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1.
Acta Neurochir (Wien) ; 163(11): 2941-2946, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-34580755

RESUMEN

BACKGROUND: Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines the neurologic outcomes of patients ≥ 80 years of age treated for aSAH. METHOD: A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2. RESULTS: During the study period, 1418 patients were treated for aSAH. The mean (standard deviation) age was 55.1 (13.6) years, the mean follow-up was 24.6 (40.0) months, and the rate of functional independence (mRS 0-2) at follow-up was 54% (751/1395). Logistic regression analysis found increasing age strongly associated with declining functional independence (R2 = 0.929, p < 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67% [n = 29] vs 33% [n = 14], p < 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly. CONCLUSIONS: Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.


Asunto(s)
Hemorragia Subaracnoidea , Anciano de 80 o más Años , Comorbilidad , Humanos , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Hemorragia Subaracnoidea/terapia , Resultado del Tratamiento
2.
Neurocrit Care ; 31(3): 507-513, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31187434

RESUMEN

BACKGROUND: Traumatic brain injury (TBI) is associated with one-third of all deaths from trauma. Preinjury exposure to cardiovascular drugs may affect TBI outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) exacerbate brain cell damage and worsen functional outcomes in the laboratory setting. ß-blockers (BBs), however, appear to be associated with reduced mortality among patients with isolated TBI. OBJECTIVE: Examine the association between preinjury ACEI and BB use and clinical outcome among patients with isolated TBI. METHODS: A retrospective cohort study of patients age ≥ 40 years admitted to an academic level 1 trauma center with isolated TBI between January 2010 and December 2014 was performed. Isolated TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3, with chest, abdomen, and extremity AIS scores ≤ 2. Preinjury medication use was determined through chart review. All patients with concurrent BB use were initially excluded. In-hospital mortality was the primary measured outcome. RESULTS: Over the 5-year study period, 600 patients were identified with isolated TBI who were naive to BB use. There was significantly higher mortality (P = .04) among patients who received ACEI before injury (10 of 96; 10%) than among those who did not (25 of 504; 5%). A multivariate stepwise logistic regression analysis revealed a threefold increased risk of mortality in the ACEI cohort (P < .001), which was even greater than the twofold increased risk of mortality associated with an Injury Severity Score ≥ 16. A second analysis that included patients who received preinjury BBs (n = 98) demonstrated slightly reduced mortality in the ACEI cohort with only a twofold increased risk in multivariate analysis (P = .05). CONCLUSIONS: Preinjury exposure to ACEIs is associated with an increase in mortality among patients with isolated TBI. This effect is ameliorated in patients who receive BBs, which provides evidence that this class of medications may provide a protective benefit.


Asunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Lesiones Traumáticas del Encéfalo/mortalidad , Mortalidad Hospitalaria , Escala Resumida de Traumatismos , Adulto , Anciano , Presión Sanguínea , Craneotomía/estadística & datos numéricos , Lesión Axonal Difusa/epidemiología , Femenino , Escala de Coma de Glasgow , Hematoma Subdural/epidemiología , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Factores Protectores , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiología
5.
Acta Neurochir (Wien) ; 158(3): 547-50, 2016 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-26743915

RESUMEN

Vascular malformations of the central nervous system are thought to originate from abnormal developmental processes during embryogenesis. Reports have cited the dynamic nature of these lesions and their "maturation" into other types of malformations. Herein we report on three patients with vascular malformations who exhibited dynamic alterations with stepwise progression of their lesions. These cases lend support to the hypothesis that these malformations may constitute the spectrum of a single disease caused by alterations in a common developmental program and that accumulating injury (e.g., by radiation) may allow one malformation type to mature into another. This concept warrants further investigation.


Asunto(s)
Malformaciones Arteriovenosas/patología , Malformaciones Vasculares del Sistema Nervioso Central/patología , Niño , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Adulto Joven
6.
Neurocrit Care ; 24(1): 61-81, 2016 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26738503

RESUMEN

External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. Despite their widespread use, there are a lack of high-quality data regarding the best methods for placement and management of EVDs to minimize these risks. Existing recommendations are frequently based on observational data from a single center and may be biased to the authors' view. To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.


