Quality of Life After Poor-Grade Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and poor disability outcome. Data on quality of life (QoL) among survivors are scarce because patients with poor-grade aSAH are underrepresented in clinical studies reporting on QoL after aSAH.

OBJECTIVE

To provide prospective QoL data on survivors of poor-grade aSAH to aid clinical decision making and counseling of relatives.

METHODS

The herniation World Federation of Neurosurgical Societies scale study was a prospective observational multicenter study in patients with poor-grade (World Federation of Neurosurgical Societies grades 4 & 5) aSAH. We collected data during a structured telephone interview 6 and 12 months after ictus. QoL was measured using the EuroQoL - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire, with 0 representing a health state equivalent to death and 1 to perfect health. Disability outcome for favorable and unfavorable outcomes was measured with the modified Rankin Scale.

RESULTS

Two hundred-fifty patients were enrolled, of whom 237 were included in the analysis after 6 months and 223 after 12 months. After 6 months, 118 (49.8%) patients were alive, and after 12 months, 104 (46.6%) patients were alive. Of those, 95 (80.5%) and 89 (85.6%) reached a favorable outcome with mean EQ-5D-3L index values of 0.85 (±0.18) and 0.86 (±0.18). After 6 and 12 months, 23 (19.5%) and 15 (14.4%) of those alive had an unfavorable outcome with mean EQ-5D-3L index values of 0.27 (±0.25) and 0.19 (±0.14).

CONCLUSION

Despite high initial mortality, the proportion of poor-grade aSAH survivors with good QoL is reasonably large. Only a minority of survivors reports poor QoL and requires permanent care.

Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort.

METHODS

We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version-the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4-6).

RESULTS

Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, P<0.001) whereas the sensitivity decreased from 0.88 to 0.37 (P<0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, P<0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, P<0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, P<0.001).

CONCLUSIONS

The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification-presence of brain stem signs is required for grade V-should be added to the WFNS classification.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.

Percutaneous transluminal angioplasty using the novel drug-coated balloon catheter SeQuent Please NEO for the treatment of symptomatic intracranial severe stenosis: feasibility and safety study

Objectives

Intracranial arteriosclerotic disease is a relevant cause of ischemic stroke worldwide with a high recurrence rate despite best medical treatment. Following the SAMMPRIS trial, endovascular treatment has remained a second-line therapy. Meanwhile, there has been significant advances in device technology. SeQuent Please NEO is a novel polymer-free, drug-coated (paclitaxel/iopromide) balloon (DCB) primarily designed for cardiology. Because of its high flexibility and pushability, it may also be suitable for intracranial use. The aim of this study was to assess the feasibility and safety of SeQuent Please NEO DCB in symptomatic intracranial severe stenosis.

Methods

A single-center retrospective cohort study of patients with symptomatic intracranial severe stenosis treated with SeQuent Please NEO DCB was performed at a tertiary stroke center.

Results

Ten patients (all men, median age 73 years (IQR 69–77)) were included. Median pre-treatment stenosis grade was 78% (IQR 75–80%) with four internal carotid artery, two mid-basilar artery, and four vertebral artery lesions. Median post-treatment stenosis grade was 50% (IQR 45–53%). Successful angioplasty was achieved in all cases without technical failure. There were no cases of peri-procedural reocclusion and no deaths at median follow-up of 3 months (IQR 2–3).

Conclusion

In this pilot study, SeQuent Please NEO DCB was feasible and safe in the treatment of symptomatic intracranial severe stenosis. It might represent a promising alternative to medical treatment in selected cases.

Acute administration of tirofiban versus aspirin in emergent carotid artery stenting

BACKGROUND

Carotid artery stenting requires antiplatelet therapy for prevention of in-stent thrombosis. Patients suffering from acute ischemic stroke undergoing intravenous thrombolysis and emergent carotid artery stenting (eCAS) are at high risk for intracranial bleeding. We assessed efficacy and safety of acute administration of intravenous tirofiban versus aspirin in these patients.

METHODS

A retrospective, single center, cohort study was carried out of 32 patients who underwent eCAS (18 received tirofiban, 14 received aspirin) at our comprehensive stroke center (2008-2016).

