Vascular anomalies and the risk of multiple aneurysms development and bleeding.

SUMMARY: The pathogenesis of aneurysmal subarachnoid hemorrhage is still debated and the prognosis remains severe, especially in multiple aneurysms, where the therapeutic management is complex. The aim of this study was to look for vascular anomalies and assess their relationship with aneurysm formation and bleeding in patients with multiple intracranial aneurysms. A prospective angiographical review was performed on 141 patients with multiple intracranial aneurysms seen from 1992 to 2000. Three hundred and fifty three aneurysms were studied. In 88% of the patients vascular anomalies were found. The most common were: asymmetric caudal basilar fusion (43.2%), variations of the anterior communicating artery (AcoA) complex (31.2%), symmetric caudal basilar fusion (26.2%), antero-inferior cerebellar artery-postero- inferior cerebellar artery (AICA-PICA) (15.6%), extradural origin of the PICA (10.6%), cavernous origin of the ophthalmic artery or dorsal ophthalmic artery (dOPH) (3.5%). Some aneurysm locations were associated with a high rate of vascular anomalies, e.g.: posterior cerebral aneurysm with asymmetric caudal fusion, AcoA aneurysm with AcoA complex variation, basilar tip aneurysm with extradural PICA or symmetric caudal fusion, PICA aneurysm with AICA-PICA, para-ophthalmic aneurysm with dOPH. These aneurysm locations bled proportionally more frequently when associated with the related vascular anomaly. In conclusion, these results suggest that vascular anomalies are associated with aneurysm development and bleeding.

What to do when the doctor sees double: identical twins with nearly identical aneurysms.

SUMMARY: This report details the case of identical twins, both of whom had an aneurysm in the same anatomic location. Such aneurysms should be considered as a discrete subset of familial aneurysms. The implications for patient management are discussed.

Endovascular and Surgical Management of Multiple Intradural Aneurysms. Review of 122 Patients Managed between 1993 and 1999.

SUMMARY: Patients with multiple intradural aneurysms present unique clinical challenges, particularly when presenting with subarachnoid haemorrhage. This study was undertaken to retrospectively review the management of such patients treated at a single institution. Consecutive patients with multiple intradural aneurysms managed at our institution between 1993 and 1999 were studied. The 122 patients had a total of 305 aneurysms. In most patients presenting with subarachnoid haemorrhage, the aneurysm responsible for the bleed could be identified with a fair degree of certainty, as confirmed by subsequent surgical and autopsy findings. Irregularity of the aneurysm (false sac or polylobulation) was the most useful criterion for making this determination. Failure to recognize all aneurysms on the original angiogram remained an uncommon but clinically important problem. Posterior inferior cerebellar and anterior communicating artery aneurysm locations were disproportionately more likely, and para-ophthalmic less likely, to be responsible for the subarachnoid haemorrhage. There was a trend for patients with uncertainty regarding the site of bleeding to have all aneurysms treated, and for cure to be obtained in a shorter time. Surgical and endovascular complication rates and patient outcomes were not dissimilar from what one would expect for single aneurysm patients. During follow-up, we observed a haemorrhage rate from unruptured aneurysms of 1.1% per patient-year of observation, and a de novo aneurysm formation rate of 0.76% of patients per year. In conclusion, we feel that although patients with multiple intradural aneurysms have more complex management issues than those with single aneurysms, good outcomes can be achieved with appropriate use of endovascular and/or surgical therapy. The goal in the acute setting following subarachnoid haemorrhage is recognition of all aneurysms and urgent treatment of the one responsible for the haemorrhage. When there is uncertainty, more than one aneurysm may need to be treated. Decisions on subsequent treatment of remaining unruptured aneurysms must be individualized.

