Time Course of Early Hematoma Expansion in Acute Spot-Sign Positive Intracerebral Hemorrhage: Prespecified Analysis of the SPOTLIGHT Randomized Clinical Trial.

BACKGROUND: In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 µg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. METHODS: Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. RESULTS: Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2-2.6). Median time from baseline CT to study drug was 62.5 (55-80) minutes, and from study drug to early post-dose CT was 19 (14.5-30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (-0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8-8.3) in the placebo arm (P=0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (-2.6 to 8.3) in the rFVIIa arm and 0.7 mL (-1.6 to 2.1) in the placebo arm (P=0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71-1.43]; P=0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994-1.003]; P=0.50; Table 3). CONCLUSIONS: In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01359202.

Classification of Scalp EEG States Prior to Clinical Seizure Onset.

OBJECTIVE: To investigate the feasibility of improving the performance of an EEG-based multistate classifier (MSC) previously proposed by our group. RESULTS: Using the random forest (RF) classifiers on the previously reported dataset of patients, but with three improvements to classification logic, the specificity of our alarm algorithm improves from 82.4% to 92.0%, and sensitivity from 87.9% to 95.2%. DISCUSSION: The MSC could be a useful approach for seizure-monitoring both in the clinic and at home. METHODS: Three improvements to the MSC are described. Firstly, an additional check using RF outputs is made prior to alarm to confirm increasing probability of a seizure onset state. Secondly, a post-alarm detection horizon that accounts for the seizure state duration is implemented. Thirdly, the alarm decision window is kept constant.

Classification of Pre-Clinical Seizure States Using Scalp EEG Cross-Frequency Coupling Features.

OBJECTIVE: This work proposes a machine-learning based system for a scalp EEG that flags an alarm in advance of a clinical seizure onset. METHODS: EEG recordings from 12 patients with drug resistant epilepsy were marked by an expert neurologist for clinical seizure onset. Scalp EEG recordings consisted of 56 seizures and 9.67 h of interictal periods. Data from six patients were reserved for testing, and the rest was split into training and testing sets. A global spatial average of a cross-frequency coupling (CFC) index, , was extracted in 2 s windows, and used as the feature for the machine learning. A multistage state classifier (MSC) based on random forest algorithms was trained and tested on these data. Training was conducted to classify three states: interictal baseline, and segments prior to and following EG onset. Classifier performance was assessed using a receiver-operating characteristic (ROC) analysis. RESULTS: The MSC produced an alarm 45 16 s in advance of a clinical seizure onset across seizures from the 12 patients. It performed with a sensitivity of 87.9%, a specificity of 82.4%, and an area-under-the-ROC of 93.4%. On patients for whom it received training, performance metrics increased. Performance metrics did not change when the MSC used reduced electrode ring configurations. CONCLUSION: Using the scalp , the MSC produced an alarm in advance of a clinical seizure onset for all 12 patients. Patient-specific training improved the specificity of classification. SIGNIFICANCE: The MSC is noninvasive, and demonstrates that CFC features may be suitable for use in a home-based seizure monitoring system.

An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management.

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

Mortality with brainstem seizures from focal 4-aminopyridine-induced recurrent hippocampal seizures.

OBJECTIVE: Sudden unexplained death in epilepsy is the leading cause of death in young adult epilepsy patients, typically occurring during the early postictal period, presumably resulting from brainstem and cardiorespiratory dysfunction. We hypothesized that ictal discharges in the brainstem disrupt the cardiorespiratory network, causing mortality. To study this hypothesis, we chose an animal model comprising focal unilateral hippocampal injection of 4-aminopyridine (4-AP), which produced focal recurrent hippocampal seizures with secondary generalization in awake, behaving rats. METHODS: We studied ictal and interictal intracranial electrographic activity (iEEG) in 23 rats implanted with a custom electrode array into the hippocampus, the contralateral cortex, and brainstem. The hippocampal electrodes contained a cannula to administer the potassium channel blocker and convulsant (4-AP). iEEG was recorded continuously before, during, and after seizures induced by 4-AP infusion into the hippocampus. RESULTS: The control group (n = 5) was monitored for 2-3 months, and the weekly baseline iEEG recordings showed long-term stability. The low-dose group (1 µL 4-AP, 40 mm, n = 5) exhibited local electrographic seizures without spread to the contralateral cerebral cortex or brainstem. The high-dose group (5 µL 4-AP, 40 mm, n = 3) had several hippocampal electrographic seizures, which spread contralaterally and triggered brainstem discharges within 40 min, and were associated with violent motor seizures followed by dyspnea and respiratory arrest, with cortical and hippocampal iEEG flattening. The group that received high-dose 4-AP without brainstem implantation (n = 5) had similar seizure-related respiratory difficulties. Finally, five rats that received high-dose 4-AP without EEG recording also developed violent motor seizures with postictal respiratory arrest. Following visualized respiratory arrest in groups III, IV, and V, manual respiratory resuscitation was successful in five of 13 animals. SIGNIFICANCE: These studies show that hippocampal seizure activity can spread or trigger brainstem epileptiform discharges that may cause mortality, possibly mediated by respiratory network dysfunction.

