Walton – Comparison of Manual and Automated Fiber Quantification Tractography in Patients with Temporal Lobe Epilepsy

Author(s): Kreilkamp B.A.K.; Lisanti L.; Marson A.G.; Keller S.S.; Wieshmann U.C.; Glenn G.R.; Das K.

Source: NeuroImage: Clinical; 2019; vol. 24

Publication Date: 2019

Publication Type(s): Article

Abstract:Objective: To investigate the agreement between manually and automatically generated tracts from diffusion tensor imaging (DTI) in patients with temporal lobe epilepsy (TLE). Whole and along-the-tract diffusivity metrics and correlations with patient clinical characteristics were analyzed with respect to tractography approach. Method(s): We recruited 40 healthy controls and 24 patients with TLE who underwent conventional T1-weighted imaging and 60-direction DTI. An automated (Automated Fiber Quantification, AFQ) and manual (TrackVis) deterministic tractography approach was used to identify the uncinate fasciculus (UF) and parahippocampal white matter bundle (PHWM). Tract diffusion scalar metrics were analyzed with respect to agreement across automated and manual approaches (Dice Coefficient and Spearman correlations), to side of onset of epilepsy and patient clinical characteristics, including duration of epilepsy, age of onset and presence of hippocampal sclerosis. Result(s): Across approaches the analysis of tract morphology similarity revealed Dice coefficients at moderate to good agreement (0.54 – 0.6) and significant correlations between diffusion values (Spearman’s Rho=0.4-0.9). However, within bilateral PHWM, AFQ yielded significantly lower FA (left: Z = 4.4, p<0.001; right: Z = 5.1, p<0.001) and higher MD values (left: Z=-4.7, p<0.001; right: Z=-3.7, p<0.001) compared to the manual approach. Whole tract DTI metrics determined using AFQ were significantly correlated with patient characteristics, including age of epilepsy onset in FA (R = 0.6, p = 0.02) and MD of the ipsilateral PHWM (R=-0.6, p = 0.02), while duration of epilepsy corrected for age correlated with MD in ipsilateral PHWM (R = 0.7, p<0.01). Correlations between clinical metrics and diffusion values extracted using the manual whole tract technique did not survive correction for multiple comparisons. Both manual and automated along-the-tract analyses demonstrated significant correlations with patient clinical characteristics such as age of onset and epilepsy duration. The strongest and most widespread localized ipsi- and contralateral diffusivity alterations were observed in patients with left TLE and patients with HS compared to controls, while patients with right TLE and patients without HS did not show these strong effects. Conclusion(s): Manual and AFQ tractography approaches revealed significant correlations in the reconstruction of tract morphology and extracted whole and along-tract diffusivity values. However, as non-identical methods they differed in the respective yield of significant results across clinical correlations and group-wise statistics. Given the absence of excellent agreement between manual and AFQ techniques as demonstrated in the present study, caution should be considered when using AFQ particularly when used without reference to benchmark manual measures.

Copyright © 2019 The Author(s)

Database: EMBASE

Walton – Clobazam Add-On Therapy for Drug-Resistant Epilepsy

Author(s): Bresnahan R.; Martin-Mcgill K.J.; Marson A.G.; Williamson J.; Michael B.D.

Source: Cochrane Database of Systematic Reviews; Oct 2019; vol. 2019 (no. 10)