RESULTS

Of our 32 consecutive eCAS patients, favorable clinical outcomes (modified Rankin scale ≤ 2) were achieved in eight (47%) tirofiban patients and six (46%) aspirin patients ( p = 0.96). Overall rates were similar for symptomatic intracranial bleeding (tirofiban 22%, aspirin 29%, p = 0.68) and mortality (tirofiban 18%, aspirin 23%, p = 0.71).

CONCLUSIONS

Tirofiban and aspirin demonstrated similar efficacy and safety in thrombolyzed stroke patients who underwent eCAS in our cohort. Intravenous tirofiban with its short half-life might represent an alternative to aspirin in select patients.

Neuro Elutax SV drug-eluting balloon versus Wingspan stent system in symptomatic intracranial high-grade stenosis: a single-center experience

BACKGROUND

Intracranial atherosclerotic disease is a well-known cause of ischemic stroke. Following the SAMMPRIS trial, medical treatment is favored over stenting. Drug-eluting balloons (DEB) are widely used in coronary angioplasty, showing better results than bare-surface balloons. There is little evidence of DEB employment in intracranial stenosis, especially of paclitaxel-eluted balloons (pDEB). The Neuro Elutax SV (Aachen Resonance) is the first CE certificated pDEB for intracranial use.

OBJECTIVE

To compare pDEB Neuro Elutax SV (ElutaxDEB) with the Wingspan/Gateway stent system (WingspanStent).

MATERIALS AND METHODS

A single-center, open-label, retrospective cohort study of 19 patients with symptomatic atherosclerotic intracranial high-grade stenosis treated with either ElutaxDEB or WingspanStent from a tertiary stroke center in Switzerland.

RESULTS

Eight patients (42%) received ElutaxDEB. Median clinical follow-up was 10 months for the WingspanStent and 9.5 months for ElutaxDEB (P=0.36). No differences were found in the clinical baseline characteristics, with a median stenosis grade of 80% for the WingspanStent and 81% for the ElutaxDEB (P=0.87). The compound endpoint 'ischemic re-event and/or restenosis' was significantly lower for ElutaxDEB (13% vs 64%; P=0.03, OR 0.08 (95% CI 0.007 to 0.93; P=0.043) than for the WingspanStent.

CONCLUSIONS

The ElutaxDEB may be a promising alternative treatment for patients with symptomatic high-grade intracranial stenosis showing a significantly lower rate of ischemic re-events or restenosis in comparison with the WingspanStent-treated patients with a similar safety profile. Further studies will be needed to definitively elucidate the role of pDEB in the management of symptomatic intracranial high-grade stenosis.

Modulation of the Emotional Response to Viewing Strabismic Children in Mothers-Measured by fMRI

PURPOSE

Strabismus influences not only the individual with nonparallel eyes but also the observer. It has previously been demonstrated by fMRI that adults viewing images of strabismic adults have a negative reaction to the images as demonstrated by limbic activation, especially activation of the left amygdala. The aim of this study was to see if mothers would have a similar reaction to viewing strabismic children and whether or not that reaction would be different in mothers of strabismic children.

METHODS

Healthy mothers of children with strabismus (n = 10, Group I) and without strabismus (n = 15, Group II) voluntarily underwent fMRI at 3T. Blood oxygen level dependent signal responses to viewing images of strabismic and non-strabismic children were analyzed.

RESULTS

Group II, while viewing images of strabismic children, showed significantly increased activation of the limbic network (p < 0.05) and bilateral amygdala activation. Group I showed considerably less limbic activation, compared to the group II, and had no amygdala activation. Both groups revealed statically significant activation in the FEF (frontal eye field) when they were viewing images of strabismic children as compared to when they were viewing children with parallel eyes. The activated FEF area for Group II was much larger than for group I.

CONCLUSION

Mothers of non-strabismic children showed similar negative emotional fMRI patterns as adults did while viewing strabismic adults. Strabismus is an interpersonal organic issue for the observer, which also impacts the youngest members of our society.

High EDSS can predict risk for upper urinary tract damage in patients with multiple sclerosis

BACKGROUND

Neurogenic lower urinary tract dysfunction (NLUTD) is very common in patients with multiple sclerosis (MS), and it might jeopardize renal function and thereby increase mortality. Although there are well-known urodynamic risk factors for upper urinary tract damage, no clinical prediction parameters are available.

