = 2.9), and recurrence rate within 14 days (P = 0.001; OR = 3.3; with an incidence of 13%) as independent predictors for ASz/SE. Overall, patients with ASz/SE had significantly unfavorable outcome at discharge (54.7%; P < 0.001) and follow-up (39.5%; P < 0.001) with only slight improvement. Late seizures occurred in 3.8% within follow-up period. Any patient with SE had an unfavorable outcome at discharge without any improvement at follow-up having a mortality rate of 14.2%. CONCLUSION Independent predictors for ASz/SE are GCS ≤13 at admission, remote stroke, and recurrent hematoma in patients with cSDH, which is associated with worse functional outcome, particularly those with SE. Due to the higher rate of seizures than recurrence rate, a routine pre- and postoperative EEG besides CT is recommended.
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Affiliation(s)
- Sae‐Yeon Won
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Daniel Dubinski
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Lisa Sautter
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Elke Hattingen
- Institute of Neuroradiology University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Volker Seifert
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine‐Main University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Thomas Freiman
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine‐Main University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Juergen Konczalla
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
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Goertz L, Speier J, Schulte AP, Stavrinou P, Krischek B, Goldbrunner R, Timmer M. Independent Risk Factors for Postoperative Seizures in Chronic Subdural Hematoma Identified by Multiple Logistic Regression Analysis. World Neurosurg 2019; 132:e716-e721. [PMID: 31421304 DOI: 10.1016/j.wneu.2019.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postoperative seizures are potential complications of chronic subdural hematoma (cSDH). Knowledge of risk factors may help to identify patients that may benefit from antiepileptic prophylaxis. METHODS A total of 101 patients (mean age, 70.1 ± 32.1 years) with surgical evacuation of cSDH were enrolled. We retrospectively collected patient characteristics, hematoma specifics, and procedural aspects and evaluated their impact on postoperative seizures within a 14-day follow-up period by means of bivariate logistic regression analysis. RESULTS Postoperative seizures occurred in 14 patients (13.9%). At discharge, the mean Markwalder grading scale score was 1.1 ± 1.1 and 0.5 ± 0.8 in patients with and without seizures, respectively (P = 0.04). In the univariate analysis, preoperative midline shift (8.3 vs. 4.5 mm, P = 0.045), open craniotomy (85.7% vs. 55.2%, P = 0.031), and membranectomy (57.1% vs. 20.7%, P = 0.004) were significantly associated with postoperative seizures, respectively. In the multivariate analysis, preoperative midline shift (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01-1.26; P = 0.029) and membranectomy (OR, 3.9; 95% CI, 1.0-15.0; P = 0.048) remained as independent risk factors for seizures. CONCLUSIONS Perioperative antiepileptic prophylaxis may be recommended in patients with preoperative midline shift. Membranectomy may not be routinely applied during surgery.
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Affiliation(s)
- Lukas Goertz
- Department of General Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Joerg Speier
- Department of General Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | | | - Pantelis Stavrinou
- Department of General Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Boris Krischek
- Department of General Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of General Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of General Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.
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Pruitt P, Naidech A, Van Ornam J, Borczuk P. Seizure frequency in patients with isolated subdural hematoma and preserved consciousness. Brain Inj 2019; 33:1059-1063. [PMID: 31007086 DOI: 10.1080/02699052.2019.1606446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Seizures are a complication of subdural hematoma (SDH), and there is substantial variability in the use of seizure prophylaxis for patients with SDH. However, the incidence of seizures in patients with SDH without severe neurotrauma is not clear. The objective of this study was to assess the frequency of and factors associated with seizures in patients with isolated SDH (iSDH) without severe neurotrauma. Methods: In this retrospective, observational study, we identified adults with Glasgow Coma Score (GCS) ≥13 and computed tomography (CT)-documented iSDH. The primary outcome was clinical seizure frequency. Seizure medication use was also assessed. Fisher's exact test and logistic regression were used to assess association. Results: Of 643 patients with iSDH, 14 (2.2%) had seizures during hospitalization. Of 630 patients (98%) not receiving seizure medication prior to SDH, 522 (82.9%) received levetiracetam. Of the patients who received a seizure medication, 12 (2.3%) had a seizure, while of the 121 patients who did not receive seizure medications, 2 (1.9%) had a seizure (p = .49). In multivariable regression, the only variable significantly associated with seizure was thickness of subdural hematoma (OR 1.16, p = .005). Conclusion: In patients with iSDH and preserved consciousness, in-hospital seizures were rare regardless of seizure medications use.
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Affiliation(s)
- Peter Pruitt
- a Department of Emergency Medicine , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Andrew Naidech
- b Department of Neurology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Jonathan Van Ornam
- c Harvard Affiliated Emergency Medicine Residency , Boston , MA , USA.,d Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA.,e Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
| | - Pierre Borczuk
- d Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA.,e Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
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Marshman LAG. Is there any benefit from short-term perioperative antiepileptic prophylaxis in patients with chronic subdural haematoma? Neurochirurgie 2019; 65:98-99. [PMID: 30922838 DOI: 10.1016/j.neuchi.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/12/2019] [Accepted: 03/09/2019] [Indexed: 11/18/2022]
Affiliation(s)
- L A G Marshman
- Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville 4810, Queensland, Australia; School of Medicine and Dentistry, James Cook University, Douglas, Townsville 4810, Queensland, Australia.