Publication Date: Oct 2019

Publication Type(s): Review

PubMedID: 31638272

Abstract:Background Epilepsy affects approximately 1% of the population, with up to 30% of patients continuing to have seizures, despite antiepileptic drug treatment. Clobazam is a 1,5-benzodiazepine and is commonly used as an add-on treatment for drug-resistant epilepsy. This review is an updated version of the original Cochrane Review, first published in 2008, and examines the most current literature regarding clobazam as an add-on for drug-resistant epilepsy. Objectives To assess the efficacy, effectiveness and tolerability of clobazam as an add-on therapy for drug-resistant generalised-onset and focal-onset seizures, with or without secondary generalisation, in adults and children. Search methods For the latest update, we searched the following databases on 9 October 2018: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (Ovid) 1946 to 8 October, 2018, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP). For some previous updates we also searched SCOPUS, DARE, and BIOSIS Previews, but these are no longer needed. (SCOPUS was searched as a substitute for EMBASE, but randomised and quasi-randomised controlled trials in EMBASE are now included in CENTRAL; DARE ceased operation at the end of March 2015; BIOSIS Previews yielded no relevant items that were not found in the other databases). Selection criteria Randomised trials of add-on clobazam, with adequate methods of allocation concealment, recruiting patients with drug-resistant focal or generalised-onset seizures, with a minimum treatment period of eight weeks. Data collection and analysis Two review authors independently selected trials for inclusion and extracted relevant data. The following outcomes were assessed: 50% or greater reduction in seizures, seizure freedom, treatment withdrawal and adverse events. Main results Four double-blind, placebo-controlled, cross-over studies, representing 197 participants, were included in the review. All four studies were assessed as having unclear risk of bias due to the unavailability of methodological details. The studies demonstrated significant method-ological heterogeneity and differences in outcome measures were noted. Consequently, it was not possible to summarise the data in a meta-analysis. Instead, findings were summarised in a narrative data synthesis, Only two of the studies reported 50% or greater seizure reduction. They respectively reported that 57.7% and 52.4% of participants receiving add-on clobazam experienced a 50% or greater reduction in seizure frequency, although publication bias needs to be considered (2 RCTs, n = 47, very low-quality evidence). Seizure freedom was reported by three of the included studies. Collectively, 27 out of 175 patients were seizure-free during treatment with clobazam (3 RCTs, n = 175, very low-quality evidence). Two studies specifically stated that seizure freedom was not observed in any of the participants receiving add-on placebo. Treatment withdrawal was reported by all four studies. There was a slightly higher incidence of treatment withdrawal associated with receiving clobazam, although the overall incidence was still fairly low (4 RCTs, n = 197, very low-quality evidence). Adverse events were only described in two of the studies, reportedly 36% and 85% of participants experienced one or more adverse events whilst receiving clobazam. The most commonly reported adverse event was drowsiness.

Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Database: EMBASE

Walton – Topiramate Add-On Therapy for Drug-Resistant Focal Epilepsy

Author(s): Bresnahan R.; Marson A.G.; Hounsome J.; Jette N.; Hutton J.L.

Source: Cochrane Database of Systematic Reviews; Oct 2019; vol. 2019 (no. 10)

