HRT May Increase Risk of SAH in the Presence of Unruptured Intracranial Aneurysms

Hormone replacement therapy and risk of subarachnoid hemorrhage in postmenopausal women

Adnam I. Quereshi, Ahemed A. Malik, Omar Saeed, et al. (JNS)

In this paper they analyzed 93,676 women between 50-79 years old. They studied the effect of hormone replacement therapy (HRT) on the risk of subarachnoid hemorrhage (SAH) through 12 years. Also they identified the risk associated with “estrogen only” and “estrogen and progesterone together” as HRT. Only 114 (0,1%) participants developed SAH during the follow up period. The absolute difference among women on active HRT (0.14%) compared to those without HRT use (0.11%) was 0,03%. When the analysis is unadjusted for age, systolic blood pressure, cigarette smoking, alcohol consumption, body mass index, race/ethnicity, diabetes and cardiovascular disease the risk of SAH were 60% more likely woman on active use of HRT after adjusting to be higher. Mainly the combination of cigarette smoking and oral contraceptive use resulted in a synergistic increase of the risk. There is no any difference between uses ”estrogen and progesterone”, both were associated with an increased risk of SAH. Presence of unruptured aneurysms, family history, or cardiovascular risk factors were identify as risk for SAH. Postmenopausal women with those conditions should be counseled against use HRT.

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ETV Acceptable Option for Hydrocephalus in Adults Except in NPH

Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus: Patient Selection, Outcomes, and Complications.

Grand W, Leonardo J, Chamczuk AJ, et al. (Neurosurgery)

This is a single center, retrospective review of 250 patients over 14.5 years who received Endoscopic Third Ventriculostomy (ETV) for hydrocephalus. The patients were categorized into several groups that included the following: Aqueduct stenosis, intraventricular hemorrhage, communicating hydrocephalus (including normal pressure hydrocephalus, non-NPH, remote head trauma, hydrocephalus post craniotomy for posterior fossa tumor without residual tumor, SAH without ventricular hemorrhage), obstruction from tumor or cyst, VP shunt obstruction, miscellaneous cause (obstruction), and other. A successful ETV was defined as now further CSF diverting procedures and clinical improvement. The overall success rate of ETV for treating hydrocephalus was 72.8%. The groups that demonstrated the best success score were those treated for aqueductal stenosis (91% success), IVH (90%), hydrocephalus post craniotomy for posterior fossa tumor without residual tumor (85.7%), and obstruction from tumor or cyst (85.7%). The group with the worst success score was the communicating hydrocephalus with a successful ETV in 43.8% of the time. This lead the authors to conclude that ETV in adults is a reasonable alternative to VP shunt placement in certain causes of hydrocephalus; however, it is not a proper alternative in certain cases, specifically in cases of normal pressure hydrocephalus.

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Anticoagulation Bridge for Surgical Procedures Not Necessary for AFib Patient

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

James D. Douketis, M.D., Alex C. Spyropoulos, M.D., Scott Kaatz, D.O., et al (NEJM)

This is a randomized, double-blinded, placebo controlled trial in which Warfarin was stopped in the perioperative period and patients either received a bridge with heparin or a placebo. The primary outcomes measured were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding. Patients were over 18 and had a diagnosis of atrial fibrillation or atrial flutter and had a therapeutic INR. Patients also had to have a CHADS2 risk factor.The authors claim that there is a benefit to not pursuing bridging when holding peri operative Warfarin. The specifically state that there wasn’t a difference in arterial thromboembolism between the two groups and that the risk of major and minor bleeding was decreased in the no bridging group when compared to the bridging group.

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Image Guidance Helpful But Not Necessary For Ventricular Catheter Placement In VP Shunt

Image Guidance in Ventricular Cerebrospinal Fluid Shunt Catheter Placement: A Systematic Review and Meta-Analysis

Cody Nesvick, B.A. et al (Neurosurgery)

The utility of intraoperative image guidance in decreasing the rate of shunt malfunction is being vigorously researched. A recent systematic review of the literature on pediatric hydrocephalus by Flannery et al concluded that there is insufficient evidence to recommend the routine use of intraoperative image guidance for placement of shunt catheters in the pediatric population, though these remain options. The authors of this study set out to further investigate with a systematic review and meta-analysis of pertinent literature for both adults and children. Specifically, they wanted two questions answered: “(1) does the use of image guidance improve the accuracy of ventricular catheter placement and (2) does the use of image guidance decrease the overall shunt failure rate?” Image guidance included ultrasound, stereotaxy, or both. Accurate placement of the shunt catheter was defined as “the hole-bearing region of the catheter inside the targeted ventricle or loculated CSF space.” They discovered that although each modality did not increase catheter placement accuracy, a combined random-effects meta-analysis of 738 catheters (136 guided by ultrasound, 168 guided by frameless stereotaxy, and 434 freehand) demonstrated a weak benefit of image guidance (risk ratio: 1.19, 95% confidence interval: 1.02-1.39, P = .02), but this result was limited by considerable heterogeneity among studies (I2 = 86%, P < .001 by Cochrane’s Q test). A meta-analysis could not be performed for shunt survival due to heterogeneity in data reporting. In conclusion, the authors of this article believe that although frameless stereotaxy and intraoperative ultrasound are valuable tools for shunt surgery, especially in patients with small and dismorphic ventricles, there is not yet a clear benefit of this technology in improving shunt survival. This study reiterates the need for multicenter prospective studies to combat the heterogeneity encountered in this study, in order to come up with more meaningful answers.

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