RESUMEN
BACKGROUND: Incidence, clinical course, and fatality of spontaneous subarachnoid haemorrhage (SAH) are evolving, with prevalence of risk factors diminishing, implementation of early detection programs and strategies for priority aneurysm exclusion, technical refinement towards less invasive procedures, and improvements in neurocritical care. Modern epidemiological and prognostic data are lacking, especially in southern European and Mediterranean populations. METHODS: A prospective multicentre observational study on SAH was held in Catalonia, Northeast Spain, 2020-2022 (HSACat project). All public tertiary hospitals participated in a common registry. Primary endpoints were functional outcomes (modified Rankin Scale, mRS) and mortality at 12-months. Secondary aims included epidemiological data, flux of patients between referral and tertiary hospitals, diagnostic and treatment delays, and in-hospital complications. RESULTS: Of 550 SAH cases reported in Catalonia (2020-2022), 474 had a complete registry for analysis. Death rate was 20.6% during hospital admission and 26.9% at one year. Good functional outcome (mRS 0-2) was observed in 63.4%, 70.1% and 76.0% at 3, 6 and 12 months. Age at presentation was lower in men, smokers, and hypertensives (p<0.05). The female:male ratio was 3:2, except in non-aneurysmal group. Time from onset to tertiary-hospital admission was longer in rural than metropolitan zones (7.0h vs 4.7h, p<0.01). Aneurysm occlusion in the first 72h was achieved in 83.3%; mainly endovascularly (77.5%) than microsurgically (19.3%). CONCLUSION: Even when most patients received timely aneurysmal treatment, rates of case fatality are considerably high. Data provided by the HSAcat project may have public health repercussions and be used to guide prevention programs and screening strategies.
RESUMEN
We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l -carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration (AU)
Se presenta el caso de un paciente con un glioma insulofrontotemporal izquierdo, tratado con levetiracetam, valproato y clobazam. Se realizó una primera cirugía bajo anestesia general para la exéresis del lóbulo temporal tumoral, y 8 días después se sometió a una cirugía con el paciente despierto para mapeo del lenguaje, bajo sedación consciente con remifentanilo y anestesia local. A la llegada a quirófano, el paciente se encontraba cansado y con cierta bradipsiquia; tras parar la infusión de remifentanilo, y antes de abrir la duramadre, el paciente presentó una disminución del nivel de consciencia con privación respiratoria que requirió intubación endotraqueal y la finalización de la cirugía. En el periodo posoperatorio se apreció bradipsiquia moderada, cansancio y temblor de manos. Fueron detectados niveles altos de amonio en sangre, y la clínica mejoró tras la administración de L-carnitina y la suspensión del valproato. La encefalopatía por amonio, aunque con mínima sintomatología, debería ser considerada en pacientes tratados con valproato que van a ser sometidos a una cirugía bajo sedación, donde se requiere que el paciente colabore (AU)
Asunto(s)
Compuestos de Amonio/efectos adversos , Intoxicación del Sistema Nervioso por Metales Pesados/complicaciones , Mapeo Encefálico/métodos , Craneotomía/métodos , Glioma/cirugía , Insuficiencia del Tratamiento , Vigilia , Ácido Valproico/efectos adversosRESUMEN
We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration.