Cause Of Unfavorable Outcome Research Articles

Modern Aspects of Endovascular Thrombectomy of Acute Ischemic Stroke. Selection Criteria for Endovascular Thrombectomy. Prediction Of Treatment Outcomes

Endovascular thrombectomy (ET) effectively and safely recanalizes the occluded artery and restores the ischemic area in patients with acute ischemic stroke (IS), improving the clinical prognosis of stroke in the anterior and posterior circulation system, expanding the time therapeutic window from no more than 6 to 24 hours, greatly increasing the chances of functional independence and survival. However, some patients develop an unfavorable postoperative outcome, complications and “ineffectiveness” of revascularization. The thrombectomy result depends not only on the patient selection criteria, timing and success of the procedure, but on many other factors as well. Despite the advances in stroke treatment, the issues of neuroimaging and patient selection for ET remain relevant; the pathophysiological mechanisms of the influence of some factors on the effectiveness of the procedure are not completely clear; the causes of “uneffective” revascularization, unfavorable outcome and mortality after ET are unclear. An analysis of global experience in treating ischemic stroke with ET showed the heterogeneity of the patient selection criteria, clinical and neuroimaging variables, prognostic factors and treatment outcomes, which makes it difficult to draw a general conclusion and requires further targeted research. The article discusses the issues of patient selection, pathophysiological mechanisms of the influence of some risk factors on the outcome of ischemic stroke and the causes of unfavorable outcome and death after ET.

Examinations of medical cases conducted in the Bureau of Forensic Medical Examination of the Tambov region

BACKGROUND: Over the past 5 years, the number of commission examinations on improper provision of medical care by the Bureau of Forensic Medical Examination of the Tambov Region has increased. These examinations were performed to identify defects in the provision of medical care and determine their effect on an unfavorable outcome for the patient.
 AIM: To analyze and evaluate forensic medical examinations performed at the Tambov Regional Bureau of Forensic Medicine in so-called medical cases.
 MATERIALS AND METHODS: To identify medical specialties with the most frequent cases of inadequate medical care, which are the direct cause of unfavorable outcomes, an analysis of examinations was conducted for 2017–2021. The study included examinations performed from both the Tambov region and other regions.
 RESULTS: The number of cases of inadequate provision of medical care, for which the examination confirmed a cause-and-effect relationship with an unfavorable outcome, remains approximately at the same level throughout 2017–2021, and the largest number of defects in the provision of medical care were identified in the profile “obstetrics and gynecology.” However, the identified defects in the provision of medical care do not directly correlate with the number of examinations prescribed.
 CONCLUSION: The analysis of medical cases showed that the number of examinations in which a direct causal link was established between defects in the provision of medical care and adverse outcomes remained low annually (not more than 9%). The largest number of defects in the provision of medical care was found in the profile “obstetrics and gynecology,” which relates to defects in diagnosis and treatment.

Infectious complications after elective surgeries on the liver and pancreas

Aim. To analyze the complications of liver and pancreas surgeries, including infectious complications, and to describe the evolution of microbial flora in the hepatopancreatobiliary surgery unit.Materials and methods. The study involved 650 patients who underwent pancreatoduodenectomy and 1253 patients after liver resection. Types of preoperative biliary drainage were evaluated in terms of their influence on the treatment results. The incidence and nature of postoperative bile leakage were studied. The study included an analysis of microbial flora in the hepatopancreatobiliary surgery unit for 10 years.Results. The rate of significant complications, including infectious complications, appeared to be unaffected by a type of bile ducts drainage with potential infection at a standard course after pancreatoduodenectomy. A pancreatic fistula is considered to be a major factor in the development of abdominal infectious complications and the main cause of unfavorable outcomes. A bile leakage was most often revealed after liver resection in 95 observations (7.5%), and significantly more often after extensive liver resections. Gram-negative flora prevailed in bile from external drains of bile ducts and wound exudates in two thirds of cases. Gram-positive microorganisms were detected in one third of patients, fungi – in less than 5% of cases. The drainage fluids mostly obtained polyresistant gram-negative microorganisms. The majority of strains revealed resistance to cephalosporins, fluoroquinolones, penicillins, and an increasing resistance to carbapenems in dynamics.Conclusion. Bacterobilia after bile duct drainage significantly determines a microbial landscape of a hepatopancreatobiliary surgery unit. Pancreatodigestive anastomotic leakage is recognized as an important predictor of infectious complications in the area of intervention after pancreatoduodenectomy. Cases of this kind require the antimicrobial therapy with respect to the initial flora of the biliary tract. A bile leakage is considered to be a main contributor to infectious complications after liver resection. Extensive liver resection can lead to a sepsis-like state in the early postoperative period, predisposing to infectious complications.

Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool.

Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations. A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis. These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.

Absolute serum neurofilament light chain levels and its early kinetics predict brain injury after out-of-hospital cardiac arrest

ObjectivesTo test if the early kinetics of neurofilament light (NFL) in blood adds to the absolute values of NFL in the prediction of outcome, and to evaluate if NFL can discriminate individuals with severe hypoxic–ischemic brain injury (sHIBI) from those with other causes of poor outcome after out-of-hospital cardiac arrest (OHCA).Design and settingMonocentric retrospective study involving individuals following non-traumatic OHCA between April 2014 and April 2016. NFL concentrations were determined on a SiMoA HD-1 device using NF-Light Advantage Kits.ParticipantsOf 73 patients screened, 53 had serum samples available for NFL measurement at three timepoints (after 3, 24, and 48 h of admission). Of these 53 individuals, 43.4% had poor neurologic outcome at discharge as assessed by Glasgow–Pittsburgh cerebral performance categories, and, according to a current prognostication algorithm, poor outcome due to sHIBI in 20.7%.Main outcome measureBlood NFL and its early kinetics for prognostication of outcome and prediction of sHIBI after OHCA.ResultsAn absolute NFL > 508.6 pg/ml 48 h after admission, or a change in NFL > 494 pg/ml compared with an early baseline value predicted outcome, and discriminated severe sHIBI from other causes of unfavorable outcome after OHCA with high sensitivity (100%, 95%CI 70.0–100%) and specificity (91.7%, 95%CI 62.5–100%).ConclusionsNot only absolute values of NFL, but also early changes in NFL predict the outcome following OHCA, and may differentiate sHIBI from other causes of poor outcome after OHCA with high sensitivity and specificity. Our study adds to published data, overall corroborating that NFL measured in blood should be implemented in prognostication algorithms used in clinical routine.

Predictive Risk Factors for Early Seizures in Traumatic Brain Injury.

Background Early posttraumatic seizure (PTS) is a significant cause of unfavorable outcomes in traumatic brain injury (TBI). This study was aimed to investigate the incidence and determine a predictive model for early PTS. Materials and Methods A prospective cohort study of 484 TBI patients was conducted. All patients were evaluated for seizure activities within 7 days after the injury. Risk factors for early PTS were identified using univariate analysis. The candidate risk factors with p < 0.1 were selected into multivariable logistic regression analysis to identify predictors of early PTS. The fitting model and the power of discrimination with the area under the receiver operating characteristic (AUROC) curve were demonstrated. The nomogram for prediction of early PTS was developed for individuals. Results There were 27 patients (5.6%) with early PTS in this study. The final model illustrated chronic alcohol use (odds ratio [OR]: 4.06, 95% confidence interval [CI]: 1.64–10.07), epidural hematoma (OR: 3.98, 95% CI: 1.70–9.33), and Glasgow Coma Scale score 3–8 (OR: 3.78, 95% CI: 1.53–9.35) as predictors of early PTS. The AUROC curve was 0.77 (95% CI: 0.66–0.87). Conclusions The significant predictors for early PTS were chronic alcohol use, epidural hematoma, and severe TBI. Our nomogram was considered as a reliable source for prediction.

Correction to: Catheter retention as a consequence rather than a cause of unfavorable outcome in candidemia.

In the original publication the members of the FUNGINOS network were provided in such a way that they could not be indexed as collaborators on PubMed.

Recovery of Patients with Pure Diffuse Axonal Injury Who Remained in a Coma for 6 Hours or More.