OBJECTIVE

We aimed to assess clinical parameters potentially predicting urodynamic risk factors for upper urinary tract damage.

METHODS

A consecutive series of 141 patients with MS referred from neurologists for primary neuro-urological work-up including urodynamics were prospectively evaluated. Clinical parameters taken into account were age, sex, duration, and clinical course of MS and Expanded Disability Status Scale (EDSS).

RESULTS

Multivariate modeling revealed EDSS as a clinical parameter significantly associated with urodynamic risk factors for upper urinary tract damage (odds ratio = 1.34, 95% confidence interval (CI) = 1.06-1.71, p = 0.02). Using receiver operator characteristic (ROC) curves, an EDSS of 5.0 as cutoff showed a sensitivity of 86%-87% and a specificity of 52% for at least one urodynamic risk factor for upper urinary tract damage.

CONCLUSION

High EDSS is significantly associated with urodynamic risk factors for upper urinary tract damage and allows a risk-dependent stratification in daily neurological clinical practice to identify MS patients requiring further neuro-urological assessment and treatment.

Intrathecal insulin-like growth factor 1 but not insulin enhances myelin repair in young and aged rats

One main pathological hallmark of multiple sclerosis (MS) is demyelination. Novel therapies which enhance myelin repair are urgently needed. Insulin and insulin-like growth factor 1 (IGF-1) have strong functional relationships. Here, we addressed the potential capacity of IGF-1 and insulin to enhance remyelination in an animal demyelination model in vivo. We found that chronic intrathecal infusion of IGF-1 enhanced remyelination after lysolecithin-induced demyelination in the spinal cord of young and aged rats. Aged rats showed a weaker innate remyelination capacity and are therefore a good model for progressive MS which is defined by chronic demyelination. In contrast to IGF-1, Insulin had no effect on remyelination in either age group. Our findings highlight the potential use of IGF-1 as remyelinating therapy for MS, particularly the progressive stage in which chronic demyelination is the hallmark.

Parasagittal Dural Arteriovenous Fistula Treated With Embozene Microspheres

PURPOSE

To describe the use of Embozene microspheres as an alternative treatment for intracranial dural arteriovenous fistulas (DAVF).

CASE REPORT

The DAVF was located close to the vertex and mainly fed by the left medial meningeal artery (MMA). Embolization was performed using Embozene microspheres due to stenosis in the posterior branch of the left MMA and a conglomerate of tortuous courses in the anterior branch. Complete occlusion was achieved without complication. Neurological symptoms improved, and the patient remained asymptomatic during 1-year follow-up. Angiography at 1 year did not reveal any revascularization.

CONCLUSION

Use of microspheres may be a safe and effective alternative treatment, particularly in patients with impeded access to the DAVF.

Mechanical Thrombectomy Using the New ERIC Retrieval Device Is Feasible, Efficient, and Safe in Acute Ischemic Stroke: A Swiss Stroke Center Experience

BACKGROUND AND PURPOSE

Intravenous thrombolysis and mechanical thrombectomy predominantly using stent retrievers have been shown to effectively restore cerebral blood flow and improve functional outcome in patients with acute ischemic stroke. We sought to determine the safety and feasibility of mechanical thrombectomy using the new ERIC retrieval device.

MATERIALS AND METHODS

We identified 36 consecutive patients from our Stroke Center registry with acute ischemic stroke who were treated with the new ERIC retriever from September 2013 to December 2014. Patients with ischemic stroke meeting the following criteria were eligible: onset-to-treatment time of ≤4.5 hours or wake-up stroke (n = 10) with relevant CT perfusion mismatch, NIHSS score of ≥4, and proof of large-vessel occlusion in the anterior circulation on CT angiography. We assessed the baseline characteristics including age, sex, comorbidities, stroke severity, site of vessel occlusion, presence of tissue at risk, and treatment-related parameters such as onset-to-treatment time, recanalization grade, and outcome.

