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Journal of Neurosurgery 04/2013; · 2.96 Impact Factor
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Journal of Neurosurgery 11/2012; · 2.96 Impact Factor
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ABSTRACT: The aim of this study was to determine the probability of seizures after treatment of a ruptured cerebral aneurysm by clip occlusion and coil embolization, and to identify the risks and predictors of seizures over the short- and long-term follow-up period.
The study population included 2143 patients with ruptured intracranial aneurysms who were enrolled in 43 centers and randomly assigned to clip application or coil placement. Those patients suffering a seizure were identified prospectively at various time points after randomization, as follows: before treatment; after treatment and before discharge; after discharge to 1 year; and annually thereafter.
Two hundred thirty-five (10.9%) of the 2143 patients suffered a seizure after randomization; 89 (8.3%) of 1073 and 146 (13.6%) of 1070 in the endovascular and neurosurgical allocations, respectively (p = 0.014). In 19 patients the seizure was associated with a rehemorrhage. Of those patients who underwent coil placement alone, without additional procedures, 52 suffered a seizure, and in the group with clip occlusion alone, 91 patients suffered a seizure. The risk of a seizure after discharge in the endovascular group was 3.3% at 1 year and 6.4% at 5 years. In the neurosurgical group it was 5.2% at 1 year and 9.6% at 5 years. The risk of seizure was significantly greater in the neurosurgical group at both 2 years and at up to 14 years (p = 0.005 and p = 0.013, respectively). The significant predictors of increased risk were as follows: neurosurgical treatment allocation, hazard ratio (HR) 1.64 (95% CI 1.19-2.26); younger age, HR 1.54 (95% CI 1.14-2.13); Fisher grade > 1 on CT scans, HR 1.34 (95% CI 0.62-2.87); delayed ischemic neurological deficit due to vasospasm, HR 2.10 (95% CI 1.49-2.94); and thromboembolic complication, HR 5.08 (95% CI 3.00-8.61). A middle cerebral artery (MCA) aneurysm location was also a significant predictor of increased risk in both groups; the HR was 2.23 (95% CI 1.57-3.17), with the probability of seizure at 6.1% and 11.5% at 1 year in the endovascular and neurosurgery groups, respectively.
The risk of seizures after coil embolization is significantly lower than that after clip occlusion. An MCA aneurysm location increased the risk of seizures in both groups.
Journal of Neurosurgery 08/2011; 115(6):1159-68. · 2.96 Impact Factor
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ABSTRACT: This prospective randomized double-blinded in-vitro study was conducted to determine the relative Packing Density (PD) of the new Deltapaq coil (Micrus Endovascular) as compared to Micrus's conventional filling CHE (Helipaq) and finishing CFS (Ultipaq) coils.
Two physicians independently deployed the coils under fluoroscopy into a 4mm berry shaped glass aneurysm. Each coil tested was a 4mm x 35cm coil specially made for this study. Physicians and observer were blinded as to the type of coil. Five samples per group, per operator, were deployed.
mean PD were 36.6% (Helipaq), 37.9% (Ultipaq) and 40.4% (Deltapaq). Two-sample T-test showed a significantly higher PD of Deltapaq versus Helipaq (p < 0.022). Discussion: Higher coil PD and better neck coverage may provide an increased biomechanical stability and may potentially reduce the recanalization rate of aneurysms.
The new Deltapaq coil may have the potential to achieve higher packing densities in the treatment of aneurysms.
Vascular and Endovascular Surgery 05/2010; 44(4):289-93. · 0.99 Impact Factor
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ABSTRACT: Delayed ischaemic neurological deficit (DID) following subarachnoid haemorrhage from aneurysm rupture (aSAH) is a serious complication and a major cause of mortality and morbidity. No empirical estimates of resource use and costs of patients with delayed ischaemic deficit compared to those without have been reported to date.
A detailed cost analysis of the UK National Health Service health care costs of DID was performed using resource use data from the International Subarachnoid Aneurysm Trial (ISAT) over the 24 months following haemorrhage. Resource use categories included direct health care and employment-related costs. A prognostic model of baseline predictors of DID and overall total health care costs was also constructed.
Mean (standard deviation) total health care costs at 24 months follow-up were estimated to be pound sterling 28175 (pound sterling 26773) in the DID group and pound sterling 18805 (pound sterling 17287) in the no DID group, a significant difference (95 % confidence interval) of pound sterling 9370 (pound sterling 6880 to pound sterling 12516). This cost difference was driven by statistically significant differences on imaging and investigations, longer length of stay and higher cost of complications and adverse events experienced by patients with DID. Patients with DID also spent on average 62 days less in paid employment than patients without this complication. The prognostic model found CT Fisher grading, WFNS grade, aneurysm location and time from aSAH to intervention statistically significant baseline predictors of delayed ischaemic deficit.
Patients who developed DID incurred substantially higher costs and a significantly slower resumption of employment than patients without at 24 months follow-up after aSAH.
Journal of Neurology 03/2009; 256(3):364-73. · 3.47 Impact Factor
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ABSTRACT: Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomised, multicentre trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments.
We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n=1070) or endovascular treatment by detachable platinum coils (n=1073). Clinical outcomes were assessed at 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale score of 3-6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol.
190 of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) allocated neurosurgical treatment (p=0.0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively.
In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.
The Lancet 11/2002; 360(9342):1267-74. · 38.28 Impact Factor
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ABSTRACT: The pathogenesis of leukoaraiosis on computed tomographic (CT) scanning is unknown, but cerebrovascular risk factors for leukoaraiosis show overlap with those for Alzheimer disease (AD).
To investigate the contribution of cerebrovascular risk factors, in particular plasma total homocysteine (tHcy), to leukoaraiosis in patients with AD and controls.
Cross-sectional case-control study.
Referral population to a hospital clinic and community volunteers from the Oxfordshire region in England seen between July 1, 1988, and July 1, 2000.
One hundred thirty-seven AD cases (104 confirmed post mortem) and 277 controls matched for age (mean +/- SD, 73 +/- 8 years) and sex.
Cerebrovascular risk factors and leukoaraiosis on CT scans of cases and controls; the odds ratio (OR) of having moderate to severe leukoaraiosis with higher levels of plasma tHcy and cerebrovascular risk factors such as age, sex, systolic blood pressure, smoking, diabetes mellitus, and apolipoprotein E epsilon4 genotype.
Leukoaraiosis was more prevalent in AD cases. For a 5-micromol/L increase in tHcy levels, the OR for leukoaraiosis was 1.40 (95% confidence interval, 1.02-1.91) independent of other risk factors. The distribution pattern of leukoaraiosis was more marked in the deep white matter than in the periventricular area in individuals with elevated tHcy levels, particularly in patients with AD.
Higher tHcy levels are an independent risk factor for moderate to severe leukoaraiosis in individuals with AD and of leukoaraiosis of the deep white matter in particular. The nature of the relationship between tHcy levels and leukoaraiosis in AD requires further longitudinal and intervention studies.
Archives of Neurology 06/2002; 59(5):787-93. · 7.58 Impact Factor
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