Acute human histopathology of an intracranial aneurysm treated using Guglielmi detachable coils: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: This case study provided us with the opportunity to explore the histopathological effects of Guglielmi detachable coil (GDC) therapy on the aneurysm orifice and parent vessel-aneurysm neck interface. This type of study is important to the understanding of the mechanisms of obliteration of aneurysms by GDCs. CLINICAL PRESENTATION: The patient presented with a Hunt and Hess Grade III subarachnoid hemorrhage that occurred secondary to the rupture of a small anterior communicating artery aneurysm. INTERVENTION: The aneurysm was successfully coiled without complication, but the patient died 36 hours later. We examined the gross and microscopic pathological findings of this GDC-treated anterior communicating artery aneurysm 36 hours after coiling. A discrete membrane composed of fibrin had formed completely across the aneurysm orifice, excluding the aneurysm sac from the circulation. This membrane was contiguous with the parent vessel. CONCLUSION: This case represents one of the first examples in humans of the formation of a membrane over the aneurysm orifice after GDC therapy. The formation of this membrane, shown to be composed of fibrin, was found at 36 hours after coiling, which is the earliest time frame at which membrane formation has been noted in either humans or animal models. This fibrin membrane may function both as a scaffold for subsequent endothelialization across the aneurysm neck as well as to isolate the aneurysm from the parent circulation, permitting thrombus within the aneurysm sac to mature to an endovascular scar. The factors contributing to the formation of this membrane and its clinical implications are discussed.

Quality of life of stroke in younger individuals. Utility assessment in patients with arteriovenous malformations.

BACKGROUND AND PURPOSE: Patients with arteriovenous malformations are younger individuals who are at risk of a stroke or have experienced one. Our objective was to determine these patients' perceptions of quality of life with a stroke by eliciting utility values. METHODS: Utility values were obtained with the standard gamble technique. Utilities are a holistic, quality of life measure between 0 and 1. We evaluated the patients' current health state and written descriptions of major and minor stroke. RESULTS: Thirty-one consecutive outpatients participated. The mean age was 37 years (range, 18 to 57 years). Approximately 65% had suffered a stroke, of which 55% were major. Approximately 61% had a persistent deficit. The mean utilities were 0.45 for major stroke (95% confidence interval [CI], 0.33 to 0.56; range, 0.00 to 1.00), 0.81 for minor stroke (95% CI, 0.75 to 0.88; range, 0.30 to 1.00), and 0.81 for current health (95% CI, 0.73 to 0.89; range, 0.01 to 1.00). Subgroup analyses by demographic and clinical characteristics showed no significant differences. However, in both those patients who had never had a stroke and those who had survived a major stroke, values for the major stroke scenario were clustered at the two extremes. Among those with a current deficit, 79% preferred their own health state to that of the stroke scenario that was similar in severity. CONCLUSIONS: Younger people who have had a stroke or are at risk demonstrate wide variations in their perception of quality of life. Furthermore, patients tend to be more risk averse with their own lives than with theoretical scenarios. We suggest tailoring medical decision making to individual preferences.

Surgery versus stereotactic radiosurgery for small, operable cerebral arteriovenous malformations: a clinical and cost comparison.

OBJECTIVE: Cerebral arteriovenous malformations (AVMs) may cause stroke and death in young patients. For small AVMs, the major curative treatment options are surgery and stereotactic radiosurgery (SR). Although the initial costs and risks of SR are less, there is a latency to cure and ultimately the success rate is lower than with surgery. Thus, these two treatment modalities were compared with respect to clinical outcomes and associated costs by means of a cost-effectiveness analysis. METHODS: A decision analysis model was developed using Smltree software (J.P. Hollenberg, Roslyn, NY). Probability estimates for cure and complications for both therapies were derived from the literature. Utility values for minor and major stroke were measured in patients with AVMs who were treated at the University of Toronto clinic, using the standard gamble technique. Costs were obtained from several sources, including the case costing systems of several hospitals in Ontario, Canada. RESULTS: Surgery confers a 0.98 quality-adjusted life year (QALY) advantage over SR, at an additional cost of $6937 per patient. Thus, from a societal perspective, the incremental cost-effectiveness ratio is $7100 per QALY for a patient treated surgically. The result is sensitive to only two variables: surgical morbidity and surgical mortality. However, the preferred treatment strategy changes to favor SR only at the extreme high end of the possible range for these variables, when the rate of permanent neurological morbidity resulting from surgery exceeds 12% or the surgical mortality rate exceeds 4%. CONCLUSIONS: In the treatment of small AVMs, surgery confers a large clinical benefit over SR. The reason is that surgery protects the patient from hemorrhage earlier and with greater success than does SR. The associated cost-effectiveness ratio, $7100/QALY, is highly economically attractive. Therefore, surgery achieves important improvements in clinical outcomes and is associated with an excellent ratio of incremental costs per QALY gained.

