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BACKGROUND AND OBJECTIVES: Frameless deep brain stimulation (DBS) offers advantages in terms of patient comfort and reduced operative time. However, the need for bony fiducial markers for localization remains a drawback due to the time-consuming and uncomfortable procedure. An alternative localization method involves the direct tracking of an intraoperative 3-dimensional scanner. This study aims to assess the accuracy of the NexFrame frameless DBS system in conjunction with the O-Arm (Medtronic Inc.), both with and without fiducial markers. METHODS: The locations of 100 DBS leads were determined, with 50 cases using fiducial-free localization and 50 involving fiducial markers. The coordinates were compared with the expected intraoperative targets. Absolute errors in the X, Y, and Z coordinates (ΔX, ΔY, and ΔZ) were calculated, along with the vector error (Euclidean) (vector error ). RESULTS: The vector error averaged 1.61 ± 0.49 mm (right) and 1.52 ± 0.60 mm (left) for the group without fiducial bone markers and 1.66 ± 0.69 (right) and 1.44 ± 0.65 mm (left) for the other cohort (P = .76 right; P = .67 left). Absolute errors in the X, Y, and Z coordinates for the fiducial-free group were 0.88 ± 0.55, 0.79 ± 0.45, and 0.79 ± 0.57 mm (right) and 0.72 ± 0.37, 0.78 ± 0.56, and 0.77 ± 0.71 mm (left). For the group with fiducial markers, these errors were 0.87 ± 0.72, 0.92 ± 0.39, and 0.86 ± 0.50 mm (right) and 0.75 ± 0.33, 0.80 ± 0.51, and 0.73 ± 0.64 mm (left) with no statistically significant difference. CONCLUSION: Our analysis of the accuracy of NexFrame DBS, both with and without fiducial markers, using an intraoperative navigable cone-beam computed tomography, demonstrates that both techniques provide sufficient and equivalent 3-dimensional accuracy.
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Estimulación Encefálica Profunda , Marcadores Fiduciales , Neuronavegación , Humanos , Estimulación Encefálica Profunda/instrumentación , Estimulación Encefálica Profunda/métodos , Masculino , Femenino , Neuronavegación/métodos , Neuronavegación/instrumentación , Persona de Mediana Edad , Anciano , Imagenología Tridimensional/métodos , Adulto , Electrodos ImplantadosRESUMEN
BACKGROUND: Hypopituitarism seems to be rather common following aneurysmal subarachnoid haemorrhage (aSAH), even though its real prevalence remains unclear and the effects on six-month patient functional outcomes are debatable. This study correlated hypopituitarism after aSAH and cognitive performances using neuropsychological tests. METHODS: In a prospective cohort of patients with aSAH, basal pituitary hormone testing was undergone and two neuropsychological tests, Montreal Cognitive Assessment (MoCA) and Mini Mental Status Examination (MMSE), were administered in three phases: in the subacute phase (2 weeks), the chronic phase (3-6 months) and the follow-up phase (6-12 months) post aSAH. RESULTS: Twenty-five patients were enrolled in the study. Considering the median values of MMSE and MoCA in the subacute phase there was an association with hypo-free triiodothyronine (fT3) (p = 0.03, p = 0.03), hypo-luteinizing hormone (LH) (p = 0.002, p = 0.0002), hypo-follicle stimulating hormone (FSH) (p = 0.002, p = 0.002) and hypo-testosterone (p = 0.02, p = 0.05) respectively. Similarly, in the chronic phase we found an association of median values of MMSE and MoCA with hypo-free thyroxine (fT4) (p = 0.03, p = 0.03), hypo-LH (p = 0.03, p = 0.03) and hypo-FSH (p = 0.03, p = 0.03), respectively. Finally, in the follow-up phase, MMSE and MoCA correlated with hypo-fT4 (p = 0.03, p = 0.03), hypo-LH (p = 0.05, p = 0.05) and hypo-FSH (p = 0.05, p = 0.05), respectively. CONCLUSIONS: For aSAH patients in the post-acute phase, neuropsychological tests can represent an inexpensive tool to confirm cognitive impairment, which can be associated with neuroendocrine dysfunction.
