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Purpose To compare the short- and long-term (>1 year) efficacy and safety of radiofrequency ablation (ClosureFAST™) versus endovenous laser ablation (980 nm diode laser) for the treatment of superficial venous insufficiency of the great saphenous vein. Materials and methods Two hundred patients with superficial venous insufficiency of the great saphenous vein were randomized to receive either radiofrequency ablation or endovenous laser ablation (and simultaneous adjunctive therapies for surface varicosities when appropriate). Post-treatment sonographic and clinical assessment was conducted at one week, six weeks, and six months for closure, complications, and patient satisfaction. Clinical assessment of each patient was conducted at one year and then at yearly intervals for patient satisfaction. Results Post-procedure pain ( p < 0.0001) and objective post-procedure bruising ( p = 0.0114) were significantly lower in the radiofrequency ablation group. Improvements in venous clinical severity score were noted through six months in both groups (endovenous laser ablation 6.6 to 1; radiofrequency ablation 6.2 to 1) with no significant difference in venous clinical severity score ( p = 0.4066) or measured adverse effects; 89 endovenous laser ablation and 87 radiofrequency patients were interviewed at least 12 months out with a mean long-term follow-up of 44 and 42 months ( p = 0.1096), respectively. There were four treatment failures in each group, and every case was correctable with further treatment. Overall, there were no significant differences with regard to patient satisfaction between radiofrequency ablation and endovenous laser ablation ( p = 0.3009). There were no cases of deep venous thrombosis in either group at any time during this study. Conclusions Radiofrequency ablation and endovenous laser ablation are highly effective and safe from both anatomic and clinical standpoints over a multi-year period and neither modality achieved superiority over the other.
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Ablación por Catéter , Terapia por Láser , Ondas de Radio , Vena Safena/cirugía , Insuficiencia Venosa/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Vena Femoral/cirugía , Estudios de Seguimiento , Humanos , Láseres de Semiconductores , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias , Estudios Prospectivos , Várices/terapia , Adulto JovenRESUMEN
Targeted therapies for cutaneous squamous cell carcinoma (cSCC) remain limited. Extensive genetic heterogeneity complicates a robust molecular characterization of the evolution of cSCC. Nonetheless, potential targeted therapies for this cancer are under investigation, including the inhibition of epidermal growth factor receptor (EGFR), which may yield promising results. In addition, the emergence of immune checkpoint blockade therapy and vaccine-based methods may provide novel treatment strategies for cSCC that are tailored to the individual patient. Ultimately, a combination of such methods may yield a multi-pronged targeted approach to personalize the treatment of cSCC.
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Carcinoma de Células Escamosas/tratamiento farmacológico , Neoplasias Cutáneas/tratamiento farmacológico , Antineoplásicos/uso terapéutico , Antígeno CTLA-4/antagonistas & inhibidores , Vacunas contra el Cáncer , Carcinoma de Células Escamosas/inmunología , Carcinoma de Células Escamosas/metabolismo , Receptores ErbB/antagonistas & inhibidores , Humanos , Terapia Molecular Dirigida , Receptor de Muerte Celular Programada 1/antagonistas & inhibidores , Neoplasias Cutáneas/inmunología , Neoplasias Cutáneas/metabolismoRESUMEN
BACKGROUND: Dermatologic surgeons may encounter challenging defects of the head and neck that are not amenable to repair with local flaps or grafts. OBJECTIVE: We offer a comprehensive review of the temporoparietal fascia flap (TPFF) and provide a step-by-step illustration of its application performed under local anesthesia for a challenging reconstructive scenario. MATERIALS AND METHODS: A 66-year-old male initially underwent Mohs micrographic surgery resulting in a large full-thickness defect at the postauricular scalp contiguous with a through-and-through defect of the upper right ear. A TPFF was performed under local anesthesia to reconstruct the surgical defect. RESULTS: Complete healing in our patient was noted at 10 weeks after completion of the TPFF. However, granulation caused adherence of the ear to the postauricular scalp, which was corrected by a dividing incision to release the ear. At 4 weeks after the division, lateral projection of the ears was symmetric and readherence of the ear did not recur. CONCLUSION: The TPFF is a highly versatile pedicled flap that can be performed under local anesthesia to reconstruct a variety of complex defects on the head and neck. This case reveals that the TPFF adds a powerful tool to the armamentarium of dermatologic surgeons.
