Plasmapheresis for Management of Antiphospholipid Syndrome in the Neurosurgical Patient

2018 ◽  
Vol 16 (4) ◽  
pp. E124-E129
Author(s):  
Eric J Arias ◽  
Brent Bruck ◽  
Ananth K Vellimana ◽  
Charles Eby ◽  
Matthew R Reynolds ◽  
...  
Keyword(s):  
Antiphospholipid Syndrome ◽  
Anticoagulation Therapy ◽  
Artery Aneurysm ◽  
Perioperative Period ◽  
Autoimmune Disorder ◽  
Left Internal Carotid Artery ◽  
Neurosurgical Procedures ◽  
Internal Carotid Artery Aneurysm ◽  
Increased Risk ◽  
Neurosurgical Patients

Abstract BACKGROUND AND IMPORTANCE Antiphospholipid syndrome (APS) is an autoimmune disorder associated with a hypercoagulable state and increased risk of intraoperative and postoperative thrombosis. Few neurosurgical studies have examined the management of these patients, though the standard of care in most other disciplines involves the use of anticoagulation therapy. However, this is associated with risks such as hemorrhage, thrombosis due to warfarin withdrawal, and is not compatible with operative intervention. CLINICAL PRESENTATION We report the cases of 2 antiphospholipid positive patients who were on anticoagulant therapy and underwent surgical bypasses and received perioperative management with plasmapheresis. The first was a 44-yr-old woman who presented with worsening vision, recurring headaches, and a known left internal carotid artery aneurysm that was unsuccessfully treated twice via extracranial to intracranial (ECIC) bypass at another institution. Preoperative tests at our institution revealed elevated beta 2 glycoprotein 1 IgA autoantibodies. The second case was a 24-yr-old woman with previously diagnosed APS, who presented for surgical evaluation of moyamoya disease after sustaining recurrent left hemispheric strokes. Both cases were managed with perioperative plasmapheresis to avoid the need for anticoagulation during the perioperative period, and both underwent successful ECIC bypass procedures without perioperative ischemic or hemorrhagic complications. CONCLUSION Management of neurosurgical patients with APS can be a precarious proposition. We describe the successful use of plasmapheresis and antiplatelet therapy to better manage patients undergoing neurosurgical procedures, specifically ECIC bypass, and feel this approach can be considered in future cases.

scholarly journals Marked Hyperprolactinemia Caused by Carotid Aneurysm

1997 ◽  
Vol 24 (1) ◽  
pp. 64-66 ◽  
Author(s):  
Susan R. Kahn ◽  
Richard Leblanc ◽  
Abbas F. Sadiko ◽  
I. George Fantus
Keyword(s):  
Prolactin Level ◽  
Artery Aneurysm ◽  
Cranial Computed Tomography ◽  
Serum Prolactin ◽  
Left Internal Carotid Artery ◽  
Carotid Artery Aneurysm ◽  
Pituitary Dysfunction ◽  
Internal Carotid Artery Aneurysm ◽  
Aneurysm Repair

ABSTRACT:Background:Pituitary dysfunction caused by intracranial aneurysms is rare. We report a patient with the unique feature of hyperprolactinemia to a degree previously seen only with prolactinsecreting tumours.Method:Case report.Result:A 42-year-old woman had a galactorrhea, left-sided headache, reduced vision in the left eye and a left temporal hemianopsia. Serum prolactin was elevated (365 μg/L). Cranial computed tomography (CT) revealed a suprasellar mass, which carotid angiography showed to be a left internal carotid artery aneurysm. At craniotomy, this aneurysm and a smaller one of the ophthalmic artery were repaired, and the patient's vision returned to normal. The prolactin level fell to normal. Follow-up CT showed no evidence of pituitary adenoma or hypothalamic lesion.Conclusions:Carotid aneurysm can cause reversible pituitary dysfunction. A prolactin level >300 μg/L is not a reliable cut-off for distinguishing prolactin-secreting adenomas from other causes of elevated prolactin. A co-existing prolactinoma was felt to be ruled out by both a normal CT scan and normal prolactin levels following aneurysm repair. Patients with marked hyperprolactinemia should be considered for angiography or MRI to rule out carotid aneurysm, since the consequences of pituitary exploration in this setting are potentially grave.

scholarly journals Limiting foetal doses during a four-vessel angiogram and endovascular stent-assisted berry aneurysm repair: A case report

2017 ◽  
Vol 21 (1) ◽  
Author(s):  
Demaré Potgieter ◽  
William I.D. Rae ◽  
Coert S. De Vries
Keyword(s):  
Radiation Protection ◽  
Artery Aneurysm ◽  
Active Management ◽  
Left Internal Carotid Artery ◽  
Endovascular Stent ◽  
Cerebral Angiogram ◽  
Carotid Artery Aneurysm ◽  
Paraclinoid Aneurysm ◽  
Internal Carotid Artery Aneurysm ◽  
Aneurysm Repair

A 36-year-old female patient, 20 weeks pregnant, was diagnosed with a left internal carotid artery aneurysm. Fluoroscopically guided repair was justified. A four-vessel cerebral angiogram was performed, and a left paraclinoid aneurysm was demonstrated. The patient subsequently underwent endovascular stent-assisted berry aneurysm repair. As the patient was pregnant, the procedure was preceded by consideration of the required radiation protection. The foetal dose was estimated as negligible. Active management of foetal exposures may improve radiation protection during pregnancy.

