Recurrent bleeding is one of the major causes of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Antifibrinolytic therapy is known to reduce recurrent bleeding, ...however, its beneficial effect on outcome remains unclear. The effect of treatment with tranexamic acid (TXA) until aneurysm treatment on clinical outcome is evaluated.
Patients with an aSAH from two high-volume tertiary referral treatment centers in the Netherlands, Academic Medical Center (AMC) and Radboud University Medical Center (RUMC), between January 2012 and December 2015 were included. Patients were classified into one of two groups; standard treatment or TXA treatment. Demographic and clinical characteristics, in-hospital complications and clinical outcome were compared between the two groups. Multivariate logistic regression was used to adjust for the influence of treatment center and baseline differences.
Standard treatment was given in 509 patients, and 119 patients received additional TXA therapy before aneurysm occlusion. Patients treated with TXA did not experience less recurrent bleeding adjusted or unadjusted for treatment center (adjusted odds ratio aOR 0.80, 95% confidence interval 95% CI: 0.37-1.73). In-hospital mortality, was significantly lower in the TXA group than the standard care group (adjusted OR aOR 0.42, 95% CI: 0.20-0.85). Poor outcome (mRS 4-6) assessed after six months was not different between treatment groups (aOR 1.05, 95% CI: 0.64-1.74).
Pooled data from two high-volume treatment centers did not show improved clinical outcome after additional TXA treatment in aSAH patients. However, TXA treatment was associated with a decrease in mortality.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Patients with diffuse intrinsic pontine gliomas (DIPG) have a poor prognosis. Although DIPG constitute only 10–15% of all pediatric brain tumors, they are the main cause of death in this ...group. Despite 26 clinical trials in newly diagnosed DIPG in the past 5 years (including several targeted agents), there is no clear improvement in prognosis. However, knowledge on DIPG biology is increasing, mainly due to the (re)introduction of biopsies and autopsies, the possibility of gene expression profiling, and the development of in vivo models. Translation of this knowledge into clinical trials in combination with improved drug distribution methods may eventually lead to more effective treatment of this devastating disease.
Chronic subdural haematoma (cSDH) occurs mainly in the elderly. Surgical evacuation is effective, but in these old, often frail, patients with multi-comorbidity, surgery carries significant risks for ...future cognitive functioning and loss of independency. Therefore, a growing interest is noted for a non-surgical treatment with medication such as tranexamic acid (TXA). In five small retrospective series, this antifibrinolytic drug showed a beneficial effect on the spontaneous resolution of the haematoma, and with that, the necessity for surgery.
For this randomised, placebo-controlled clinical multicentre trial, all cSDH patients, over 50 years old with mild symptoms (Glasgow Coma Score (GCS) ≥ 14, modified National Institutes of Health Stroke Scale (mNIHSS) ≤ 4), a midline shift of ≤ 10 mm and in whom a primary conservative treatment is chosen, are eligible for study participation. After informed consent, 140 patients will be randomised to receive either TXA 500 mg or placebo two times daily for 28 days. The primary outcome is the necessity for surgery within 12 weeks; secondary outcomes are cSDH volume, neurological impairment (mNIHSS), falling incidents, cognitive functioning (Montreal Cognitive Assessment (MOCA)), performance in activities of daily living (Barthel and Lawton score), functional outcome (modified Rankin Scale (mRS)), quality of life (Short Form Health Survey (SF-36) and EuroQol 5-Dimension Health Survey (EQ-5D)), mortality and the use of care and health-related costs (Medical Consumption Questionnaire (iMCQ) and Productivity Cost Questionnaire (iPCQ)) at 12 weeks and 6 months.
This phase III trial investigating the efficacy of TXA to prevent surgery for cSDH is the first in including patients using anticoagulants and mentally incompetent patients, since these comprise a significant part of the target population. Also, this study is one of the first to prospectively measure functional outcome and quality of life in cSDH patients. Final results of this study are expected in 2024.
Dutch Trial Registry (Nederlands Trial Register) NL6584 . Registered on 11 November 2017 ClinicalTrials.gov NCT03582293 . Registered on 11 July 2018 EU Clinical Trials Register 2017-004311-40 . Registered on 29 March 2018.
Purpose
To study the long-term outcome of revision microdiscectomy after classic microdiscectomy for lumbosacral radicular syndrome (LSRS).
Methods
Eighty-eight of 216 patients (41%) who underwent a ...revision microdiscectomy between 2007 and 2010 for MRI disc-related LSRS participated in this study. Questionnaires included visual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36, and seven-point Likert scores for recovery, leg pain, and back pain. Any further lumbar re-revision operation(s) were recorded.
Results
Mean (SD) age was 59.8 (12.8), and median IQR time of follow-up was 10.0 years 9.0–11.0. A favourable general perceived recovery was reported by 35 patients (40%). A favourable outcome with respect to perceived leg pain was present in 39 patients (45%), and 35 patients (41%) reported a favourable outcome concerning back pain. The median VAS for leg and back pain was worse in the unfavourable group (48.0/100 mm (IQR 16.0–71.0) vs. 3.0/100 mm (IQR 2.0–5.0) and 56.0/100 mm (IQR 27.0–74.0) vs. 4.0/100 mm (IQR 2.0–17.0), respectively; both
p
< 0.001). Re-revision operation occurred in 31 (35%) patients (24% same level same side); there was no significant difference in the rate of favourable outcome between patients with or without a re-revision operation.