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Procedimientos Quirúrgicos Dermatologicos/métodos , Oído Externo/cirugía , Fascia/trasplante , Procedimientos de Cirugía Plástica/métodos , Cuero Cabelludo/cirugía , Colgajos Quirúrgicos , Anciano , Tejido de Granulación/cirugía , Humanos , Masculino , Cirugía de Mohs/efectos adversos , Cuidados Posoperatorios , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Procedimientos de Cirugía Plástica/efectos adversos , Colgajos Quirúrgicos/irrigación sanguínea , Adherencias Tisulares/etiología , Adherencias Tisulares/cirugíaRESUMEN
Patients treated with ipilimumab or targeted inhibitors of the RAF-MEK-ERK pathway (vemurafenib, dabrafenib, and trametinib) for advanced cutaneous melanoma often experience drug-related skin toxicities denoted as dermatologic adverse events (DAEs). Although rarely life-threatening, DAEs may emerge dramatically and potentially compromise oncologic therapy if not managed in a timely and effective manner. Early recognition of DAEs is critical to providing optimal skin care and prompt consultation with a dermatologist should be obtained when a diagnosis is unclear. The expanding utilization of new melanoma drugs compels physicians to maintain a watchful eye for both known and novel DAEs and to adopt a low threshold to biopsy worrisome skin findings. Numerous therapeutic options are available to manage DAEs including topical and systemic agents as well as surgical and destructive modalities. Applying such methods improves overall patient care and optimizes the effectiveness of new therapies for advanced cutaneous melanoma.
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Antineoplásicos/efectos adversos , Melanoma/tratamiento farmacológico , Neoplasias Cutáneas/tratamiento farmacológico , Piel/efectos de los fármacos , Anticuerpos Monoclonales/efectos adversos , Humanos , Imidazoles/efectos adversos , Indoles/efectos adversos , Inflamación , Ipilimumab , Oximas/efectos adversos , Piridonas/efectos adversos , Pirimidinonas/efectos adversos , Enfermedades de la Piel/inducido químicamente , Sulfonamidas/efectos adversos , Resultado del Tratamiento , Vemurafenib , Melanoma Cutáneo MalignoRESUMEN
INTRODUCTION: Caloric restriction (CR) delays cancer growth in animals, though translation to humans is difficult. We hypothesized intermittent fasting (i.e., intermittent extreme CR), may be better tolerated and prolong survival of prostate cancer (CaP) bearing mice. METHODS: We conducted a pilot study by injecting 105 male individually-housed SCID mice with LAPC-4 cells. When tumors reached 200 mm(3), 15 mice/group were randomized to one of seven diets and sacrificed when tumors reached 1,500 mm(3): Group 1: ad libitum 7 days/week; Group 2: fasted 1 day/week and ad libitum 6 days/week; Group 3: fasted 1 day/week and fed 6 days/week via paired feeding to maintain isocaloric conditions to Group 1; Group 4: 14% CR 7 days/week; Group 5: fasted 2 days/week and ad libitum 5 days/week; Group 6: fasted 2 day/week and fed 5 days/week via paired feeding to maintain isocaloric conditions to Group 1; Group 7: 28% CR 7 days/week. Sera from mice at sacrifice were analyzed for IGF-axis hormones. RESULTS: There were no significant differences in survival among any groups. However, relative to Group 1, there were non-significant trends for improved survival for Groups 3 (HR 0.65, P = 0.26), 5 (0.60, P = 0.18), 6 (HR 0.59, P = 0.16), and 7 (P = 0.59, P = 0.17). Relative to Group 1, body weights and IGF-1 levels were significantly lower in Groups 6 and 7. CONCLUSIONS: This exploratory study found non-significant trends toward improved survival with some intermittent fasting regimens, in the absence of weight loss. Larger appropriately powered studies to detect modest, but clinically important differences are necessary to confirm these findings.