Diffuse axonal injury (DAI) is a traumatic brain injury and one of the most common causes of unfavorable outcome and death. The aim of this study was to investigate the recovery of patients with pure DAI who remained in a coma for 6 hours or longer after brain injury. This was a follow-up study of 75 patients diagnosed with pure DAI, aged 18-60 years, with a Glasgow Coma Scale score ≤8 at hospital admission. Patient data were collected at hospital admission, hospital discharge, and 3 and 6 months after DAI. Recovery was assessed by score changes in the Katz Index of Independence in Activities of Daily Living and Extended Glasgow Outcome Scale. The percentage of patients in a coma for 6-24 hours, >24 hours without brainstem signs, and >24 hours with brainstem signs was 42.7%, 20%, and 37.3%, respectively. The 6-month mortality rate was 32.0%, and the mean Extended Glasgow Outcome Scale score among survivors decreased from 3.8 at discharge (SD= 1.2) to 2.1 at 3 months (SD= 1.6) and 1.2 at 6 months (SD= 1.6). The mean Katz Index of Independence in Activities of Daily Living scores were 8.5 (SD= 5.5), 3.5 (SD= 5.8), and 1.8 (SD= 4.5) at discharge and 3 and 6 months after trauma, respectively. Statistically significant differences were observed among the 3 evaluation periods. Mortality was high among patients with DAI, but almost all survivors had favorable outcomes at 6 months. Functional improvement was more pronounced in the first 3 months.

Simple Lateral Suboccipital Approach and Modification for Vertebral Artery Aneurysms: A Study of 52 Cases Over 10 Years.

Complex skull base approaches are frequently used to treat intracranial vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) aneurysms. These complex procedures are associated with higher risk of neurovascular injury. Hence, a less-invasive surgical approach is needed to improve the efficacy and safety of treatment. A retrospective analysis was conducted on clinical and radiologic data from surgeries in which simple lateral suboccipital and "lateral-enough" approaches were used to clip VA aneurysms in the Department of Neurosurgery at Helsinki University Central Hospital from 2000 to2009. Fifty-two VA or PICA aneurysms were treated using the simple lateral suboccipital approach. Sixteen patients (31%) presented with an unruptured aneurysm, 21 patients (40%) with World Federation of Neurosurgical Societies (WFNS) grade 1-3, and 15 patients (29%) with World Federation of Neurosurgical Societies grade 4-5. The aneurysms were saccular in 48 cases (92%), dissecting in 3 cases (6%), and fusiform in 1 case (2%). The most common aneurysm location was the VA-PICA junction (81%). The mean final modified Rankin Scale score was 2, and in unruptured cases, all patients had favorable clinical outcomes. The main causes of unfavorable outcome were poor preoperative clinical grade (P= 0.002), preoperative intraventricular hemorrhage (P= 0.008), postoperative hydrocephalus (P= 0.003), brain infarction (P= 0.005), and postoperative pneumonia (P < 0.001). We describe a 10-year experience using a simple lateral suboccipital approach and its modification by the senior author (J.H.) to treat VA and proximal PICA aneurysms. Unfavorable outcome was related to the poor preoperative clinical grade, preoperative intraventricular hemorrhage, and postoperative pneumonia.

Long-term Outcome of Lupus Nephritis Class II in Argentine Patients: An Open Retrospective Analysis.

BackgroundThere is controversy in medical literature over the outcome of patients with lupus nephritis (LN) class II. The aim of this study was to explore the risk of histological transformation (HT) and possible factors related to negative response to treatment in patients with mesangial LN class II.MethodsA retrospective and multicenter study was carried out that includes patients who had received a diagnosis of LN class II on their first renal biopsy. Creatinine, urine sediment, and proteinuria were recorded at the time of the first biopsy, 6 months, and 1, 2, and 5 years after the first biopsy. Response to treatment, HT, and long-term outcome were evaluated.ResultsForty-one patients were included. The manifestation at first biopsy was proteinuria greater than 0.5 g/d in 28 patients (68.29%; 8 [28.57%] of 28 patients had nephrotic syndrome), hematuria in 18 patients (43.90%), and deterioration of renal function in 3 patients (7.31%). During the follow-up (median, 8 years; range, 1–35 years), a new biopsy was performed in 18 patients (43.90%), and in 17 patients (17/18 [94.44%]), there was HT. Median time at rebiopsy was 32 months (range, 11–305 months). Of the 18 patients who had a second biopsy, 10 (55.55%) were on hydroxychloroquine versus 100% (19/19) of patients who did not undergo the procedure (P = 0.001). A year after the first renal biopsy, there are data available from 34 patients; of them, 24 patients (70.58%) had achieved response, and 10 patients (29.41%) had no response (NR) (missing data in 7). A higher 24-hour urinary protein at 6 months was predictor of worse outcome at 1 year, with statistical significance difference for the nonresponder group (median proteinuria, 2.3 g/d [range, 0–4.7 g/d]) compared with responders (median proteinuria, 0.28 g/d [range, 0–1.7 g/d]) (P = 0.0133).In the long-term follow-up (5 years), HT was the main cause of unfavorable outcome and was measured in 78.57% of patients (11/14 patients).ConclusionsThis series shows a high rate of HT in long-term follow-up. Proteinuria at 6 months made it possible to set aside patients who will have an unfavorable outcome in the long term and who will thus benefit from a more aggressive treatment. The results suggest that hydroxychloroquine had a nephroprotective effect.

