Endovascular repair of an extracranial carotid artery aneurysm complicated by late stent thrombosis.

Extracranial carotid artery aneurysms (ECAA) are extremely rare, accounting for less than 1% of all peripheral artery aneurysms. The most common presentation is central neurologic dysfunction, typically due to embolization of thrombus from the aneurysm. Historically open surgical intervention is the treatment of choice for symptomatic ECAA. Recent data suggest that endovascular repair is a valuable alternative, with a high procedural success rate and relatively low complication rate. We present a case of an ECAA with symptoms of vision loss, successfully treated by endovascular covered stenting but complicated by late in stent thrombosis and cerebral infarction. The patient was subsequently treated with IV thrombolysis and life-long warfarin. The patient had discrete residual symptoms at follow-up 3 months later.

Single seizure and epilepsy in patients with a cerebral territorial infarct.

BACKGROUND: The risk factors to develop stroke-related seizures are actually better understood. However, it is not known which patients are at risk to develop recurrent seizures and epilepsy. OBJECTIVES: This retrospective study compares the characteristics of patients with a territorial infarct who develop a single seizure to those who develop epilepsy. PATIENTS AND METHODS: The demographic and clinical features, the seizure type and onset time, the infarct location and the electroencephalographic (EEG) findings of 106 stroke patients with a single seizure and of 89 ones with epilepsy are compared. RESULTS: No differences in age, gender, vascular risk factors, stroke type and aetiology, and post-ictal EEG are observed between both groups. The most significant difference is the time of seizure onset, with a low recurrence rate in patients with early- compared to those with late-onset after stroke. Patients with a primary generalised tonic-clonic insult and with a subcortical infarct are less at risk of seizure recurrence. CONCLUSIONS: The main consequences of these findings are that patients with early-onset seizures do not need sustained antiepileptic drugs (AEDs) after the acute treatment. Patients who develop late-onset seizures need AEDs after the first spell.

Short-term outcome of patients with cardiac- and thrombo-embolic cerebral infarcts.

OBJECTIVES: It has already been demonstrated by previous studies that patients suffering from a cardiac-embolic stroke (CES) have a worse outcome than those with a thrombo-embolic stroke (TES). Many factors, such as age, initial stroke severity, stroke recurrence and vascular risk factors have been quoted as a possible explanation. The present retrospective study re-investigates more in detail which variables are the most important to explain the difference in disability between patients with CES and with TES on hospital discharge. PATIENTS AND METHODS: Seven hundred forty-two consecutive patients with a territorial infarct were admitted to the Stroke Unit of the Ghent University Hospital between October 2002 and June 2007. The groups of CES and TES consisted, respectively of 283 and of 459 patients. Age, gender, vascular risk factors including previous strokes and pacemaker implantation, initial stroke severity and outcome, determined by the mean modified Rankin (mR) scale on hospital discharge, were compared between both groups. RESULTS: Although the hospital stay of the patients with CES and TES was quite similar, the former group was much older with more females, more vascular risk factors, worse neurological deficit on admission and more disability on discharge. On logistic regression analysis coronary artery disease, isolated atrial fibrillation and cardiac valve disorder appear as independent predictors of stroke outcome. CONCLUSION: The worse outcome in the CES patients is mainly due to the cardiac status of the patients.

Generator replacement in epilepsy patients treated with vagus nerve stimulation.

PURPOSE: In epilepsy patients treated with vagus nerve stimulation (VNS), the occurrence of end of battery life (EOBL), when the generator will no longer deliver any stimulation, was investigated with regard to seizure control. EOBL is preceeded by end of effective stimulation (EOES) when irregular stimulation may occur. METHODS: In 14/78 patients, treated with VNS at Ghent University Hospital, generators were replaced at different times following EOES or EOBL. We retrospectively analysed the time of occurrence of EOES and EOBL and seizure control before and after generator replacement. RESULTS: EOES or EOBL was indicated by loss of seizure control, decreased perception of stimulation and recurrence of depression in 3, 3 and 1/14 patient(s), respectively. In 2 and 1/14 patient(s), EOBL and premature generator failure, respectively, were detected during routine check-up at the epilepsy clinic. In 4/14 patients, generator replacement was performed before estimated EOES. Pre-replacement seizure control could not be regained in 2/14 patients in whom replacement had been postponed for several months. Estimation of EOES and EOBL occurrence proved difficult in individual patients. CONCLUSION: EOES or EOBL may be indicated by loss of seizure control, decreased or irregular perception of stimulation by the patient and loss of other VNS-induced effects. Postponing generator replacement may result into permanent loss of seizure control. In responders we suggest generator replacement before EOBL. Our results call for performance of prospective studies in larger patient groups that may eventually lead to general guidelines on the indication and timing of generator replacement.

Vagus nerve stimulation for refractory epilepsy: a transatlantic experience.

Vagus nerve stimulation (VNS) is an alternative treatment for medically or surgically refractory epilepsy. The long-term efficacy and safety of VNS were evaluated in a large patient series at Ghent University Hospital and Dartmouth-Hitchcock Medical Center. Between March 1995 and February 2003, seizure frequency and type as well as prescribed antiepileptic drugs and side effects were prospectively assessed in 131 patients treated with VNS in either center. Patients with a minimum follow-up duration of 6 months were included in the efficacy and safety analysis. A total of 118 of 131 implanted patients had a minimum postimplantation follow-up period of 6 months (mean, 33 months). The mean age of these patients was 32 years and the mean duration of refractory epilepsy was 22 years. The mean reduction in monthly seizure frequency in all patients was 55% (range, 0-100; SD = 31.6). Seven percent of patients were free of seizures with impaired consciousness, 50% of patients had a seizure frequency reduction of more than 50%, and 21% of patients were nonresponders. Fifteen patients reported stimulation-related side effects such as hoarseness or gagging. In a large patient series from two geographically distinct epilepsy centers located in two different continents, VNS proved to be efficacious and safe during long-term follow-up.