Spatial Coherence Profiles of Ictal High-Frequency Oscillations Correspond to Those of Interictal Low-Frequency Oscillations in the ECoG of Epileptic Patients.

GOAL: We have previously demonstrated that the coherence of high-frequency oscillations (HFOs; 80-300 Hz) increased during extratemporal lobe seizures in a consistent and spatially focused electrode cluster. In this study, we have investigated the relationship between cohered HFO intracranial EEG (iEEG) activity with that of slower low-frequency oscillations (LFOs; <80 Hz). METHODS: We applied wavelet phase coherence analysis to the iEEGs of patients with intractable extratemporal lobe epilepsy (ETLE). RESULTS: It was observed that areas on the implanted patient subdural grids, which exhibited strong ictal HFO coherence were similar to tissue regions displaying strong interictal LFO coherence in the 5-12 Hz frequency range, relative to all other electrodes. A positive surgical outcome was correlated with having the clinically marked seizure onset zone(s) in close proximity to HFO/LFO coherence highlighted regions of interest (ROIs). CONCLUSION: Recent studies have suggested that LFOs (in the 8-12 Hz frequency range) play an important role in controlling cortical excitability, by exerting an inhibitory effect on cortical processing, and that the presence of strong theta activity (4-8 Hz) in awake adults is suggestive of abnormal and/or pathological activity. We speculate that the overlapping spatial regions exhibiting increased coherence in both ictal HFOs and interictal LFOs identified local abnormalities that underlie epileptogenic networks. SIGNIFICANCE: Whereas it is worthwhile to note that the small patient group ( n = 7) studied here, somewhat limits the clinical significance of our study, the results presented here suggest targeting HFO activity in the 80-300 Hz frequency range and/or interictal LFO activity in the 5-12 Hz frequency range, when defining seizure-related ROIs in the iEEGs of patients with ETLE.

Defining regions of interest using cross-frequency coupling in extratemporal lobe epilepsy patients.

OBJECTIVE: Clinicians identify seizure onset zones (SOZs) for resection in an attempt to localize the epileptogenic zone (EZ), which is the cortical tissue that is indispensible for seizure generation. An automated system is proposed to objectively localize this EZ by identifying regions of interest (ROIs). METHODS: Intracranial electroencephalogram recordings were obtained from seven patients presenting with extratemporal lobe epilepsy and the interaction between neuronal rhythms in the form of phase-amplitude coupling was investigated. Modulation of the amplitude of high frequency oscillations (HFOs) by the phase of low frequency oscillations was measured by computing the modulation index (MI). Delta- (0.5-4 Hz) and theta- (4-8 Hz) modulation of HFOs (30-450 Hz) were examined across the channels of a 64-electrode subdural grid. Surrogate analysis was performed and false discovery rates were computed to determine the significance of the modulation observed. Mean MI values were subjected to eigenvalue decomposition (EVD) and channels defining the ROIs were selected based on the components of the eigenvector corresponding to the largest eigenvalue. ROIs were compared to the SOZs identified by two independent neurologists. Global coherence values were also computed. MAIN RESULTS: MI was found to capture the seizure in time for six of seven patients and identified ROIs in all seven. Patients were found to have a poorer post-surgical outcome when the number of EVD-selected channels that were not resected increased. Moreover, in patients who experienced a seizure-free outcome (i.e., Engel Class I) all EVD-selected channels were found to be within the resected tissue or immediately adjacent to it. In these Engel Class I patients, delta-modulated HFOs were found to identify more of the channels in the resected tissue compared to theta-modulated HFOs. However, for the Engel Class IV patient, the delta-modulated HFOs did not identify any of the channels in the resected tissue suggesting that the resected tissue was not appropriate, which was also suggested by the Engel Class IV outcome. A sensitivity of 75.4% and a false positive rate of 15.6% were achieved using delta-modulated HFOs in an Engel Class I patient. SIGNIFICANCE: LFO-modulated HFOs can be used to identify ROIs in extratemporal lobe patients. Moreover, delta-modulated HFOs may provide more accurate localization of the EZ. These ROIs may result in better surgical outcomes when used to compliment the SOZs identified by clinicians for resection.