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Disfunción Cognitiva , Hipopituitarismo , Hemorragia Subaracnoidea , Cognición , Disfunción Cognitiva/complicaciones , Disfunción Cognitiva/etiología , Hormona Folículo Estimulante , Humanos , Hipopituitarismo/complicaciones , Hipopituitarismo/etiología , Hormona Luteinizante , Pruebas Neuropsicológicas , Proyectos Piloto , Estudios Prospectivos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/epidemiologíaRESUMEN
BACKGROUND: The prevalence of pituitary dysfunction after aneurysmal subarachnoid hemorrhage (aSAH) remains incompletely elucidated. Furthermore, it is not clear whether these abnormalities impact patient outcomes. The aim of this study was to evaluate the prevalence of pituitary dysfunction after aSAH and its effect on outcomes. METHODS: We carried out a prospective, cohort study including adult patients (18 y of age or older) with a diagnosis of aSAH who were admitted to the intensive care unit in 3 centers between January 2017 and January 2019. Exclusion criteria were previous hypopituitarism, hormonal replacement therapies for pituitary dysfunction or any corticosteroid treatment. Endocrine function was tested within the first 48 hours after aSAH onset (acute phase), after 1 to 3 weeks (subacute phase), and after 6 to 12 months (chronic phase). Clinical outcomes were assessed at 6 to 12 months using the modified Rankin Scale. RESULTS: Fifty-six patients were included in the study; all were studied in the acute phase, 34 were studied in the subacute phase, and 49 in the chronic phase. Pituitary dysfunction was identified in 92.3% (95% confidence interval; [CI]: 86.6%-98.0%) of cases in the acute phase, in 83.3% (95% CI: 70.8%-95.8%) in the subacute phase, and in 83.3% (95% CI: 72.7%-93.9%) of cases in the chronic phase. The most commonly identified abnormality was dysfunction of the pituitary-gonadal axis. There was no correlation between pituitary dysfunction and clinical outcome. CONCLUSION: Pituitary dysfunction is common after aSAH, but does not affect 6 to 12-month clinical outcomes.
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Hipopituitarismo , Hemorragia Subaracnoidea , Adulto , Estudios de Cohortes , Humanos , Hipopituitarismo/epidemiología , Hipopituitarismo/etiología , Prevalencia , Estudios Prospectivos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/epidemiologíaRESUMEN
OBJECTIVES: The aim was to evaluate plasma and cerebrospinal fluid (CSF) nimodipine concentrations in patients with aneurysmal subarachnoid hemorrhage and their correlation with clinical outcome. METHODS: Nimodipine infusion was started at 1 mg/h and increased up to 2 mg/h and continued up to 21 days in surviving patients. Arterial and CSF samples were collected at least after 24 hours of stable nimodipine dosing. Delayed cerebral ischemia and vasospasm were documented by new neurological deficits and neuroimaging. The clinical outcome was assessed at 9 months by the modified Rankin scale. RESULTS: Twenty-three patients were enrolled. Nimodipine dose was 13 to 38 µg/kg per hour. Nimodipine arterial and CSF concentrations were 24.9 to 71.8 ng/mL and 37 to 530 pg/mL, respectively. Dose did not correlate with arterial or CSF concentrations. Arterial concentrations did not correlate with corresponding CSF concentrations. Doses and arterial concentrations did not correlate with the clinical outcome and were not associated with the occurrence of delayed cerebral ischemia. However, patients with no significant disability after 9 months of hemorrhage showed significantly higher CSF nimodipine concentrations (P = 0.015) and CSF-to-plasma ratios (P = 0.011) compared with patients who showed some degree of disability or who died. CONCLUSIONS: Cerebrospinal fluid nimodipine concentrations measured during hospital drug infusion showed a correlation with long-term clinical outcome in patients with aneurysmal subarachnoid hemorrhage. These very preliminary data suggest that CSF concentrations monitoring may have some value in managing these patients.
