Acute Optic Neuritis Diagnosed by Bedside Ultrasound in an Emergency Department.

BACKGROUND: Transorbital ultrasound was used to diagnose acute optic neuritis (AON) at bedside in an emergency department (ED). CASE REPORT: A 59-year-old female patient presented to an ED after 7 days of progressive unilateral visual loss while she was receiving outpatient treatment for relapsing-remitting multiple sclerosis. Transorbital ultrasound revealed a disparity between the optic nerve sheath diameters of the affected and nonaffected eyes and striking optic nerve edema in the affected eye. These findings led to a diagnosis of AON and early definitive treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given an absence of reliable diagnostic criteria for AON, comorbidity with multiple sclerosis, and limitations inherent to magnetic resonance imaging, transorbital sonography may facilitate diagnosis of this condition in emergent presentations.

Complications following cranioplasty: incidence and predictors in 348 cases.

OBJECT: The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death. METHODS: The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI. RESULTS: Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22-3.02), increasing age (OR 1.02, CI 1.00-1.04), and hemorrhagic stroke (OR 3.84, CI 1.93-7.63). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56-36.58), seizures (OR 7.25, CI 1.238-42.79), bifrontal cranioplasty (OR 5.40, CI 1.20-24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51-112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hematoma evacuation, the development of hydrocephalus, and the development of infections. CONCLUSIONS: The authors' goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient's risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.

Flow-diversion for ophthalmic segment aneurysms.

BACKGROUND: The use of flow-diversion to treat ophthalmic segment aneurysms (OSA) has not been well evaluated. OBJECTIVE: To assess the visual outcomes, the obliteration rate, and the need for retreatment of OSA treated by the pipeline embolization device (PED). METHODS: Patients who underwent treatment with PED for OSA from 2009 to 2014 were selected and retrospectively reviewed. Patient's age, sex, mode of presentation, and aneurysm size were recorded. The complication rates, the need for retreatment (due to recurrence of the aneurysm or worsening symptoms), the aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered. RESULTS: Forty-one patients harboring 44 OSA treated by flow-diversion were identified. Females constituted 87.80% (37/41) of the cohort. The mean age was 59.16 ± 12.54 years. At final angiographic follow-up, 77.27% (34/44) had complete occlusion, 6.81% (3/44) had near-complete occlusion, and 15.90% (7/44) had incomplete occlusion. Of the 22 symptomatic OSA, complete resolution or significant improvement was noted in 72.72% (16/22), while worsening of symptoms occurred in 4.54% (1/22). Five patients out of 22 (22.72%; 5/22) had no significant changes in their symptoms. The complication rate was 2.27% (1/44). The mortality rate was 0%. CONCLUSION: The low complication rate, the high obliteration rate, and the high rate of improvement in the visual symptoms make flow-diversion an appealing option for the treatment of OSA.

Predictors of infections following cranioplasty: a retrospective review of a large single center study.

INTRODUCTION: The variables that predispose to postcranioplasty infections are poorly described in the literature. We formulated a multivariate model that predicts the risk of infection in patients undergoing cranioplasty. METHOD: Retrospective review of all patients who underwent cranioplasty following craniectomy from January, 2000, to December, 2011. Tested predictors were age, sex, diabetic status, hypertensive status, reason for craniectomy, urgency status of craniectomy, location of cranioplasty, reoperation for hematoma, hydrocephalus postcranioplasty, and material type. A multivariate logistic regression analysis was performed. RESULTS: Three hundred forty-eight patients met the study criteria. Infection rate was 26.43% (92/348). Of these cases with infection, 56.52% (52/92) were superficial (supragaleal), 43.48% (40/92) were deep (subgaleal), and 31.52% (29/92) were present in both the supragaleal and subgaleal spaces. The predominant pathogen was coagulase-negative staphylococcus (30.43%) followed by methicillin-resistant Staphylococcus aureus (22.83%) and methicillin-sensitive Staphylococcus aureus (15.22%). Approximately 15.22% of all cultures were polymicrobial. Multivariate analysis revealed convex craniectomy, hemorrhagic stroke, and hydrocephalus to be associated with an increased risk of infection (OR = 14.41; P < 0.05, OR = 4.33; P < 0.05, OR = 1.90; P = 0.054, resp.). CONCLUSION: Many of the risk factors for infection after cranioplasty are modifiable. Recognition and prevention of the risk factors would help decrease the infection's rate.

Flow diversion versus conventional treatment for carotid cavernous aneurysms.

BACKGROUND AND PURPOSE: Several endovascular treatment options are available for cavernous carotid aneurysms. We compared pipeline embolization device (PED) versus conventional endovascular treatment in terms of evolution of mass effect, complications, recurrence, and retreatment rate. METHODS: One hundred fifty-seven patients harboring 167 cavernous carotid aneurysms were treated using PED placement, coiling, stent-assisted coiling, and carotid vessel destruction. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. RESULTS: There were no difference in age, sex, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small-size aneurysms (<10 mm) and a shorter follow-up duration. Multivariate analysis revealed treatment other than PED (PED: odds ratio [OR], 0.03; P=0.002) and size >15 mm (OR, 4.27; P=0.003) to be predictors of no improvement in symptoms. The rate of complete occlusion was 81.36% (48 of 59) for PED, 42.25% (39 of 71) for stent-assisted coiling, 27.27% (6 of 22) for coiling, and 73.33% (11 of 15) for carotid vessel destruction. Retreatment was needed in patients with aneurysm size >15 mm (OR, 2.67; P=0.037) and those who were not treated with PED (PED: OR, 0.16; P=0.006). The rate of major complications was 6.6% (11 of 167). Patients who were treated with PED or stent-assisted coiling had 3.84 lower odds to develop complications (OR, 0.26; P<0.05). CONCLUSIONS: The use of PED should be encouraged, especially in symptomatic patients. We found PED to be associated with less need for future treatment, higher improvement in symptoms rate, and lower rate of complications.