Sankalp Gokhale

Sex Differences in Incidence, Pathophysiology, and Outcome of Primary Intracerebral Hemorrhage

Primary intracerebral hemorrhage (ICH) is a common, yet devastating, stroke subtype. Although ethnicity and age can predispose individuals to ICH and affect outcome, little investigation has been made into investigating sex differences in incidence, pathophysiology, or outcome after ICH. In order to understand fundamental mechanisms, improve preclinical research models, and develop effective treatment options for patients with ICH, assessing the effects of sex in ICH is imperative. Thus, the purpose of this review is to gather available information on incidence, pathophysiology, outcome, and preclinical study to provide basis for further investigations. Comprehensive literature search of Medline and National Library of Medicine (PubMed) publications was performed (last accessed December 1, 2013) using ICH, gender, sex, gender difference, sex difference, race, stroke, mortality, preclinical model, animal model, and neuroprotection as keywords. Articles in English were fully reviewed and included if clear definition of primary ICH and available sex data were reported. Primary ICH was defined as intraparenchymal hemorrhage not because of trauma or underlying structural lesion, for example, aneurysm, tumor, and so on. A total of 73 articles were included: (1) epidemiological studies assessing incidence and outcome (47 articles); (2) hospital-based studies assessing hematoma characteristics, treatment response, ICH-related complications or goals of care (14 articles); and (3) preclinical studies assessing gonadal hormones effects on ICH outcomes (12 articles). Published data are reported in chronological and geographical manner. Significant P values, relative risk (RR), odds ratios (OR), and confidence intervals (CI) are noted when available. Notably, epidemiological stroke studies generally treat ICH as a stroke subtype. Further, African and Indian population studies were absent from the literature. Over the last few decades, incidence of primary ICH in developed countries is unchanged or, perhaps, decreasing.4–8 Decreasing incidence may be attributable to greater public awareness of preventive measures, such as healthy lifestyle …

Comparison of surgical and endovascular approach in management of spinal dural arteriovenous fistulas: A single center experience of 27 patients

Background: Spinal dural arteriovenous fistula (SDAVF) is a rare spinal vascular malformation with an annual incidence of 5-10 cases per million. The data on efficacy, recurrence rates and complications of endovascular versus surgical treatment of SDAVF is limited. Methods: We conducted a retrospective chart review of 27 adult patients with a diagnosis of SDAVF and who underwent treatment at Duke University Hospital between January 1, 1993 and December 31, 2012. We compared the outcome measures by Aminoff–Logue score (ALS) in patients who underwent treatment with endovascular embolization versus surgical ligation of fistula. We compared complication rates, recurrence rates as well as data on long-term follow up in these patients. Results: Out of 27 patients in the study, 10 patients underwent endovascular embolization (Onyx was used in 5 patients and NBCA in 5 patients) as the first line therapy. Seventeen patients underwent surgical ligation as initial therapeutic modality. Patients in both groups showed significant improvement in clinical status (ALS) after treatment. One patient in endovascular group developed spinal infarction due to accidental embolization of medullary artery. Three patients in embolization group had recurrence of fistula during the course of follow up requiring surgical ligation. Two patients in surgical group developed local wound infection. None of the patients in surgical group had recurrence of fistula during the course of follow up. Conclusions: Endovascular embolization and surgical ligation are effective treatment strategies for SDAVF. Our observations show that surgical ligation may offer permanent cure without any recurrence. Endovascular approach is associated with higher incidence of recurrence, especially with use of onyx.

Thrombolysis in Ischemic Stroke Without Arterial Occlusion at Presentation

Background and Purpose— None of the randomized trials of intravenous tissue-type plasminogen activator reported vascular imaging acquired before thrombolysis. Efficacy of tissue-type plasminogen activator in stroke without arterial occlusion on vascular imaging remains unknown and speculative. Methods— We performed a retrospective, multicenter study to collect data of patients who presented to participating centers during a 5-year period with ischemic stroke diagnosed by clinical examination and MRI and with imaging evidence of no vascular occlusion. These patients were divided into 2 groups: those who received thrombolytic therapy and those who did not. Primary outcome measure of the study was excellent clinical outcome defined as modified Rankin Scale of 0 to 1 at 90 days from stroke onset. Secondary outcome measures were good clinical outcome (modified Rankin Scale, 0–2) and perfect outcome (modified Rankin Scale, 0). Safety outcome measures were incidence of symptomatic intracerebral hemorrhage and poor outcome (modified Rankin Scale, 4–6). Results— A total of 256 patients met study criteria, 103 with thrombolysis and 153 without. Logistic regression analysis showed that patients who received thrombolysis had more frequent excellent outcomes with odds ratio of 3.79 (P<0.01). Symptomatic intracerebral hemorrhage was more frequent in thrombolysis group (4.9 versus 0.7%; P=0.04). Thrombolysis led to more frequent excellent outcome in nonlacunar group with odds ratio 4.90 (P<0.01) and more frequent perfect outcome in lacunar group with odds ratio 8.25 (P<0.01). Conclusions— This study provides crucial data that patients with ischemic stroke who do not have visible arterial occlusion at presentation may benefit from thrombolysis.

