Pravastatin may improve neurological outcome following low-grade aneurysmal subarachnoid hemorrhage.

Statins may improve outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH) but randomized controlled trials, including all patients with aSAH whatever their clinical severity, were negative. We studied whether pravastatin improved neurologic outcome in patients with early good neurological status, whose prognosis is related to secondary lesions as delayed cerebral ischemia (DCI). We conducted a single-center study of cases and historical controls in a neurocritical care unit. We included consecutive patients with aSAH from 2011 to 2016 with early good neurological status defined by a WFNS score ≤ 3 on the third day. Patients treated before 2014 with oral pravastatin (40 mg/day for 14 days) as a standard of care were matched using propensity score to patients treated after 2014 without pravastatin. Good neurologic outcome was defined by a Glasgow Outcome Scale ≥ 4 at neurocritical care unit discharge. We included 270 patients (135 patients with pravastatin), mostly treated with coiling (94.1%). Demographic, initial and subacute features were the same in the 2 groups. More patients experienced good outcome in the pravastatin group than in the control group (94.8% vs 74.2%; OR 7.16 95% CI [3.07 - 16.72], p < 0.001). There was no difference in the occurrence of DCI in the 2 groups. In our study, outcome on neurocritical care discharge was better in patients with early good neurological status treated with pravastatin. Another randomized controlled trial should be conducted on this subtype of population.

Diagnostic accuracy of quantitative EEG to detect delayed cerebral ischemia after subarachnoid hemorrhage: A preliminary study.

OBJECTIVE: Delayed cerebral ischemia (DCI) is the most important and preventable morbidity cause after subarachnoid hemorrhage (SAH). Therefore, DCI early detection is a major challenge. Yet, neurological examination can be unreliable in poor grade SAH patients. EEG provides information from most superficial cortical area, with ischemia-related changes. This study aims at defining an alpha-theta/delta (AT/D) ratio decrease thresholds to detect DCI. METHODS: We used EEG with a montage matching vascular territories (right and left anterior central and posterior) and compared them to follow-up brain imaging. RESULTS: 15 SAH patients (Fischer ≥ 3, World Federation of Neurological Surgeons scale ≥4, 9 DCI) were monitored during 6.4 [4-8] days (min = 2d, max = 13d). AT/D changes could follow three different patterns: (1) prolonged or (2) transient decrease and (3) no decrease or progressive increase. A regional 30% decrease outlasting 3.7 h reached 100% sensitivity and 88.9% specificity to detect DCI. Only 22.6% were in a zone of uncertain diagnosis (3.7-8.04 h). These prolonged decreases, with a loss of transient changes, started in cortical areas evolving toward DCI, and preceded intracranial changes when available. CONCLUSION: Although this study has a small sample size, prolonged AT/D decrease seems to be a reliable biomarker of DCI. SIGNIFICANCE: cEEG changes are likely to precede cerebral infarction and could be useful at the bedside to detect DCI before irreversible damage.

Prognostic factors of long-term outcome in cases of severe traumatic brain injury.

INTRODUCTION: The purpose of this monocentric study was to assess the long-term outcome of a group of severe traumatic brain-injured patients and explore the prognostic values of some clinical and paraclinical parameters available at the initial stage. METHODOLOGY: The patients included were victims of severe traumatic brain injuries in 2007 or 2008. A standardized assessment was performed for each patient including clinical, radiological, and electrophysiological data collected at the initial stage, The outcomes were assessed at least 2 years after injury. Depending on the patients' availability and ability to communicate, the assessments included measures of dependency for activities of daily living (ADL), cognitive functions, behaviour, mood, and quality of life. RESULTS: Eighteen patients were included, of whom ten were autonomous for ADL at the time of assessment. Memory complaints, attentional deficits, anxiety, and irritability were the main long-term impairments observed. A correlation analysis showed significant correlations between the dependency level (as rated by the Functional Independence Measure) and each of length of coma, length of the post-traumatic amnesia, and the N100 auditory evoked potentials. DISCUSSION: These results confirm the uniqueness of each patient regarding the long-term consequences of a traumatic brain injury and the multi-determined nature of each prognosis.

Ultrasonographic anatomic variations of the major veins in paediatric patients.

BACKGROUND: The aim of our study was to describe the anatomic relationships in internal jugular (IJV), subclavian (SCV), and femoral (FV) vein sites. METHODS: One hundred and forty-two children had a two-dimensional (2D) ultrasound (US) evaluation of IJV, SCV, and FV sites. They were enrolled according to their age: 0-1 month old (n=9), 1 month old to 2 yr old (n=61), 2-6 yr old (n=22), 6-12 yr old (n=32), and 12-18 yr old (n=18). RESULTS: We found about 7.7% variation for the IJV. The most common anatomic variations were a lateral (nine children) or anterior (nine children) position of the IJV to the carotid artery. Regardless of the age category, about 9.8% of the anatomic variations were found for the FV. The most common anatomic variation in our study was that the FV ran anteromedially to the femoral artery (17 children). Anatomic variation of the SCV, regardless of age category, was about 7.4%. The most common anatomic variation was the SCV, which ran medially (10 children) to the subclavian artery. CONCLUSIONS: The relevant percentages of anatomic variations obtained for all these areas support at least a systematic US screening before attempting to obtain central venous access, ideally using a US-guided technique.