Mapping the coherence of ictal high frequency oscillations in human extratemporal lobe epilepsy.

OBJECTIVE: High frequency oscillations (HFOs) have recently been recorded in epilepsy patients and proposed as possible novel biomarkers of epileptogenicity. Investigation of additional HFO characteristics that correlate with the clinical manifestation of seizures may yield additional insights for delineating epileptogenic regions. To that end, this study examined the spatiotemporal coherence patterns of HFOs (80-400 Hz) so as to characterize the strength of HFO interactions in the epileptic brain. We hypothesized that regions of strong HFO coherence identified epileptogenic networks believed to possess a pathologic locking nature in relation to regular brain activity. METHODS: We applied wavelet phase coherence analysis to the intracranial EEG (iEEG)s of patients (n = 5) undergoing presurgical evaluation of drug-resistant extratemporal lobe epilepsy (ETLE). We have also computed HFO intensity (related to the square-root of the power), to study the relationship between HFO amplitude and coherence. RESULTS: Strong HFO (80-270 Hz) coherence was observed in a consistent and spatially focused channel cluster during seizures in four of five patients. Furthermore, cortical regions possessing strong ictal HFO coherence coincided with regions exhibiting high ictal HFO intensity, relative to all other channels. SIGNIFICANCE: Because HFOs have been shown to localize to the epileptogenic zone, and we have demonstrated a correlation between ictal HFO intensity and coherence, we propose that ictal HFO coherence can act as an epilepsy biomarker. Moreover, the seizures studied here showed strong spatial correlation of ictal HFO coherence and intensity in the 80-270 Hz frequency range, suggesting that this band may be targeted when defining seizure-related regions of interest for characterizing ETLE.

Severe hypoglycemia in a juvenile diabetic rat model: presence and severity of seizures are associated with mortality.

It is well accepted that insulin-induced hypoglycemia can result in seizures. However, the effects of the seizures, as well as possible treatment strategies, have yet to be elucidated, particularly in juvenile or insulin-dependent diabetes mellitus (IDDM). Here we establish a model of diabetes in young rats, to examine the consequences of severe hypoglycemia in this age group; particularly seizures and mortality. Diabetes was induced in post-weaned 22-day-old Sprague-Dawley rats by streptozotocin (STZ) administered intraperitoneally (IP). Insulin IP (15 U/kg), in rats fasted (14-16 hours), induced hypoglycemia, defined as <3.5 mM blood glucose (BG), in 68% of diabetic (STZ) and 86% of control rats (CON). Seizures occurred in 86% of STZ and all CON rats that reached hypoglycemic levels with mortality only occurring post-seizure. The fasting BG levels were significantly higher in STZ (12.4 ± 1.3 mM) than in CON rodents (6.3 ± 0.3 mM), resulting in earlier onset of hypoglycemia and seizures in the CON group. However, the BG at seizure onset was statistically similar between STZ (1.8 ± 0.2 mM) and CON animals (1.6 ± 0.1 mM) as well as between those that survived (S+S) and those that died (S+M) post-seizure. Despite this, the S+M group underwent a significantly greater number of seizure events than the S+S group. 25% glucose administered at seizure onset and repeated with recurrent seizures was not sufficient to mitigate these continued convulsions. Combining glucose with diazepam and phenytoin significantly decreased post-treatment seizures, but not mortality. Intracranial electroencephalograms (EEGs) were recorded in 10 CON and 9 STZ animals. Predictive EEG changes were not observed in these animals that underwent seizures. Fluorojade staining revealed damaged cells in non-seizing STZ animals and in STZ and CON animals post-seizure. In summary, this model of hypoglycemia and seizures in juvenile diabetic rats provides a paradigm for further study of underlying mechanisms. Our data demonstrate that severe hypoglycemia (<2.0 mM) is a necessary precondition for seizures, and the increased frequency of these seizures is associated with mortality.