Asunto(s)
Cuidados Críticos/normas , Drenaje/normas , Medicina Basada en la Evidencia/normas , Neurología/normas , Sociedades Médicas/normas , Ventriculostomía/normas , Consenso , Humanos
7.
Neurosurg Focus ; 38(VideoSuppl1): Video12, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25554834

RESUMEN

Posterior circulation aneurysms are commonly treated with endovascular techniques. In select cases, microsurgery remains an essential tool for treating these lesions. We present a case of a ruptured posterior inferior cerebellar artery (PICA) aneurysm approached via a craniotomy. Given the labyrinth of neurovascular bundles present in the posterior fossa, surgical exposure of PICA aneurysms can be challenging. This video demonstrates the steps of the craniotomy, subarachnoid dissection, mobilization of the vertebral artery and lower cranial nerves, and clipping of the aneurysm. The video can be found here: http://youtu.be/fQSxQj7oL0U .


Asunto(s)
Aneurisma Roto/cirugía , Cerebelo/irrigación sanguínea , Microcirugia/métodos , Instrumentos Quirúrgicos , Arteria Vertebral/cirugía , Angiografía Cerebral , Humanos , Masculino
8.
Neurosurg Focus ; 38(VideoSuppl1): Video13, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25554835

RESUMEN

Middle cerebral artery aneurysms, especially those with complex morphology, are considered excellent aneurysms for surgical clipping, given the challenges that exist with current endovascular techniques. We present a case of a large, complex, left middle cerebral artery aneurysm treated with microsurgical clipping. This video highlights critical steps in obtaining proximal and distal control as well as subarachnoid dissection necessary to prepare the aneurysm for final clipping. The video can be found here: http://youtu.be/RlKH2Km9z5Y .


Asunto(s)
Arterias Cerebrales/cirugía , Aneurisma Intracraneal/cirugía , Microcirugia/métodos , Instrumentos Quirúrgicos , Humanos
9.
Neurosurg Focus ; 38(VideoSuppl1): Video10, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25554832

RESUMEN

Unruptured posterior circulation aneurysms pose a treatment challenge. Although data supports the use of endovascular technique for select ruptured cases, in unruptured cases, there may be clinical equipoise. Furthermore, wide-necked basilar apex aneurysms commonly require the use of stents and placement of patients on dual therapy. We present a case of a healthy 50-year-old woman with an incidental basilar tip aneurysm treated via an orbitozygomatic craniotomy. This video highlights the steps of dynamic retraction, which is retraction without placement of permanent rigid retraction system, and the added maneuverability afforded by the use of the mouthpiece on the microscope. The video can be found here: http://youtu.be/jVfC6CCXdZY .


Asunto(s)
Aneurisma Intracraneal/cirugía , Microcirugia/métodos , Instrumentos Quirúrgicos , Femenino , Humanos , Persona de Mediana Edad , Tomógrafos Computarizados por Rayos X
10.
Neurosurg Focus ; 38(VideoSuppl1): Video14, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25554836

RESUMEN

Intraoperative rupture of an intracranial aneurysm is a potentially devastating but controllable complication. The authors have successfully used the previously described cotton-clip technique to repair tears at the necks of aneurysms. (1-4) A tear on the neck of the aneurysm is covered with a piece of cotton and held in place with a suction device. The cotton is then clipped onto the tear with an aneurysm clip, using the cotton as a bolster. This simple, effective method has been useful in repairing a partial avulsion of the neck of an aneurysm. (1 , 3) The video can be found here: http://youtu.be/nT86RYVQWpc .


Asunto(s)
Aneurisma Roto/cirugía , Complicaciones Intraoperatorias/cirugía , Microcirugia , Hemorragia Subaracnoidea/cirugía , Instrumentos Quirúrgicos , Angiografía Cerebral , Humanos , Hemorragia Subaracnoidea/etiología
11.
J Am Heart Assoc ; 12(3): e027572, 2023 02 07.
Artículo en Inglés | MEDLINE | ID: mdl-36695309