Predicting fluid responsiveness in mechanically ventilated children under general anaesthesia using dynamic parameters and transthoracic echocardiography.

BACKGROUND: Dynamic variables are accurate predictors of fluid responsiveness in adults undergoing mechanical ventilation. They can be determined using respiratory variation in aortic flow peak velocity (▵Vpeak), arterial pulse pressure [▵PP and pulse pressure variation (PPV)], or plethysmographic waveform amplitude [▵POP and pleth variability index (PVI)]. These indices have not been validated in children. We studied the ability of these variables to predict fluid responsiveness in mechanically ventilated children. METHODS: All results are expressed as median [median absolute deviation (MAD)]. Thirty mechanically ventilated children were studied after undergoing general anaesthesia. Mechanical ventilation was maintained with a tidal volume of 10 ml kg(-1) of body weight. ▵PP, PPV, ▵POP, PVI, ▵Vpeak, and aortic velocity-time integral were recorded before and after volume expansion (VE). Patients were considered to be responders to VE when the aortic velocity-time integral increased more than 15% after VE. RESULTS: VE induced significant changes in ▵PP [13 (MAD 4) to 9 (5)%], PPV [15 (5) to 9 (5)%], ▵POP [15 (10) to 10 (6)%], PVI [13 (6) to 8 (5)%], and ▵Vpeak [16 (9) to 8 (3)%] (P<0.05 for all). Differences in ▵PP, ▵POP, PPV, and PVI did not reach statistical significance. Only ▵Vpeak was significantly different between responders (R) and non-responders (NR) to VE [22 (3) vs 7 (1)%, respectively; P<0.001]. The threshold ▵Vpeak value of 10% allowed discrimination between R and NR. CONCLUSIONS: In this study, ▵Vpeak was the most appropriate variable to predict fluid responsiveness.

[Design and evaluation of the quality of information written for scanner and magnetic resonance imaging in neuropediatrics]. / Conception et évaluation de la qualité d'une information écrite sur le scanner et l'imagerie par résonance magnétique en neuropédiatrie.

INTRODUCTION: We designed written information concerning two medical imaging techniques: the computed tomography scanner and the magnetic resonance imaging (MRI), and we evaluated the quality of the information in particular its readability. METHODS: Written information concerning scanner and MRI were elaborate starting from a reference frame based on a lexicon of the good practices. The written information sheets were initially reviewed by eight doctors, 45 nurses and by 26 couples of parents of hospitalized children, and finally by the communication and juridical services of our hospital. They were asked to improve the lexico-syntactic readability in order to increase the comprehension of the written information. Seventy-two couples of parents of hospitalized children who had not taken part of the protocol before evaluated the final version of the documents. The quality of the documents was evaluated using the scores of readability of Flesch and the Flesch-Kincaid, and a questionnaire of comprehension, managed before and after the delivery of written information. RESULTS: A total of 144 persons participated in the study. The number of right answers after reading written information increased by 38 % and by 35 % for the scanner and MRI information's respectively. Flesch and Flesch-Kincaid scores were not improved in the revised version of the written information compared to the first version. CONCLUSION: Although readability scores for information sheets were low, our results suggest that they brought information, which contributed to a better understanding of these two medical imaging techniques by parents.

[Ondansetron: a meta-analysis on its efficacy to prevent postoperative nausea and vomiting after craniotomy in adults and children]. / Méta-analyse : ondansétron en prophylaxie des nausées et vomissements postopératoires chez l'adulte et l'enfant après craniotomie.

OBJECTIVE: To justify the use of ondansetron as a preventive treatment for postoperative nausea and vomiting (PONV) of adults and children in neurosurgery. STUDY DESIGN: Meta-analysis. PATIENTS AND METHODS: Six published, randomized, double-blinded, placebo-controlled trials were selected to study the efficacy of ondansetron on PONV in adults undergoing craniotomy. Similarly, three studies were selected in children. The treated adults received 4 or 8 mg of ondansetron during the peroperative period. As for children, they were given a repeated dose of 0.15 mg/kg of ondansetron. The emetic episodes noted for 24 hours in children and until 48 hours in adults were analyzed. The results were presented as relative risks (RR) following a fixed model and a 95% confidence interval (CI). The test for heterogeneity was measured with the I(2) Altman DG test. RESULTS: At 24 hours, among the 308 adults tested, nausea and vomiting were significantly reduced by 22% and 57%, respectively; no significant reduction in vomiting was noted for the 149 children patients. At 48 hours, no significant modification was observed in adults. CONCLUSIONS: Peroperative intravenous dose of ondansetron 4 mg in neurosurgery in adults is required to prevent PONV during the first postoperative 24 hours. However, further studies are needed to determine best time and dose infusion to prolong clinical efficacy.