Publication Date: Oct 2019

Publication Type(s): Article

PubMedID: 31642054

Abstract:Background The majority of people with epilepsy have a good prognosis and their seizures are controlled by a single antiepileptic drug. However, up to 20% of patients from population-based studies, and up to 30% from clinical series (not population-based), develop drug-resistant epilepsy, especially those with focal-onset seizures. In this review, we summarise the current evidence regarding topiramate, an antiepileptic drug first marketed in 1996, when used as an add-on treatment for drug-resistant focal epilepsy. This is an update of a Cochrane Review first published in 1999, and last updated in 2014. Objectives To evaluate the efficacy and tolerability of topiramate when used as an add-on treatment for people with drug-resistant focal epilepsy. Search methods For the latest update of this review we searched the following databases on 2 July 2018: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (Ovid, 1946-); ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions. We also contacted the manufacturers of topiramate and researchers in the field to identify any ongoing or unpublished studies. Selection criteria Randomised, placebo-controlled add-on trials of topiramate, recruiting people with drug-resistant focal epilepsy. Data collection and analysis Two review authors independently selected trials for inclusion and extracted the relevant data. We assessed the following outcomes: (1) 50% or greater reduction in seizure frequency; (2) seizure freedom; (3) treatment withdrawal (any reason); (4) adverse effects. Primary analyses were intention-to-treat (ITT), and summary risk ratios (RRs) with 95% confidence intervals (95% CIs) are presented. We evaluated dose-response in regression models. We carried out a ‘Risk of bias’ assessment for each included study using the Cochrane ‘Risk of bias’ tool and assessed the overall certainty of evidence using the GRADE approach. Main results We included 12 trials, representing 1650 participants. Baseline phases ranged from four to 12 weeks and double-blind phases ranged from 11 to 19 weeks. The RR for a 50% or greater reduction in seizure frequency with add-on topiramate compared to placebo was 2.71 (95% CI 2.05 to 3.59; 12 studies; high-certainty evidence). Dose regression analysis showed increasing effect with increasing topiramate dose demonstrated by an odds ratio (OR) of 1.45 (95% CI 1.28 to 1.64; P < 0.001) per 200 mg/d increase in topiramate dosage. The proportion of participants achieving seizure freedom was also significantly increased with add-on topiramate compared to placebo (RR 3.67, 95% CI 1.79 to 7.54; 8 studies; moderate-certainty evidence). Treatment withdrawal was significantly higher for add-on topiramate compared to placebo (RR 2.37, 95% CI 1.66 to 3.37; 12 studies; high-certainty evidence). The RRs for the following adverse effects indicate that they are significantly more prevalent with topiramate, compared to placebo: ataxia 2.29 (99% CI 1.10 to 4.77; 4 studies); concentration difficulties 7.81 (99% CI 2.08 to 29.29; 6 studies; moderate-certainty evidence); dizziness 1.52 (99% CI 1.07 to 2.16; 8 studies); fatigue 2.08 (99% CI 1.37 to 3.15; 10 studies); paraesthesia 3.65 (99% CI 1.58 to 8.39; 7 studies; moderate-certainty evidence); somnolence 2.44 (99% CI 1.61 to 3.68; 9 studies); ‘thinking abnormally’ 5.70 (99% CI 2.26 to 14.38; 4 studies; high-certainty evidence); and weight loss 3.99 (99% CI 1.82 to 8.72; 9 studies; low-certainty evidence). Evidence of publication bias for the primary outcome was found (Egger test, P = 0.001). We rated all studies included in the review as having either low or unclear risk of bias. Overall, we assessed the evidence as moderate to high certainty due to the evidence of publication bias, statistical heterogeneity and imprecision, which was partially compensated for by large effect sizes.

Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Database: EMBASE

Aintree – A Facebook Based Breastfeeding Support Group for Doctors in the UK and Ireland

Author(s): Powell R.; Reynolds S.; Thomas V.; Raja J.; Colleran G.