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Ayuno/fisiología , Neoplasias de la Próstata/patología , Animales , Composición Corporal/fisiología , Peso Corporal/fisiología , Procesos de Crecimiento Celular/fisiología , Proteínas de Unión a Factor de Crecimiento Similar a la Insulina/sangre , Factor I del Crecimiento Similar a la Insulina/metabolismo , Masculino , Ratones , Ratones SCID , Proyectos Piloto , Modelos de Riesgos Proporcionales , Neoplasias de la Próstata/metabolismo , Distribución Aleatoria , Análisis de SupervivenciaRESUMEN
PURPOSE: Numerous dietary factors elevate serum levels of insulin and insulin-like growth factor I (IGF-I), both potent prostate cancer mitogens. We tested whether varying dietary carbohydrate and fat, without energy restriction relative to comparison diets, would slow tumor growth and reduce serum insulin, IGF-I, and other molecular mediators of prostate cancer in a xenograft model. EXPERIMENTAL DESIGN: Individually caged male severe combined immunodeficient mice (n = 130) were randomly assigned to one of three diets (described as percent total calories): very high-fat/no-carbohydrate ketogenic diet (NCKD: 83% fat, 0% carbohydrate, 17% protein), low-fat/high-carbohydrate diet (LFD: 12% fat, 71% carbohydrate, 17% protein), or high-fat/moderate-carbohydrate diet (MCD: 40% fat, 43% carbohydrate, 17% protein). Mice were fed to maintain similar average body weights among groups. Following a preliminary feeding period, mice were injected with 1 x 10(6) LNCaP cells (day 0) and sacrificed when tumors were >or=1,000 mm(3). RESULTS: Two days before tumor injection, median NCKD body weight was 2.4 g (10%) and 2.1 g (8%) greater than the LFD and MCD groups, respectively (P < 0.0001). Diet was significantly associated with overall survival (log-rank P = 0.004). Relative to MCD, survival was significantly prolonged for the LFD (hazard ratio, 0.49; 95% confidence interval, 0.29-0.79; P = 0.004) and NCKD groups (hazard ratio, 0.59; 95% confidence interval, 0.37-0.93; P = 0.02). Median serum insulin, IGF-I, IGF-I/IGF binding protein-1 ratio, and IGF-I/IGF binding protein-3 ratio were significantly reduced in NCKD relative to MCD mice. Phospho-AKT/total AKT ratio and pathways associated with antiapoptosis, inflammation, insulin resistance, and obesity were also significantly reduced in NCKD relative to MCD tumors. CONCLUSIONS: These results support further preclinical exploration of carbohydrate restriction in prostate cancer and possibly warrant pilot or feasibility testing in humans.
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Adenocarcinoma/dietoterapia , Dieta Baja en Carbohidratos , Carbohidratos de la Dieta/toxicidad , Grasas de la Dieta/uso terapéutico , Neoplasias de la Próstata/dietoterapia , Adenocarcinoma/sangre , Adenocarcinoma/genética , Adenocarcinoma/patología , Animales , Apoptosis/efectos de los fármacos , Glucemia/análisis , Línea Celular Tumoral/trasplante , Dieta Cetogénica , Carbohidratos de la Dieta/administración & dosificación , Grasas de la Dieta/administración & dosificación , Progresión de la Enfermedad , Hígado Graso/etiología , Regulación Neoplásica de la Expresión Génica/efectos de los fármacos , Humanos , Insulina/sangre , Resistencia a la Insulina , Proteína 1 de Unión a Factor de Crecimiento Similar a la Insulina/sangre , Proteína 3 de Unión a Factor de Crecimiento Similar a la Insulina/sangre , Factor I del Crecimiento Similar a la Insulina/análisis , Cetonas/orina , Masculino , Ratones , Ratones SCID , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/genética , Neoplasias de la Próstata/patología , Proteínas Proto-Oncogénicas c-akt/sangre , Distribución Aleatoria , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
OBJECTIVE: Dietary carbohydrate is the major determinant of postprandial glucose levels, and several clinical studies have shown that low-carbohydrate diets improve glycemic control. In this study, we tested the hypothesis that a diet lower in carbohydrate would lead to greater improvement in glycemic control over a 24-week period in patients with obesity and type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS: Eighty-four community volunteers with obesity and type 2 diabetes were randomized to either a low-carbohydrate, ketogenic diet (<20 g of carbohydrate daily; LCKD) or a low-glycemic, reduced-calorie diet (500 kcal/day deficit from weight maintenance diet; LGID). Both groups received group meetings, nutritional supplementation, and an exercise recommendation. The main outcome was glycemic control, measured by hemoglobin A1c. RESULTS: Forty-nine (58.3%) participants completed the study. Both interventions led to improvements in hemoglobin A1c, fasting glucose, fasting insulin, and weight loss. The LCKD group had greater improvements in hemoglobin A1c (-1.5% vs. -0.5%, p = 0.03), body weight (-11.1 kg vs. -6.9 kg, p = 0.008), and high density lipoprotein cholesterol (+5.6 mg/dL vs. 0 mg/dL, p < 0.001) compared to the LGID group. Diabetes medications were reduced or eliminated in 95.2% of LCKD vs. 62% of LGID participants (p < 0.01). CONCLUSION: Dietary modification led to improvements in glycemic control and medication reduction/elimination in motivated volunteers with type 2 diabetes. The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet. Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes.
