Prospective hemorrhage risk of intracerebral cavernous malformations

OBJECTIVE

Our goal was to describe the prospective risk and timing of symptomatic hemorrhage in a large cohort of followed patients with intracerebral cavernous malformations (ICMs).

METHODS

All patients between 1989 and 1999 with the radiographic diagnosis of intracerebral cavernous malformation were identified retrospectively. The records and radiographic data were reviewed, and follow-up after diagnosis was obtained. An incidence rate was used to calculate annual risk of symptomatic hemorrhage. Predictive factors for outcomes used univariate and multivariable analysis with p < 0.05.

RESULTS

A total of 292 patients were identified (47.3%male) with 2,035 patient years of follow-up. Seventy-four patients presented with hemorrhage, 108 with symptoms not related to hemorrhage (seizure or focal deficit), and 110 as asymptomatic. The overall annual rate of hemorrhage in those presenting initially with hemorrhage, with symptoms not related to hemorrhage, or as an incidental finding was 6.19%, 2.18%, and 0.33%, respectively. Patients who presented initially with symptomatic hemorrhage (hazard ratio 5.14; 95% confidence interval [CI] 2.54-10.4; p < 0.001) were at higher risk for future hemorrhage, and hemorrhage risk decreased with time. Male gender (hazard ratio 2.36; 95% CI 1.14-4.89; p = 0.02), and multiplicity of ICMs (hazard ratio 2.65; 95% CI 1.30-5.43; p = 0.01) also increased the risk of hemorrhage. The median time from first to second hemorrhage was 8 months.

CONCLUSIONS

This study provides an estimate of prospective annual symptomatic hemorrhage risk in patients with ICMs stratified by initial presenting symptom. Prior hemorrhage, male gender, and multiplicity of ICMs may predict future hemorrhage. Hemorrhage risk decreases with time in those initially presenting with hemorrhage.

Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy

BACKGROUND

Chronic wounds such as leg ulcers, diabetic foot ulcers and pressure sores are common in both acute and community healthcare settings. The prevention and treatment of these wounds involves many strategies: pressure-relieving beds, mattresses and cushions are universally used as measures for the prevention and treatment of pressure sores; compression therapy in a variety of forms is widely used for venous leg ulcer prevention and treatment; and a whole range of therapies involving laser, ultrasound and electricity is also applied to chronic wounds. This report covers the final three reviews from a series of seven.

AIMS

To assess the clinical effectiveness and cost- effectiveness of: (1) pressure-relieving beds, mattresses and cushions for pressure sore prevention and treatment; (2) compression therapy for the prevention and treatment of leg ulcers; (3) low-level laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy for the treatment of chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases, including MEDLINE, CINAHL, EMBASE and the Cochrane Controlled Trials Register (CENTRAL), were searched. Relevant journals, conference proceedings and bibliographies of retrieved papers were handsearched. An expert panel was also consulted.

METHODS - STUDY SELECTION

Randomised controlled trials (RCTs) which evaluated these interventions were eligible for inclusion in this review if they used objective measures of outcome such as wound incidence or healing rates. RESULTS - BEDS, MATTRESSES AND CUSHIONS FOR PRESSURE SORE PREVENTION AND TREATMENT: A total of 45 RCTs were identified, of which 40 compared different mattresses, mattress overlays and beds. Only two trials evaluated cushions, one evaluated the use of sheepskins, and two looked at turning beds/kinetic therapy. RESULTS - COMPRESSION FOR LEG ULCERS: A total of 24 trials reporting 26 comparisons were included (two of prevention and 24 of treatment strategies). RESULTS - LOW-LEVEL LASER THERAPY, THERAPEUTIC ULTRASOUND, ELECTROTHERAPY AND ELECTROMAGNETIC THERAPY: Four RCTs of laser (for venous leg ulcers), 10 of therapeutic ultrasound (for pressure sores and venous leg ulcers), 12 of electrotherapy (for ischaemic and diabetic ulcers, and chronic wounds generally) and five of electromagnetic therapy (for venous leg ulcers and pressure sores) were included. Studies were generally small, and of poor methodological quality. CONCLUSIONS (1) Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure sores in people at risk, as can pressure-relieving overlays on the operating table. One study suggests that air-fluidised therapy may increase pressure sore healing rates. (2) Compression is more effective in healing venous leg ulcers than is no compression, and multi-layered high compression is more effective than single-layer compression. High-compression hosiery was more effective than moderate compression in preventing ulcer recurrence. (3) There is generally insufficient reliable evidence to draw conclusions about the contribution of laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy to chronic wound healing.