Source: Breastfeeding Medicine; Oct 2019; vol. 14

Publication Date: Oct 2019

Publication Type(s): Conference Abstract

Abstract:Background: Despite the well recognised risks of not breastfeeding, it has long been understood that doctors face almost overwhelming barriers in trying to meet their own breastfeeding goals. Doctors are a unique group of professionals who are expected to know everything about breastfeeding but who receive very little education around it. Clinical practice varies wildly with much advice from doctors given to breastfeeding mothers being based on myth and opinion rather than hard evidence. In 2017 I recognised that the internet, and particularly Facebook was somewhere mothers turn to for advice (this is likely due to convenience while feeding a baby multiple times overnight) and I saw that there was no specific, safe place for doctors to turn to for personal breastfeeding advice. When doctors did reach out for breastfeeding support online, they were most often given advice to just feed formula and weren’t supported to continue breastfeeding. I decided to set up an evidence based Facebook group for doctors who are breastfeeding. Objective(s): To set up a Facebook group aiming to provide support and advice to its members who are doctors and who are/were breastfeeding mothers, and to try to change the culture around breastfeeding in medical circles. The focus of the group is breastfeeding solutions to breastfeeding problems with the aim of continuing the breastfeeding relationship. The membership is extended to breastfeeding mothers, pregnant women who plan to breastfeed or would like to find out more about it, mothers who are feeding expressed milk or mixed feeding, or any other way of feeding a child some breastmilk, and doctors who wish to support others to find breastfeeding solutions to breastfeeding problems. The group supports the WHO recommendation of exclusive breastfeeding until 6 months with the introduction of complementary foods thereafter and that ideally breastfeeding should continue until age 2 and beyond. The group has a page associated with it, on which we aimed to post evidence based information for educational purposes. Materials/Methods: In September 2017 I put a team together as I realised I didn’t have the time or expertise to run such a group on my own. I had previously identified a number of doctors from other Facebook doctor groups who seemed to have breastfeeding expertise and passion, so I approached them to ask if they would like to be involved. Out of 8 initially approached, 7 agreed to become involved and so I set up a Facebook messenger group that we would use as virtual meetings (as we were spread throughout the UK and Ireland). Over time, two members realised they didn’t have time to be involved as much as they would like to, and so have left the admin group, although they remain active group members. The current admin group is made up of myself Dr Robyn Powell (an Emergency Medicine registrar and breastfeeding mother of 3), Dr Jane Raja (a GP trainee and breastfeeding mother of 2), Dr Gabrielle Colleran (a Paediatric Radiology Consultant and breastfeeding mother of 2), Dr Victoria Thomas (a Consultant Paediatrician and breastfeeding mother of 2), Dr Sofia Reynolds (an Emergency Medicine Staff Grade doctor, breastfeeding peer supporter, and exclusively pumping mother of 2), and Dr Natalie Shenker (who runs the Hearts HumanMilk Bank and previously breastfeeding mother of 2). We set up the group with objectives as listed above, and three screening questions when someone requests membership. The questions included providing GMC number and place of work, so that we could try to ensure a safe space formembers, and amention of theWHOrecommendations so peoplewere aware of the ethos of the group. We set up the page simultaneously and began posting informative, evidence based articles/links/videos on it.Within the group, we responded quickly to people’smembership requests and between all of us admins, almost immediately to posts for help.We were aware we didn’t want to keep desperate mothers with newborns waiting, and as a number of uswere breastfeeding ourselves, it was easy to provide 24/7 cover of the group. The support we offered was emotional (reassurance in early weeks/around breastfeeding in public/breastfeeding beyond 12 mths) and practical (signposting, specific advice re latch, thrush, mastitis). Result(s): The group was set up in September 2017, and at the end of March 2019 it has 2,150 members. Initially much of the advice and evidence was provided by the administrators of the group only, but in the last 6 months we have noticed the members are now giving out the same advice to newer members, and it is rare that misinformation about breastfeeding is given by a member. It has become a valued safe space for members to seek support during their own breastfeeding journeys, and for members to provide advice for others. There is an ongoing survey currently to try to assess the impact of the group, and initial results are favourable. ‘I’m not sure I would have carried on so long without this group”Knowing other women.have had shared experiences.helps reduce anxiety”Knowing other women feed beyond 12m and the evidence they have shared.is a huge support”Invaluable support, helped guide realistic expectations, troubleshooting and emotional support”Very difficult start and relied heavily on this group”I thought there was something wrong with and my initial reaction was that I would have to start formula top ups.asked group for help.kind reassurance, advice.links to good quality videos meant things got remarkably better very quickly. I’m now breastfeeding at 11 months and have no intention to stop”This group.has totally normalised ‘extended’ BF for me”Feeling part of a supportive online community is invaluable”It has not only helped me continue breastfeeding but also educated me so much. I can’t believe I didn’t really know anything about breastfeeding as a doctor I was so ignorant”I.feel better informed about bfing patients and drug effects on lactation as well as not being a brutish medic about it anymore ie the mantra about no evidence after 6 mo and fed is best”So nice to be in a group that isn’t full of the doctor-bashing so prevalent on other BFing support groups”I am ashamed to say that I had previously thought that you need to pump and dump post GA’Conclusion(s): To date, the feedback from the survey has been entirely positive, with mothers finding the group a useful source of information and support. As admins of the group, we have observed what we consider to be a culture change amongst our members, and it seems that some of our members use education from the group to support their clinical practice. The group has met our initial objectives and is very successful in continuing to meet these. We have plans to take the group forward and improve it, particularly as an educational resource, and initial survey responses have given us food for thought.