Conclusion
The long-term results after revision microdiscectomy for LSRS show an unfavourable outcome in the majority of patients and a high risk of re-revision microdiscectomy, with similar results. Based on also the disappointing results of alternative treatments, revision microdiscectomy for recurrent LSRS seems to still be a valid treatment. The results of our study may be useful to counsel patients in making appropriate treatment choices.
Brain imaging in diffuse glioma is used for diagnosis, treatment planning, and follow-up.
In this meta-analysis, we address the diagnostic accuracy of imaging to delineate diffuse glioma.
We ...systematically searched studies of adults with diffuse gliomas and correlation of imaging with histopathology.
Study inclusion was based on quality criteria. Individual patient data were used, if available.
A hierarchic summary receiver operating characteristic method was applied. Low- and high-grade gliomas were analyzed in subgroups.
Sixty-one studies described 3532 samples in 1309 patients. The mean Standard for Reporting of Diagnostic Accuracy score (13/25) indicated suboptimal reporting quality. For diffuse gliomas as a whole, the diagnostic accuracy was best with T2-weighted imaging, measured as area under the curve, false-positive rate, true-positive rate, and diagnostic odds ratio of 95.6%, 3.3%, 82%, and 152. For low-grade gliomas, the diagnostic accuracy of T2-weighted imaging as a reference was 89.0%, 0.4%, 44.7%, and 205; and for high-grade gliomas, with T1-weighted gadolinium-enhanced MR imaging as a reference, it was 80.7%, 16.8%, 73.3%, and 14.8. In high-grade gliomas, MR spectroscopy (85.7%, 35.0%, 85.7%, and 12.4) and
C methionine-PET (85.1%, 38.7%, 93.7%, and 26.6) performed better than the reference imaging.
True-negative samples were underrepresented in these data, so false-positive rates are probably less reliable than true-positive rates. Multimodality imaging data were unavailable.
The diagnostic accuracy of commonly used imaging is better for delineation of low-grade gliomas than high-grade gliomas on the basis of limited evidence. Improvement is indicated from advanced techniques, such as MR spectroscopy and PET.
To assess long-term functional outcome and survival among patients with meningioma World Health Organization (WHO) grade I.
Retrospective analysis of 205 patients after resection of WHO grade I ...intracranial meningioma from 1985 through 2003. Expected age- and sex-specific survival was calculated by applying Dutch life-table statistics to each patient for the individual duration of follow-up. Long-term functional outcome was assessed using a mailed questionnaire to the general practitioner.
The mean duration of follow-up was 11.5 years. Survival at 5, 10, 15, and 20 years was 92%, 81%, 63%, and 53%, respectively, which is significantly lower than the expected survival (94%, 86%, 78%, and 66%, respectively). Survival was worse with higher age (P < .001). Survival among patients younger than 45 years and older than 65 years was comparable to the expected survival but significantly worse among patients aged 45-65 years. Analysis of the cause of death suggests an excess mortality associated with both brain tumor death and stroke (P = .07). Recurrence rates at 5, 10, and 15 years were 18%, 26%, and 32%, respectively. Higher Simpson grade (P < .001) and lower age (P = .02) were associated with a higher recurrence rate. In 29 patients (14%) receiving radiotherapy, the 5-year recurrence rate was 18% and the 5-year survival was only 58%. Long-term functioning (≥ 5 years after last treatment) could be assessed in 89 long-term survivors: 29 patients (33%) showed no deficits, and 60 (67%) showed at least 1 neurological symptom, of whom 24 (27%) were unable to perform normal daily activities.
Long-term survival in WHO grade I meningioma is challenged in patients more than 45 years of age. Excess mortality seems to be associated with both tumor recurrence and stroke. The majority of patients have long-term neurological problems.
Although rare, spinal haematoma and abscess after central neuraxial blocks may cause severe permanent neurological injury. Optimal treatment and outcome remain unclear. In order to identify possible ...predisposing patient characteristics and describe the ensuing clinical course, we searched Medline, Embase, and the Cochrane Library for reports of spinal haematomas and abscesses associated with central neuraxial blocks. Extracted data included patient characteristics, symptoms, treatment, and outcome. We analysed 409 reports, including 647 patients (387 patients with spinal haematoma and 260 patients with spinal abscess). Spinal haematoma and abscess occurred predominantly after epidural anaesthesia (58% and 83%, respectively). Neurological recovery was correlated with the severity of initial neurological deficit. When decompression of spinal haematoma was delayed for >12 h after clinical diagnosis, neurological outcome was worse compared with earlier decompression (odds ratio 4.5, 95% confidence interval 2.1–9.9, P<0.001, n=163). After spinal haematoma, 47% of published patients had full recovery, 28% had partial recovery, and in 25% no recovery was observed. Good outcome after conservative management was observed in patients with mild symptoms or with spontaneous recovery during the diagnostic and therapeutic workup. After spinal abscess, 68% of reported patients recovered fully, 21% showed partial recovery, and no recovery was reported in 11%. Persistent neurological symptoms after spinal haematoma and abscess are common and correlate with the severity of initial neurological deficit. Neurological outcome seems worse when decompressive surgery of haematoma is delayed. Notwithstanding the considerable risk of selection bias and publication bias, conservative management may be feasible in patients with mild symptoms or spontaneous recovery.