RESULTS

The mean age was 70 ± 13 years, and the median NIHSS score on admission was 18 (interquartile range, 10-20). Seventeen of 36 patients were on platelet inhibitors or anticoagulants before endovascular treatment (47.2%); 20 patients received intravenous thrombolysis (55.5%). The ERIC was used as the sole retriever in 28 patients (77.8%) and as a rescue device in 8. Excellent recanalization was achieved in 30/36 patients (83.3%) with TICI 3 in 19/36 and 2b in 11/36, respectively. Median procedural time in these patients was 90 minutes (interquartile range, 58-133 minutes). No intraprocedural complications occurred.

CONCLUSIONS

In this observational study, the new ERIC retrieval device was technically feasible, safe, and effective in acute ischemic stroke with large-vessel occlusion.

Impact of intraoperative MRI-guided transsphenoidal surgery on endocrine function and hormone substitution therapy in patients with pituitary adenoma

BACKGROUND

Pituitary adenomas are rare with an incidence of 0.4-8.2 per 105 inhabitants. Symptoms range from headaches to pituitary insufficiency or excessive output of hormones with associated disease. Except for prolactinomas, surgery is recommended as the first line and most effective treatment for the majority of these tumours. One of the refinements of surgical therapy introduced was intraoperative magnetic resonance imaging (iMRI).

OBJECTIVE

The aim of this study was to analyse the postoperative pituitary function and the general outcome of patients treated for non-functioning and GH-producing pituitary adenomas with a transsphenoidal iMRI-assisted approach using the PoleStar™ N20 imager.

METHODS

A total of 148 consecutive iMRI-guided surgeries for GH-producing and non-functioning pituitary adenomas were retrospectively analysed. Patients' clinical data, endocrinological parameters, clinical examinations and pre-/post- and intraoperative imaging studies were evaluated.

RESULTS

A total of 101 patients could be classified as being in remission at follow-up; 26 (17.6%) of them due to iMRI allowing additional tumour removal. A total of 44 patients (29.7%) had more complete tumour removal because remnants were detected by iMRI. The mean hormone levels of patients did not differ significantly between pre- and postoperative examinations. There were 62 patients with preoperative, and 43 patients with postoperative pituitary insufficiency, thus, due to surgery there were 19 (12.8%) patients with improved pituitary function.

CONCLUSIONS

The results show this method to be a safe and effective treatment option increasing remission rate and keeping complication rate low. Postoperative pituitary function was preserved or improved - possibly due to more exact iMRI-assisted tumour removal.

Intraoperative magnetic resonance imaging–assisted transsphenoidal pituitary surgery in patients with acromegaly

Object

Acromegaly is a rare disease, usually caused by a growth hormone (GH)–producing pituitary adenoma. If untreated, severe cardiovascular, metabolic, cosmetic, and orthopedic disturbances will result. Surgery is generally recommended as the first-line treatment. Transsphenoidal surgical techniques were recently extended by the introduction of intraoperative MR (iMR) imaging. In the present study, the contribution of ultra-low-field (0.15-T) iMR imaging to tumor resection, complication avoidance, and endocrinological and neurological outcome was analyzed.

Methods

A series of 39 consecutive transsphenoidal iMR imaging–guided (using the PoleStar N20 device) surgical procedures performed between September 2005 and August 2009 for GH-producing pituitary adenomas was retrospectively analyzed. In addition to the patients' clinical data, the following criteria were evaluated independently: duration of surgery; length of hospital stay; endocrinological parameters; results of neurological examinations; and pre-, post-, and intraoperative MR imaging results.

Results

Thirty-seven patients with acromegaly underwent 39 transsphenoidal surgeries for pituitary adenomas. During a median follow-up period of 30 months (range 9–56 months), the remission rate was 73.5% in 34 patients with primary surgery and 20% in 5 cases with previous surgery; overall the remission rate was 66.7%. There were no serious postoperative complications. Detection of tumor remnant on iMR imaging led to a 5.1% increase in remission rate.

Conclusions

In this largest study to date of GH-producing pituitary adenomas in which iMR imaging–guided transsphenoidal surgery was analyzed, the results suggest that this method is a highly effective and safe treatment modality, even compared with previously published surgical series in which high-field iMR imaging was used. Limitations of iMR imaging are the detection of small residual tumor in the cavernous sinus and persisting disease that could not be observed, even on diagnostic high-field follow-up MR images. This points to a general limitation regarding remission rates that can be achieved using iMR imaging. Nevertheless, iMR imaging led to an increase of the remission rate in this study.