Database: EMBASE

Aintree – Relationship Between Focal and Diffuse Fibrosis Assessed by CMR and Clinical Outcomes in Heart Failure with Preserved Ejection Fraction

Author(s): Kanagala P.; Cheng A.S.H.; Singh A.; Khan J.N.; Gulsin G.S.; Patel P.; Gupta P.; Arnold J.R.; Squire I.B.; Ng L.L.; McCann G.P.

Source: JACC: Cardiovascular Imaging; Nov 2019; vol. 12 (no. 11); p. 2291-2301

Publication Date: Nov 2019

Publication Type(s): Article

Abstract:Objectives: This study sought to assess the presence and extent of focal and diffuse fibrosis in heart failure in patients with preserved ejection fraction (HFpEF) compared to asymptomatic control subjects, and the relationship of fibrosis to clinical outcome. Background(s): Myocardial fibrosis has been implicated in the pathophysiology of HFpEF. Method(s): In this prospective, observational study, 140 subjects of similar age and sex (HFpEF: n = 96; control subjects: n = 44; 73 +/- 8 years of age; 49% males) underwent cardiac magnetic resonance imaging. Late gadolinium-enhanced (LGE) imaging and T1 mapping to calculate myocardial extracellular volume indexed to body surface area (iECV) were used to assess fibrosis. Result(s): Patients with HFpEF had more concentric remodeling and worse diastolic function. Focal fibrosis was more frequent in HFpEF subjects (overall: n = 49; infarction: n = 17; nonischemic cases: n = 36; mixed patterns: n = 4) than in control subjects (overall: n = 3). Diffuse fibrosis was also greater in HFpEF subjects than control subjects (iECV: 13.7 +/- 4.4 ml/m2 versus 10.9 +/- 2.8 ml/m2; p < 0.0001). During median follow-up (1,429 days), there were 42 composite events (14 deaths; 28 heart failure hospitalizations) in cases of HFpEF. Myocardial infarction revealed on LGE imaging was a predictor of outcomes on univariate analysis only. With multivariate analysis, iECV (hazard ratio [HR]: 1.689; 95% confidence interval [CI]: 1.141 to 2.501; p = 0.009) was an independent predictor of outcome along with mitral peak velocity of early filling (E)-to-early diastolic mitral annular velocity (E’) (E/E’) ratio (HR: 1.716; 95% CI: 1.191 to 2.472; p = 0.004) and prior HF hospitalization (HR: 2.537; 95% CI: 1.090 to 5.902; p = 0.031). iECV was also significantly associated with ventricular/left atrial remodeling and renal dysfunction: right ventricular end-diastolic volume indexed (r = 0.456; p < 0.0001), left ventricular mass/volume (r = 0.348; p = 0.001), maximal left atrial volume indexed (r = 0. 269; p = 0.009), and creatinine (r = 0.271; p = 0.009). Conclusion(s): Both focal and diffuse myocardial fibrosis are more prevalent in HFpEF subjects than in control subjects of similar age and sex. iECV significantly correlates with indices of ventricular/left atrial remodeling and renal dysfunction and is an independent predictor of adverse outcome in HFpEF. (Developing Imaging And plasMa biOmarkers iN Describing Heart Failure With Preserved Ejection Fraction [DIAMONDHFpEF]; NCT03050593)

Copyright © 2019 American College of Cardiology Foundation

Database: EMBASE

Walton – POSPOM Score to Predict Inpatient Mortality in Interventional Neuroradiology Patients: Our Experience

Author(s): Srinivasaiah R.; Lemos C.; Spencer L.; Nair V.

