Initial experience using middle meningeal artery embolisation for patients with recurrent and high-recurrence-risk chronic subdural haematoma.

Recurrence rates following surgical management of chronic subdural haematoma (CSDH) range from 5 to 33 %. There is growing evidence which suggests middle meningeal artery embolisation (MMAe) may reduce recurrence rates when used as surgical adjunct or standalone treatment. In this study we described our experience of this new procedure in the our UK institution. Patients with recurrent CSDH or CSDH at high risk of recurrence were selected for MMAe on a case-by-case basis following MDT discussion. A departmental database was used to identify patients treated. 26 CSDH were embolised in 20 patients; 9 CSDH were de-novo and 17 were recurrent. 10/26 CSDH were treated with MMAe only. No procedural mortality, access site or thrombo-embolic complications occurred. One patient experienced symptomatic collection growth 12 h following MMAe and required surgical drainage. 15 (75 %) of patients were living at home at follow-up (mean 14 months). On imaging follow-up 15/18 showed CSDH volume reduction or resolution, 1/18 remained stable requiring no further treatment, 2/18 patients suffered recurrent CSDH requiring treatment. In both recurrent cases incomplete embolisation was noted on procedural imaging (posterior division of MMA not embolised). Persistent posterior MMA division filling was significantly associated with collection recurrence (p = 0.002). Our results suggest MMAe as a stand-alone or adjuvant therapy can be performed safely in a UK neuroscience setting and is associated with high rates of symptomatic CSDH size reduction or resolution in problematic CSDH that have either recurred or are prone to recurrence.

Factors impacting on technical success in stroke thrombectomy: experience of a UK neuro-interventional unit.

AIM: To investigate factors that could impact on recanalisation and reperfusion in patients undergoing mechanical thrombectomy and to assess the technical success over time. MATERIALS AND METHODS: Two hundred consecutive patients who underwent thrombectomy for a proximal anterior circulation occlusion were dichotomised into equal groups (groups 1 and 2) based on the date that immediate access to emergency general anaesthesia (GA) commenced. RESULTS: Recanalisation success using thrombolysis in cerebral infarction (TICI) 2b/3 or TICI 2c/3 significantly improved in group 2 (67% versus 93%, p<0.0001; 52% versus 78%, p=0.0002). Symptomatic haemorrhage also reduced from 9% to 4%. Despite similar presentation Alberta Stroke Program Early (computed tomography) CT Scores (ASPECTS), post-procedural ASPECTS was significantly increased in group 2 (7; [interquartile range {IQR} 4-9] versus 8 [IQR 7-9]; p=0.0034). The number of patients with a post procedural ASPECTS of 8-10 increased (46% versus 64%, p=0.0155) and the difference in ASPECTS between pre- and post-thrombectomy CT was significantly lower (2 [IQR 1-4] versus 1 [IQR 0-2], p<0.0001). GA use increased from 8% to 56% (p=0.0001) as did use of distal aspiration (59% versus 87%, p=0.0001) mostly in combination with a stent-retriever. Failed access fell from 8% to 3%. When GA was used, successful recanalisation (TICI 2b/3) was achieved more frequently (90.5% versus 76.7%; OR 3.04, 1.2-7.69, p=0.0187). CONCLUSION: Technical results for thrombectomy are improving over time. Technique modification, operator experience, and judicious use of GA may be contributing.

Neonatal presentation of lethal neuromuscular glycogen storage disease type IV.

A total of 11 types of glycogen storage disorders have been recognized with variable clinical presentations. Type IV, also known as Andersen disease, represents a rare subtype that can induce severe clinical findings early in life. We report on a patient with early fetal onset of symptoms with severe neuromuscular findings at birth. The pregnancy was further complicated by polyhydramnios and depressed fetal movement. At birth severe hypotonia was noticed requiring active resuscitation and then mechanical ventilation. His lack of expected course for hypoxic ischemic encephalopathy prompted genetic testing, including a muscle biopsy, which confirmed the diagnosis of glycogen storage disease IV (GSD IV). Mutation analysis of the glycogen branching enzyme 1 gene demonstrated a previously unrecognized mutation. We review recent information on early presentation of GSD IV with particular interest in the presentation of the neonatal lethal neuromuscular form of this rare disorder.