RESUMEN

Background Familial cerebral cavernous alformation (CCM) is an autosomal dominant disease caused by mutations in KRIT1, CCM2, or PDCD10. Cases typically present with multiple lesions, strong family history, and neurological symptoms, including seizures, headaches, or other deficits. Intracranial hemorrhage (ICH) is a severe manifestation of CCM, which can lead to death or long-term neurological deficits. Few studies have reported ICH rates and risk factors in familial CCM. We report ICH rates and assess whether CCM lesion burden, a disease severity marker, is associated with risk of symptomatic ICH during follow-up in a well-characterized cohort of familial CCM cases. Methods and Results We studied 386 patients with familial CCM with follow-up data enrolled in the Brain Vascular Malformation Consortium CCM Project. We estimated symptomatic ICH rates overall and stratified by history of ICH before enrollment. CCM lesion burden (total lesion count and large lesion size) assessed at baseline enrollment was tested for association with increased risk of subsequent ICH during follow-up using Cox regression models adjusted for history of ICH before enrollment, age, sex, and family structure and stratified on recruitment site. The symptomatic ICH rate for familial CCM cases was 2.8 per 100 patient-years (95% CI, 1.9-4.1). Those with ICH before enrollment had a follow-up ICH rate of 4.5 per 100 patient-years (95% CI, 2.6-8.1) compared with 2.0 per 100 patient-years (95% CI, 1.3-3.5) in those without (P=0.042). Total lesion count was associated with increased risk of ICH during follow-up (hazard ratio [HR], 1.37 per doubling of total lesion count [95% CI, 1.10-1.71], P=0.006). The symptomatic ICH rate for familial CCM cases was 2.8 per 100 patient-years (95% CI, 1.9-4.1). Those with ICH before enrollment had a follow-up ICH rate of 4.5 per 100 patient-years (95% CI, 2.6-8.1) compared with 2.0 per 100 patient-years (95% CI, 1.3-3.5) in those without (P=0.042). Total lesion count was associated with increased risk of ICH during follow-up (hazard ratio [HR], 1.37 per doubling of total lesion count [95% CI, 1.10-1.71], P=0.006). Conclusions Patients with familial CCM with prior history of an ICH event are at higher risk for rehemorrhage during follow-up. In addition, total CCM lesion burden is significantly associated with increased risk of subsequent symptomatic ICH; hence lesion burden may be an important predictor of patient outcome and aid patient risk stratification.


Asunto(s)
Malformaciones Vasculares del Sistema Nervioso Central , Hemangioma Cavernoso del Sistema Nervioso Central , Humanos , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/genética , Hemangioma Cavernoso del Sistema Nervioso Central/complicaciones , Hemangioma Cavernoso del Sistema Nervioso Central/genética , Hemangioma Cavernoso del Sistema Nervioso Central/patología , Malformaciones Vasculares del Sistema Nervioso Central/complicaciones , Factores de Riesgo , Hemorragia Cerebral/etiología
12.
Neurosurgery ; 91(3): 470-476, 2022 09 01.
Artículo en Inglés | MEDLINE | ID: mdl-35876676

RESUMEN

BACKGROUND: In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. METHODS: All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. RESULTS: Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. CONCLUSION: Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.


Asunto(s)
Aneurisma Roto , Procedimientos Endovasculares , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Aneurisma Roto/complicaciones , Costos y Análisis de Costo , Humanos , Aneurisma Intracraneal/complicaciones , Microcirugia/efectos adversos , Estudios Retrospectivos , Hemorragia Subaracnoidea/complicaciones , Resultado del Tratamiento
13.
World Neurosurg ; 161: e168-e173, 2022 05.
Artículo en Inglés | MEDLINE | ID: mdl-35092812

RESUMEN

BACKGROUND: Nationwide study results have suggested varying trends in the incidence of aneurysmal subarachnoid hemorrhage (aSAH) over time. Herein, trends over time for aSAH treated at a quaternary care center are compared with low-volume hospitals. METHODS: Cases were retrospectively reviewed for patients with aSAH treated at our institution. Trend analyses were performed on the number of aSAH hospitalizations, treatment type, Charlson Comorbidity Index (CCI), Hunt and Hess grade, aneurysm location, aneurysm type, and in-hospital mortality. The National Inpatient Sample (NIS) was queried to compare the CCI scores of our patients with those of patients in low-volume hospitals (<20 aSAH/year) in our census division. RESULTS: Some 1248 patients (321 during 2004-2006; 927 during 2008-2018) hospitalized with aSAH were treated with endovascular therapy (489, 39%) or microsurgery (759, 61%). A significant downtrend in the annual aSAH caseload occurred (123 patients in 2004, 75 in 2018, P < 0.001). A linear uptrend was observed for the mean CCI score of patients (R 2 = 0.539, P < 0.001), with no change to in-hospital mortality (R 2 = 0.220, P = 0.24). Mean (standard deviation) CCI for small-volume hospitals treating aSAH within our division was significantly lower than that of our patient population (1.8 [1.6] vs 2.1 [2.0]) for 2012-2015. CONCLUSIONS: A decreasing number of patients were hospitalized with aSAH throughout the study. Compared with patients with aSAH admitted in 2004, those admitted more recently were sicker in terms of preexisting comorbidity and neurologic complexity. These trends could be attributable to the increasing availability of neurointerventional services at smaller-volume hospitals capable of treating healthier patients.