Effect of surgical clipping versus endovascular coiling on recovery from oculomotor nerve palsy in patients with posterior communicating artery aneurysms: A retrospective comparative study and meta-analysis

Background: Oculomotor nerve palsy (OMNP) is a well-recognized complication of posterior communicating artery (PCOM) aneurysms. Only a few comparative studies have assessed the effect of clipping versus coiling on recovery from OMNP in PCOM aneurysms. A retrospective review and meta-analysis was conducted to assess the relationship between PCOM aneurysm treatment and OMNP. Materials and Methods: Medical records of all patients presenting between January 2000 and February 2013 with intracranial aneurysm were searched. All patients with OMNP secondary to PCOM aneurysm were included for analysis. Patients undergoing surgical clipping or endovascular coiling were compared with respect to complete resolution of OMNP after aneurysm surgery (i.e., primary outcome). A meta-analysis of published studies of OMNP associated with PCOM aneurysm was performed after a MEDLINE search. Results: Seventeen patients with OMNP secondary to PCOM aneurysms met the inclusion criteria. Surgical clipping (seven of eight patients, or 87.5%) resulted in greater complete resolution of OMNP compared with endovascular coiling (four of nine patients, or 44.4%), P = 0.13. A meta-analysis of similar studies revealed that complete resolution of OMNP was more commonly associated with surgical clipping (36 of 43 patients, or 83.7%) than with endovascular coiling (29 of 55 patients, or 52.7%), yielding an adjusted odds ratio (OR) of 6.04 [confidence interval (CI) =1.88-19.45, P = 0.003]. Multivariate analysis found that the degree of pre-operative OMNP (OR = 0.07, CI = 0.02-0.28, P = 0.001) and surgical clipping (OR = 6.37, CI = 1.73-23.42, P = 0.005) were significant factors that affected the complete recovery of OMNP. Conclusion: Complete recovery of OMNP with PCOM aneurysms is more commonly associated with surgical clipping than with endovascular coiling. Also, the degree of pre-operative OMNP and the treatment modality are significant factors that affect the complete recovery of OMNP.

Perioperative cardiac complications and 30-day mortality in patients undergoing intracranial aneurysmal surgery with adenosine-induced flow arrest: A retrospective comparative study

BACKGROUND Adenosine-induced flow arrest is a technique used to assist in the surgical clipping of complex aneurysms. OBJECTIVE To assess the safety associated with adenosine-assisted intracranial aneurysm surgery. METHODS Medical records of all patients presenting between January 1, 2009, and December 31, 2012, for intracranial aneurysm surgery were analyzed. Patients were divided into 2 groups based on the intraoperative administration of adenosine: the nonadenosine group (n = 262) and the adenosine group (n = 64). The primary outcome compared between groups included a composite of 30-day mortality and incidences of perioperative cardiac complications (perioperative myocardial infarction or perioperative cardiac arrhythmias). RESULTS The study groups were statistically similar except for a difference in the size and location of cerebral aneurysms and the incidence of coronary artery disease. The primary composite outcome occurred in 4.6% and 9.4% of patients in the nonadenosine and adenosine groups, respectively (P = .13). After adjustment for differences in the incidence of coronary artery disease between the 2 groups, the odds of the primary outcome were not significantly different between the groups (adjusted odds ratio = 2.12; 95% confidence interval, 0.76-5.93; P = .15). There were also no significant differences in the durations of hospital and intensive care unit stay between the study groups. CONCLUSION Our results suggest that adenosine-assisted intracranial aneurysm surgery is not associated with an increase in perioperative cardiac complications or mortality in patients with low risk of coronary artery disease and may be considered a safe technique to assist clipping of complex aneurysms.

Levetiracetam seizure prophylaxis in craniotomy patients at high risk for postoperative seizures.

