An unusual case of posterior reversible encephalopathy syndrome in a patient being weaned from intrathecal morphine

Jasper Van Aalst,1 Onno P Teernstra,1 Wim E Weber,2 Kim Rijkers,31Department of Neurosurgery, 2Department of Neurology, Maastricht University Medical Center+, Maastricht, 3Department of Neurosurgery, Zuyderland Medical Center, Heerlen, the Netherlands Abstract: Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity based on clinical signs, including headache, visual abnormalities, and seizures, and radiological abnormalities mostly consisting of vasogenic brain edema predominantly in the posterior parietal-temporal-occipital regions. PRES typically develops in the setting of a significant “systemic process”, including preeclampsia, transplantation, infection/sepsis/shock, autoimmune disease, and cancer chemotherapy, in which hypertension often plays an important role. We present a case of PRES in a 63-year-old female patient with an infected intrathecal morphine pump on a cocktail of antibiotics, morphine, clonidine, diazepam, and amitriptyline. It is the first PRES case in a chronic pain patient, which illustrates that PRES can occur in the absence of any of the established risk factors. We hypothesize it may have been caused by antibiotic treatment in our patient. Keywords: PRES, intrathecal morphine, neuropathic pai

STICH 2: does decompression have a role in superficial intracerebral hematoma?

The recently published second Surgical Trial in Intracerebral Haemorrhage (STICH-2) tested whether surgical evacuation of superficial spontaneous intracerebral haemorrhage was effective at reducing death and disability at 6 months after onset. Participants were randomised to a policy of early surgical intervention or initial medical management alone within 48 hours of symptom onset. After enrolling 601 patients across 78 centres in 27 countries, intention to treat analysis showed no difference in outcome. Time to intervention was a median of 26 hours after symptom onset in the surgical arm, and craniotomy accounted for 98% of all surgical procedures. The interpretation of the overall neutral result is confounded by a high proportion of crossovers from the medical management arm of the study, predominantly of more severely affected patients. Further analysis may clarify whether decompressive surgery late after superficial intracerebral haemorrhage has any role in management

Endoscopic surgery versus conservative treatment for the moderate-volume hematoma in spontaneous basal ganglia hemorrhage (ECMOH): study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Spontaneous intracerebral hemorrhage is a disease with high morbidity, high disability rate, high mortality, and high economic burden. Whether patients can benefit from surgical evacuation of hematomas is still controversial, especially for those with moderate-volume hematomas in the basal ganglia. This study is designed to compare the efficacy of endoscopic surgery and conservative treatment for the moderate-volume hematoma in spontaneous basal ganglia hemorrhage.</p> <p>Methods</p> <p>Patients meet the criteria will be randomized into the endoscopic surgery group (endoscopic surgery for hematoma evacuation and the best medical treatment) or the conservative treatment group (the best medical treatment). Patients will be followed up at 1, 3, and 6 months after initial treatment. The primary outcomes include the Extended Glasgow Outcome Scale and the Modified Rankin Scale. The secondary outcomes consist of the National Institutes of Health Stroke Scale and the mortality. The Barthel Index(BI) will also be evaluated. The sample size is 100 patients.</p> <p>Discussion</p> <p>The ECMOH trial is a randomized controlled trial designed to evaluate if endoscopic surgery is better than conservative treatment for patients with moderate-volume hematomas in the basal ganglia.</p> <p>Trial registration</p> <p>Chinese Clinical Trial Registry: ChiCTR-TRC-11001614</p> <p>(<url>http://www.chictr.org/en/proj/show.aspx?proj=1618</url>)</p