Extracranial internal carotid artery aneurysm presenting as pharyngeal mass with dysphagia

2005 ◽  
Vol 120 (2) ◽  
pp. 1-3 ◽  
Author(s):  
Bruno Sergi ◽  
Vittorio Alberti ◽  
Gaetano Paludetti ◽  
Francesco Snider
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Artery Aneurysm ◽  
Left Internal Carotid Artery ◽  
Extracranial Internal Carotid Artery ◽  
Carotid Artery Aneurysm ◽  
Internal Carotid Artery Aneurysm

Aneurysms of the extracranial portion of the internal carotid artery are rare. Generally, they occur just at the level of, or above, the bifurcation. Here we report a case of a left internal carotid artery aneurysm presenting as an oropharyngeal mass causing dysphagia.

The incidence of postoperative hyponatremia and associated neurological sequelae in children with intracranial neoplasms

2014 ◽  
Vol 13 (3) ◽  
pp. 283-290 ◽  
Author(s):  
Cydni N. Williams ◽  
Jennifer S. Belzer ◽  
Jay Riva-Cambrin ◽  
Angela P. Presson ◽  
Susan L. Bratton
Keyword(s):  
Obstructive Hydrocephalus ◽  
Cerebral Performance Category ◽  
Young Age ◽  
Neurosurgical Procedures ◽  
Intracranial Tumors ◽  
Performance Category ◽  
Increased Risk ◽  
Neurosurgical Patients ◽  
Cerebral Performance Category Score ◽  
Category Score

Object Intracranial tumors are common pediatric neoplasms and account for substantial morbidity among children with cancer. Hyponatremia is a known complication of neurosurgical procedures and is associated with higher morbidity among neurosurgical patients. The authors aimed to estimate the incidence of hyponatremia, identify clinical characteristics associated with hyponatremia, and assess the association between hyponatremia and patient outcome among children undergoing surgery for intracranial tumors. Methods This is a retrospective cohort study of children ranging in age from 0 to 19 years who underwent an initial neurosurgical procedure for an intracranial tumor between January 2001 and February 2012. Hyponatremia was defined as serum sodium ≤ 130 mEq/L during admission. Results Hyponatremia during admission occurred in 39 (12%) of 319 patients and was associated with young age and obstructive hydrocephalus (relative risk [RR] 2.9 [95% CI 1.3–6.3]). Hyponatremic patients were frequently symptomatic; 21% had seizures and 41% had altered mental status. Hyponatremia was associated with complicated care including mechanical ventilation (RR 4.4 [95% CI 2.5–7.9]), physical therapy (RR 4 [95% CI 1.8–8.8]), supplemental nutrition (RR 5.7 [95% CI 3.3–9.8]), and infection (RR 5.7 [95% CI 3.3–9.5]). Hyponatremic patients had a 5-fold increased risk of moderate or severe disability on the basis of their Pediatric Cerebral Performance Category score at discharge (RR 5.3 [95% CI 2.9–9.8]). Obstructive hydrocephalus (adjusted odds ratio [aOR] 3.24 [95% CI 1.38–8.94]) and young age (aOR 0.92 [95% CI 0.85–0.99]) were independently associated with hyponatremia during admission. Hyponatremia was independently associated with moderate or worse disability by Pediatric Cerebral Performance Category score at discharge (aOR 6.2 [95% CI 3.0–13.03]). Conclusions Hyponatremia was common, particularly among younger children and those with hydrocephalus. Hyponatremia was frequently symptomatic and was associated with more complicated hospital courses. Hyponatremia was independently associated with worse neurological outcome when adjusted for age and tumor factors. This study serves as an exploratory analysis identifying important risk factors for hyponatremia and associated sequelae. Further research into the causes of hyponatremia and the association with poor outcome is needed to determine if prevention and treatment of hyponatremia can improve outcomes in these children.

scholarly journals Assessment of risk and incidence of falls in neurosurgical inpatients

2008 ◽  
Vol 16 (4) ◽  
pp. 752-757 ◽  
Author(s):  
Solange Diccini ◽  
Priscila Gomes de Pinho ◽  
Fabiana Oliveira da Silva
Keyword(s):  
Risk Factors ◽  
Cohort Study ◽  
Falls Prevention ◽  
Neurosurgical Procedures ◽  
Risk Of Falling ◽  
Post Operative Period ◽  
Related Risk ◽  
Increased Risk ◽  
Neurosurgical Patients ◽  
Research Population