Purpose
The optimal surgical timeframe for neurological recovery in traumatic spinal cord injury (tSCI) still remains unknown. Recent guidelines have recommended performing surgery within 24 h for ...all patients with tSCI regardless of initial neurological deficit. It remains unclear whether patients with complete, incomplete tSCI, or traumatic central cord injury (TCCI) will experience the same degree of improvement after urgent surgical intervention. We investigated if the severity of initial neurological injury influenced surgeons on their decision-making of surgical timing in tSCI.
Methods
With a web-based survey, we investigated the current opinion in The Netherlands on timing of surgical decompression and stabilization, depending on the initial degree of neurological injury.
Results
Surgeons prefer to perform more urgent surgery for incomplete tSCI compared to complete tSCI. In addition, 43% of patients with complete tSCI are not preferably operated within the recommended 24 h. Even though TCCI is the most common form of incomplete tSCI, these patients are preferably managed less urgently than patients with other types of incomplete tSCI.
Conclusion
The severity of initial neurological injury seems to play an important role in the urgency of surgical timing for tSCI. A substantial number of patients with complete tSCI are not preferably treated within the recommended surgical timeframe, while patients with incomplete tSCI are preferably operated far more urgent than recommended in the current guidelines.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
In this single-institution trial, we investigated whether fractionated stereotactic radiation therapy is superior to single-fraction linac-based radiosurgery with respect to treatment-related ...toxicity and local control in patients with vestibular schwannoma.
All 129 vestibular schwannoma patients treated between 1992 and June 2000 at our linac-based radiosurgery facility were analyzed with respect to treatment schedule. Dentate patients were prospectively selected for a fractionated schedule of 5 × 4 Gy and later on 5 × 5 Gy at the 80% isodose in 1 week with a relocatable stereotactic frame. Edentate patients were prospectively selected for a nonfractionated treatment of 1 × 10 Gy and later on 1 × 12.5 Gy at 80% isodose with an invasive stereotactic frame. Both MRI and CT scans were made in all 129 patients within 1 week before treatment. All patients were followed yearly with MRI and physical examination.
A fractionated schedule was given to 80 patients and a single fraction to 49 patients. Mean follow-up time was 33 months (range: 12–107 months). There was no statistically significant difference between the single-fraction group and the fractionated group with respect to mean tumor diameter (2.6 vs. 2.5 cm) or mean follow-up time (both 33 months). Only mean age (63 years vs. 49 years) was statistically significantly different (
p = 0.001). Outcome differences between the single-fraction treatment group and the fractionated treatment group with respect to 5-year local control probability (100% vs. 94%), 5-year facial nerve preservation probability (93% vs. 97%), and 5-year hearing preservation probability (75% vs. 61%) were not statistically significant. The difference in 5-year trigeminal nerve preservation (92% vs. 98%) reached statistical significance (
p = 0.048).
Linac-based single-fraction radiosurgery seems to be as good as linac-based fractionated stereotactic radiation therapy in vestibular schwannoma patients, except for a small difference in trigeminal nerve preservation rate in favor of a fractionated schedule.
Background
Conservative therapy for chronic subdural hematoma (cSDH) is an option for patients who express no, or only mild symptoms, thereby preventing surgery in some. Because it is not clear for ...whom conservative therapy is successful, we aimed to estimate the success rate of conservative therapy and to identify which factors might influence success.
Methods
We systematically searched MEDLINE and EMBASE databases to identify all available publications reporting outcome of conservative therapy for cSDH patients. Studies containing >10 patients were included. The primary outcome was the success rate of conservative therapy, defined as “no crossover to surgery” during follow-up. In addition, factors possibly associated with success of conservative therapy were explored. Bias assessment was performed with the Newcastle Ottowa Scale and the Cochrane risk-of-bias tool. We calculated pooled incidence and mean estimates, along with their 95% confidence intervals (CIs), using OpenMetaAnalyst software.
Results
The search yielded 1,570 articles, of which 11 were included in this study, describing 1,019 conservatively treated patients. The pooled success rate of conservative therapy was 66% (95% CI: 50–82%). One study (
n
= 98) reported smaller hematoma volume to be associated with success, whilst another study (
n
= 53) reported low hematoma density and absence of paresis at diagnosis to be associated with success.
Conclusion
Conservative therapy is reported to be successful in the majority of cSDH patients who have either no, or only mild symptoms. Hematoma volume, low hematoma density and absence of paresis could be factors associated with success. However, further research is warranted in order to establish factors consistently associated with a successful conservative therapy.
Other
No funding was acquired for this study. The study was not registered nor was a study protocol prepared.
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