Long-term, serial screening for intracranial aneurysms in individuals with a family history of aneurysmal subarachnoid haemorrhage: a cohort study.

Individuals with two or more first-degree relatives who have had aneurysmal subarachnoid haemorrhage (aSAH) have an increased risk of aneurysms and aSAH. We investigated the yield of long-term serial screening for intracranial aneurysms in these individuals.

In a cohort study, we reviewed the results of screening of individuals with a positive family history of aSAH (two or more first-degree relatives who had had aSAH or unruptured intracranial aneurysms) done at the University Medical Centre Utrecht (Utrecht, Netherlands) between April 1, 1993, and April 1, 2013. Magnetic resonance angiography or CT angiography was done from age 16-18 years to 65-70 years. After a negative screen, we advised individuals to contact us after 5 years, but did not actively call them for repeated screening. We recorded familial history of ruptured and unruptured intracranial aneurysms, smoking history, hypertension, previous aneurysms, screening dates, and screening results. We identified risk factors for positive initial and follow-up screens with univariable and multivariable regression analysis.

We identified aneurysms in 51 (11%, 95% CI 9-14) of 458 individuals at first screening, in 21 (8%, 5-12) of 261 at second screening, in seven (5%, 2-11) of 128 at third screening, and three (5%, 1-14) of 63 at fourth screening. Five (3%, 95% CI 1-6) of 188 individuals without a history of aneurysms and with two negative screens had a de-novo aneurysm in a follow-up screen. Smoking (odds ratio 2·7, 95% CI 1·2-5·9), history of previous aneurysms (3·9, 1·2-12·7), and familial history of aneurysms (3·5, 1·6-8·1) were significant risk factors for aneurysms at first screening in the multivariable analysis. History of previous aneurysms was the only significant risk factor for aneurysms at follow-up screening (hazard ratio 4·5, 1·1-18·7). Aneurysms were identified in six (5%, 95% CI 2-10) of 129 individuals who were screened before age 30 years. One patient developed a de-novo aneurysm that ruptured 3 years after the last negative screen.
INTERPRETATION:
In individuals with a family history of aSAH, the yield of long-term screening is substantial even after more than 10 years of follow-up and two initial negative screens. We advocate long-term serial screening in these individuals, although the risk of aSAH within screening intervals is not eliminated.
FUNDING:
The Dutch Heart Foundation1

  1. Bor AS, Rinkel GJ, van Norden J, Wermer MJ. Long-term, serial screening for
    intracranial aneurysms in individuals with a family history of aneurysmal
    subarachnoid haemorrhage: a cohort study. Lancet Neurol. 2014 Apr;13(4):385-92.
    doi: 10.1016/S1474-4422(14)70021-3. Epub 2014 Mar 5. PubMed PMID: 24618352. []

La mitad dejan daños graves

En México la incidencia de accidentes automovilísticos que dejan traumatismo craneoencefálico es alta. Las estadísticas señalan que de cada 100 mil habitantes 200 se ven involucrados. Eduardo Nares, jefe del Servicio de Neurocirugía del Hospital Universitario de Saltillo, sostuvo que en Estados Unidos son más frecuentes.
Lo anterior se debe a que no se ha dado una precaución y estudios de patología moderna, que es muy antigua, ya que el primer accidente de tránsito sucedió hace 130 años en Nueva York, Estados Unidos.
“Si vemos todos los lastres que ha dejado esto en tan poco tiempo la situación es preocupante”.
Destacó la importancia de no dañar al paciente, ya que “en medicina no está especificada la manera de tratar a los enfermos y en ocasiones en lugar de beneficiar empeora, lo anterior porque nos quedamos con información no actualizada desde hace 10 años”1

  1. http://www.eldiariodecoahuila.com.mx/notas/2014/4/13/mitad-dejan-danos-graves-428323.asp []

CT scan in pediatric traumatic brain injury

As a general rule, in pediatric trauma patients with a Glasgow Coma Scale (GCS) less than 13, focal neurological deficits, and deteriorating consciousness should receive CT scan. However, for children with milder head injury, there is no clear consensus about requesting CT 7).

Most of the children with minor head trauma attend the emergency department nonsymptomatically or with minimal symptoms. Neurological examination is difficult in children, especially in newborns, infants (between one month and 12 months), and those under 3 years of age. Also, concern of the parents for their children and fear of malpractice litigation may force the physicians to request radiological imaging, especially the CT. The rate of requesting CT scans in children with minor head trauma (MHT) is between 5 and 50% 8).

There is a need for further prospective, multicentered studies with a large number of patients to make decision rules especially for children in this age group.

The fear of malpractice litigation should be reduced by various measures which will protect physicians such as robust departmental guidelines 9).

8) K. S. Quayle, D. M. Jaffe, N. Kuppermann et al., “Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?” Pediatrics, vol. 99, no. 5, article e11, 1997.
7) B. Simon, P. Letourneau, E. Vitorino, and J. McCall, “Pediatric minor head trauma: indications for computed tomographic scanning revisited,” Journal of Trauma, vol. 51, no. 2, pp. 231–238, 2001.
9) Gülşen I, Ak H, Karadaş S, Demır I, Bulut MD, Yaycioğlu S. Indications of brain computed tomography scan in children younger than 3 years of age with minor head trauma. Emerg Med Int. 2014;2014:248967. doi: 10.1155/2014/248967. Epub 2014 Mar 2. PubMed PMID: 24724031.

Early Decompressive craniectomy does not seem to significantly improve mortality

Early Decompressive craniectomy (DC) does not seem to significantly improve mortality in patients with refractory intracranial hypertension (ICH) compared with medical therapy (MT).

Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH.

Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls.

There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher.

CONCLUSION:
Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy.
LEVEL OF EVIDENCE:
Therapeutic care/management, level III1

  1. Nirula R, Millar D, Greene T, McFadden M, Shah L, Scalea TM, Stein DM,
    Magnotti LJ, Jurkovich GJ, Vercruysse G, Demetriades D, Scherer LA, Peitzman A,
    Sperry J, Beauchamp K, Bell S, Feiz-Erfan I, O’Neill P, Coimbra R. Decompressive
    craniectomy or medical management for refractory intracranial hypertension: An
    AAST-MIT propensity score analysis. J Trauma Acute Care Surg. 2014
    Apr;76(4):944-55. doi: 10.1097/TA.0000000000000194. PubMed PMID: 24662856. []

3D Neuroanatomy Today

CEREBRAL INTRINSIC TUMORS. NEUROANATOMIC BASIS AND SURGICAL MANAGEMENT

Juan Ramón Gras MD, Jaime Lloret MD, PhD
Pedro Moreno MD

Craniometric points of the skull and the cerebral cortical surface.Microanatomic correlation
Víctor Fernández MD, PhD

Microsurgical anatomy of the sulci and giry of the brain. Cerebral tumors
Pablo González-López MD, PhD

The cerebral substance. Lateral aspect of the brain
Pablo González-López MD, PhD

The cerebral substance. Medial and basal aspects of the brain
Pablo González-López MD, PhD

Ventricular system anatomy and surgical implications
Samer K. Elbabaa MD, FACS

Radiological anatomy of the cerebral substance. The surgeon