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Suzhen Lin, Yiwen Wu, Hongxia Li, Chencheng Zhang, Tao Wang, Yixin Pan, Lu He, Ruinan Shen, Zhengdao Deng, Bomin Sun, Jianqing Ding and Dianyou Li

OBJECTIVE

Surgical procedures involving deep brain stimulation (DBS) of the globus pallidus internus (GPi) or subthalamic nucleus (STN) are well-established treatments for isolated dystonia. However, selection of the best stimulation target remains a matter of debate. The authors’ objective was to compare the effectiveness of DBS of the GPi and the STN in patients with isolated dystonia.

METHODS

In this matched retrospective cohort study, the authors searched an institutional database for data on all patients with isolated dystonia who had undergone bilateral implantation of DBS electrodes in either the GPi or STN in the period from January 30, 2014, to June 30, 2017. Standardized assessments of dystonia and health-related quality of life using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and SF-36 were conducted before and at 1, 6, and 12 months after surgery. No patients were lost to the 6-month follow-up; 5 patients were lost to the 12-month follow-up.

RESULTS

Both GPi (14 patients) and STN (16 patients) stimulation produced significant improvement in dystonia and quality of life in all 30 patients found in the database search. At the 1-month follow-up, however, the percentage improvement in the BFMDRS total movement score was significantly (p = 0.01) larger after STN DBS (64%) than after GPi DBS (48%). At the 12-month follow-up, the percentage improvement in the axis subscore was significantly (p = 0.03) larger after GPi DBS (93%) than after STN DBS (83%). Also, the total amount of electrical energy delivered was significantly (p = 0.008) lower with STN DBS than with GPi DBS (124 ± 52 vs 192 ± 65 μJ, respectively).

CONCLUSIONS

The GPi and STN are both effective targets in alleviating dystonia and improving quality of life. However, GPi stimulation may be better for patients with axial symptoms. Moreover, STN stimulation may produce a larger clinical response within 1 month after surgery and may have a potential economic advantage in terms of lower battery consumption.

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Toshikazu Kimura, Chikayuki Ochiai, Kensuke Kawai, Akio Morita and Nobuhito Saito

OBJECTIVE

To investigate the risk of bleeding from unruptured cerebral aneurysms (UCAs), previous studies have used Kaplan-Meier analyses without treating the definitive treatment as a competing risk event, which may underestimate the rupture rate. The authors analyzed the survival of patients with UCAs alongside the occurrence of aneurysm bleeding and its competing risk events.

METHODS

A retrospective analysis was conducted on 722 patients diagnosed with UCAs in the period from 2000 to 2009 using an institution’s electronic medical records and telephone interviews. The cumulative incidence of aneurysm rupture was examined, and factors contributing to rupture were assessed using regression analyses.

RESULTS

By 2014, 19 patients had experienced aneurysm rupture, with an overall rupture rate of 0.57% per year over 3320.8 person-years. However, cumulative incidence analysis indicated that 1.3% of all patients had a rupture within 2 years after aneurysm identification, and 38.4% of the patients underwent definitive treatment in the same period. Among the patients who experienced rupture, regression analysis revealed that an aneurysm size greater than 5 mm, a location in the anterior or posterior communicating arteries, and an irregular shape contributed to aneurysm rupture, with HRs of 4.4 (95% CI 1.2–15.7), 3.5 (95% CI 1.4–8.7), and 2.1 (95% CI 0.7–6.0), respectively.

CONCLUSIONS

Rupture rate analyses using the person-year or standard Kaplan-Meier method are not as informative without consideration of the competing risks. The incidence of aneurysm rupture should be presented clearly with those of competing risks.

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Andrej Paľa, Julia Schick, Moritz Klein, Benjamin Mayer, Bernd Schmitz, Christian Rainer Wirtz, Ralph König and Thomas Kapapa

OBJECTIVE

Delayed cerebral ischemia (DCI) is a major factor contributing to the inferior outcome of patients with spontaneous subarachnoid hemorrhage (SAH). Nimodipine and induced hypertension using vasopressors are an integral part of standard therapy. Consequences of the opposite effect of nimodipine and vasopressors on blood pressure on patient outcome remain unclear. The authors report the detailed general characteristics and influence of nimodipine and vasopressors on outcome in patients with SAH.

METHODS

The authors performed a 2-center, retrospective, clinical database analysis of 732 SAH patients treated between 2008 and 2016. Demographic and clinical data such as age, sex, World Federation of Neurosurgical Societies (WFNS) grade, BMI, Fisher grade, history of arterial hypertension and smoking, aneurysm location, C-reactive protein (CRP) level, and detailed dosage of vasopressors and nimodipine during the treatment period were evaluated. Clinical outcome was analyzed using the modified Rankin Scale (mRS) 6 months after treatment. Univariate and multivariate regression analyses were performed. Additionally, mean arterial pressure (MAP), age, nimodipine, and vasopressor dose cutoff were evaluated with regard to outcome. The level of significance was set at ≤ 0.05.