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BACKGROUND: Recent evidence suggests carbohydrate intake may influence prostate cancer biology. We tested whether a no-carbohydrate ketogenic diet (NCKD) would delay prostate cancer growth relative to Western and low-fat diets in a xenograft model. METHODS: Seventy-five male SCID mice were fed a NCKD (84% fat-0% carbohydrate-16% protein kcal), low-fat (12% fat-72% carbohydrate-16% protein kcal), or Western diet (40% fat-44% carbohydrate-16% protein kcal). Low-fat mice were fed ad libitum and the other arms fed via a modified-paired feeding protocol. After 24 days, all mice were injected with LAPC-4 cells and sacrificed when tumors approached 1,000 mm(3). RESULTS: Despite consuming equal calories, NCKD-fed mice lost weight (up to 15% body weight) relative to low-fat and Western diet-fed mice and required additional kcal to equalize body weight. Fifty-one days after injection, NCKD mice tumor volumes were 33% smaller than Western mice (rank-sum, P = 0.009). There were no differences in tumor volume between low-fat and NCKD mice. Dietary treatment was significantly associated with survival (log-rank, P = 0.006), with the longest survival among the NCKD mice, followed by the low-fat mice. Serum IGFBP-3 was highest and IGF-1:IGFBP-3 ratio was lowest among NCKD mice while serum insulin and IGF-1 levels were highest in Western mice. NCKD mice had significantly decreased hepatic fatty infiltration relative to the other arms. CONCLUSIONS: In this xenograft model, despite consuming more calories, NCKD-fed mice had significantly reduced tumor growth and prolonged survival relative to Western mice and was associated with favorable changes in serum insulin and IGF axis hormones relative to low-fat or Western diet.
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Carbohidratos de la Dieta/farmacología , Proteína 3 de Unión a Factor de Crecimiento Similar a la Insulina/sangre , Factor I del Crecimiento Similar a la Insulina/metabolismo , Neoplasias de la Próstata/dietoterapia , Neoplasias de la Próstata/patología , Animales , Peso Corporal , Línea Celular Tumoral , Dieta Baja en Carbohidratos , Dieta con Restricción de Grasas , Grasas de la Dieta/farmacología , Ingestión de Energía , Hígado Graso/dietoterapia , Humanos , Insulina/sangre , Estimación de Kaplan-Meier , Cetonas/sangre , Masculino , Ratones , Ratones SCID , Neoplasias de la Próstata/metabolismo , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
The persistence of an epidemic of obesity and type 2 diabetes suggests that new nutritional strategies are needed if the epidemic is to be overcome. A promising nutritional approach suggested by this thematic review is carbohydrate restriction. Recent studies show that, under conditions of carbohydrate restriction, fuel sources shift from glucose and fatty acids to fatty acids and ketones, and that ad libitum-fed carbohydrate-restricted diets lead to appetite reduction, weight loss, and improvement in surrogate markers of cardiovascular disease.
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Dieta Baja en Carbohidratos , Carbohidratos de la Dieta/metabolismo , Enfermedades Cardiovasculares/epidemiología , Dieta Baja en Carbohidratos/efectos adversos , Ejercicio Físico , Humanos , Cuerpos Cetónicos/metabolismo , Estado Nutricional , Factores de Riesgo , Pérdida de PesoRESUMEN
OBJECTIVES: To determine whether elevated serum prostate-specific antigen (PSA) values in black men are due, at least partially, to larger prostate size among black men. METHODS: The study population consisted of two cohorts: (1) 1410 men undergoing radical prostatectomy between 1988 and 2005 at five equal-access medical centers comprising the Shared Equal Access Regional Cancer Hospital (SEARCH) Database; and (2) 9601 men undergoing radical prostatectomy between 1988 and 2004 at the Johns Hopkins Hospital. We evaluated the association between race and serum PSA value and prostate weight using multivariable linear regression while adjusting for demographic and clinicopathologic cancer characteristics. RESULTS: In both cohorts, black men had higher serum PSA values (P < or = 0.001). After adjusting for either demographic characteristics or demographic and cancer-specific characteristics, there were no significant associations between race and prostate size in either cohort. After adjusting for multiple demographic, clinical, and pathologic cancer-specific characteristics, black men had 15% higher serum PSA values relative to white men in both the SEARCH (P = 0.001) and Hopkins cohorts (P < 0.001). CONCLUSIONS: In this study of patients undergoing radical prostatectomy in two very different practice settings, black men in both cohorts had higher serum PSA values relative to white men, despite adjustment for demographic and cancer-specific characteristics, including prostate weight. The lack of significant association between race and prostate size suggests that alternative reasons are needed to explain higher serum PSA values in black men.