Neurosurgical patients may present motor, sensitive and balance impairment and increased risk of falling. The aim of this study was to evaluate the fall-related risk factors and the incidence of falls in the pre and post-operative period of neurosurgical patients. A prospective cohort study with a research population of patients undergoing elective neurosurgical procedures. Ninety-seven patients took part in the study. Eight (8.2%) have presented falls with a total of 12 falls (12.4%). In two falls (16.7%), bed side rails were down, whereas in six falls (50%), beds had no rails at all. There was no difference among fall-related risk factors during pre and the post-operative periods. We have concluded that most falls could have been prevented through an improvement in the hospital internal structure and with the introduction of a falls prevention program.

scholarly journals Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases

2017 ◽  
Vol 127 (5) ◽  
pp. 1096-1104 ◽  
Author(s):  
Jian Guan ◽  
Andrea A. Brock ◽  
Michael Karsy ◽  
William T. Couldwell ◽  
Meic H. Schmidt ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Body Mass ◽  
Secondary Outcome ◽  
Neurosurgical Procedures ◽  
Complication Rates ◽  
Increased Risk ◽  
Neurosurgical Patients ◽  
Physical Classification ◽  
The Impact ◽  
Surgery Duration

OBJECTIVEOverlapping surgery—the performance of parts of 2 or more surgical procedures at the same time by a single lead surgeon—has recently come under intense scrutiny, although data on the effects of overlapping procedures on patient outcomes are lacking. The authors examined the impact of overlapping surgery on complication rates in neurosurgical patients.METHODSThe authors conducted a retrospective review of consecutive nonemergent neurosurgical procedures performed during the period from May 12, 2014, to May 12, 2015, by any of 5 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Overlapping surgery was defined as any case in which 2 patients under the care of a single lead surgeon were under anesthesia at the same time for any duration. Information on patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed. Primary outcome was the occurrence of any complication from the beginning of surgery to 30 days after discharge. A secondary outcome was the occurrence of a serious complication—defined as a life-threatening or life-ending event—during this same period.RESULTSOne thousand eighteen patients met the inclusion criteria for the study. Of these patients, 475 (46.7%) underwent overlapping surgery. Two hundred seventy-one patients (26.6%) experienced 1 or more complications, with 134 (13.2%) suffering a serious complication. Fourteen patients in the cohort died, a rate of 1.4%. The overall complication rate was not significantly higher for overlapping cases than for nonoverlapping cases (26.3% vs 26.9%, p = 0.837), nor was the rate of serious complications (14.7% vs 11.8%, p = 0.168). After adjustments for surgery type, surgery duration, body mass index, American Society of Anesthesiologists (ASA) physical classification grade, and intraoperative blood loss, overlapping surgery remained unassociated with overall complications (OR 0.810, 95% CI 0.592–1.109, p = 0.189). Similarly, after adjustments for surgery type, surgery duration, body mass index, ASA grade, and neurological comorbidity, there was no association between overlapping surgery and serious complications (OR 0.979, 95% CI 0.661–1.449, p = 0.915).CONCLUSIONSIn this cohort, patients undergoing overlapping surgery did not have an increased risk for overall complications or serious complications. Although this finding suggests that overlapping surgery can be performed safely within the appropriate framework, further investigation is needed in other specialties and at other institutions.

scholarly journals Acquired bleeding disorders in the elderly

Hematology ◽  
2015 ◽  
Vol 2015 (1) ◽  
pp. 231-236 ◽  
Author(s):  
Rebecca Kruse-Jarres
Keyword(s):  
Anticoagulation Therapy ◽  
Dynamic Environment ◽  
Treatment Decision ◽  
Autoimmune Disorder ◽  
The Elderly ◽  
Clotting Factor ◽  
Bleeding Disorders ◽  
Thrombotic Risk ◽  
Acquired Von Willebrand Syndrome ◽  
Increased Risk

Abstract The hemostatic balance changes with advancing age which may be due to factors such as platelet activation, increase of certain clotting factor proteins, slowing of the fibrinolytic system, and modification of the endothelium and blood flow. Generally, this predisposes the elderly to thrombosis rather than bleeding. It often necessitates antiplatelet or anticoagulation therapy, which can cause significant bleeding problems in an aging population. Additionally, changing renal function, modification in immune regulation, and a multitude of other disease processes, can give rise to acquired bleeding disorders. Bleeding can prove difficult to treat in a dynamic environment and in a population that may have underlying thrombotic risk factors. This article discusses some specific challenges of acquired bleeding arising in the elderly. The use of anticoagulation and nonsteroidal anti-inflammatory medications is prevalent in the treatment of the elderly and predisposes them to increased bleeding risk as their physiology changes. When prescribing and monitoring these therapies, it is exceedingly important to weigh thrombotic versus bleeding risks. There are additional rare acquired bleeding disorders that predominantly affect the elderly. One of them is acquired hemophilia, which is an autoimmune disorder arising from antibodies against factor VIII. The treatment challenge rests in the use of hemostatic agents in a population that is already at increased risk for thrombotic complications. Another rare disorder of intensifying interest, acquired von Willebrand syndrome, has a multitude of etiologic mechanisms. Understanding the underlying pathophysiology is essential in making a treatment decision for this disorder.

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