Prevalence of Intracranial Aneurysms in Patients with Aortic Aneurysms

BACKGROUND AND PURPOSE

Previous studies have suggested an association between aortic aneurysms and intracranial aneurysms with a higher prevalence of intracranial aneurysms in patients with aortic aneurysms. The aims of the present study were to evaluate the incidence of intracranial aneurysms in a large cohort of patients with aortic aneurysms and to identify potential risk factors for intracranial aneurysms in this population.

MATERIALS AND METHODS

We included all patients with aortic aneurysms (either abdominal and/or thoracic) who had available cerebral arterial imaging and were seen at our institution during a 15-year period. We identified patients with intracranial aneurysms. Patient demographics, comorbidities, and aortic aneurysm and intracranial aneurysm sizes and locations were analyzed. Univariate analysis was performed with a χ(2) test for categoric variables and a Student t test or ANOVA for continuous variables.

RESULTS

A total of 1081 patients with aortic aneurysms were included. Of them, 440 (40.7%) had abdominal aortic aneurysms, 446 (41.3%) had thoracic aortic aneurysms, and 195 (18.0%) had both abdominal aortic and thoracic aortic aneurysms. The overall prevalence of associated intracranial aneurysms in patients with aortic aneurysms was 11.8% (128/1081), with 12.7% (56/440), 10.8% (48/446), and 12.3% (24/195), respectively, in patients with abdominal aortic aneurysms, thoracic aortic aneurysms, and both thoracic aortic aneurysms and abdominal aortic aneurysms. Female patients had a higher risk of associated intracranial aneurysms (OR = 2.08; 95% CI, 1.49-3.03; P = .0002). There was a slight association between abdominal aortic aneurysm size and the prevalence of intracranial aneurysms (OR = 1.02; 95% CI, 1.01-1.03; P = .045). There was no significant association between the locations of the aortic and intracranial aneurysms (P = .93).

CONCLUSIONS

The prevalence of intracranial aneurysms is high in patients with aortic aneurysms. Further studies examining the role and cost-effectiveness of intracranial aneurysm screening in patients are warranted.

Can we predict poor outcome at presentation in patients with lobar hemorrhage?

OBJECTIVE

Supratentorial lobar hemorrhage can be devastating. Outcome prediction at presentation is important in triage and management decisions as well as appropriate resource utilization. We performed a decision tree analysis combining clinical and CT scan features to predict poor and hopeless outcome at initial presentation in patients with lobar hemorrhage.

METHODS

We analyzed 81 patients with spontaneous lobar hemorrhage presenting within 48 hours of initial neurologic symptoms. In the first analysis, poor outcome was defined as Glasgow outcome score (GOS) of 1 (death), 2 (vegetative state) or 3 (dependence) at discharge. A second analysis was based on worst possible outcome (GOS 1-2). Binary recursive partitioning was fitted in a model, and odds ratios with 95% confidence intervals (CI) were calculated.

RESULTS

Lobes involved were temporal (36%), parietal (33%), frontal (25%) and occipital (6%). Seventy-three percent of patients presented less than 17 h after initial ictus. The probability of poor outcome was 97% (CI 85-100%) in patients with hemorrhage greater than 40 cm(3). In the subset of patients with a volume less than 40 cm(3), time interval from ictus to presentation (< 17 h) together with a Glasgow coma score (GCS) less than or equal to 13 predicted poor outcome. Eighty-five percent (CI 42-99%) of those presenting early with GCS less than or equal to 13 had a poor outcome. In the second analysis, all patients with GCS less than or equal to 12 and septum pellucidum shift > 6 mm had GOS of 1 or 2 (CI 72-100%).