Source: Journal of Neurosurgical Anesthesiology; Oct 2019; vol. 31 (no. 4); p. 522-523

Publication Date: Oct 2019

Publication Type(s): Conference Abstract

Abstract:Introduction: An accurate risk score able to predict inpatient mortality helps improve both risk communication and clinical decision making. Preoperative score to predict postoperative mortality (POSPOM) is a risk scoring system developed in France by Le Manach et al can predict inpatient mortality of patients admitted for different surgeries including interventional neuroradiology. POSPOM score is based on patient’s age, comorbidities and the type of planned surgery. We used this new risk scoring system in our hospital to assess its validity in predicting inpatient mortality in INR patients. Method(s): We obtained permission from our hospital’s clinical governance department for the retrospective review of case notes of patients who underwent INR procedures for the treatment of intracranial aneurysms during January 2017 to June 2017. We reviewed 100 case notes out of 126 patients who underwent INR procedures. We collected the data on patient’s age, sex, urgency of the procedure, grade of SAH if it was an emergency procedure, POSPOM score, postoperative destination and complications, inpatient mortality and outcome at 1 year as measured by modified Rankin scale. Result(s): Of the 100 patients, 71 patients were female and 29 patients were male, with an age distribution from 24 to 80 years. A total of 58 patients underwent elective INR procedure and 42 patients had emergency INR procedure for acute subarachnoid haemorrhage (SAH). 52% of the emergency patients belonged to grade 1 SAH and 21% of the patients belonged to grade 5 SAH. The mean POSPOM score was 26 with a range from 20 to 36. Mean POSPOM score was almost similar in both elective and emergency patients. Sixty-seven percent of the patients did not had any postprocedure complications, however, 33 patients had 1 or more complications during their hospital stay. Majority of the patients had good outcome at 1 year with 92 patients with a MRS score of 0 to 3. Four patients died during their hospital stay and 2 of them brainstem dead and were organ donors and 1 patient died within 1 year after the procedure. Discussion(s): The predicted mortality rate for patients with POSPOM score of 26 was 2%. The observed Inpatient mortality was 4% in our study group and an overall mortality rate of 5% within a year. Al the patients who died during their hospital stay had emergency INR procedures. The POSPOM study did not differentiate between elective and emergency surgery. Although our sample size was small in our study group (n = 100) when compared with POSPOM study (n = 2926), we conclude that the mortality rate is higher for the patients undergoing emergency INR procedures when compared to elective INR procedures and POSPOM scoring system may not be a suitable prediction tool for emergency INR patients.

Database: EMBASE

Walton – Perioperative Management of Sneddon Syndrome for Basilar Artery Anaurysnm Clipping

Author(s): Srinivasaiah R.; Lemos C.; Vadivel D.

Source: Journal of Neurosurgical Anesthesiology; Oct 2019; vol. 31 (no. 4); p. 478-479

Publication Date: Oct 2019

Publication Type(s): Conference Abstract

Abstract:Background: Sneddon syndrome is a rare progressive disease affecting small and medium sized blood vessels of multiple organs including brain. We report a case of patient with Sneddon syndrome posted for clipping of basilar artery aneurysm. Managing this patient was challenging as she had an aneurysm in the artery which was providing major contribution to cerebral circulation, she had virtually no carotid circulation. Case Description: A 42-year-old woman who was newly diagnosed with Sneddon syndrome presented to our institute with a 9 mm Basilar artery aneurysm with a wide neck. Her presenting symptoms were headache associated with nausea, photophobia, and dizziness. CT angiogram showed significant narrowing of both internal carotid arteries (picture 1) and lack of flow across both frontal areas. She had a 60% lifetime risk of rupture (ISUIA) therefore she was considered for clipping of the aneurysm. Pre-operative assessment was performed 1 week before the surgery, routine blood investigations, and physical examinations were normal. She was taking Aspirin, Propranolol, and Citalopram. Aspirin was stopped 1 week before surgery. After performing WHO checklist we established invasive arterial blood pressure monitoring before induction in the Anesthetic room and commenced on prophylactic Metaraminol and Nimodipine infusion. The goal of the anaesthetic management was to ensure adequate cerebral perfusion and to preserve the collateral circulation. Anesthesia was induced with Remifentanil TCI, Propofil, and Vecuronium. After the insertion of endotracheal tube patient was positioned prone on blocks for the surgery. Anesthesia was maintained with Remifentanil TCI and Desflurane. Intraop period was uneventful. After the successful clipping of the Basilar artery patient was woken up with a GCS of 15. Nimodipine and Metaraminol infusions were stopped at the end of the surgery and transferred her to Neurocritical care. On third postop day patient developed third nerve palsy, dysphasia and cognitive changes. Apixaban was started to prevent further ischaemic complications. Later she was transferred to neuro rehab facility. Discussion(s): Sneddon syndrome is a rare progressive disease characterised by presence of Livedo reticularis and neurological abnormalities. They can present with CVA, TIA, headache, dizziness, memory loss, reduced intellectual ability, hypertension, heart disease, etc., symptoms and presentations can vary, the important ones for the anesthetists are cerebral ischemia, valvular heart disease, renal failure, and thrombosis of vital blood vessels. Majority of the patients will be on anticoagulants and cardiac medications. Most of the anesthetic drugs used in everyday practice can be safely used in these patients.1 Use of ihromboelastog-raphy perioperatively is useful for managing bleeding. These patients should be monitored in neurocritical care during postop period.