Efficacy and tolerability of the modified Atkins diet in adults with pharmacoresistant epilepsy: a prospective observational study.

PURPOSE: Evidence from the pediatric population exists for the efficacy of ketogenic diets in reducing seizure frequency in patients with intractable epilepsy. Recent evidence suggests that a Modified Atkins Diet may be a beneficial form of cotherapy for adult patients with pharmacoresistant epilepsy. METHODS: A prospective, open-label study was performed of adults > 18 years of age with pharmacoresistant epilepsy. Carbohydrates were restricted to 20 g/day. Fluids and calories from protein and fat were allowed ad libitum. KEY FINDINGS: Eighteen patients, ages 18-55 years, were initially enrolled. Using an intent-to-treat analysis, 12% had a >50% seizure reduction after 3 months; 28% after 6 months, and 21% after 12 months. Response at 3 months predicted response at 12 months in 79% of patients. The mean decrease in weight was 10.9 kg and the mean decrease in body mass index (BMI) was 3.8, p = 0.01. Fourteen of 18 patients (78%) completed 12 months of this diet. Patients experienced a decrease in triglycerides from (mean) 1.22 to 0.9 mm (p = 0.02). SIGNIFICANCE: The Modified Atkins Diet demonstrates modest efficacy as cotherapy for some adults with pharmacoresistant epilepsy and may be also helpful for weight loss. Financial and logistical barriers were significant factors for those who declined enrollment and for those who discontinued the study.

Spectral features of electroencephalogram in characterizing various brain states under anesthesia.

The administration of the anesthetic agents is known to alter the electroencephalogram (EEG) signal significantly with the brain being their primary target. In this study, we analyzed the EEG recorded from six ASA I/II patients undergoing a 1-2 hour surgery. The EEG was collected before and during induction, maintenance and recovery of anesthesia using the 10/20 lead-system. A combination of fentanyl and propofol (± rocuronium) was used for induction and a Sevoflurane in air/O(2) mixture was administered through an endotracheal tube to achieve the steady minimum alveolar concentration (MAC). This study showed that 0 to 4 Hz signal power was most sensitive to the changes associated with induction of anesthesia whereas the 4 to 12 Hz power was important in classifying states during maintenance of anesthesia. Anesthesia also promoted heightened phase coherence in 8 to 16 Hz and 16 to 30 Hz ranges during maintenance and induction of anesthesia, respectively. Additionally, strong cross-frequency coupling between 7 to 20 Hz and 10 to 40 Hz was observed during anesthesia suggesting alteration of neural coding.

Seizure-like activity in the hypoglycemic rat: lack of correlation with the electroencephalogram of free-moving animals.

BACKGROUND: The neuropathology of hypoglycemia and its mechanisms have been well studied. However, the physiopathogenesis of hypoglycemia-related seizures has escaped elucidation. Various animal models reportedly show "seizures" when rendered hypoglycemic, however, correlation with the electroencephalogram (EEG) is inconsistent. In order to characterize the role of the hippocampus and frontal neocortex in the generation of hypoglycemic seizures, this study was undertaken. METHODS: Adult rats were implanted stereotaxically with electrodes in the left hippocampus and right frontal cortex. After 1 week, they were fasted 18-24h, then injected intraperitoneally with insulin, 35 IU/kg. Simultaneous EEG/video monitoring was conducted. RESULTS: Interpretable EEG recordings were obtained in 8/12 animals. Two showed poor association of seizure-like behaviour (neck extension, vocalizations, tonic extension of the tail, digging or running limb movements) with ictal EEG patterns. Four animals exhibited such behaviours during periods of high amplitude polymorphic slow wave activity, burst-suppression patterns or non-rhythmic spiking. Two others were encephalopathic (behaviourally and electroencephalographically) until death. CONCLUSIONS: Not all animals develop seizure-like behaviour when hypoglycemic. If these are seizures, they may originate from subcortical structures, or the "convulsive" behaviours observed may simply be flight/fight reflexes released during profound encephalopathy. Spike activity in the EEG may be a manifestation of this state. Recording EEG from rat cortex and hippocampus during seizure-like activity brought on by hypoglycemia correlates poorly with seizure-like behaviours suggesting that the relevant electrophysiological correlates, if present, are generated from deeper brain structures.