CONCLUSION

Poor outcome in patients with lobar hemorrhage is associated with a hemorrhage size of more than 40 cm(3), GCS less than or equal to 13, but also dependent on time interval between ictus and presentation. This is consistent with prior studies demonstrating deterioration from enlargement may occur when patients present early on. Stupor and septum pellucidum shift greater than 6 mm on CT scan at presentation predict a hopeless outcome in conservatively treated patients. Ninety-one percent of patients were treated medically, thus these outcomes are largely a reflection of the natural history of spontaneous lobar hemorrhage. These signs may influence triage and management decisions.

Prevalence of Enterotoxin Producing Staphylococcus aureus in Stools of Patients with Nosocomial Diarrhea

BACKGROUND

Nosocomial diarrhea causes prolonged hospital stay leading to additional diagnostic and therapeutic procedures resulting in higher costs. A total of 20%-25% of antibiotic-associated diarrhea (AAD) cases are attributed to Clostridium difficile. Other microorganisms like Clostridium perfringens and Staphylococcus aureus are discussed to be associated with AAD.

PATIENTS AND METHODS

This study evaluated the prevalence of enterotoxigenic S. aureus in stool samples submitted to the laboratory with the diagnosis nosocomial diarrhea. A total of 2,727 stools from clinical patients were investigated for S. aureus and C. difficile. Samples were cultured for both bacteria and a C. difficile toxin A and B assay was performed from all stools. Isolated S. aureus were investigated for enterotoxin production and for resistance against methicillin. In addition, both assays were evaluated for determination of S. aureus enterotoxins directly in stool samples.

RESULTS

Out of 2,727 stools investigated, 198 grew S. aureus and 148 C. difficile. Toxins A/B from C. difficile were detected in 184 stools. A total of 114 S. aureus strains produced the following enterotoxins in vitro: A, 36; B, 20; C, 19; D, 68; E, 2. Both pathogens were found in 25 stools. Twenty-nine (14.6%) S. aureus strains were identified as methicillin-resistant. The two toxin assays evaluated in this study were not able to detect S. aureus enterotoxins directly in stools.

CONCLUSION

The role of enterotoxigenic S. aureus in the pathogenesis of nosocomial and AAD needs further consideration. It might be necessary to investigate stool samples from patients with AAD/nosocomial diarrhea for S. aureus on a routine basis.

Predicting deterioration in patients with lobar haemorrhages

OBJECTIVE

To study the clinical course and determine predictors of deterioration in patients with lobar haemorrhages).

METHODS

A comprehensive review of 61 consecutive patients with lobar haemorrhages was performed. Neurological deterioration was defined as (1) decrease in Glasgow coma sum score by 2 points, (2) new neurological deficit, or (3) clinical signs of brain herniation. A univariate logistic regression was performed and expressed in odds ratios.

RESULTS

Sixteen of 61 (26%) patients with lobar haemorrhages deteriorated after admission. In a univariate analysis, only a Glasgow coma score <14 predicted deterioration (75% of deteriorators v 24% who did not deteriorate; p<0.0001). Initial CT characteristics predictive of deterioration included haemorrhage volume >60 ml (63% v 16%, p< 0.0001), shift of the septum pellucidum (75% v 36%, p<0.01), effacement of the contralateral ambient cistern (33% v 0%, p<0.0001), and widening of the contralateral temporal horn (50% v 0%, p<0.0001). Patients presenting and deteriorating within 12 hours of ictus declined due to enlargement of the haemorrhage. Those who deteriorated more than 12 hours after initial neurological symptoms, showed increased mass effect secondary to oedema. CONCLUSION-Patients with lobar haemorrhages presenting immediately after ictus are at risk for deterioration from enlargement of the haemorrhage and predictors of deterioration may be absent. Patients with large volume lobar haemorrhages presenting to the emergency department with decreased level of consciousness and shift on CT are at risk for further deterioration from worsening oedema. These patients require close observation and early aggressive management may be warranted.

Distinguishing clinical and radiological features of non-traumatic convexal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The full spectrum of causes of convexal subarachnoid hemorrhage (cSAH) requires further investigation. Therefore, our objective was to describe the spectrum of clinical and imaging features of patients with non-traumatic cSAH.

