Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study.

BACKGROUND: Decompressive craniectomy (DC) has been shown to be an effective treatment for malignant cerebral infarction (MCI). There are limited nationwide studies evaluating outcome after craniectomy for MCI. OBJECTIVE: To describe the evolution in DC practices for MCI, long-term survival, and associated prognostic factors. METHODS: We searched the French medico-administrative national database to retrieve patients who underwent DC between 2008 and 2017. RESULTS: A total of 1841 cases of DC were performed over 10 years in 51 centers. Mean age at procedure was 50.9 years, 18% were above 60 years, and 64.4% were male. There was a significant increase in DC for MCI over the 10 years (p < 0.001), and the annual volume of procedures more than doubled (95/year vs. 243/year). Early survival at one week and one month was 86%, 95%CI (84.5, 87.6) and 79.7%, 95%CI (77.8, 81.5), respectively. Long-term survival at 1 and 5 years were 73.6%, 95%CI (71.6, 75.7) and 68.9%, 95%CI (66.5, 71.4), respectively. Patients below 60 years at the time of DC (HR = 0.5; 95%CI [0.4, 0.7], p < 0.001), DC being performed in a center with a high surgical activity (HR = 0.8; 95%CI [0.6, 0.9], p = 0.002), and the patients having unimpaired consciousness (HR = 0.6; 95%CI [0.5, 0.8], p < 0.001) were associated with increased survival in both univariate and adjusted Cox regressions. 18.7% of the survivors had a cranioplasty inserted within 3 months and 57.8% within 6 months. The probability of having a cranioplasty at one year was 75.6%, 95%CI (77.9, 73.1). CONCLUSION: Over the past 10 years in France, DC has been increasingly performed for MCI regardless of age. However, in-hospital mortality remains considerable, as about one quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC.

Catatonic Stupor in Schizophrenic Disorders and Subsequent Medical Complications and Mortality.

OBJECTIVE: Although catatonia can occur secondary to a general medical condition, catatonia itself has been known to lead to various medical compolications. Although case reports on the association of catatonia with subsequent medical complications have been documented, no comprehensive large-scale study has been performed. To investigate specific medical complications after catatonia, we conducted a retrospective cohort study of specific medical complications of schizophrenia patients with catatonia. METHODS: The 1719 schizophrenia inpatients in our study were categorized into two groups: the catatonia group, i.e., those who exhibited catatonic stupor while they were hospitalized, and the noncatatonia group, i.e., those who never exhibited catatonic stupor. Differences between the two groups in the occurrence of subsequent medical complications were examined using linear and logistic regression analyses, and models were adjusted for potentially confounding factors. RESULTS: The catatonia group had an increased risk for mortality (odds ratio = 4.8, 95% confidence interval = 2.0-10.6, p < .01) and certain specific medical complications, i.e., pneumonia, urinary tract infection, sepsis, disseminated intravascular coagulation, rhabdomyolysis, dehydration, deep venous thrombosis, pulmonary embolism, urinary retention, decubitus, arrhythmia, renal failure, neuroleptic malignant syndrome, hypernatremia, and liver dysfunction (all p values < .01, except for deep venous thrombosis, p = .04 in the multiple linear regression analysis). CONCLUSIONS: Catatonic stupor in schizophrenia substantially raises the risk for specific medical complications and mortality. Hyperactivity of the sympathetic nervous system, dehydration, and immobility, which are frequently involved in catatonia, might contribute to these specific medical complications. In catatonia, meticulous care for both mental and medical conditions should be taken to reduce the risk of adverse medical consequences.

Electro-Radiological Observations of Grade III/IV Hepatic Encephalopathy Patients with Seizures.

BACKGROUND: Neurological complications in liver failure are common. Often under-recognized neurological complications are seizures and status epilepticus. These may go unrecognized without continuous electroencephalography (CEEG). We highlight the observed electro-radiological changes in patients with grade III/IV hepatic encephalopathy (HE) found to have seizures and/or status epilepticus on CEEG and the associated neuroimaging. METHODS: This study was a retrospective review of patients with West Haven grade III/IV HE and seizures/status epilepticus on CEEG. RESULTS: Eleven patients were included. Alcohol was the most common cause of HE (54.5%). All patients were either stuporous/comatose. The most common CEEG pattern was diffuse slowing (100%) followed by generalized periodic discharges (GPDs; 36.4%) and lateralized periodic discharges (LPDs, 36.4%). The subtype of GPDs with triphasic morphology was only seen in 27.3%. All seizures and/or status epilepticus were without clinical signs. Magnetic resonance imaging (MRI) was available in six patients. Cortical hyperintensities on diffusion weighted imaging sequence were seen in all six patients. One patient had CEEG seizure concomitantly with the MRI. Seven patients died prior to discharge. CONCLUSION: Seizures or status epilepticus in the setting of HE were without clinical findings and could go unrecognized without CEEG. The finding of cortical hyperintensity on MRI should lead to further evaluation for unrecognized seizure or status epilepticus.

Early predictors of refractory status epilepticus: an international two-center study.