Patient awareness of seizures as documented in the epilepsy monitoring unit.

Treatment for epilepsy depends largely on seizure frequency reported by patients through their seizure diaries. However, patients may be unaware of some of their seizures, which may lead to incomplete diary data, impacting on appropriate treatment plans. The purpose of this study was to quantify awareness of seizures in patients admitted to an epilepsy monitoring unit through post event assessments by registered nurses. Results indicated that only 44.5% of complex partial and secondarily generalized tonic-clonic seizures were recognized by patients with epilepsy. Incomplete data in seizure diaries are likely a widespread problem, which may have an important impact on treatment and, thereby, on the safety and quality of life of individuals with epilepsy.

A glue-based, screw-free method for implantation of intra-cranial electrodes in young mice.

Intra-cranial electroencephalographic recordings are increasingly employed in mice because of the availability of genetically manipulated mouse models. Currently, dental acrylic and anchoring screws are used to cement implanted electrodes. This technique works well for adult animals but often encounters difficulty when employed in young mice because their skulls are not strong enough to bear the anchoring screws. Here we describe a novel method favorable for implantation of intra-cranial electrodes in mice as young as postnatal 18 days and suitable for long-term intra-cranial electroencephalographic recordings. Our approach is to construct a multi-electrode assembly according to the desired stereotaxic coordinates of intra-cranial recordings and to secure the implanted electrode assembly to the skull via glue rather than dental acrylic/anchoring screws. The surgical operation for such electrode implantation is relatively quick and rarely associated with complications such as infection, bleeding, neurological deficits, spontaneous seizures or behavioral disturbances. The implanted electrodes are stable, allowing repeated monitoring for several months. Data obtained by simultaneous intra-hippocampal and intra-cortical recordings indicate that our method is suitable for the examination of behaviorally related electroencephalographic activities and experimentally induced seizures. Technical aspects of our methods are discussed, and the procedures for constructing the electrode assembly are presented in detail.

Deep brain stimulation of the anterior nucleus of the thalamus: effects of electrical stimulation on pilocarpine-induced seizures and status epilepticus.

PURPOSE: Electrical stimulation of the anterior nucleus of the thalamus appears to be effective against seizures in animals and humans. As the optimal stimulation settings remain elusive, we studied the effects of different stimulation parameters against pilocarpine induced seizures and status epilepticus (SE). METHODS: Adult rats had electrodes implanted bilaterally into the AN. Five days later, different groups of animals were stimulated with 1000 microA, 500 microA, or 200 microA and frequencies of either 20 Hz or 130 Hz. Pilocarpine (350 mg/kg i.p.) was injected 5 min after stimulation onset and seizures were monitored. Sham-treated controls had electrodes implanted but did not receive stimulation until they developed SE. After SE, these animals had the electrodes turned on to assess whether AN stimulation could arrest ongoing ictal activity. RESULTS: Compared to sham-treated controls (n=8), stimulation at 500 microA (n=13) significantly increased the latency for seizures and SE by 1.9-2.2-fold. In contrast, stimulation at 1000 microA (n=8) produced a non-significant decrease in the latencies to these events. No major effect was observed with stimulation at 200 microA (n=11). Similar results were obtained for each current intensity, regardless of the stimulation frequency used (20 Hz and 130 Hz). In sham-treated controls that had the electrodes turned on after SE, stimulation was not able to arrest ongoing ictal activity. CONCLUSIONS: The anticonvulsant effects of AN stimulation against pilocarpine-induced seizures were mainly determined by the current and not the frequency of stimulation. AN stimulation initiated after SE onset was ineffective.