METHODS

A retrospective observational study of consecutive patients with non-traumatic cSAH was performed at a tertiary referral center. The underlying cause of cSAH was characterized and clinical and imaging features that predict a specific etiology were identified. The frequency of future cSAH or intracerebral hemorrhage (ICH) was determined.

RESULTS

In all, 88 patients [median age 64 years (range 25-85)] with non-traumatic cSAH were identified. The most common causes were reversible cerebral vasoconstriction syndrome (RCVS) (26, 29.5%), cerebral amyloid angiopathy (CAA) (23, 26.1%), indeterminate (14, 15.9%) and endocarditis (9, 10.2%). CAA patients commonly presented at an older age than RCVS patients (75 years versus 51 years, P < 0.0001). Thirteen patients (14.7%) had recurrent cSAH, and 12 patients (13.6%) had a subsequent ICH. However, the risk was high amongst those with CAA compared to those caused by RCVS, with recurrent cSAH in 39.1% and subsequent lobar ICH in 43.5% of CAA cases.

CONCLUSIONS

Our study demonstrates the clinical diversity of cSAH. Older age, sensorimotor dysfunction and stereotyped spells suggest CAA as the underlying cause. Younger age and thunderclap headache predict RCVS. Yet, various other causes also need to be considered in the differential diagnosis.

Laser therapy for venous leg ulcers

OBJECTIVES

To assess the effectiveness of low level laser therapy in the treatment of venous leg ulcers.

SEARCH STRATEGY

Searches of 19 databases, hand searching of journals and conference proceedings from 1948 onwards, and examination of bibliographies.

SELECTION CRITERIA

Randomised controlled trials comparing low level laser therapy with: sham laser; no laser; non-coherent light. There was no restriction on date or language. The main outcome measure used was complete healing of the ulcers.

DATA COLLECTION AND ANALYSIS

Data extraction was done by one reviewer and checked by a second. Meta analysis was used to combine the results of trials where the interventions and outcome measures were sufficiently similar.

MAIN RESULTS

There were 4 eligible trials. Two RCTs compared laser therapy with sham, 1 with ultraviolet therapy and 1 with non-coherent, unpolarised red light. Neither of the two RCTs comparing laser with sham found a significant difference in healing rates; there was no significant of laser evident when the trials were pooled. A three-arm study compared: - laser therapy alone - laser therapy plus infrared light - non-coherent, unpolarised red light. Significantly more ulcers completely healed in the group receiving a combination of laser and infrared light compared with non-coherent, unpolarised red light. A fourth trial compared laser and ultraviolet light and found no difference.

REVIEWER'S CONCLUSIONS

We have found no evidence of any benefit associated with low level laser therapy on venous leg ulcer healing. One small study suggests that a combination of laser and infrared light may promote the healing of venous ulcers, however more research is needed.

Therapeutic ultrasound for venous leg ulcers

BACKGROUND

Venous leg ulceration is a common problem, representing a significant burden on the patient and the healthcare system. They are caused by venous insufficiency and tend to be chronic and recurring. Management usually includes use of wound dressings plus compression stockings or bandages. It has been suggested that therapeutic ultrasound may have an adjuvant effect and promote healing however its effects are unclear.

OBJECTIVES

To determine whether therapeutic ultrasound increases the healing of venous leg ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (August 2007), The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 3, 2007, Ovid MEDLINE - 1950 to July Week 4 2007, Ovid EMBASE - 1980 to 2007 Week 31, Ovid CINAHL - 1982 to August Week 1 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing therapeutic ultrasound with placebo (sham) ultrasound, or other (standard) treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the results of the searches for eligible RCTs and obtained full reports. A third author assessed the results of the update searches for eligible RCTs. Details from the eligible studies were extracted and summarised by a review author using a data extraction sheet. Attempts were made to contact trial authors to obtain missing data or for clarification.

MAIN RESULTS

A total of eight eligible trials were identified and were all of either medium or high risk of bias. Five trials compared ultrasound therapy with placebo (sham) ultrasound, three trials compared ultrasound therapy with standard treatment. Trials varied in terms of ulcer size, regimen and duration of follow up. No trials individually found a statistically significant difference in the number of ulcers healed between any of the therapies, however on pooling trials (different durations of follow up) for the outcome of risk healing, significantly more ulcers were completely healed with ultrasound (RR 1.49, 95% CI 1.07 to 2.09). Some trials also found that ultrasound increases the rate of change of wound size and/or reduces the size of existing ulcers, whilst other trials did not find this effect to be significant. When all trials reporting percentage ulcer area remaining were pooled there was a significant benefit associated with ultrasound (WMD -5.34%, 95% CI -8.38 to -2.30).

