Ching-Chang Chen

Mapping Gray Matter Reductions in Obstructive Sleep Apnea: An Activation Likelihood Estimation Meta-Analysis

STUDY OBJECTIVES The authors reviewed the literature on the use of voxel-based morphometry (VBM) in obstructive sleep apnea (OSA) magnetic resonance imaging (MRI) studies via the use of a meta-analysis of neuroimaging to identify consistent and specific structural deficits in patients with sleep apnea compared with healthy subjects. DESIGN Neuroimaging meta-analysis. DATA SOURCES We used PubMed to retrieve articles published between January 2000 and February 2012. STUDY SELECTION The authors included all VBM research on patients with OSA and healthy controls. They compared the findings of the studies by using gray matter volume (GMV) or gray matter concentration (GMC) to index differences in gray matter. DATA EXTRACTION Stereotactic data were extracted from eight VBM studies of 213 patients with OSA and 195 control subjects. RESULTS Regional gray matter reduction in the bilateral parahippocampus and less-convincing right superior frontal and left middle temporal gyri was demonstrated in patients with sleep apnea using an activation likelihood estimation (ALE) procedure to analyze significant differences. CONCLUSIONS Significant reductions in gray matter in patients with sleep apnea occurred in the bilateral parahippocampus and less-convincing frontotemporal regions, which may be related to the neurocognitive processing abnormalities that are common among populations of patients with sleep apnea.

Coadjuvant Treatment of Vasospasm in Ruptured Unsecured Cerebral Aneurysms with Aggressive Angioplasty, Intra-Arterial Nimodipine, and Aneurysm Embolization

BACKGROUND Vasospasm is a major cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage. Early treatment of ruptured aneurysms is advocated; delayed intervention complicates the treatment strategy leading to significant vasospasm and poor prognosis. We report an endovascular protocol for occlusion of the unsecured aneurysm and angioplasty for vasospasm in a single session. METHODS Between January 2011 and May 2017, among 660 patients with aneurysmal subarachnoid hemorrhage, 24 patients with significant vasospasm and unsecured ruptured cerebral aneurysm were reviewed. Continuous nimodipine drip through a pressure line of the guiding catheter was set up. Aggressive angioplasty with a compliant balloon catheter either before or after embolization of the aneurysm in the major branches of vasospastic territory was performed. The goal was complete embolization of the aneurysm. RESULTS Of 24 patients, 17 had ischemic symptoms at presentation, and the average delay from aneurysm rupture to presentation was 7.58 days. Angioplasty and nimodipine drip were performed on all patients. Severity of vasospasm was significantly reduced, and outcome improved in each patient. Two patients required a second angioplasty. In 20 patients, embolization of aneurysms was achieved without any aneurysmal sac or residual neck. Clinical outcome was good recovery (modified Rankin Scale score 0-2) in 23 patients (95.8%) and moderate disability in 1 patient (modified Rankin Scale score 3). CONCLUSIONS Aggressive endovascular treatment of patients with unsecured ruptured cerebral aneurysm and associated vasospasm is safe and effective.

Outcomes of chronic subdural hematoma in patients with liver cirrhosis

OBJECTIVEBurr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown.METHODSA nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed.RESULTSThe in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC.CONCLUSIONSEven for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.

Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke Patients Receiving Thrombectomy: Standard or Low Dose Therapy?

BACKGROUND We compared the clinical outcomes of low and standard dose recombinant tissue Plasminogen Activator (rtPA) treatment in Acute Ischemic Stroke (AIS) patients receiving Endovascular Mechanical Thrombectomy (EVT). METHODS Between April 01, 2015 and September 30, 2017, all AIS patients admitted to the Linkou and Chiayi Chang Gung Memorial Hospital were retrospectively reviewed. Patients with large vessel occlusions, who underwent bridging therapy with rtPA and EVT, were further enrolled. The enrolled patients were categorized into low (0.6-0.7 mg/kg; LD) or standard dose (0.9 mg/kg; SD) group based on the dose of rtPA they received. Baseline characteristics, reperfusion status, and clinical outcomes were compared between the two groups. RESULTS Forty-two patients were enrolled in the final analyses, including 13 in the LD and 29 in the SD group. In all groups analyzed, the frequencies of moderate to severe and severe stroke at discharge were significantly decreased compared to those at stroke onset (p < 0.01). Compared to the SD group, patients of the LD group had a similar rate of mortality (LD vs. SD; 0% vs. 3.4%, p = 1.00), and comparable frequencies of functional independence at 3 months after stroke onset (LD vs. SD; 33.3% vs. 44.8%, p = 0.50). The rates of symptomatic intracerebral hemorrhage were also similar between the two groups (LD vs. SD; 0% vs. 6.9%, p =1.00). CONCLUSIONS Compared to standard dose treatment, low dose rtPA may have similar clinical efficacy and safety outcomes in AIS patients receiving bridging therapy.

Propensity Score Matched Analysis of Mechanical vs. Bioprosthetic Valve Replacement in Patients With Previous Stroke

BACKGROUND This study compared the long-term outcomes of prosthetic heart valve replacement with mechanical or bioprosthetic valves in patients with prior stroke.Methods and Results:In total, 1,984 patients with previous stroke who had received valve replacement between 2000 and 2011 were identified using the Taiwan National Health Insurance Research Database. Propensity score matching analysis was used. Ultimately, 547 patients were extracted from each group and were eligible for analysis. On survival analysis, the risks of all-cause mortality and recurrence of stroke were similar. The incidence of major bleeding was greater in the mechanical valve group than in the bioprosthetic valve group (P=0.040), whereas no difference was observed in re-do valve surgery. On subgroup analysis, the bioprosthetic valve was favored for older age (≥60 years) and previous gastrointestinal (GI) bleeding patients. The mechanical valve, however, was favored for younger patients (<60 years). CONCLUSIONS In patients with previous stroke, bioprosthetic valves had a lower incidence of complications connected to major bleeding than did the mechanical valves. Survival and stroke recurrence rates, however, did not differ between the 2 groups. We recommend bioprosthetic valves for patients >60 years or who have a history of GI bleeding.