Proteomic profiling identifies the inorganic pyrophosphatase (PPA1) protein as a potential biomarker of metastasis in laryngeal squamous cell carcinoma.

Relapse and metastasis are the main causes of unfavorable outcome in head and neck cancers. Whereas, understanding of the molecular background of these processes is far from being complete. Therefore, in this study we aimed to identify potential biomarker candidates of relapse and metastasis in laryngeal squamous cell carcinoma (LSCC) by combining the 2D electrophoresis based protein screen and immunohistochemical analysis of candidate proteins. We screened three groups of LSCC cell lines derived from primary tumors, recurrent tumors and metastases and identified seven proteins that differed significantly in relative abundance between the analyzed groups. Among the identified proteins were the heat shock proteins HSP60 and HSP70 that were significantly downregulated both in recurrences- and metastases-derived cell lines but not in primary tumor-derived cell lines. Moreover, we identified significant upregulation of the annexin V, calreticulin and the inorganic pyrophosphatase (PPA1) exclusively in the metastases-derived cell lines. As these upregulated proteins could potentially become novel biomarkers of metastasis, we have compared their abundance in primary tumor LSCC N(0) cases, primary tumor LSCC N(+) cases as well as in LSCC metastases N(+). Our results show an intense increase of cytoplasmic PPA1 abundance in the N(+) (p = 0.000042) compared to the N(0) group. In summary, we show a group of proteins deregulated in recurrences and metastases of LSCC. Moreover, we suggest the PPA1 protein as a potential new biomarker for metastasis in this cancer.Electronic supplementary materialThe online version of this article (doi:10.1007/s00726-016-2201-8) contains supplementary material, which is available to authorized users.

80歳代のくも膜下出血症例に対する開頭クリッピング治療

The number of elderly patients with subarachnoid hemorrhage has been increasing. In this retrospective study, we aimed to develop guidelines to select patients among octogenarians for surgical clipping of anterior circulation aneurysms. Between Jan. 2001 and Dec. 2010, 3,471 patients were admitted within 72 hours after SAH at 21 participating centers. Of the 3,471 patients, 513 (14.8%) were aged 80–89 years and 75 (2.2%) were over 90 years. Among patients aged 80–89 years, 351 had anterior circulation aneurysms and 68 had posterior circulation aneurysms. Anterior circulation aneurysms were treated by surgical clipping in 236 patients and by endo-vascular coiling in 48 patients. Favorable outcomes after surgical clipping were obtained in 51 of 95 (53.7%) patients with Hunt & Hess Grades I–II, 21 of 59 (35.6%) patients with Hunt & Hess Grade III, and 8 of 57 (14.0%) patients with Hunt & Hess Grade IV. The proportions of favorable outcome among patients aged 85–89 years were 35.0% in Hunt and Hess Grades I–II and 19.0% in Hunt and Hess Grade III. On the other hand, among patients aged 80–84 years, the rates of favorable outcomes were 58.4% in Hunt and Hess Grades I–II and 44.7% in Hunt & Hess Grade III. The main causes of unfavorable outcome in Hunt & Hess Grades I–II after surgical clipping were delayed ischemic neurological deficits in 18 of 44 patients (40.9%) and surgical procedures in 10 of 44 patients (22.7%). Our results indicated that surgical clipping for anterior circulation aneurysms is acceptable for 80–89 year-old patients with Hunt & Hess Grades I–II and 80–84 year-old patients with Hunt & Hess Grade III.