Extradural clonidine combined with sufentanil and 0.0625% bupivacaine for analgesia in labour.

We have studied the use of clonidine combined with low doses of sufentanil and bupivacaine in 45 parturients requiring extradural analgesia for the first stage of labour, in a double-blind, randomized study. We gave 0.0625% bupivacaine 10 ml containing 1:200,000 adrenaline and sufentanil 10 micrograms (1 ml) to which was added 0.9% saline, or clonidine 100 or 150 micrograms (1 ml). We compared the quality (VAS scores) and duration of analgesia, motor block, maternal haemodynamic state (mean arterial pressure and heart rate) and fetal and maternal side effects. Mean duration of anaesthesia was prolonged slightly: 105 (SD 21) min without clonidine, 130 (26) min with clonidine 100 micrograms (P < 0.05 vs control) and 144 (40) min with clonidine 150 micrograms (P < 0.01 vs control, ns vs 100 micrograms). There were no differences in VAS scores, onset times, heart rate, ventilatory frequency, motor block, sedation, pruritus or bradycardia between the groups. Analgesia was associated with a reduction in mean arterial pressure with clonidine. However, these adverse side effects were of minor clinical importance regardless of the extradural clonidine dose, except for a high incidence of fetal heart tracing abnormalities when clonidine 150 micrograms was used. These effects associated with a limited effect on analgesia may curtail the widespread use of clonidine as an adjunct to extradural 0.0625% bupivacaine with sufentanil 10 micrograms during labour.

[Cerebrovascular reactivity to CO2 during general anesthesia maintained with either isoflurane-N2O or propofol-N2O. A comparative study by transcranial Doppler velocimetry]. / Réactivité vasculaire cérébrale au CO2 sous anesthésie générale entretenue par isoflurane-N2O ou propofol-N2O. Etude comparative par vélocimétrie Doppler transcrânienne.

OBJECTIVES: To compare, using transcranial doppler velocimetry (TDV), the cerebral blood flow velocity and CO2 reactivity during general anaesthesia maintained with either isoflurane-N2O-O2(IF) or propofol-N2O-O2 (PF) in adults with a normal brain. STUDY DESIGN: Nonrandomized controlled trial. PATIENTS: Forty ASA I patients (mean age 41 +/- 13 yrs, 15 F/35 M) undergoing surgery of the lumbar spine in prone position. The first 20 were allocated into the IF group and the subsequent 20 into the PF group. METHODS: General anaesthesia was induced with midazolam (0.05 mg.kg-1), phenoperidine (0.03 mg.kg-1), thiopentone (5 mg.kg-1), vecuronium (0.1 mg.kg-1) and maintained with N2O (50 vol %) and O2 (50 vol %) and either isoflurane (0.8 < Fet < 1 vol %) in IF group or propofol (6 mg.kg-1.h-1) in PF group. The vascular reactivity was assessed with velocimetry measurements (Angiodine DMS, with a probe transmitting a 2-MHz pulsed wave) of flow in the middle cerebral artery at a given PetCO2 (obtained by adjustments of VT) during systole (SV) and diastole (DV). Three measurements were made: at T1 (PetCO2 = 30 +/- 2 mmHg), at T2 (PetCO2 = 40 +/- 2) and at T3 (PetCO2 = 30 +/- 2 mmHg). RESULTS: In the IF group, VS increased by +32% at T2 (P = 0.006) with an increase of + 3.4 %/1 mmHg of PetCO2. Similarly, in the PF group VS increased by + 31 % at T2 (P < 0.0001) with an increase of 2.9 %/1 mmHg of PetCO2. In both groups the VS returned to baseline values at T3. In the IF group, VD increased by + 66% at T2 (P < 0.0001), with an increase of + 7%/1 mmHg of PetCO2. Similarly in the PF group, VD increased by + 61% (P < 0.0001) with an increase of + 5.7%/1 mmHg of PetCO2. In both groups the VD returned to baseline values at T3. CONCLUSIONS: During anaesthesia maintained with either isoflurane-N2O-O2 or propofol-N2O-O2, a change in PetCO2 results in similar changes in VS and VD. These anaesthetic agents preserve the cerebrovascular reactivity of the normal brain. The results of this study are in accordance with those obtained with other reference techniques in healthy volunteers. Transcranial doppler velocimetry can be a useful noninvasive tool of clinical research in neuroanaesthesia.