AUTHORS' CONCLUSIONS

The available evidence suggests that ultrasound may increase healing of venous leg ulcers. These conclusions are based on the results of only eight small studies of generally poor quality and therefore should be interpreted with caution.

Rapidly progressive hippocampal atrophy: evidence for a seizure-induced mechanism

Hippocampal formation atrophy (HFA) developed in an adult, who did not have epilepsy previously, after the occurrence of new-onset partial seizures from acute thrombosis of an ipsilateral parietal venous angioma. There was no evidence of hippocampal injury, and the patient had only one brief, generalized tonic-clonic seizure. Although HFA progressed rapidly over 5.5 months, the partial seizures did not become prolonged or secondarily generalized. Evidence from the patient indicates that partial seizure activity can cause rapid and progressive hippocampal atrophy.

Clinical and Imaging Characteristics of Diffuse Intracranial Dolichoectasia

BACKGROUND AND PURPOSE

Among patients with vertebrobasilar dolichoectasia is a subset of patients with disease affecting the anterior circulation as well. We hypothesized that multivessel intracranial dolichoectasia may represent a distinct phenotype from single-territory vertebrobasilar dolichoectasia. The purpose of this study was to characterize clinical characteristics and angiographic features of this proposed distinct phenotype termed "diffuse intracranial dolichoectasia" and compare them with those in patients with isolated vertebrobasilar dolichoectasia.

MATERIALS AND METHODS

We retrospectively reviewed a consecutive series of patients with diffuse intracranial dolichoectasia and compared their demographics, vascular risk factors, additional aneurysm prevalence, and clinical outcomes with a group of patients with vertebrobasilar dolichoectasia. "Diffuse intracranial dolichoectasia" was defined as aneurysmal dilation of entire vascular segments involving ≥2 intracranial vascular beds. Categoric and continuous variables were compared by using χ² and Student t tests, respectively.

RESULTS

Twenty-five patients had diffuse intracranial dolichoectasia, and 139 had vertebrobasilar dolichoectasia. Patients with diffuse intracranial dolichoectasia were older than those with vertebrobasilar dolichoectasia (70.9 ± 14.2 years versus 60.4 ± 12.5 years, P = .0002) and had a higher prevalence of abdominal aortic aneurysms (62.5% versus 14.3%, P = .01), other visceral aneurysms (25.0% versus 0%, P < .0001), and smoking (68.0% versus 15.9%, P < .0001). Patients with diffuse intracranial dolichoectasia were more likely to have aneurysm growth (46.2% versus 21.5%, P = .09) and rupture (20% versus 3.5%, P = .007) at follow-up. Patients with diffuse intracranial dolichoectasia were less likely to have good neurologic function at follow-up (24.0% versus 57.6%, P = .004) and were more likely to have aneurysm-related death (24.0% versus 7.2%, P = .02).

CONCLUSIONS

The natural history of patients with diffuse intracranial dolichoectasia is significantly worse than that in those with isolated vertebrobasilar dolichoectasia. Many patients with diffuse intracranial dolichoectasia had additional saccular and abdominal aortic aneurysms. These findings suggest that diffuse intracranial dolichoectasia may be a distinct vascular phenotype secondary to a systemic arteriopathy affecting multiple vascular beds.

Therapeutic ultrasound for pressure ulcers

BACKGROUND

Pressure ulcers have been recorded as occurring in 5 to 32% of patients admitted to a UK District General Hospital (the precise rate depends on case-mix) and 4 to 7% in the community. They represent a major burden of sickness and reduced quality of life for patients and their carers, and are costly to health service providers. Pressure ulcers are treated by using wound dressings, relieving pressure on the wound, by treating concurrent conditions which may delay healing, and by the use of physical therapies such as electrical stimulation, laser therapy and ultrasound.

