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Mariam Ishaque, David J. Wallace and Ramesh Grandhi

Throughout history, neurosurgical procedures have been fundamental in advancing neuroscience; however, this has not always been without deleterious side effects or harmful consequences. While critical to the progression of clinical neuroscience during the early 20th century, yet, at the same time, poorly tolerated by patients, pneumoencephalography is one such procedure that exemplifies this juxtaposition. Presented herein are historical perspectives and reflections on the role of the pneumoencephalography in the diagnosis and treatment of neuropsychiatric illnesses.

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Cian J. O'Kelly, Abhaya V. Kulkarni, Peter C. Austin, David Urbach and M. Christopher Wallace

Object

Chronic shunt-dependent hydrocephalus is a recognized complication of aneurysmal subarachnoid hemorrhage. While its incidence and risk factors have been well described, the long-term performance of shunts in this setting has not been not widely reported.

Methods

Using administrative databases, the authors derived a retrospective cohort of patients undergoing treatment of a ruptured aneurysm in Ontario, Canada, between 1995 and 2005. The authors determined the incidence of shunt-dependent hydrocephalus and analyzed putative risk factors. Mortality rates and indicators of morbidity were recorded. Patients were followed up for the occurrence of shunt failure over time.

Results

Of 3120 patients in the cohort, 585 (18.75%) developed shunt-dependent hydrocephalus. On multivariate analysis, age, acute hydrocephalus, ventilation on admission, aneurysms in the posterior circulation and giant aneurysms were all significant predictors of shunt-dependent hydrocephalus. The mortality rate was not increased in patients with chronic hydrocephalus (hazard ratio 1.04, p = 0.63); however, indicators of morbidity were increased in these patients. Of the 585 patients with shunt-dependent hydrocephalus, only 173 (29.6%) underwent a subsequent revision procedure. Ninety-eight percent of these revisions were completed within 6 months. Subsequent revisions occurred more frequently. On multivariate analysis, significant predictors of shunt revision included aneurysm location in the posterior circulation and endovascular treatment of the initial ruptured aneurysm.

Conclusions

Shunt-dependent hydrocephalus affects a significant proportion of subarachnoid hemorrhage survivors, contributing to additional morbidity among these patients. Shunt failures occur less frequently in patients who underwent treatment for a ruptured aneurysm than with other forms of hydrocephalus. Most failures occur within 6 months, suggesting that shunt dependency may be transient in the majority of patients.

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Cian J. O'Kelly, Abhaya V. Kulkarni, Peter C. Austin, M. Christopher Wallace and David Urbach

Object

Enrolling a selected sample of ruptured intracranial aneurysms, the International Subarachnoid Aneurysm Trial (ISAT) found endovascular coiling to be superior to microsurgical clipping. The performance of coiling in a more general population of ruptured aneurysms has not been adequately studied.

Methods

Using provincial administrative data from Ontario, the authors conducted a retrospective cohort study of adult patients with subarachnoid hemorrhage (SAH) who underwent aneurysm repair. The exposure was defined as endovascular versus surgical aneurysm repair. The prespecified primary outcome was time to death or readmission for SAH. Data from the entire cohort were analyzed using a multivariable adjusted Cox proportional hazards model. Propensity scores were used to compare a matched subgroup of patients with aneurysms who had similar baseline characteristics. The potential impact of unmeasured confounding was assessed using sensitivity analysis.

Results

Between 1995 and 2004, 2342 aneurysms were clipped and 778 were coiled in Ontario. The proportion of aneurysms treated by coiling increased steadily over time. In the adjusted analysis of the entire cohort, endovascular coiling was associated with a significantly increased hazard of death or SAH readmission (hazard ratio 1.25 [95% CI 1.00–1.55], p = 0.04). Similar results were obtained from the propensity score matched analysis (hazard ratio 1.25 [95% CI 1.04–1.50], p = 0.02). Measures of procedural morbidity and mortality were not significantly different between groups.

Conclusions

The results of the current analysis call into question the generalizability of the ISAT to all ruptured aneurysms. Given the limitations inherent in this form of analysis, further clinical studies—rigorously assessing the performance of endovascular therapy in patients with non-ISAT-like aneurysms—are indicated.

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David J. Wallace, Naomi L. Sayre, T. Tyler Patterson, Susannah E. Nicholson, Donald Hilton and Ramesh Grandhi

In addition to standard management for the treatment of the acute phase of spinal cord injury (SCI), implementation of novel neuroprotective interventions offers the potential for significant reductions in morbidity and long-term health costs. A better understanding of the systemic changes after SCI could provide insight into mechanisms that lead to secondary injury. An emerging area of research involves the complex interplay of the gut microbiome and the CNS, i.e., a brain–gut axis, or perhaps more appropriately, a CNS–gut axis. This review summarizes the relevant literature relating to the gut microbiome and SCI. Experimental models in stroke and traumatic brain injury demonstrate the bidirectional communication of the CNS to the gut with postinjury dysbiosis, gastrointestinal-associated lymphoid tissue–mediated neuroinflammatory responses, and bacterial-metabolite neurotransmission. Similar findings are being elucidated in SCI as well. Experimental interventions in these areas have shown promise in improving functional outcomes in animal models. This commensal relationship between the human body and its microbiome, particularly the gut microbiome, represents an exciting frontier in experimental medicine.