Stent coronario en el infarto agudo del miocardio / Coronary stent in acute myocardial infraction

De diciembre de 1995 a marzo de 1997 se implantaron en 50 pacientes, durante la fase aguda del infarto del miocardio, un total de 57 stents en 50 arterias relacionadas con el infarto (ARI). El tiempo de evolución de este último fue de 3.7 ñ 2.9 hrs. Arterias con diámetro = 2.5 mm, y aquéllas con trombo grande agregado > 20 mm fueron excluídas. Las indicaciones para implante de los 57 stents utilizados fueron: "de novo" en 24 casos, resultado sub-óptimo en 17, amenaza de cierre en 5 y disección compleja en otros once. Las ARI tratadas con stent fueron: la descendente anterior en el 42 por ciento de los casos, la coronaria derecha en 42 por ciento, la circunfleja en 10 por ciento, injertos venosos en 4 por ciento, el ramo intermedio en 1 por ciento y la obtusa marginal en 1 por ciento. Los stents utilizados fueron en su mayoría AVE (67 por ciento de los casos), seguidos de Palmaz-Schatz, Wiktor, Crown, Gianturco-Roubin y Wallstent. El flujo snguíneo coronario pre-procedimiento fue TIMI O en el 66 por ciento, TIMI 1 en 10 por ciento y TIMI 2 en el 24 por ciento de las ARI. Después del procedimientos se obtuvo TIMI 3 en el 92 por ciento y en otras 4 ARI hubo fenómeno de "no-reflow". El grado de estenosisi inicial fue de 96 por ciento ñ 3.1 y post-stent de 1.76 por ciento ñ 2.6, con una relaciónstent/diámetro vascular de 1.01. Existio técnico se obtuvo en el 100 por ciento de los casos y éxito clínico en 48/50 enfermos (96 por ciento). Dos pacientes fallecieron como con secuencia del procedimiento: uno por oclusión trombótica aguda del stent y otro por choque cardiogénico dos días después de implante exitoso de un stent en la arteria descendente anterior. No hubo necesidad de cirugía urgente, ni re-infarto o re-angioplastía en el resto de los enfermos analizados. Otros dos sujetos murieron por causas no relacionadas con el procedimiento: pancreatitis aguda en uno y septicemia en otro. Al egreso, el 96 por ciento de los enfermos fueron tratados con aspirina y ticlopidina. Una hematoma inguinal mayor se presentó en un solo caso. El seguimiento clinico promedio en 45 sujetos fue de 5.6 ñ 4.2 meses y mostró que el 73 por ciento se encontraban en clase funcional I y en ninguno había habido eventos de re-infarto, re-revascularización o muerte. En conclusión el stent implantado en la fase aguda del infarto en un método eficaz y seguro con una tasa baja de eventos isquémicos recurrentes

[Prolactinemia in children anesthetized with propofol]. / Prolactinemia en niños anestesiados con propofol.

OBJECTIVES: To assess the relation between plasma levels of prolactin and spontaneous movements in children anesthetized with propofol and to compare the prolactin endocrine response for 2 different techniques of anesthetic maintenance. PATIENTS AND METHOD: This was a prospective study of 35 ASA I children between 4 and 11 years of age, with no history of epilepsy or febrile convulsions, who underwent herniorrhaphy or orchidopexy. The patients were not premedicated. Before induction they received 0.02 mg/kg atropine and 2.5 micrograms/kg i.v.; induction was with 4 mg/kg propofol and 0.5 mg/kg atracurium. For maintenance the sample was randomly divided into 2 groups. Group A (n = 18) received 10 mg/kg/h propofol and 40% O2/air. Group B (n = 17) received 1-0.7% isoflurane and 40% N2O/O2. We measured plasma levels of prolactin before induction (baseline prolactin) and after extubation (postoperative prolactin). We also assessed pain upon injection of propofol by observing and recording spontaneous movement. RESULTS: The number of children who remained in the study was 24, with 14 in group A and 10 in group B. We observed a significant increase (p < 0.05) of postoperative prolactin in children with spontaneous movement (15.3 +/- 7.5 vs. 87.1 +/- 42.9 ng/ml) as well as in those with no movement (23.8 +/- 15.9 vs. 82.4 +/- 29.7 ng/ml). There were no significant differences between baseline prolactin (20.9 +/- 16.9 vs. 21.8 +/- 10.8 ng/ml) and postoperative levels (90 +/- 35.4 vs. 75 +/- 29 ng/ml) related to technique. CONCLUSIONS: Increase in prolactin is unrelated to spontaneous movements, which are attributable to low induction dose. Differences in prolactin plasma levels are not related to anesthetic technique.