Traumatic Brain Injury in an Aging Population

The epidemiology of traumatic brain injury (TBI) is changing in several Western countries, with an increasing proportion of elderly TBI patients admitted to the intensive care unit (ICU). We describe a series of 1366 adult patients admitted to three neuro-ICUs in which 44% of cases were 50 years of age or older. The health status before trauma (rated using the APACHE score) was worse in older patients. In all 604 patients had emergency removal of intracranial masses, with extradural hematomas more frequent in young cases and subdural hematomas more frequent in older patients. Outcomes were classified according to the Glasgow Outcome Scale (GOS) 6 months post-trauma, as favorable (GOS score 4-5), or unfavorable (GOS score 1-3). Favorable outcomes were achieved by 50% of patients, but the proportions of unfavorable outcomes rose with age. Mortality was the main cause of unfavorable outcomes 6 months after injury in older patients. Logistic regression analysis indicates that several parameters independently contributed to outcome, including the motor component of the Glasgow Coma Scale (GCS), pupils, CT findings, and early hypotension. Additionally, the odds ratios were very high for age and health status before TBI. Patients admitted to the ICU are increasingly older, have co-morbidities, and have specific types of intracranial lesions. Early rescue, surgical treatment, and intensive care of these patients may produce excellent results up to the age of 59 years, with favorable outcomes still possible for 39% of cases aged 60-69 years, without an excessive burden of severely disabled patients.

破裂脳動脈瘤の治療成績 高齢者の破裂脳動脈瘤に対する，単一施設における治療成績の検討

The incidence of aneurysmal subarachnoid hemorrhage (SAH) increases with age. Aged patients of SAH are thought to have higher risk for complications and poorer prognosis. We retrospectively reviewed the consecutive medical records of ruptured intracranial aneurysm patients over 75 years old (y/o), who were admitted to our hospital, where endovascular treatment was adopted as the first option between April 2004 and July 2010. Thirty-eight patients (6 males and 32 females) ranging from 75 to 90 (average 82.1) y/o were enrolled. They were divided into a course observation (CO) group (n=7), clipping (CL) group (n=13) and coil embolization (CE) group (n=18). Among these 3 groups, we evaluated the clinical characteristics, Hunt & Kosnik (H&K) grade on admission, and modified Rankin Scale (mRS) and Glasgow Outcome Scale (GOS) 3 months after ictus as the outcomes. Furthermore, we analyzed the main cause leading to unfavorable outcomes. According to the location of radically treated aneurysms, all MCA aneurysms were clipped and all VBA aneurysms were coil embolized, while ACoA aneurysms were more likely to be treated with coil embolization. Although it was necessary in some cases to alter the approach route from trans-femoral to trans-brachial or trans-carotid due to atherosclerotic tortuosity, every coil embolization was successful without procedure-related complications. Moreover, neither re-rupture nor re-growth requiring further treatment occurred during follow-up period (range, 6 months–6 years). Among the CL group and CE group, 20 (64.5%) of 31 resulted in mRS 3–6 despite aggressive treatment. However, the results of the CO group were much worse than those of the CL group and CE group. All 7 patients in the CO group died of primary brain damage (PBD) 3, re-rupture 3, pneumonia 1, respectively. There was no significant difference between the CL group and CE group in age distribution or H&K grade. Nevertheless, the proportion of mRS 0 and 1 in the CE group was larger than that in the CL group (44.4% vs. 23.1%), although there was no statistical difference. No vegetative survival (V) was found in this study, so we regarded severely disabled (SD) and dead (D) as unfavorable outcomes. There were 6 SD and 3 D of 13 in the CL group, whereas there were 7 SD and 3 D of 18 in the CE group. As the main cause of unfavorable outcomes, PBD, systematic complications such as pneumonia, pre-existing comorbidities etc. were named, but above all, vasospasm was strongly correlated with SD in the CL group (4 of 6) compared with the CE group (2 of 7). Though there were inherent limitations and biases in this study and the overall results were unsatisfactory, we validated the usefulness of coil embolization for ruptured aneurysm in elderly patients. Because coil embolization was effective against re-rupture, it might be a preferred alternative for aneurysms not amenable to clipping. Optimum treatment should be considered individually when both microsurgical and endovascular treatment modalities are available. Furthermore, intensive peri-procedural management of patients’ clinical conditions especially focused on preventing vasospasm as well as greater skill in both treatments are important to improve outcomes.