RESULTS

Follow-up was assessed for 397 patients, 260 (65.5%) of whom achieved a good outcome (defined as an mRS score of 0–3). Univariate and multivariate analyses confirmed that nimodipine (p = 0.049), age (p = 0.049), and CRP level (p = 0.002) are independent predictors of good outcome. WFNS grade, Fisher score, hypertension, initial hydrocephalus, and total vasopressor dose showed significant influence on outcome in univariate analysis, and patient sex, smoking status, BMI, and MAP showed no significant association with outcome. A subgroup analysis of patients with milder initial SAH (WFNS grades I–III) revealed that initial hydrocephalus (p = 0.003) and CRP levels (p = 0.001) had significant influence on further outcome. When evaluating only patients with WFNS grade IV or V, age, CRP level (p = 0.011), vasopressor dose (p = 0.030), and nimodipine dose (p = 0.049) were independent predictors of patient outcome. Patients with an MAP < 93 mm Hg, a nimodipine cutoff dose of 241.8 mg, and cutoff total vasopressor dose of 523 mg had better outcomes.

CONCLUSIONS

According to the authors’ results, higher doses of vasopressors can safely provide a situation in which the maximum dose of nimodipine could be administered. Cutoff values of the total vasopressor dose were more than 3 times higher in patients with severe SAH (WFNS grade IV or V), while the nimodipine cutoff remained similar in patients with mild and severe SAH. Hence, it seems encouraging that a maximum nimodipine dosage can be achieved despite the need for a higher vasopressor dose in patients with SAH.

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Thomas K. Mattingly and Stephen P. Lownie

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Chiara Robba, Joseph Donnelly, Danilo Cardim, Tamara Tajsic, Manuel Cabeleira, Giuseppe Citerio, Paolo Pelosi, Peter Smielewski, Peter Hutchinson, David K. Menon and Marek Czosnyka

OBJECTIVE

Intracranial hypertension and impaired cerebral autoregulation are common causes of secondary injuries in patients with traumatic brain injury (TBI). The primary outcome of this study was to assess whether a noninvasive method to estimate intracranial pressure (ICP) based on the ultrasonography of the optic nerve sheath diameter (ONSD) measured at the time of neurocritical care unit (NCCU) admission is correlated with the mean ICP during NCCU stay. Secondary outcomes were to assess whether ONSD is correlated with the dose of ICP > 20 mm Hg and impaired autoregulation during NCCU stay and with instantaneous ICP and whether ONSD is associated with NCCU mortality.

METHODS

This prospective observational monocentric study included adults with severe TBI. ONSD was measured at NCCU admission, immediately after invasive ICP insertion. ONSD-predicted noninvasive ICP (nICPONSD) was calculated according the formula: nICPONSD = 5 × ONSD − 14 (nICPONSD in mm Hg, ONSD in mm). Autoregulation was measured using the pressure reactivity index (PRx).

RESULTS

In total, 100 patients were included in this study. ONSD was significantly correlated with mean ICP (r = 0.46, p < 0.0001), with mean PRx (r = 0.21, p = 0.04), and with the dose of ICP > 20 mm Hg during NCCU stay (r = 0.49, p < 0.0001). Admission nICPONSD was shown to be significantly correlated with instantaneous ICP (r = 0.85, p < 0.001). ONSD at admission was significantly correlated with NCCU mortality (p = 0.02).

CONCLUSIONS

ONSD measured at NCCU admission can give important information about patients at risk of developing intracranial hypertension and impaired autoregulation. ONSD examination could be useful to screen patients at admission to determine who would benefit from further invasive ICP monitoring.

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Robert S. Heller, Carlos A. David and Carl B. Heilman

OBJECTIVE

Surgical resection of sphenoid wing tumors and intraorbital pathology carries the dual goal of appropriately treating the target pathology as well as correcting proptosis. Residual proptosis following surgery can lead to cosmetic and functional disability. The authors sought to quantitatively assess the effect of orbital volume before and after reconstruction to determine the optimal strategy to achieve proptosis correction.

METHODS

All surgeries involving orbital wall reconstruction for orbital or intracranial pathology that preoperatively resulted in proptosis between 2007 and 2017 were reviewed. Proptosis was measured by the exophthalmos index (EI): the ratio of the distance of the anterior limit of each globe to a line drawn between the anterior limit of the frontal processes of the zygomas, comparing the pathological eye to the normal eye. Postoperative radiographic measurements were taken at least 60 days after surgery to allow surgical swelling to abate. The orbit contralateral to the pathology was used as an internal control for normal anatomical orbital volume. Cases with preoperative EI < 1.10, orbital exenteration, or enucleation were excluded.

RESULTS

Twenty-three patients (16 females and 7 males, with a mean age of 43.6 ± 22.8 years) were treated surgically for tumor-associated proptosis. Nineteen patients harbored meningiomas (11 en-plaque; 8 sphenoid wing), and one patient each harbored an orbital schwannoma, glomangioma, arteriovenous malformation, or cavernous hemangioma. Preoperative EI averaged 1.28 ± 0.10 (range 1.12–1.53). Median time to postoperative imaging was 19 months. Postoperatively, the EI decreased to a mean of 1.07 ± 0.09. Greater increases in size of the reconstructed orbit were positively correlated with greater quantitative reductions in proptosis (p < 0.01). Larger volume of soft tissue pathology was also associated with achieving greater proptosis correction (p < 0.01). Residual exophthalmos (defined as EI > 1.10) was present in 8 patients, while reconstruction in 2 patients resulted in clinically asymptomatic enophthalmos (defined as EI < 0.95). Tumor invasion into the superior orbital fissure sinus was associated with residual proptosis (p = 0.04).

CONCLUSIONS

Proptosis associated with intracranial and orbital pathology represents a surgical challenge. The EI is a reliable and quantitative assessment of proptosis. For orbital reconstruction in cases of superior orbital fissure involvement, surgeons should consider rebuilding the orbit at slightly larger than anatomical volume.