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Antígeno Prostático Específico/sangre , Próstata/anatomía & histología , Negro o Afroamericano , Anciano , Estudios de Cohortes , Humanos , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Próstata/fisiologíaRESUMEN
Nonalcoholic fatty liver disease is an increasingly common condition that may progress to hepatic cirrhosis. This pilot study evaluated the effects of a low-carbohydrate, ketogenic diet on obesity-associated fatty liver disease. Five patients with a mean body mass index of 36.4 kg/m(2) and biopsy evidence of fatty liver disease were instructed to follow the diet (<20 g/d of carbohydrate) with nutritional supplementation for 6 months. Patients returned for group meetings biweekly for 3 months, then monthly for the second 3 months. The mean weight change was -12.8 kg (range 0 to -25.9 kg). Four of 5 posttreatment liver biopsies showed histologic improvements in steatosis (P=.02) inflammatory grade (P=.02), and fibrosis (P=.07). Six months of a low-carbohydrate, ketogenic diet led to significant weight loss and histologic improvement of fatty liver disease. Further research is into this approach is warranted.
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Dieta Baja en Carbohidratos , Hígado Graso/dietoterapia , Cuerpos Cetónicos/biosíntesis , Obesidad/complicaciones , Adulto , Hígado Graso/etiología , Hígado Graso/metabolismo , Hígado Graso/patología , Femenino , Hepatitis/dietoterapia , Hepatitis/etiología , Humanos , Cetonas/orina , Cirrosis Hepática/dietoterapia , Cirrosis Hepática/etiología , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age and is associated with obesity, hyperinsulinemia, and insulin resistance. Because low carbohydrate diets have been shown to reduce insulin resistance, this pilot study investigated the six-month metabolic and endocrine effects of a low-carbohydrate, ketogenic diet (LCKD) on overweight and obese women with PCOS. RESULTS: Eleven women with a body mass index >27 kg/m2 and a clinical diagnosis of PCOS were recruited from the community. They were instructed to limit their carbohydrate intake to 20 grams or less per day for 24 weeks. Participants returned every two weeks to an outpatient research clinic for measurements and reinforcement of dietary instruction. In the 5 women who completed the study, there were significant reductions from baseline to 24 weeks in body weight (-12%), percent free testosterone (-22%), LH/FSH ratio (-36%), and fasting insulin (-54%). There were non-significant decreases in insulin, glucose, testosterone, HgbA1c, triglyceride, and perceived body hair. Two women became pregnant despite previous infertility problems. CONCLUSION: In this pilot study, a LCKD led to significant improvement in weight, percent free testosterone, LH/FSH ratio, and fasting insulin in women with obesity and PCOS over a 24 week period.
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OBJECTIVE: To assess the enzymatic activity and biochemical status of dipeptidyl peptidase IV (DPP IV), an enzyme that participates in the degradation of proinflammatory molecules, in sera from a group of patients with rheumatoid arthritis (RA; n = 15) treated with a human anti-tumor necrosis factor-a (anti-TNF-alpha) antibody (adalimumab) for 32 weeks. IgG antibody titers against chaperone Bip (GRP78), phosphoglucose isomerase (PGI), lactate dehydrogenase (LDH), fibronectin (FN), and actin were also studied. METHODS: DPP IV activity was measured in sera using Gly-Pro-p-nitroanilide as substrate. The biochemical profile of circulating DPP IV glycoforms was assessed by isoelectric focusing gel electrophoresis. All IgG autoantibody titers and their sialylation levels were determined by ELISA. RESULTS: Patients showed significant increases in serum DPP IV enzymatic activity from basal values (3.554 +/- 1.096) with respect to those obtained at 32 weeks (4.787 +/- 0.953; p < 0.05). Changes in the biochemical profile of circulating DPP IV from acidic to more neutral isoelectric point glycoforms were also seen during treatment. The elevated titers of anti-GRP78 and anti-PGI IgG observed at the beginning of treatment decreased significantly during therapy, whereas those of anti-LDH, anti-FN, and anti-actin IgG remained unchanged. At the end of treatment, sialylation levels of anti-GRP78 and anti-PGI IgG antibodies increased to nearly normal levels. The DPP IV biochemical changes were accompanied by a significant improvement of the Disease Activity Score (DAS28). CONCLUSION: The reduced activity of DPP IV along with increased titers of circulating antibodies to GRP78 and PGI may play a role in the pathogenesis of RA and can be successfully modified by administration of adalimumab.
