Seizure outcome in patients with cavernous malformation after early surgery.

OBJECTIVE: To describe seizure outcome and complications in patients with cavernous malformations (CM) undergoing early versus late surgery. METHODS: A database was created for all CM patients who presented with seizure referred to the neurosurgical clinic at an academic center. A telephone survey and chart review were conducted to evaluate for preoperative and postoperative seizure frequency. Postoperative seizure-free outcome of patients who had ≤2 preoperative seizures versus those that had >2 preoperative seizures was compared. RESULTS: A total of 35 CM patients were included for analysis. Nineteen patients had ≤2 preoperative seizures and 16 patients had >2 preoperative seizures, six of them drug resistant for over two years. Among the ≤2 seizure group, 15 had only a single seizure before surgical resection. 94.7% of patients with ≤2 preoperative seizures and 62.5% of patients with >2 preoperative seizures were seizure free one year following surgical resection (p = 0.019). 78.9% of patients with ≤2 preoperative seizures and 25% of patients with >2 preoperative seizures were able to wean off AEDs (p < 0.001). Among those patients who had a single preoperative seizure, 100% of patients were seizure free at one year. CONCLUSIONS: Early surgical resection for CM patients who present after a CM-related seizure is an effective, well tolerated treatment and has good chance to offer seizure freedom without the need for long-term antiepileptic medications. Outcome for patients operated with only one or two preoperative seizures may lead to better results than patients who delay the procedure.

High rate of inappropriate carotid endarterectomy in an urban medical center.

BACKGROUND: Some studies have reported that the appropriateness of carotid endarterectomy (CEA) has dramatically improved in the last two decades. However, these studies did not include the most recent study results for asymptomatic stenosis. METHODS: We sought to determine the appropriateness of CEA at a large, urban community hospital. A retrospective chart review of all CEA procedures during a 2-year period was conducted. CEA appropriateness was defined according to factors including age, degree of stenosis, symptomatic or asymptomatic status, and presence of high surgical risk comorbidities. RESULTS: During a 2-year period, 51 CEA procedures were performed. For patient characteristics, 73% were asymptomatic, 77% were African American, and 65% had high surgical risk comorbidities. Perioperative stroke or myocardial infarction occurred in 14.3% of symptomatic patients and 18.9% of asymptomatic patients. The rate of inappropriate CEA was 57%, and 14% of cases were of uncertain value. Patients with an inappropriate or uncertain CEA had a 19.4% rate of in-hospital stroke or myocardial infarction. CONCLUSIONS: In an urban hospital, the majority of CEA procedures were either inappropriate or of uncertain value. The periprocedure complication rate was high in these patients. Patient selection in urban hospitals is not adhering to clinical trial criteria.