Asunto(s)
Hemorragia Subaracnoidea , Comorbilidad , Mortalidad Hospitalaria , Humanos , Estudios Retrospectivos , Hemorragia Subaracnoidea/epidemiología , Hemorragia Subaracnoidea/cirugía , Resultado del Tratamiento
14.
Hum Mol Genet ; 18(5): 919-30, 2009 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-19088123

RESUMEN

Cerebral cavernous malformations (CCMs) are vascular anomalies of the central nervous system, comprising dilated blood-filled capillaries lacking structural support. The lesions are prone to rupture, resulting in seizures or hemorrhagic stroke. CCM can occur sporadically, manifesting as solitary lesions, but also in families, where multiple lesions generally occur. Familial cases follow autosomal-dominant inheritance due to mutations in one of three genes, CCM1/KRIT1, CCM2/malcavernin or CCM3/PDCD10. The difference in lesion burden between familial and sporadic CCM, combined with limited molecular data, suggests that CCM pathogenesis may follow a two-hit molecular mechanism, similar to that seen for tumor suppressor genes. In this study, we investigate the two-hit hypothesis for CCM pathogenesis. Through repeated cycles of amplification, subcloning and sequencing of multiple clones per amplicon, we identify somatic mutations that are otherwise invisible by direct sequencing of the bulk amplicon. Biallelic germline and somatic mutations were identified in CCM lesions from all three forms of inherited CCMs. The somatic mutations are found only in a subset of the endothelial cells lining the cavernous vessels and not in interstitial lesion cells. These data suggest that CCM lesion genesis requires complete loss of function for one of the CCM genes. Although widely expressed in the different cell types of the brain, these data also suggest a unique role for the CCM proteins in endothelial cell biology.


Asunto(s)
Proteínas Reguladoras de la Apoptosis/genética , Proteínas Portadoras/genética , Hemangioma Cavernoso del Sistema Nervioso Central/genética , Proteínas de la Membrana/genética , Proteínas Asociadas a Microtúbulos/genética , Mutación , Proteínas Proto-Oncogénicas/genética , Alelos , Secuencia de Aminoácidos , Secuencia de Bases , Estudios de Cohortes , Mutación de Línea Germinal , Humanos , Proteína KRIT1 , Datos de Secuencia Molecular
15.
Neurology ; 2021 Aug 13.
Artículo en Inglés | MEDLINE | ID: mdl-34389651

RESUMEN

BACKGROUND AND OBJECTIVES: Seizure incidence rates related to Familial Cerebral Cavernous Malformation (FCCM) are not well described, especially for children. To measure the seizure incidence rate, examine seizure predictors and characterize epilepsy severity, we studied a cohort of children and adults with FCCM enrolled in the Brain Vascular Malformation Consortium (BVMC). METHODS: Seizure data were collected from participants with FCCM in the BVMC at enrollment and during follow-up. We estimated seizure probability by age, and tested whether cerebral cavernous malformation (CCM) counts or genotype were associated with earlier seizure onset. RESULTS: The study cohort included 479 FCCM cases. Median age at enrollment was 42.5 years (Interquartile Range [IQR] 22.5-55.0) and 19% were children (<18 years old). Median large CCM count was 3 (IQR: 1-5). Among 393 with genotyping, mutations were: CCM1-Common Hispanic Mutations (88%), another CCM1 mutation (5%), CCM2 mutations (5%), and CCM3 mutations (2%). Prior to or during the study, 202 (42%) had a seizure. The cumulative incidence of a childhood seizure was 20.3% (95% CI 17.0 - 23.4) and by age 80 years was 60.4% (95% CI 54.2-65.7). More total CCMs (Hazard Ratio [HR] 1.24 per SD unit increase, 95% CI 1.1 - 1.4) or more large CCMs (HR=1.5 per SD unit increase, 95% CI 1.2-1.9) than expected for age and sex increased seizure risk. A CCM3 mutation also increased risk compared to other mutations (HR 3.11, 95% CI 1.15-8.45). Individuals with a seizure prior to enrollment had increased hospitalization rates during follow-up (Incidence Rate Ratio 10.9, 95% CI 2.41 - 49.32) compared to patients without a seizure history. DISCUSSION: Individuals with FCCM have a high seizure incidence, and those with more CCMs or CCM3 genotype are at greater risk. Seizures increase health care utilization in FCCM.

