Benefits from Exclusion Treatment of Unruptured Brain Arteriovenous Malformations on Epilepsy in Adults.

PURPOSE: In approximately 30% of the patients, brain arteriovenous malformations (bAVMs) are revealed by seizures, which may alter the patients' quality of life. Our objective was to evaluate the benefits of exclusion treatment (radiosurgery, embolization and/or surgery) on posttherapeutic epilepsy in bAVM patients without intracranial hemorrhage prior to treatment. METHODS: Our retrospective observational single-center study included all consecutive adult patients with an unruptured bAVM and epilepsy, treated at our institution from 1995 to 2019 and who were followed for at least 1 year. Data on angioarchitectural characteristics of bAVMs, on epilepsy and posttreatment modified Rankin Scale (mRS) were collected. The primary endpoint was a seizure-free status (defined as Engel class IA) after exclusion treatment versus conservative management. RESULTS: In this study one hundred and one consecutive adult patients with bAVMs, epilepsy and without bAVM rupture before any treatment were included; 21 (21%) in the conservative management group vs. 80 (79%) in the exclusion treatment group. After exclusion treatment, 55% of the patients from the group were Engel IA after treatment vs. 10% of the conservative management group (odds ratio [OR] 11.37, 95% confidence interval [CI] 2.48-107.24, p < 0.001). CONCLUSION: Our results suggest that exclusion treatment in unruptured bAVMs with epilepsy is associated with a higher seizure-free rate in comparison with conservative management. Data from randomized controlled studies are necessary to confirm these findings.

Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms : Case Series of 8 Consecutive Patients.

BACKGROUND AND PURPOSE: Ruptured blister-like aneurysms (BLAs) are challenging lesions to treat, without any consensus on their management. Few studies have evaluated the safety and effectiveness of flow diverter stents (FDS) for this indication, with promising results. The goal was to evaluate the safety and effectiveness of a delayed (≥5 days) flow diversion strategy for the treatment of ruptured intracranial BLAs. MATERIAL AND METHODS: A monocentric retrospective analysis of a prospectively collected database of intracranial aneurysms was performed. Eight consecutive patients with 9 ruptured intracranial BLAs from November 2010 to June 2018 were included in the study. The BLA treatment with FDS was delayed from the rupture (minimum rupture to treatment delay = 5 days, mean = 16.9 ± 9.2 days). Procedure-related complications were systematically recorded. Rebleeding occurrences were systematically assessed. Long-term clinical and angiographic follow-ups were recorded. RESULTS: No procedure-related death was recorded. Neither early nor late rebleeding was observed and one (12.5%) major procedure-related complication occurred (ischemic stroke). Most of the patients (5/8; 62.5%) had an mRS <2 at discharge. The immediate periprocedural control angiogram showed a complete exclusion of the aneurysm in one patient (12.5%) but at follow-up (mean delay = 19.8 months) all patients had a complete aneurysm occlusion. All patients had a long-term mRS <2. CONCLUSION: This case series suggests that a delayed treatment (≥5 days after the hemorrhagic event) of ruptured BLAs with FDS is feasible, and may be safe and effective in terms of rebleeding prevention and long-term angiographic outcome.

Prognosis of treated severe alcoholic hepatitis in patients with gastrointestinal bleeding.

BACKGROUND & AIMS: All trials on severe alcoholic hepatitis (AH) have included patients with "pure" AH, i.e., without concomitant gastrointestinal bleeding (GIB). Severe AH is often suspected in cirrhotic patients with GIB. We aimed at (1) assessing the prevalence of AH in patients with GIB and Maddrey discriminant function (DF) ⩾32; (2) comparing the outcome in AH patients with or without GIB (AH-GIB+, AH-GIB-); and (3) assessing the performance of the Lille model for survival in AH-GIB+ patients. METHODS: We retrospectively included all patients with alcoholic cirrhosis admitted between January 2005 and March 2011 with the following: (1) jaundice <3 months; (2) DF ⩾32 at admission; (3) bilirubin level >50 µmol/L; and (4) active drinking. Exclusion criteria were advanced hepatocellular carcinoma, other etiology of cirrhosis, severe comorbidities and DF <32 after stabilization. In our centre, we systematically plan a liver biopsy for these patients. Patients with severe AH received prednisolone. RESULTS: We screened 161 patients (86 GIB+, 75 GIB-), and analyzed data for 58 and 47 patients in each group, respectively. The 2 groups did not differ in prevalence of AH (77.3% vs. 81%), demographic data, MELD/Child-Pugh score, or DF. The 2 groups were similar in 6-month probability of survival (73.9 ± 6.0% vs. 69.9 ± 7%, p=0.49). The probability of developing infection was lower for AH-GIB+ patients (24.1% vs. 44.7%, p=0.04). The AUC for the Lille model in predicting 6-month survival was 0.71 ± 0.06 for all patients and 0.74 ± 0.06 for AH-GIB+ patients (p>0.05). CONCLUSIONS: Prevalence of AH is 80% for patients with cirrhosis and GIB, recent jaundice and DF ⩾32. Infection was lower for AH-GIB+ patients, which suggests a beneficial role of antibiotic prophylaxis treatment. Survival among subjects with GIB was the same as among subjects without GIB.