Cerebral cavernous malformations: natural history and prognosis after clinical deterioration with or without hemorrhage.

Despite recent studies of the natural history of cavernous malformations, there remains significant uncertainty concerning hemorrhage rates and the importance of lesion location. Controversy arises over varying definitions of "hemorrhage." What is ultimately important to the patient is the occurrence of a neurological event, which may or may not be associated with radiologically documented hemorrhage, as well as the chance of recovery after such an event. The purpose of this study was to determine the rates of occurrence and sequelae of neurological events in 173 patients referred to our vascular malformation clinic with cavernous malformations. All patient data were entered into a database. The mean age at presentation for the 173 patients was 37.5 years. The lesion location was deep (brainstem, cerebellar nuclei, thalamus, or basal ganglia) in 64 patients (37%) and superficial in 109 (63%). Thirty-one patients (18%) had multiple lesions. Disease presentation was due to seizures in 62 patients (36%), hemorrhage in 44 (25%), focal neurological deficit without documented hemorrhage in 35 (20%), headache alone in 11 (6%), and incidental findings in 21 patients (12%). The results obtained in the 110 patients eligible for follow-up review were used to derive information on the rates of hemorrhage and neurological events. An interval event (neurological deterioration) required both symptoms and signs. The total mean follow-up period was 46 months, the majority (65%) of which was prospective. There were 18 interval events in 427 patient-years of follow-up review, for an overall annual event rate of 4.2%. Location was the most important factor for predicting interval event occurrence, with significantly higher rates for deeply located (10.6%/year) compared with superficially located lesions (0%/year) (p = 0.0001). Of patients suffering a neurological event, only 37% had complete resolution of their deficits. This largely prospective study indicates that deep cavernous malformations carry a worse prognosis than superficial lesions with respect to annual rates of neurological deterioration. The alarming rate of adverse clinical events occurring in patients with deep lesions is punctuated by the fact that less than one-half of them recover fully during long-term follow-up review.

The attitudes of family physicians toward the peer review process.

We conducted a study to determine family physicians' attitudes and perceptions toward current peer review practices, and to discover if family physicians, general surgeons, and hospital-based physicians view the process differently. A survey instrument measured perceptions of physicians on the following four areas of the peer review process: (1) how peer reviews are administered, (2) the educational value of peer reviews, (3) the performance of peer review committees, and (4) the effect of the peer review process on physician morale. The survey was mailed to all 3528 practicing physicians who were members of a state medical society. A subgroup of 1695 family physicians, general surgeons, and hospital-based physicians was used for this study, of whom 774 (46%) responded to the questionnaire. Over one half of the family physicians responded negatively toward the peer review process on all items of the survey, with over 70% dissatisfied on five of the 17 items. Family physicians, general surgeons, and hospital-based physicians viewed the peer review process differently in the four areas measured. We found statistically significant differences of opinions regarding present peer review practices among the specialties cited. However, the overall dissatisfaction of the specialty groups studied may suggest that the concern resides more with the profession at large than with any one medical specialty group.

Ways and means of providing primary and preventive health services.

There exist today a variety of children's health programs that are cost-effective, high-quality, and accessible, and that provide important lessons for communities seeking to improve health care for their children. What is needed is the development of a communications strategy that disseminates this existing knowledge. It has been demonstrated that information in the hands of community leaders results in change and the development of creative programs. Implementation is the goal and social marketing is the methodology.