OBJECTIVES

To assess the effect of therapeutic ultrasound on the healing of pressure ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register and the Cochrane Central Register of Controlled Trials in May 2006. In addition we hand searched journals, conference proceedings, bibliographies and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing therapeutic ultrasound with sham ultrasound or standard treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently checked the result of the search to identify relevant RCTs. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing information by contacting authors. Data extraction was checked by a second author. Meta-analysis was used to combine the results of trials where the interventions and outcome measures were sufficiently similar.

MAIN RESULTS

Three trials involving 146 people were included. Two RCTs compared ultrasound therapy with sham ultrasound and the third compared a combination of ultrasound and ultraviolet light with laser and with standard treatment. Neither of the two RCTs comparing ultrasound with sham found a significant difference in healing rates. The trials were pooled, in the absence of significant heterogeneity. There was no evidence of benefit associated with the use of ultrasound in the treatment of pressure ulcers. In the three-arm comparison there was no statistically significant difference in ulcers healed.

AUTHORS' CONCLUSIONS

There is no evidence of benefit of ultrasound therapy in the treatment of pressure ulcers. However, the possibility of beneficial or harmful effect cannot be ruled out due to the small number of trials, some with methodological limitations and small numbers of participants. Further research is needed.

Electromagnetic therapy for treating venous leg ulcers

BACKGROUND

Leg ulceration is a common, chronic, recurring condition. The estimated prevalence of leg ulcers in the UK population is 1.5 to 3 per 1000. Venous ulcers (also called stasis, or varicose ulcers) comprise 80 to 85% of all leg ulcers. Electromagnetic therapy is sometimes used as a treatment to assist the healing of chronic wounds such as venous leg ulcers.

OBJECTIVES

To assess the effects of electromagnetic therapy on the healing of venous leg ulcers.

SEARCH STRATEGY

For this first review update, we searched the Cochrane Wounds Group Specialised Register (last searched October 2005); CENTRAL (The Cochrane Library 2005, Issue 4); MEDLINE (1966 to October 2005); EMBASE (1980 to October 2005); and CINAHL (1982 to October 2005).

SELECTION CRITERIA

Randomised controlled trials comparing electromagnetic therapy with sham electromagnetic therapy or other treatments.

DATA COLLECTION AND ANALYSIS

For the original review, details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. A second reviewer checked data extraction. Meta-analysis was applied to combine the results of trials where the interventions and outcome measures were adequately similar. For this first update, two reviewers independently scrutinized the results of the search to identify relevant RCTs and obtained full reports of potentially eligible studies. In the case of disagreements, a final decision was made either after discussion between two reviewers or consultation with a third party (a member of the Cochrane Wounds Group).

MAIN RESULTS

This update identified no new trials. A total of three eligible RCTs were identified by the original review. Two trials compared the use of electromagnetic therapy with sham therapy and one trial compared it with standard topical treatments. One trial found a difference in healing rates of borderline statistical significance between electromagnetic therapy and sham therapy, although the direction of treatment effect was consistently in favour of electromagnetic therapy, the difference was not statistically significant.

AUTHORS' CONCLUSIONS

There is currently no reliable evidence of benefit of electromagnetic therapy in the healing of venous leg ulcers. Further research is needed.

Baseline and Evolutionary Radiologic Features in Sporadic, Hemorrhagic Brain Cavernous Malformations

BACKGROUND AND PURPOSE

Much has been written about the initial radiologic features of cavernous malformations, but less known are the radiologic natural history and evolution of the lesions, particularly when they initially present with hemorrhage. We aimed to describe the typical evolution of a sporadic, hemorrhagic brain cavernous malformation with time.

MATERIALS AND METHODS

From our institutional review board-approved cavernous malformation registry, we assessed initial clinical and radiologic features and the subsequent MR imaging evolution of 51 patients with sporadic, hemorrhagic brain cavernous malformations (with follow-up brain MRIs available for review).

