Vineet Punia

117 Digital Substraction Angiography in CT Angiography Negative Spontaneous Subarachnoid HemorrhageA Cost-Effectiveness Analysis

Recent studies have documented the high sensitivity of CT angiography (CTA) in detecting a ruptured aneurysm in the presence of acute subarachnoid hemorrhage (SAH). The practice of digital subtraction angiography (DSA) when CTA does not reveal an aneurysm has thus been called into question. We examined the efficacy of DSA in CTA negative SAH when balanced with the costs and risks associated with the procedure.

Cost-effectiveness of digital subtraction angiography in the setting of computed tomographic angiography negative subarachnoid hemorrhage.

BACKGROUND Recent studies have documented the high sensitivity of computed tomography angiography (CTA) in detecting a ruptured aneurysm in the presence of acute subarachnoid hemorrhage (SAH). The practice of digital subtraction angiography (DSA) when CTA does not reveal an aneurysm has thus been called into question. OBJECTIVE We examined this dilemma from a cost-effectiveness perspective by using current decision analysis techniques. METHODS A decision tree was created with the use of TreeAge Pro Suite 2012; in 1 arm, a CTA-negative SAH was followed up with DSA; in the other arm, patients were observed without further imaging. Based on literature review, costs and utilities were assigned to each potential outcome. Base-case and sensitivity analyses were performed to determine the cost-effectiveness of each strategy. A Monte Carlo simulation was then conducted by sampling each variable over a plausible distribution to evaluate the robustness of the model. RESULTS With the use of a negative predictive value of 95.7% for CTA, observation was found to be the most cost-effective strategy (

Teaching NeuroImages: Cerebral adrenoleukodystrophy A rare adult form

6737/Quality Adjusted Life Year [QALY] vs

Time to push the age limit: Epilepsy surgery in patients 60 years or older

8460/QALY) in the base-case analysis. One-way sensitivity analysis demonstrated that DSA became the more cost-effective option if the negative predictive value of CTA fell below 93.72%. The Monte Carlo simulation produced an incremental cost-effectiveness ratio of

Breaking the age barrier: Epilepsy surgery in septuagenarians

83 083/QALY. At the conventional willingness-to-pay threshold of

Hypophosphatemia is Associated with the Serial Administration of Triple-Dose Gadolinium to Patients for Brain MRI.

50 000/QALY, observation was the more cost-effective strategy in 83.6% of simulations. CONCLUSION The decision to perform a DSA in CTA-negative SAH depends strongly on the sensitivity of CTA, and therefore must be evaluated at each center treating these types of patients. Given the high sensitivity of CTA reported in the current literature, performing DSA on all patients with CTA negative SAH may not be cost-effective at every institution.

Stroke after Initiating IV Penicillin for Neurosyphilis: A Possible Jarisch-Herxheimer Reaction

A 42-year-old man with Addison disease presented to the emergency department with unsteady gait for 1 year. A half-brother had epilepsy and difficulty walking, and died at 6 years of age. Another half-brother has a longstanding gait disorder. Over 3 to 4 months, his gait has become worse with marked stiffness, ataxia, and dysarthria. Neurologic examination demonstrated saccadic pursuit, ocular flutter, severe spasticity throughout, peripheral neuropathy, hyperreflexia, clonus, with bilateral extensor plantar reflexes, marked dysmetria, and dysdiadochokinesia. He stands with a marked forward stoop and flexed knees. MRI is shown in figures 1 and 2. The plasma concentration of very-long-chain fatty acids, which is a general test for peroxisomal disorders, was elevated, confirming the diagnosis of adrenoleukodystrophy (ALD). Very-long-chain fatty acids were also elevated in the surviving brothers plasma. Adult cerebral ALD is extremely rare. It is an X-linked peroxisomal disorder caused by mutation in the ABCD1 gene located at Xq28 and involves the nervous system, adrenal cortex, and Leydig cells in the testes.1,2

Extra operative intracranial EEG monitoring for epilepsy surgery in elderly patients

To summarize the existing literature on resective epilepsy surgery (RES) in older adults (≥60 years old) and examine seizure and neuropsychological outcomes in a single‐center large cohort of older adults undergoing RES and their comparison to a consecutive, younger (25‐ to45‐year‐old) adult population who underwent RES in routine clinical practice.

New onset epilepsy among patients with periodic discharges on continuous electroencephalographic monitoring

Resective epilepsy surgery (RES) has traditionally been offered to young patients (<50years). The reservation about offering RES to the elderly is multifactorial with their advanced age and comorbidities being the primary reason. The elderly age group (≥65years of age) is one of the fastest growing populations. The arbitrary age limits for RES need reconsideration in the face of an ever increasing elderly population. Considering such changes in demographics, we report the first case series in the literature of seven septuagenarians who underwent RES in the form of anterior temporal lobectomy (ATL). The 10-year median survival probability based on their comorbidities and age was more than 50%. Six patients had good surgical outcome (Engle I/II) with four of them being completely free of disabling seizures after a median follow-up of almost 2years. No significant medical or surgical morbidity was observed. However, three out of the four patients undergoing pre- and post-RES neuropsychological testing showed decline in memory function. Seizure-related injuries were noted in four out of seven patients and may have been a motivation to proceed with RES in our cohort. Our experience suggests that RES can be a safe and effective therapy in well-selected, septuagenarian patients with drug-resistant epilepsy. Neuropsychological outcomes after RES in this population need further evaluation.

Incidence of recurrent seizures following hospital discharge in patients with LPDs (PLEDs) and nonconvulsive seizures recorded on continuous EEG in the critical care setting

The purpose of this study is to report a metabolic abnormality associated with frequent, triple‐dose Gadolinium (TdGd) use in MS patients during BECOME trial.