Middle ear disease and the practice of pediatrics. Burden during the first five years of life.

To determine the burden on pediatricians imposed by disease of the middle ear, we analyzed data from 2,570 children followed up prospectively since birth. Disease of the middle ear accounted for a large proportion of all visits made during the first five years of life, rising from 22.7% during the first year to about 40% in years 4 and 5. About one visit in three made for illness of any kind resulted in the diagnosis of disease of the middle ear. Approximately three fourths of all visits to follow up any illness were made to follow up disease of the middle ear. Disease of the middle ear was diagnosed at between 5% and 10% of all well-baby visits. Children from private practice averaged fewer visits for all reasons than did children using a large neighborhood health center, but the proportions of visits accounted for by disease of the middle ear were similar in both settings.

Use of pneumococcal vaccine for prevention of recurrent acute otitis media in infants in Boston. The Greater Boston Collaborative Otitis Media Study Group.

The efficacy of pneumococcal polysaccharide vaccine for children suffering from recurrent acute otitis media (AOM) was determined by administration, in a randomized double-blind fashion, of one of two polyvalent vaccines to 124 children aged five to 21 months. The octavalent vaccine contained serotypes commonly associated with AOM: 1, 3, 6A, 7F, 14, 18C, 19F, and 23F. The heptavalent control contained serotypes not commonly associated with AOM: 2, 4, 5, 8, 9N, 12F, and 24F. Recipients of the octavalent vaccine experienced significantly (P less than 0.05) less AOM due to serotyes contained in the octavalent vaccine than did children who received the control vaccine. Although the recipients of octavalent vaccine suffered less from AOM due to types in that vaccine than did controls, their clinical experience with AOM was not different. Both groups of children were equally likely to experience at least one episode of AOM after vaccination (70% for octavalent vaccine and 78% for heptavalent vaccine). The mean numbers of episodes of AOM after vaccination also were similar (2.1 for octavalent vaccine and 2.3 for heptavalent vaccine). Similarly, the period of effusion in the middle ear after pneumococcal AOM was identical for both groups. Although immunization with pneumococcal vaccine appeared to reduce the number of episodes of AOM due to serotypes contained in octavalent vaccine, the clinical experience of the children was not favorably affected by this vaccine.

Adenosine triphosphate and diphosphoglycerate levels in red blood cells from patients with Down's syndrome.

The levels of ATP and ATP plus DPG were significantly elevated in erythrocytes from Down's syndrome patients when compared to erythrocytes from age matched controls. The hemoglobin content and hematocrit values were significantly reduced. The resultant tendency towards anemia probably explains the elevation in metabolite levels.

Municipal child health services: a ten-year reorganization.

There has been increasing interest within the medical community in developing primary care programs in teaching hospitals that meet the medical needs of a community. The Cambridge Hospital system provides a working model for such a mutually beneficial interaction. Based on principles of administrative centralization and utilization of the pediatric nurse practitioner, the neighborhood health centers operate as part of a cost-effective series of concentric circles. Administrative centralization within the Department of Pediatrics at the Cambridge Hospital has permitted the elimination of duplicate medical services and the development of a responsive community health service. The pediatric nurse practitioner under close senior staff supervision, serves as the primary caretaker in the neighborhood centers. In addition to her role as the provider of a protocol-determined, age-related series of physical psychometric, and laboratory examinations the pediatric nurse practitioner also cares for minor injuries and illnesses of childhood. Any child deviating from a clearly established range of norms for any physical, developmental, or laboratory parameter is immediately referred to the senior staff pediatrician for further evaluation. Finally, any patient requiring subspecialized inpatient care is referred to the Massachusetts General Hospital. The senior pediatric staff of the Cambridge Hospital serves the function of coordinating and supporting the rapid interlevel communication which must occur between community service, primary hospital, and a tertiary care facility. This neighborhood health care system is, we feel, a medically sound, educationally exciting, and fiscally responsible solution to a problem facing many urban areas and their academic medical institutions.