16.
World Neurosurg ; 154: e163-e167, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-34245880

RESUMEN

BACKGROUND: Owing to prolonged hospitalization and the complexity of care required for patients with aneurysmal subarachnoid hemorrhage (aSAH), these patients have a high risk of complications. The risk for wound infection after microsurgical treatment for aSAH was analyzed. METHODS: All patients who underwent microsurgical treatment for aSAH between August 1, 2007, and July 31, 2019, and were recorded in the Post-Barrow Ruptured Aneurysm Trial database were retrospectively reviewed. The patients were analyzed for risk factors for wound infection after treatment. RESULTS: Of 594 patients who underwent microsurgical treatment for aSAH, 23 (3.9%) had wound infections. There was no significant difference in age between patients with wound infection and patients without infection (mean, 52.6 ± 12.2 years vs. 54.2 ± 4.0 years; P = 0.45). The presence of multiple comorbidities (including diabetes, tobacco use, and obesity), external ventricular drain, ventriculoperitoneal shunt, pneumonia, or urinary tract infection was not associated with an increased risk for wound infection. Furthermore, there was no significant difference in mean operative time between patients with wound infection and those without infection (280 ± 112 minutes vs. 260 ± 92 minutes; P = 0.38). Patients who required decompressive craniectomy (DC) were at increased risk of wound infection (odds ratio, 5.0; 95% confidence interval, 1.8-14.1; P = 0.002). Among the 23 total infections, 9 were diagnosed following cranioplasty after DC. CONCLUSIONS: Microsurgical treatment for aSAH is associated with a relatively low risk of wound infection. However, patients undergoing DC may be at an increased risk for infection. Additional attention and comprehensive wound care are warranted for these patients.


Asunto(s)
Aneurisma Roto/cirugía , Revascularización Cerebral/métodos , Craniectomía Descompresiva/métodos , Hemorragia Subaracnoidea/cirugía , Infección de la Herida Quirúrgica/epidemiología , Adulto , Anciano , Comorbilidad , Femenino , Humanos , Aneurisma Intracraneal/cirugía , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos , Riesgo , Resultado del Tratamiento , Derivación Ventriculoperitoneal
17.
World Neurosurg ; 155: 64-73, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-34389521

RESUMEN

Various well-known people associated with the history of the presidency of the United States have experienced neurologic disease or injury, especially trauma to the head or spine. Nancy Reagan, however, as the wife of President Ronald Reagan and First Lady, would leave a significant and lasting mark on the progress of neurosurgical science and education. Recognized for endeavors against drug abuse, Alzheimer disease, and polio, her interest in neurosurgical research is less well known. Nancy's father Loyal Davis was a remarkable neurosurgeon and educator of extraordinary influence. When Barrow Neurological Institute (BNI) founder John Green experienced complications after an illness, Davis served as BNI director during 1966 - 1967. After Davis's death in 1982, Robert Spetzler, who had been a student of Davis at Northwestern University Medical School and was then BNI director, convinced Green, despite his misgivings, to support a neurosurgical laboratory recognizing Davis. In 1988, Nancy Reagan, then First Lady, dedicated the Loyal and Edith Davis Neurosurgical Research Laboratory. At the dedication, she remarked on her years growing up in the home of a pioneering neurosurgeon and remarked that "my father believed deeply in the importance of research to develop new methods for treating patients." Green and Spetzler's unified efforts honored the extraordinary career of Davis in a manner he would have appreciated, were supported by a First Lady with deep involvement in politics and philanthropy dedicated to promoting advances in medicine, and are part of neurosurgery's unique heritage.


Asunto(s)
Academias e Institutos/historia , Personajes , Neurocirujanos/historia , Neurocirugia/historia , Femenino , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Masculino , Estados Unidos
18.
Neurosurgery ; 89(6): 973-977, 2021 11 18.
Artículo en Inglés | MEDLINE | ID: mdl-34460915

RESUMEN

BACKGROUND: Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement. OBJECTIVE: To investigate whether intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence. METHODS: Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement. RESULTS: Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio [OR]: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04). CONCLUSION: Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.