BACKGROUND AND PURPOSE: Status epilepticus (SE) refractory to first- and second-line antiepileptic drugs carries high mortality. Little is known on early prediction of refractory SE (RSE)­an essential tool for planning appropriate therapy. Our aim was to identify and validate independent early RSE predictors in adults. METHODS: Clinical and laboratory data on consecutive intensive care unit patients with SE from two academic care centers (a derivation data set from a Swiss center and a validation data set from a US center) were assessed. Multivariable analysis was performed with the derivation set to identify RSE predictors at SE onset. Their external validity was evaluated with an independent validation set. Measures of calibration and discrimination were assessed. RESULTS: In all, 302 patients were analyzed (138 with and 164 without RSE), 171 in the derivation data set and 131 in the validation data set. Acute SE etiology, coma/stupor and serum albumin <35 g/l at SE onset were independent predictors for RSE in the derivation data set [odds ratio (OR) 2.02, 95% confidence interval (CI) 1.01-4.07; OR 4.83, 95% CI 2.42-9.68; OR 2.45, 95% CI 1.16-5.16]. The prediction model showed good measures of calibration (Hosmer-Lemesow goodness-of-fit test P = 0.99) and discrimination (area under the receiver operating characteristic curve 0.8) on the derivation data set­results that were similar in the validation data set (Hosmer-Lemeshow P = 0.24; area under the receiver operating characteristic curve 0.73). CONCLUSIONS: This study confirms the independent prognostic value of readily available parameters for early RSE prediction. Prospective studies are needed to identify additional robust predictors, which could be added to the proposed model for further optimization towards a reliable prediction scoring system.

Persistence of critical flicker fusion frequency impairment after a 33 mfw SCUBA dive: evidence of prolonged nitrogen narcosis?

One of the possible risks incurred while diving is inert gas narcosis (IGN), yet its mechanism of action remains a matter of controversy. Although providing insights in the basic mechanisms of IGN, research has been primarily limited to animal studies. A human study, in real diving conditions, was needed. Twenty volunteers within strict biometrical criteria (male, age 30-40 years, BMI 20-23, non smoker) were selected. They performed a no-decompression dive to a depth of 33 mfw for 20 min and were assessed by the means of critical flicker fusion frequency (CFFF) measurement before the dive, during the dive upon arriving at the bottom, 5 min before the ascent, and 30 min after surfacing. After this late measurement, divers breathed oxygen for 15 min and were assessed a final time. Compared to the pre-dive value the mean value of each measurement was significantly different (p < 0.001). An increase of CFFF to 104 ± 5.1 % upon arriving to the bottom is followed by a decrease to 93.5 ± 4.3 %. This impairment of CFFF persisted 30 min after surfacing, still decreased to 96.3 ± 8.2 % compared to pre-dive CFFF. Post-dive measures made after 15 min of oxygen were not different from control (without nitrogen supersaturation), 124.4 ± 10.8 versus 124.2 ± 3.9 %. This simple study suggests that IGN (at least partially) depends on gas-protein interactions and that the cerebral impairment persists for at least 30 min after surfacing. This could be an important consideration in situations where precise and accurate judgment or actions are essential.

[Familial hemiplegic migraine type 2: two paediatric case reports]. / Migraña hemipléjica familiar tipo II:a propósito de dos casos pediátricos.

INTRODUCTION: Familial hemiplegic migraine is a rare subtype of migraine with aura that includes, as it progresses, a motor defect together with visual or sensory symptoms or speech disorders. It may be associated to symptoms such as basilar migraine, coma and convulsions. Familial hemiplegic migraine type 2 accounts for 25% of them. CASE REPORTS: Two patients, who started at the age of 4 years with episodes of motor deficits or seizures, together with an important sensory disorder that lasted for hours, which were sometimes triggered by banal traumatic injuries. A detailed description of the clinical and developmental features, as well as the studies conducted, is provided. The genetic study revealed mutations in gene ATP1A2: in one case this consisted in a nucleotide substitution in exon 18 (G2501A) that had already been reported, while in the other case there was a previously unknown change (c.381+3 G>T) in intron 4. CONCLUSIONS: We recommend that this condition should be suspected when a disagreement between the duration or the severity of the seizures and the duration and characteristics of the ensuing stupor is detected.

High pressure effects in anaesthesia and narcosis.

There is growing interest in determining the effects of high pressure on biological functions. Studies of brain processes under hyperbaric conditions can give a unique insight into phenomena such as nitrogen narcosis, inert gas anaesthesia, and pressure reversal of the effects of anaesthetic and narcotic agents. Such research may shed light on the action of anaesthetics, which remains poorly understood, and on the nature of consciousness itself. Various studies have established the behavioural response of organisms to hyperbaric conditions, in the presence or absence of anaesthetic agents. At the molecular level, X-ray crystallography has been used to investigate the incorporation of species like Xe in hydrophobic pockets within model ion channels that may account for pressure effects on neuronal transmission. New magnetic resonance imaging techniques are providing tomographic three-dimensional images that detail brain structure and function, and that can be correlated with behavioural studies and psychological test results. Such whole organ techniques are linked to the molecular scale via voltage-sensitive dye (VSD) imaging studies on brain slices that provide time-resolved images of the dynamic formation and interconnection of inter-neuronal complexes. The VSD experiments are readily adapted to in situ studies under high pressure conditions. In this tutorial review we review the current state of knowledge of hyperbaric effects on brain processes: anaesthesia and narcosis, recent studies at the molecular level via protein crystallography at high pressure in a Xe atmosphere, and we also present some preliminary results of VSD imaging of brain slices under hyperbaric conditions.