Failed anterior lumbar interbody fusion due to incomplete foraminal decompression

Anterior lumbar interbody fusion (ALIF) has gained widespread popularity for spinal disorders requiring fusion. The purpose of this study was to analyze ALIF failures. The medical records of 223 patients treated with ALIF between January 2007 and June 2008 were retrospectively reviewed. Patients with unfavorable outcomes, including subsequent posterior decompression at the index level or poor outcomes after ALIF were identified based on clinical and radiological findings. The patients were divided into two groups: an unfavorable group and a favorable group. Preoperative clinical and radiological factors for each group were statistically analyzed. Two hundred of the 223 patients were enrolled in this study. Thirteen (6.5%) of 200 patients resulted in unfavorable outcome. Four patients (2%) of them underwent posterior decompressive surgery. The main cause of unfavorable outcomes was incomplete decompression of the foraminal stenosis. Unfavorable outcomes were obtained in patients with the level of L5-S1 (p = 0.036), higher body mass index (p = 0.048), higher percentage of slippage (p = 0.024), and severe facet arthropathy (p = 0.013). However, there was no difference in preoperative disc height, foraminal size, facet angle, facet tropism, or preoperative visual analog scale for back and leg pain, the Oswestry disability index, symptom duration, and fusion rate between the two groups. Based on these results, posterior decompression and fusion may be considered for obese patients with the level of L5-S1, high-grade spondylolisthesis, or severe facet arthropathy. On the other hand, ALIF can be used an effective alternative treatment in many spinal disorders requiring fusion.

Statins for community-acquired pneumonia: current state of the science

In spite of the many advances in the diagnosis and management of community-acquired pneumonia (CAP), the mortality associated with this infection remains high. In recent years scientific evidence has emerged that shows that an excessive inflammatory response is a major cause of unfavorable outcome in patients with CAP, especially in the first few days. The use of immunomodulation appears to be an appealing option for improving prognosis in CAP. It has recently been demonstrated that statins have immunomodulatory, antioxidative and anticoagulant effects, and the beneficial effects of these drugs in sepsis have been discussed. Experimental studies have shown their effect in the modulation of the cytokine cascade and in the organization of the immunological response to respiratory infection. Most observational studies published to date support the idea that the use of statins may improve the prognosis of CAP. Randomized controlled trials are needed to validate these findings.

Predictors and outcome of acute symptomatic cerebral infarctions following aneurysmal subarachnoid hemorrhage

The leading cause of unfavorable outcomes following aneurysmal subarachnoid hemorrhage (SAH) is cerebral infarction. In this 3-year retrospective study, we have retrospectively evaluated 172 hospitalized patients with aneurysmal SAH, and compared those who developed a complicated cerebral infarction with those who did not. In this study, acute symptomatic cerebral infarctions accounted for 22.6% (39/172) of all episodes. Significant statistical analysis between the two patient groups included age at onset, hypertension as the underlying disease, presence of symptomatic vasospasm, mean hospitalization days and Glasgow Outcome Score at the time of discharge. After a minimum 1.5-year follow-up period, the median (interquantile range) Barthel index score was 75 (6-85) for those patients who had cerebral infarctions, and 80 (0-90) for those who had no cerebral infarctions. Multiple logistic regression analysis demonstrated that the presence of symptomatic vasospasm was independently associated with the presence of acute symptomatic cerebral infarctions. The presence of symptomatic vasospasm implies the danger of acute symptomatic cerebral events after aneurysmal SAH. Although our study demonstrates a worse short-term outcome and longer duration of hospitalization in this special group of patients, the functional outcome for patients with cerebral infarction was not inferior to those patients without cerebral infarction after a follow-up of at least 1.5-years.

Older Age Does Not Increase Risk of Hemorrhagic Complications after Intravenous and/or Intra-Arterial Thrombolysis for Acute Stroke

The elderly have significantly higher incidence of ischemic stroke and have higher mortality and morbidity compared with younger patients. Intracranial hemorrhage (ICH) after thrombolysis is one of the causes of unfavorable outcome. However, it is unclear whether age over 80 years is a predictor for hemorrhagic transformation after intravenous, intra-arterial, or a combination of both thrombolytic therapies. A database of 488 consecutive patients with ischemic stroke who received thrombolytic therapy was analyzed using logistic regression model to determine whether factors such as age over 80 years, demographic characteristics, onset to treatment time, severity of neurologic deficits, route of administration, blood glucose, or mean arterial pressure were associated with symptomatic ICH. The rates of symptomatic hemorrhage were 12.82% and 10.4% in older and younger groups, respectively. The odds of symptomatic hemorrhage after thrombolytic therapy for patients over 80 years of age after adjusting for route of administration, National Institutes of Health Stroke Scale score, mean arterial pressure, and glucose was not significantly different from that of the younger age group (odds ratio [OR] = 1.64; 95% confidence interval [CI]: 0.729-3.66). Hyperglycemia (>150 mg/dL) was associated with increased odds of symptomatic ICH (OR = 2.32; 95% CI: 1.09-4.93). Patients older than 80 years had similar rates of recanalization (OR = 0.8; 95% CI: 0.4-1.8) and rates of asymptomatic ICH (OR = 2.40; 95% CI: 0.89-6.5). Risks of ICH after thrombolysis for acute ischemic stroke are similar in patients over and under 80 years of age. Our data suggest that the decision to provide thrombolytic therapy should not be solely based on patient's age.