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Driver J, DiRisio AC, Mitchell H, Threlkeld ZD, Gormley WB. Non-electrographic Seizures Due to Subdural Hematoma: A Case Series and Review of the Literature. Neurocrit Care 2019; 30:16-21. [PMID: 29476391 DOI: 10.1007/s12028-018-0503-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Seizures due to subdural hematoma (SDH) are a common finding, typically diagnosed using electroencephalography (EEG). At times, aggressive management of seizures is necessary to improve neurologic recovery and outcomes. Here, we present three patients who had undergone emergent SDH evacuation and showed postoperative focal deficits without accompanying electrographic epileptiform activity. After infarction and recurrent hemorrhage were ruled out, seizures were suspected despite a negative EEG. Patients were treated aggressively with AEDs and eventually showed clinical improvement. Long-term monitoring with EEG revealed electrographic seizures in a delayed fashion. EEG recordings are an important tool for seizure detection, but should be used as an adjunct to, rather than a replacement for, the clinical examination in the acute setting. At times, aggressive treatment of suspected postoperative seizures is warranted despite lack of corresponding electrographic activity and can improve clinical outcomes.
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Affiliation(s)
- Joseph Driver
- Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Aislyn C DiRisio
- Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Heidi Mitchell
- Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
| | - Zachary D Threlkeld
- Department of Neurology, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
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Rumalla K, Smith KA, Letchuman V, Gandham M, Kombathula R, Arnold PM. Nationwide incidence and risk factors for posttraumatic seizures in children with traumatic brain injury. J Neurosurg Pediatr 2018; 22:684-693. [PMID: 30239282 DOI: 10.3171/2018.6.peds1813] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/25/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPosttraumatic seizures (PTSs) are the most common complication following a traumatic brain injury (TBI) and may lead to posttraumatic epilepsy. PTS is well described in the adult literature but has not been studied extensively in children. Here, the authors utilized the largest nationwide registry of pediatric hospitalizations to report the national incidence, risk factors, and outcomes associated with PTS in pediatric TBI.METHODSThe authors queried the Kids' Inpatient Database (KID) using ICD-9-CM codes to identify all patients (age < 21 years) who had a primary diagnosis of TBI (850.xx-854.xx) and a secondary diagnosis of PTS (780.33, 780.39). Parameters of interest included patient demographics, preexisting comorbidities, hospital characteristics, nature of injury (open/closed), injury type (concussion, laceration/contusion, subarachnoid hemorrhage, subdural hematoma, or epidural hematoma), loss of consciousness (LOC), surgical management (Clinical Classification Software code 1 or 2), discharge disposition, in-hospital complications, and in-hospital mortality. The authors utilized the IBM SPSS statistical package (version 24) for univariate comparisons, as well as the identification of independent risk factors for PTS in multivariable analysis (alpha set at < 0.05).RESULTSThe rate of PTS was 6.9% among 124,444 unique patients hospitalized for TBI. The utilization rate of continuous electroencephalography (cEEG) was 0.3% and increased between 2003 (0.1%) and 2012 (0.7%). The most common etiologies of TBI were motor vehicle accident (n = 50,615), accidental fall (n = 30,847), and blunt trauma (n = 13,831). However, the groups with the highest rate of PTS were shaken infant syndrome (41.4%), accidental falls (8.1%), and cycling accidents (7.4%). In multivariable analysis, risk factors for PTS included age 0-5 years (compared with 6-10, 11-15, and 16-20 years), African American race (OR 1.4), ≥ 3 preexisting comorbidities (OR 4.0), shaken infant syndrome (OR 4.4), subdural hematoma (OR 1.6), closed-type injury (OR 2.3), brief LOC (OR 1.4), moderate LOC (OR 1.5), and prolonged LOC with baseline return (OR 1.8). Surgically managed patients were more likely to experience PTS (OR 1.5) unless they were treated within 24 hours of admission (OR 0.8). PTS was associated with an increased likelihood of in-hospital complications (OR 1.7) and adverse (nonroutine) discharge disposition (OR 1.2), but not in-hospital mortality (OR 0.5). The overall utilization rate of cEEG was 1.3% in PTS patients compared with 0.2% in patients without PTS. Continuous EEG monitoring was associated with higher rates of diagnosed PTS (35.4% vs 6.8%; OR 4.9, p < 0.001).CONCLUSIONSPTS is common in children with TBI and is associated with adverse outcomes. Independent risk factors for PTS include younger age (< 5 years), African American race, increased preexisting comorbidity, prolonged LOC, and injury pattern involving cortical exposure to blood products. However, patients who undergo urgent surgical evacuation are less likely to develop PTS.