Asunto(s)
Hidrocefalia , Hemorragia Subaracnoidea , Ventrículos Cerebrales , Humanos , Hidrocefalia/complicaciones , Hidrocefalia/cirugía , Estudios Retrospectivos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/cirugía , Activador de Tejido Plasminógeno/uso terapéutico
19.
J Neurosurg ; : 1-8, 2021 Nov 26.
Artículo en Inglés | MEDLINE | ID: mdl-34826811

RESUMEN

OBJECTIVE: The Barrow Ruptured Aneurysm Trial (BRAT) was a single-center trial that compared endovascular coiling to microsurgical clipping in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). However, because patients in the BRAT were treated more than 15 years ago, and because there have been advances since then-particularly in endovascular techniques-the relevance of the BRAT today remains controversial. Some hypothesize that these technical advances may reduce retreatment rates for endovascular intervention. In this study, the authors analyzed data for the post-BRAT (PBRAT) era to compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the two time periods and to examine how the results of the original BRAT have influenced the practice of neurosurgeons at the study institution. METHODS: In this retrospective cohort study, the authors evaluated patients with saccular aSAHs who were treated at a single quaternary center from August 1, 2007, to July 31, 2019. The saccular aSAH diagnoses were confirmed by cerebrovascular experts. Patients were separated into two cohorts for comparison on the basis of having undergone microsurgery or endovascular intervention. The primary outcome analyzed for comparison was poor neurological outcome, defined as a modified Rankin Scale (mRS) score > 2. The secondary outcomes that were compared included retreatment rates for both therapies. RESULTS: Of the 1014 patients with aSAH during the study period, 798 (79%) were confirmed to have saccular aneurysms. Neurological outcomes at ≥ 1-year follow-up did not differ between patients treated with microsurgery (n = 451) and those who received endovascular (n = 347) treatment (p = 0.51). The number of retreatments was significantly higher among patients treated endovascularly (32/347, 9%) than among patients treated microsurgically (6/451, 1%) (p < 0.001). The retreatment rate after endovascular treatment was lower in the PBRAT era (9%) than in the BRAT (18%). CONCLUSIONS: Similar to results from the BRAT, results from the PBRAT era showed equivalent neurological outcomes and increased rates of retreatment among patients undergoing endovascular embolization compared with those undergoing microsurgery. However, the rate of retreatment after endovascular intervention was much lower in the PBRAT era than in the BRAT.

20.
J Clin Invest ; 131(3)2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33301422

RESUMEN

Propranolol, a pleiotropic ß-adrenergic blocker, has been anecdotally reported to reduce cerebral cavernous malformations (CCMs) in humans. However, propranolol has not been rigorously evaluated in animal models, nor has its mechanism of action in CCM been defined. We report that propranolol or its S(-) enantiomer dramatically reduced embryonic venous cavernomas in ccm2 mosaic zebrafish, whereas R-(+)-propranolol, lacking ß antagonism, had no effect. Silencing of the ß1, but not ß2, adrenergic receptor mimicked the beneficial effects of propranolol in a zebrafish CCM model, as did the ß1-selective antagonist metoprolol. Thus, propranolol ameliorated cavernous malformations by ß1 adrenergic antagonism in zebrafish. Oral propranolol significantly reduced lesion burden in 2 chronic murine models of the exceptionally aggressive Pdcd10/Ccm3 form of CCM. Propranolol or other ß1-selective antagonists may be beneficial in CCM disease.


Asunto(s)
Antagonistas de Receptores Adrenérgicos beta 1/efectos adversos , Hemangioma Cavernoso del Sistema Nervioso Central , Propranolol/farmacología , Antagonistas de Receptores Adrenérgicos beta 1/farmacología , Animales , Proteínas Reguladoras de la Apoptosis/genética , Proteínas Reguladoras de la Apoptosis/metabolismo , Femenino , Quinasa 2 del Receptor Acoplado a Proteína-G/genética , Quinasa 2 del Receptor Acoplado a Proteína-G/metabolismo , Hemangioma Cavernoso del Sistema Nervioso Central/inducido químicamente , Hemangioma Cavernoso del Sistema Nervioso Central/tratamiento farmacológico , Hemangioma Cavernoso del Sistema Nervioso Central/genética , Hemangioma Cavernoso del Sistema Nervioso Central/metabolismo , Masculino , Proteínas de la Membrana/genética , Proteínas de la Membrana/metabolismo , Ratones , Ratones Noqueados , Receptor de Muerte Celular Programada 1/genética , Receptor de Muerte Celular Programada 1/metabolismo , Proteínas Proto-Oncogénicas/genética , Proteínas Proto-Oncogénicas/metabolismo , Receptores Adrenérgicos beta 2/genética , Receptores Adrenérgicos beta 2/metabolismo , Pez Cebra , Proteínas de Pez Cebra/genética , Proteínas de Pez Cebra/metabolismo
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