The timing of skin acidification in very low birth weight infants.

OBJECTIVE: The purpose of this study was to examine the development of the pH mantle of the skin in very low birth weight (VLBW) infants. STUDY DESIGN: Forty VLBW infants underwent repeated measurements of skin pH over the first month of life using a glass flat-surface pH electrode. Six skin sites were measured, daily for the first week of life and then twice weekly for the next 3 weeks. RESULTS: The only factor that affected the initial skin pH was sex, with males having a significantly higher pH at birth. Over time, birth weight, skin area, and postnatal age had significant effects on skin pH. The pattern of postnatal change in skin pH was similar to that described in term infants, a rapid decrease in pH over the first week followed by a more gradual decrease over the next 3 weeks. CONCLUSION: The development of the skin's acid mantle in VLBW infants occurs rapidly during postnatal life and closely mimics the pattern seen at term.

Herpes simplex type II infection in monozygotic twins.

The unusual occurrence of herpes simplex virus (HSV) type II infection in a set of monozygotic premature twins is described. The cases highlight the difficulty of early diagnosis of HSV disease in the absence of a positive maternal history and cutaneous lesions. Risk factors for mortality and morbidity are discussed.

A prospective clinical evaluation of an equation to predict daily lithium dose.

BACKGROUND: Conclusions about the usefulness of lithium dose-prediction equations are often based on retrospective evaluations, and the paucity of prospective tests is striking. METHOD: We prospectively evaluated the safety and accuracy of a lithium-dose prediction equation in a group of 29 psychiatric patients. Predicted doses were computed and rounded to the nearest multiple of 300 mg, and the respective doses of lithium carbonate were given either two or three times a day. On Day 4 or 5 following treatment initiation, morning blood samples were collected 8 to 12 hours after administration of the last dose. Patients were monitored carefully for signs of lithium toxicity. RESULTS: All 29 subjects achieved lithium concentrations between 0.5 and 1.3 mmol/L within 5 days of beginning treatment, and no participant showed any signs of lithium toxicity. CONCLUSION: The equation may be a safe, reasonable alternative to empiric dosing.

Lipid tolerance in the very low birth weight infant on intravenous and enteral feedings.

Nutrition is of critical importance to very low birth weight (VLBW) survival. Intravenous (iv) lipid tolerance has been studied using a soybean or safflower-based lipid emulsion. We studied lipid levels in a group of VLBW infants on both intravenous lipids (soybean-safflower emulsion) and on enteral feedings (24 cal/oz premature formula). Levels were obtained on 1, 2, and 3 g/kg/day of iv lipid and after 3 and 10 days of feeding. Triglyceride (TG) and free fatty acid (FFA) proved the most sensitive indicator of both iv and enteral tolerance. The higher the lipid dose, the more likely there would be elevated lipid levels, especially FFA. Mean lipid levels for the group of enteral-fed infants were normal. Comparison of lipid levels on iv to those on enteral feedings showed significant differences in trough iv levels of TG compared to preprandial TG. FFAs tended to be significantly higher on iv feedings. Monitoring lipid levels on iv and enteral feedings is appropriate to document tolerance.

Prediction of arterial blood pressure in the premature neonate using the oscillometric method.

The noninvasive oscillometric measurement of blood pressure (BP) in preterm neonates has become a common practice in intensive care nurseries. The method has gained acceptance primarily through its correlation with direct arterial measurement. In this study, the oscillometric method (using Dinamap 1846) was compared with direct intra-arterial BP monitoring in 15 preterm infants. The 95% prediction intervals for individual oscillometric measurements were wide, ranging from 17 mm Hg for the mean BP to 20 mm Hg for the systolic and diastolic BP. The oscillometric method also underestimated intra-arterial systolic and mean BP and overestimated diastolic BP. Caution must be used when oscillometrically measuring BP in premature neonates.