Background: The risk of developing immediate postoperative seizures in patients undergoing supratentorial brain tumor surgery without anti-epileptic drug (AED) prophylaxis is 15-20%. Patients who present with pre-operative seizures and patients with supratentorial meningioma or supratentorial low grade gliomas are at significantly higher risk. There is little data on the efficacy of levetiracetam as a prophylactic AED in the immediate postoperative period (within 7 days of surgery) in these patients. Methods: We conducted a retrospective chart review of 165 adult patients classified as higher risk for postoperative seizures who underwent brain tumor resection at Duke University Hospital between time May 2010 and December 2011. All patients had received levetiracetam monotherapy in doses of 1000-3000 mg/day in the immediate postoperative period. Results: We identified 165 patients with following tumor locations: Frontal 83 (50.3%), Temporal 37 (22.4%), Parietal 30 (18.2%), Occipital 2 (1.2%) and 13 (7.8%) with single lesions involving more than one lobe. Histology revealed: Glioma 98 (59.4%), Meningioma 57 (34.5%) and Brain Metastases 6 (3.6%). Preoperatively, 88/165 (53.3%) patients had presented with seizures. 12/165 patients (7.3%) developed clinical seizures (generalized 10, partial 2) in the immediate post-operative period. Other than somnolence in 7 patients (4.2%), no major side-effects were noted. Conclusions: The incidence of seizures was significantly lower in patients treated with levetiracetam (7.3%) when compared with the expected (15-20%) rate without AED prophylaxis based on the previous literature. Levetiracetam appears effective and safe for seizure prevention in patients undergoing brain tumor resection and who are at significantly higher risk of developing post-operative seizures. These findings warrant confirmation in a prospective randomized trial.

Transfusion-associated graft versus host disease (TAGVHD)-with reference to neonatal period

Abstract Transfusion-associated graft versus host disease [TAGVHD] results from the engraftment of transfused immuno-competent cells in blood transfusion recipients, whose immune system is unable to reject them. All blood products containing viable, immuno-competent T cells have been implicated in TAGVHD. Presence of a “one-way HLA match between donor and recipient” is associated with a significantly increased risk of TAGVHD. Though sharing of haplotype is the most probable explanation, it is far from adequate. Since TAGVHD is not seen in patients with AIDS, and an acute GVHD-like syndrome has been noted in some identical twins and autologous (self) transplants, some other processes, possibly of an “autoimmune” nature are responsible for TAGVHD. Most of the cases have been reported from Japan. This clustering in space and time is rather intriguing. We offer here alternative hypothesis. Foetal and then neonatal lymphocytes exhibit tolerance towards donor cytotoxic T lymphocytes; and consequently very few cases of TAGVHD have been reported in neonates than expected. This tolerance is a part of altered immunology of pregnancy. We feel that it is possible to use maternal blood for transfusion to her newborn baby by following certain protocol and procedure and TAGVHD is no barrier.

Teaching NeuroImages: Vein of Galen aneurysm mimicking pineal mass in a young adult

A 22-year-old man presented with intractable progressive headaches over 2 months. Noncontrast head CT and contrast-enhanced MRI scan revealed a hyperdense pineal-based mass (figure, A and B). Arteriogram was normal (figure, C and D).

Thrombolysis in ischemic strokes with no arterial occlusion.

Rationale Twelve million people develop ischemic stroke each year world over and 30–40% of them do not have arterial occlusions at presentation. Trials conducted to study the efficacy of thrombolytic drug reported better outcome with use of thrombolytic drug but none studied the subtypes of ischemic strokes specifically and adequately. The subgroups of patients with no arterial occlusion at presentation continue to receive thrombolytic therapy without proven benefit and with some risk. Aim The aim of this article is to study whether intravenous thrombolysis with alteplase improves clinical outcome in ischemic stroke patients who do not have arterial occlusion at presentation. Design A retrospective medical record-based observational multicenter, multinational study. Outcomes Primary outcome measure would be clinical outcome at three-months from stroke onset measured by modified Rankin Scale and National Institute of Health Stroke Scale. Secondary outcome measure will be frequency of intracerebral hemorrhage causing worsening of clinical deficit defined as increase in National Institute of Health Stroke Scale by >4.

Primary Sjogren's syndrome presenting as acute cerebellitis

A 64-year-old previously healthy man presented with acute ataxia. He was diagnosed with acute cerebellitis on the basis of clinical features, negative MRI of the head and lymphocytic pleocytosis in cerebrospinal fluid. A detailed work up for etiology revealed auto-antibodies for Sjogrens syndrome. He responded well to cyclophosphamide and steroids.