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Nimodipina/líquido cefalorraquídeo , Hemorragia Subaracnoidea/líquido cefalorraquídeo , Adulto , Anciano , Isquemia Encefálica/líquido cefalorraquídeo , Isquemia Encefálica/tratamiento farmacológico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nimodipina/administración & dosificación , Proyectos Piloto , Hemorragia Subaracnoidea/tratamiento farmacológicoRESUMEN
INTRODUCTION: We analyzed the impact of cause, severity, and duration of fever on functional outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: Fever characteristics were analyzed in 584 consecutive patients with aSAH. Fever was defined as core body temperature ≥38.3 °C on ≥2 consecutive days. Subfebrile measurements were those between 37 and 38.2 °C. Febrile and subfebrile loads were the number of hours with fever or subfebrile measurements, respectively. Univariate and multivariate logistic regression models were developed to define predictors of outcome using various categorizations of fever cause, severity, and duration. RESULTS: Febrile measurements were observed in 281/584 (48.1 %) patients, recurring over a mean duration of 2.1 ± 3.0 days. Early fever within 24 and 72 h was encountered in 69 (11.9 %) and 110 (18.9 %) of patients, respectively. An infectious source was discovered in 126 (44.8 %) febrile patients. On univariate analysis, days of fever, febrile load, and fever onset within 24 and 72 h were associated with poor outcome (all p < 0.001); but subfebrile load was not (p = 0.56). On multivariate model constructed with all variables associated with outcome on univariate analyses, days of fever remained independently associated with poor outcome (OR 1.14 of poor outcome per day of fever, 95 % CI 1.06-1.22; p = 0.0006) displacing all other fever measures from the final model. CONCLUSIONS: Early onset of fever, number of hours with fever, and especially days of fever are associated with poor functional outcome. Conversely, subfebrile load does not influence clinical outcome. These data suggest prolonged fever should be avoided, but subfebrile temperatures may not justify intervention.
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Fiebre , Evaluación de Resultado en la Atención de Salud , Hemorragia Subaracnoidea/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fiebre/etiología , Fiebre/fisiopatología , Fiebre/terapia , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
OBJECT: Case fatality rates after aneurysmal subarachnoid hemorrhage (aSAH) have decreased over time, and many patients treated with modern paradigms return to a normal life. However, there is little information on predictors of excellent functional outcome after aSAH. In this study, the authors investigated predictors of excellent outcome in a modern consecutive series of patients with aSAH. METHODS: A retrospective review was conducted of patients with aSAH admitted between 2001 and 2013. The primary outcome measure was excellent functional outcome, defined as modified Rankin Scale (mRS) score of 0 or 1 at last follow-up within 1 year of aSAH. RESULTS: Three hundred seventy-three patients were identified with posthospital follow-up. Excellent outcome was noted in 236 patients (63.3%), including an mRS score of 0 in 122 (32.7%) and an mRS score of 1 in 114 (30.6%). On univariate analysis, the following factors were associated with an excellent outcome: indicators of less severe bleeding, such as better World Federation of Neurosurgical Societies grade at any of the times of assessment, better modified Fisher grade, and absence of intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and symptomatic hydrocephalus; aneurysm treatment with coil embolization; absence of symptomatic vasospasm, delayed cerebral ischemia, and radiological infarction; absence of in-hospital seizures; lack of need for CSF diversion; fewer hours with fever; less severe anemia; and absence of transfusion. On multivariable analysis, the 4 variables that were most strongly associated with excellent outcome were presence of good clinical grade after neurological resuscitation, absence of ICH on initial CT scan, blood transfusion during the hospitalization, and radiological infarctions on final brain imaging. CONCLUSIONS: Excellent outcomes (mRS score 0-1) can be achieved in the majority of patients with aSAH. The likelihood of excellent outcome is predicted by good clinical condition after resuscitation, absence of ICH on presentation, no evidence of infarction on brain imaging, and absence of blood transfusion during hospitalization.