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Adenosina Desaminasa/metabolismo , Anticuerpos Monoclonales/administración & dosificación , Artritis Reumatoide/tratamiento farmacológico , Artritis Reumatoide/inmunología , Dipeptidil Peptidasa 4/metabolismo , Glucosa-6-Fosfato Isomerasa/inmunología , Glicoproteínas/metabolismo , Proteínas de Choque Térmico/inmunología , Chaperonas Moleculares/inmunología , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Actinas/inmunología , Adalimumab , Adulto , Anticuerpos Monoclonales Humanizados , Artritis Reumatoide/metabolismo , Autoanticuerpos/sangre , Chaperón BiP del Retículo Endoplásmico , Activación Enzimática/efectos de los fármacos , Activación Enzimática/inmunología , Femenino , Fibronectinas/inmunología , Humanos , Inmunoglobulina G/sangre , L-Lactato Deshidrogenasa/inmunología , Masculino , Persona de Mediana Edad , Ácido N-Acetilneuramínico/inmunología , Ácido N-Acetilneuramínico/metabolismoRESUMEN
In response to the emerging epidemic of obesity in the United States, a renewal of interest in alternative diets has occurred, especially in diets that limit carbohydrate intake. Recent research has demonstrated that low-carbohydrate ketogenic diets can lead to weight loss and favorable changes in serum triglycerides and high-density lipoprotein cholesterol. This review summarizes the physiology and recent clinical studies regarding this type of diet.
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Dieta Reductora , Carbohidratos de la Dieta/administración & dosificación , Cuerpos Cetónicos/biosíntesis , Obesidad/dietoterapia , HDL-Colesterol/sangre , Ensayos Clínicos como Asunto , Humanos , Cetosis/sangre , Cetosis/etiología , Obesidad/sangre , Resultado del Tratamiento , Triglicéridos/sangreRESUMEN
OBJECT: The identification of patients at an increased risk for cerebral vasospasm after subarachnoid hemorrhage (SAH) may allow for more aggressive treatment and improved patient outcomes. Note, however, that blood clot size on admission remains the only factor consistently demonstrated to increase the risk of cerebral vasospasm after SAH. The goal of this study was to assess whether clinical, radiographic, or serological variables could be used to identify patients at an increased risk for cerebral vasospasm. METHODS: A retrospective review was conducted in all patients with aneurysmal or spontaneous nonaneurysmal SAH who were admitted to the authors' institution between 1995 and 2001. Underlying vascular diseases (hypertension or chronic diabetes mellitus), Hunt and Hess and Fisher grades, patient age, aneurysm location, craniotomy compared with endovascular aneurysm stabilization, medications on admission, postoperative steroid agent use, and the occurrence of fever, hydrocephalus, or leukocytosis were assessed as predictors of vasospasm. Two hundred twenty-four patients were treated for SAH during the review period. One hundred one patients (45%) developed symptomatic vasospasm. Peak vasospasm occurred 5.8 +/- 3 days after SAH. There were four independent predictors of vasospasm: Fisher Grade 3 SAH (odds ratio [OR] 7.5, 95% confidence interval [CI] 3.5-15.8), peak serum leukocyte count (OR 1.09, 95% CI 1.02-1.16), rupture of a posterior cerebral artery (PCA) aneurysm (OR 0.05, 95% CI 0.01-0.41), and spontaneous nonaneurysmal SAH (OR 0.14, 95% CI 0.04-0.45). A serum leukocyte count greater than 15 x 10(9)/L was independently associated with a 3.3-fold increase in the likelihood of developing vasospasm (OR 3.33, 95% CI 1.74-6.38). CONCLUSIONS: During this 7-year period, spontaneous nonaneurysmal SAH and ruptured PCA aneurysms decreased the odds of developing vasospasm sevenfold and 20-fold, respectively. The presence of Fisher Grade 3 SAH on admission or a peak leukocyte count greater than 15 x 10(9)/L increased the odds of vasospasm sevenfold and threefold, respectively. Monitoring of the serum leukocyte count may allow for early diagnosis and treatment of vasospasm.