RESULTS

The initial MR imaging demonstrated mostly Zabramski type I lesions (94.2%) with T1 hyperintensity (94.2%) and associated edema (76.5%). Eight patients (15.6%) rebled in the first year with lesions characterized by new T1 hyperintensity (100%), edema (61.5%), and growth (median, 4 mm). By 90 days, most lesions had changed from Zabramski type I to type II or III (65.2%). While 76.5% had edema associated with the acute hemorrhage, none had persistent edema beyond 90 days unless rebleeding occurred. Across time, the frequency of T1 hyperintensity decreased from 94.2% at baseline to 73.9%, 57.1%, and 50.0% at <90, 91-365, and >365 days. DWI intensity at baseline and <90, 91-365, and >365 days was hypointense at 53.1%, 56.5%, 70.1%, and 81.2%, respectively.

CONCLUSIONS

Hemorrhagic cavernous malformation demonstrates a characteristic pattern of evolution on follow-up imaging. Knowing this evolution helps to analyze the timing of imaging in relation to the clinical presentation and may help distinguish true cavernous malformation hemorrhagic evolution from mimics and guide appropriate timing of interval-imaging follow-up after symptomatic bleeds in untreated patients.

Hyperhomocysteinemia in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)

OBJECTIVE

To determine whether patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) had evidence of increased homocysteine levels compared with non-CADASIL patients with ischemic stroke or transient ischemic attack.

PATIENTS AND METHODS

We compared fasting plasma homocysteine levels and levels 6 hours after oral loading with methionine, 100 mg/kg, in non-CADASIL patients with ischemic stroke or transient ischemic attack and in patients with CADASIL. Prechallenge, postchallenge, and change in homocysteine levels between the 2 groups were compared with use of the Wilcoxon rank sum test.

RESULTS

CADASIL and non-CADASIL groups were similar in age (mean, 48.8 vs. 46.5 years, respectively; 2-tailed t test, P=.56) and sex (men, 86% vs 59%; Fisher exact test, P=.12). The 59 patients in the CADASIL group had higher median plasma homocysteine levels compared with the 14 patients in the non-CADASIL group, both in the fasting state (12.0 vs 9.0 micromol/L; P=.03) and after methionine challenge (51.0 vs 34.0 micromol/L; P=.007). Median difference between homocysteine levels before and after methionine challenge was greater in the CADASIL group than in the non-CADASIL group (34.5 vs. 24.0 micromol/ L; P = .02).

CONCLUSION

Our findings raise the possibility that increased homocysteine levels or abnormalities of homocysteine metabolism may have a role in the pathogenesis of CADASIL.

Therapeutic ultrasound for venous leg ulcers

BACKGROUND

Ultrasound therapy is commonly used with the aim of improving the healing of chronic wounds such as pressure ulcers and venous leg ulcers.

OBJECTIVES

To assess the effectiveness of therapeutic ultrasound in the treatment of venous leg ulcers.

SEARCH STRATEGY

The Cochrane Wounds Group search strategy was used (see Scope) to search for randomised controlled trials (RCTs) of therapeutic ultrasound for the treatment of venous leg ulcers.

SELECTION CRITERIA

Randomised controlled trials comparing therapeutic ultrasound with sham ultrasound, or other (standard) treatment

DATA COLLECTION AND ANALYSIS

Results of searches were scrutinised by one reviewer (and checked by a second) to identify possible RCTs and full reports of these were obtained. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. Data extraction was checked by a second reviewer.

MAIN RESULTS

A total of seven eligible RCTs were identified. Four trials compared ultrasound therapy with sham ultrasound, three trials compared ultrasound therapy with standard treatment. None of the trials found a difference in healing rates between any of the therapies, though it is noteworthy that the direction of treatment effect was consistently in favour of ultrasound (though this did not reach significance in the individual studies).

REVIEWER'S CONCLUSIONS

There is no good evidence of a benefit of ultrasound therapy in the healing of venous leg ulcers.

