Seizures at the onset of aneurysmal SAH: epiphenomenon or valuable predictor?

OBJECTIVE: Seizures at the onset (SAO) of aneurysmal subarachnoid hemorrhage (aSAH) occur in up to one of every five cases. To date, there is no consensus on causal background and clinical value of these early bleeding-related seizures. This study aimed to analyze the predictors and the impact of SAO in aSAH. METHODS: All aSAH patients from the institutional observational cohort (01/2003-06/2016) were retrospectively reviewed. Patients' charts and emergency protocols from first responders were screened for the occurrence of seizures in the first 24 h after aSAH. Patients' baseline characteristics and occurrence of post-hemorrhagic complications were analyzed. Outcome endpoints included in-hospital mortality and poor outcome at 6-month follow-up (modified Rankin Scale > 3). RESULTS: Of 984 patients included in the final analysis, SAO occurred in 93 cases (9.5%) and were independently associated with younger age (< 51 years, p < 0.001), WFNS grade ≥ 4 (p < 0.001), aneurysm characteristics (location at the proximal branch of the anterior cerebral artery [p = 0.037] and irregular sac [p = 0.019]) and admission body temperature > 38.3 â„ƒ (p = 0.008). There was an association between SAO and early complications (early infarcts [p = 0.004] and primary decompressive craniectomy [p = 0.024]). Only in the subgroup analysis restricted to the younger individuals, SAO independently predicted poor outcome of aSAH (p = 0.002). SIGNIFICANCE: Onset seizures following aSAH are rare and most likely related to the severity of early brain injury. Particularly, younger individuals are not only at higher risk for SAO, but are also prone to poor outcome in case of aSAH accompanied with SAO. TRIAL REGISTRATION NUMBER: German clinical trial registry (DRKS, unique identifier: DRKS00008749, 06/09/2015).

Adjustable pressure valves for chronic hydrocephalus following subarachnoid hemorrhage: Is it worthwhile?

OBJECTIVE: Compared to fixed pressure valves (FPV), adjustable pressure valves (APV) might reduce the rates of over/underdrainage necessitating revision surgery after shunt placement. But due to higher implant costs and valve vulnerability, the use APV in neurosurgery is still limited. The aim of this study was to evaluate the clinical utility of APV in patients with aneurysmal subarachnoid hemorrhage (aSAH). MATERIAL AND METHODS: All consecutive aSAH patients undergoing ventriculoperitoneal shunt (VPS) placement at our institution between 2003 and 2016 were eligible. Rates and the risk factors for shunt valve dysfunction and over/underdrainage were evaluated. RESULTS: A total of 189 patients were included in the final analysis. FPV were implanted in the majority of patients (173/91.5 %). Revision surgery due to over/underdrainage was performed in 8 (4.6 %) cases with FPV and in no case with APV. Higher patients' age (>65 years, p = 0.011; aOR 10.36) and bone flap reimplantation following decompressive craniectomy (p = 0.044; aOR 6.53) independently predicted the need for revision surgery for over/underdrainage. There was no difference in the occurrence of valve dysfunction between the two valve types (1 [6.3 %] APV, 12 [6.9 %] FPV), p > 0.99). Patients requiring revision surgery for over/underdrainage had a higher risk for unfavorable outcome at 6 months follow-up (mRS>3, p = 0.009; aOR = 8.0). CONCLUSION: APV is a valuable option for aSAH individuals undergoing VPS implantation to reduce the need for revision surgery for over/underdrainage. Particularly, elderly patients and those requiring bone flap reimplantation might benefit from APV.

Predictors of catheter-associated meningitis in pediatric patients after brain tumor surgery: A 10-year single center experience.

OBJECTIVE: To evaluate the incidence of catheter-associated meningitis (CAM) in a pediatric population receiving brain tumor surgery, and to identify the major risk factors involved. METHODS: We retrospectively analyzed the medical and radiological records of 205 pediatric patients who received 251 external ventricular drains (EVDs) between January 2008 and December 2017. All patients less than 18 years old who underwent cerebrospinal fluid (CSF) diversion in the course of brain tumor surgery were included. Patients with central nervous system infection (CNS) at the time of EVD insertion were excluded. RESULTS: A total of 99 patients receiving 107 EVDs met the study selection criteria. Among this population, the incidence of CAM was 19.2%. Median time-to-infection was 5 days. CAM prolonged the period of drainage in 57.9% of the cases. An extended ICU stay (>3 days) was statistically significantly associated with the occurrence of CAM. In the multivariate analysis, the presence of a high-grade CNS tumor was a predictor of an extended intensive care unit (ICU) stay. Furthermore, CSF leakage along the catheter tunnel was an independent predictor of CAM. CONCLUSION: Our data confirms CAM as a significant complication in the acute treatment of hydrocephalus associated with pediatric brain tumors. To limit the incidence of CAM, measures must be taken to prevent CSF leakage, particularly among patients with high-grade CNS tumors that are likely to stay longer in the ICU and need prompt postoperative radiotherapy and oncological treatment.

Soluble B7-H4 blood serum levels are elevated in women at high risk for preeclampsia in the first trimester, as well as in patients with confirmed preeclampsia.

PROBLEM: B7-H4 negatively regulates T-cell-mediated immunity and might play an important role in preeclampsia (PE). Here, we have investigated the association between PE and maternal soluble B7-H4 (sB7-H4) serum levels and B7-H4 mRNA expression in the placenta. METHOD OF STUDY: Maternal serum levels of sB7-H4 were determined by enzyme-linked immunosorbent assay in women between 11 and 13 weeks' gestation with elevated risk for PE (n = 48) and women without elevated risk for PE (n = 47). In the third trimester, sB7-H4 serum levels (n = 166) and B7-H4 mRNA expression in the placenta (n = 54) were determined in women with early-onset PE, late-onset PE, fetal growth restriction (FGR), and in healthy controls. RESULTS: In the first trimester, significant higher levels of sB7-H4 were detected in women at elevated risk for PE compared to women without risk for PE (P < .0001). sB7-H4 has some predictive ability to identify cases with an elevated risk of developing PE with area under the curve (AUC) value of 0.88 (95% CI 0.8-0.94). Using a specificity of 90.0% led to a sensitivity of 47.9% and a threshold of 3.63 ng/mL. In the third trimester, the highest serum levels of sB7-H4 and B7-H4 mRNA expression in the placenta were observed in early-onset PE. Significant higher serum levels of sB7-H4 and B7-H4 mRNA expression in the placenta were observed in women with early-onset PE (P = .01 and P = .006, respectively) and late-onset PE (P = .03 and P = .004, respectively) compared to healthy controls, but not compared to FGR. CONCLUSION: sB7-H4 is involved in the regulation of immune tolerance in women with PE in the third trimester. In the first trimester of pregnancy, sB7-H4 might serve as a predictive immunological biomarker for women who are at elevated risk of developing PE.