THE UTILITY OF INTRAOPERATIVE BLOOD FLOW MEASUREMENT DURING ANEURYSM SURGERY USING AN ULTRASONIC PERIVASCULAR FLOW PROBE

Inadvertent vessel compromise is one major cause of unfavorable outcome from aneurysm surgery. Existing strategies for intraoperative assessment of this complication have potential limitations and disadvantages. We assessed the utility of quantitative intraoperative flow measurements using the Transonic ultrasonic flow probe (Transonic Systems, Inc., Ithaca, NY) during aneurysm surgery. Of all aneurysms treated surgically at our institution from 1998 to 2003, 103 patients with 106 aneurysms were identified in whom intraoperative flow measurements were available for analysis. We assessed the frequency of flow compromise and clip repositioning and correlated these with postoperative angiography and stroke. Significant (>25%) reduction in flow rate was apparent in 33 (31.1%) cases, and resulted in clip repositioning in 27 (25.5%), with return to baseline flow except for two cases with vessel thrombosis/dissection. In the other six cases, flow reduction was owing to spasm resolving with papaverine (n = 3) or responded to retractor repositioning (n = 3). In another six (5.7%) cases, unnecessary clip repositioning was avoided (n = 3) or safe occlusion of the parent vessel for trapping of the aneurysm was allowed by confirming adequate distal flow (n = 3). Aneurysms of the basilar, middle cerebral, anterior communicating, or carotid terminus were more likely to be associated with flow compromise (odds ratio, 4.3; P = 0.03). Postoperative angiography corroborated vessel patency in all cases, and no unexpected large vessel occlusions or strokes were evident. Use of the ultrasonic flow probe provides real-time immediate feedback concerning vessel patency. Vessel compromise is easier to interpret than with Doppler, and faster/less invasive than intraoperative angiography. Intraoperative flow measurement is a valuable adjunct for enhancing the safety of aneurysm surgery.

The Utility of Intraoperative Blood Flow Measurement During Aneurysm Surgery Using an Ultrasonic Perivascular Flow Probe

Inadvertent vessel compromise is one major cause of unfavorable outcome from aneurysm surgery. Existing strategies for intraoperative assessment of this complication have potential limitations and disadvantages. We assessed the utility of quantitative intraoperative flow measurements using the Transonic ultrasonic flow probe (Transonic Systems, Inc., Ithaca, NY) during aneurysm surgery. Of all aneurysms treated surgically at our institution from 1998 to 2003, 103 patients with 106 aneurysms were identified in whom intraoperative flow measurements were available for analysis. We assessed the frequency of flow compromise and clip repositioning and correlated these with postoperative angiography and stroke. Significant (>25%) reduction in flow rate was apparent in 33 (31.1%) cases, and resulted in clip repositioning in 27 (25.5%), with return to baseline flow except for two cases with vessel thrombosis/dissection. In the other six cases, flow reduction was owing to spasm resolving with papaverine (n = 3) or responded to retractor repositioning (n = 3). In another six (5.7%) cases, unnecessary clip repositioning was avoided (n = 3) or safe occlusion of the parent vessel for trapping of the aneurysm was allowed by confirming adequate distal flow (n = 3). Aneurysms of the basilar, middle cerebral, anterior communicating, or carotid terminus were more likely to be associated with flow compromise (odds ratio, 4.3; P = 0.03). Postoperative angiography corroborated vessel patency in all cases, and no unexpected large vessel occlusions or strokes were evident. Use of the ultrasonic flow probe provides real-time immediate feedback concerning vessel patency. Vessel compromise is easier to interpret than with Doppler, and faster/less invasive than intraoperative angiography. Intraoperative flow measurement is a valuable adjunct for enhancing the safety of aneurysm surgery.