Subarachnoid Hemorrhage

All patients who present with subarachnoid hemorrhage should be admitted to the intensive care unit for close neurologic and cardiorespiratory monitoring. Neurosurgical consultation should be obtained if external ventricular drain placement, arteriography, or surgical planning are considered. Seizure prophylaxis, antihypertensive treatment for mean arterial blood pressure greater than 130 mm Hg, pain control, and bed rest are important measures for the prevention of rebleeding, which is associated with a high mortality rate. Standard deep venous thrombosis and gastrointestinal prophylaxis are recommended to prevent medical complications associated with critical illness. In patients with good-grade subarachnoid hemorrhage, early arteriography and definitive aneurysm management are recommended. The location and neck size of the aneurysm and the medical condition of the patient are factors in the decision to proceed with surgical rather than interventional aneurysm management. Postoperatively, clinical examination and transcranial Doppler ultrasonography are recommended for surveillance of vasospasm. If clinical or arteriographic evidence of vasospasm is present, hemodilution, hypertension, and hypervolemia (triple H) therapy should be instituted. If vasospasm is resistant to conservative measures, balloon angioplasty or intra-arterial papaverine therapy should also be considered.

Electromagnetic therapy for the treatment of venous leg ulcers

BACKGROUND

Electromagnetic therapy is used with the aim of improving the healing of chronic wounds such as pressure sores and venous leg ulcers

OBJECTIVES

To assess the effectiveness of electromagnetic therapy in the treatment of venous leg ulcers

SEARCH STRATEGY

The Cochrane Wounds group search strategy was used (see Scope) to search for randomised controlled trials (RCTs) of electromagnetic therapy for the treatment of venous leg ulcers

SELECTION CRITERIA

Randomised controlled trials comparing electromagnetic therapy with sham electromagnetic therapy or other (standard) treatment

DATA COLLECTION AND ANALYSIS

Results of searches were scrutinised by one reviewer (and checked by a second) to identify possible RCTs and full reports of these were obtained. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. Data extraction was checked by a second reviewer.

MAIN RESULTS

A total of three eligible RCTs were identified. Two trials compared the use of electromagnetic therapy to sham (Ieran 1990; Kenkre 1996) and one trial (Stiller 1992) compared it with standard topical treatments. One of the trials found a difference in healing rates of borderline statistical significance between electromagnetic therapy and sham, although the direction of treatment effect was consistently in favour of electromagnetic therapy the difference was not statistically significant.

REVIEWER'S CONCLUSIONS

There is currently no reliable evidence of benefit of electromagnetic therapy in the healing of venous leg ulcers.

Electromagnetic therapy for treating pressure ulcers

BACKGROUND

Pressure ulcers are defined as areas "of localized damage to the skin and underlying tissue caused by pressure, shear, friction and/or the combination of these". In the UK, pressure ulcers occur in 5 to 32% of District General Hospitals people and in 4 to 7% of people in community settings. Electromagnetic therapy, in which electrodes produce an electromagnetic field across the wound, may improve healing of chronic wounds such as pressure ulcers.

OBJECTIVES

To assess the effects of electromagnetic therapy on the healing of pressure ulcers.

SEARCH STRATEGY

For this first update, we searched the Cochrane Wounds Group Specialised Register (last searched October 2005); CENTRAL (The Cochrane Library 2005, Issue 4); MEDLINE (1966 to October 2005); EMBASE (1980 to October 2005); and CINAHL (1982 to October 2005).

SELECTION CRITERIA

Randomised controlled trials comparing electromagnetic therapy with sham electromagnetic therapy, or other (standard) treatment.

DATA COLLECTION AND ANALYSIS

For this first update, two authors independently scrutinized the results of the search to identify relevant RCTs and obtained full reports of potentially eligible studies. For the original review, details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. Data extraction was checked by a second author. Meta-analysis was applied to combine the results of trials when the interventions and outcome measures were sufficiently similar.

MAIN RESULTS

This update identified no new trials. Two RCTs were identified for inclusion in the original review (total of 60 participants). One was a three-armed study comparing electromagnetic therapy with electromagnetic therapy in combination with standard therapy, and with standard therapy alone, on 17 female and 13 male with grade II and III pressure ulcers. The other study compared electromagnetic therapy with sham therapy in 30 male participants with a spinal cord injury and a grade II or grade III pressure ulcer.Neither study found a statistically significant difference between the healing rates of pressure ulcers in people treated with electromagnetic therapy compared with those in the control group.

AUTHORS' CONCLUSIONS

The results provide no evidence of benefit in using electromagnetic therapy to treat pressure ulcers. However, the possibility of a beneficial or harmful effect cannot be ruled out, due to the fact that there were only two included trials both with methodological limitations and small numbers of participants. Further research is recommended.