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Affiliation(s)
- Kavelin Rumalla
- 1School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Kyle A Smith
- 2Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Vijay Letchuman
- 1School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Mrudula Gandham
- 1School of Medicine, University of Missouri-Kansas City, Missouri; and
| | | | - Paul M Arnold
- 2Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
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Gunawardane N, Fields M. Acute Symptomatic Seizures and Provoked Seizures: to Treat or Not to Treat? Curr Treat Options Neurol 2018; 20:41. [DOI: 10.1007/s11940-018-0525-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Won SY, Dubinski D, Bruder M, Cattani A, Seifert V, Konczalla J. Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome. Neurosurg Focus 2018; 43:E12. [PMID: 29088960 DOI: 10.3171/2017.8.focus17421] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT-with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants-is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation. METHODS In this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified. RESULTS Of 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1-2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R2 = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R2 = 0.466). OAT itself was not an independent predictor for worse outcome. CONCLUSIONS An OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Adriano Cattani
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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Kale A. Prophylactic Anticonvulsants in Patients Undergoing Craniotomy: A Single-Center Experience. Med Sci Monit 2018; 24:2578-2582. [PMID: 29700277 PMCID: PMC5941984 DOI: 10.12659/msm.908717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background There is no consensus on the efficacy of seizure prophylaxis in patients undergoing craniotomy. Some studies show that antiepileptic use decreases the risk of seizures, but other studies do not support this. The present study investigated the role of antiepileptic drugs in patient undergoing craniotomy due to various intracranial pathologies. Material/Methods A retrospective review was performed in adult patients undergoing craniotomy between January 2013 and June 2017. Results of 282 patients who did not have a history of seizures and had craniotomies for various reasons were included. In all patients with craniotomy planned, prophylactic AEDs were initiated pre-operatively. Results The incidence of postoperative seizures was 17.7% when all craniotomized patients were considered. The most commonly used anticonvulsant agent was phenytoin (75.2%). No serious antiepileptic drug reaction occurred requiring cessation of treatment. Conclusions Prophylactic antiepileptic treatment of patients undergoing craniotomy should not be continued beyond the first perioperative week if there is no serious brain injury. The intra- or extra-axial placement of the tumor affects the prophylaxis. Further randomized controlled studies are warranted in the future to investigate the efficacy of these medications.
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Affiliation(s)
- Aydemir Kale
- Department of Neurosurgery, Bülent Ecevit Üniversitesi, Zonguldak, Turkey
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39
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Khor D, Wu J, Hong Q, Benjamin E, Xiao S, Inaba K, Demetriades D. Early Seizure Prophylaxis in Traumatic Brain Injuries Revisited: A Prospective Observational Study. World J Surg 2017; 42:1727-1732. [DOI: 10.1007/s00268-017-4373-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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40
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Won SY, Dubinski D, Herrmann E, Cuca C, Strzelczyk A, Seifert V, Konczalla J, Freiman TM. Epileptic Seizures in Patients Following Surgical Treatment of Acute Subdural Hematoma-Incidence, Risk Factors, Patient Outcome, and Development of New Scoring System for Prophylactic Antiepileptic Treatment (GATE-24 score). World Neurosurg 2017; 101:416-424. [PMID: 28213197 DOI: 10.1016/j.wneu.2017.02.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/18/2022]
Abstract
OBJECT Clinically evident or subclinical seizures are common manifestations in acute subdural hematoma (aSDH); however, there is a paucity of research investigating the relationship between seizures and aSDH. The purpose of this study is 2-fold: determine incidence and predictors of seizures and then establish a guideline in patients with aSDH to standardize the decision for prophylactic antiepileptic treatment. METHOD The author analyzed 139 patients with aSDH treated from 2007 until 2015. Baseline characteristics and clinical findings including Glasgow Coma Scale (GCS) at admission, 24 hours after operation, timing of operation, anticoagulation, and Glasgow Outcome Scale at hospital discharge and after 3 months were analyzed. Multivariate logistic regression analysis was performed to detect independent predictors of seizures, and a scoring system was developed. RESULTS Of 139 patients, overall incidence of seizures was 38%, preoperatively 16% and postoperatively 24%. Ninety percent of patients with preoperative seizures were seizure free after operation for 3 months. Independent predictors of seizures were GCS <9 (odds ratio [OR] 3.3), operation after 24 hours (OR 2.0), and anticoagulation (OR 2.2). Patients with seizures had a significantly higher rate of unfavorable outcome at hospital discharge (P = 0.001) and in 3-month follow-up (P = 0.002). Furthermore, a score system (GATE-24) was developed. In patients with GCS <14, anticoagulation, or surgical treatment 24 hours after onset, a prophylactic antiepileptic treatment is recommended. CONCLUSION Occurrence of seizures affected severity and outcomes after surgical treatment of aSDH. Therefore seizure prophylaxis should be considered in high-risk patients on the basis of the GATE-24 score to promote better clinical outcome.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Colleen Cuca
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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