Database: EMBASE

Walton – Prevalence of Anemia in Interventional Neuro Radiology Patients

Author(s): Srinivasaiah R.; Masters J.; Nair V.

Source: Journal of Neurosurgical Anesthesiology; Oct 2019; vol. 31 (no. 4); p. 479

Publication Date: Oct 2019

Publication Type(s): Conference Abstract

Abstract:Introduction: Guidelines are available for managing the preoperative anemia in Neurosurgical patients, however, no such guidelines are available for the management of anemia in Interventional Neuro Radiology (INR) patients. INR procedures are associated with significant mortality and morbidity. These patients are routinely commenced on dual antiplatelet therapy to prevent the thromboembolic complications associated with the procedure. The aim of the study was to establish the prevalence of periprocedural anemia in INR patients in our hospital. Method(s): We obtained permission from the hospital’s clinical governance department to conduct a retrospective study on prevalence of periprocedural anemia in INR patients undergoing elective treatment of intracranial aneurysm. We collected the data for 100 consecutive patients between July 2018 and January 2019 for a 6-month period. We collected patient’s demographic details, pre, and postprocedure hemoglobin and hematocrit. Result(s): The data of 100 consecutive patients was gathered, of which 70 were female individuals and 30 were male individuals. The age distribution ranged from 23 to 74 years. 42% of the patients were found to be anemic preprocedure with a hemoglobin <130 gm/L, this incidence increased to whopping 78% on day 1 of postprocedure. Preprocedure mean hemoglobin was 133.77 gm/L with a SD of 13.54, however, the mean hemoglobin on postprocedure was 118.33 gm/L with a SD of 14.84. Hematocrit values were compared as well, the mean preprocedure hematocrit was 0.3867 with a SD of 0.0407, while the post-procedure day 1 mean hematocrit was 0.3469 with a SD of 0.0425. Discussion(s): There is a statistically significant difference between preprocedure and postprocedure values of both hemoglobin and hematocrit in patients undergoing elective INR procedures (P<0.0001). This significant drop in hemoglobin can be attributed to combinations of periprocedure factors, namely preprocedure loading of dual antiplatelet drugs, use of intravenous aspirin, heparin during the procedure, use of large amounts of IV fluids during the procedure and lastly the incidence of groin hematoma is often understated. We need a well designed study to ascertain how much each factors contribute to the drop in hemoglobin in INR patients. Significant proportion of patients in the study group had a postprocedure hemoglobin of <100 gm/L. As we know cerebral oxygenation is an important goal in the management of any neurosurgical or INR procedures. By causing a significant drop in hemoglobin we are impairing cerebral oxygenation. Therefore we recommend pre procedure anaemia in INR patients should be thoroughly investigated and treated if necessary to optimize these patients.

Database: EMBASE