Saturday, December 31, 2011

Utility of intravascular ultrasound in intracranial and extracranial neurointerventions: experience

Neurosurgical Focus, Volume 32, Issue 1, Page E6, January 2012.
Intravascular ultrasound (IVUS) generates high-resolution cross-sectional images and sagittal reconstructions of the vessel wall and lumen. As a result, this imaging modality can provide accurate measurements of the degree of vessel stenosis, allow the detection of intraluminal thrombus, and analyze the plaque composition. The IVUS modality is widely used in interventional cardiology, and its use in neurointerventions has gradually increased. With case examples, the authors illustrate the utility of IVUS as an adjunct to conventional angiography for a wide range of intracranial and extracranial neurointerventions.





No comments:

Cognitive Function Linked to Later Subdural Hematoma (CME/CE)

(MedPage Today) -- Reduced cognitive function in young adulthood was strongly associated with an increased risk for subdural hematoma later in life, results of a Swedish study showed.





No comments:

Sonothrombolysis for acute ischemic stroke: a systematic review of randomized controlled trials

Neurosurgical Focus, Volume 32, Issue 1, Page E5, January 2012.
Object Sonothrombolysis has recently been considered an emerging modality for the treatment of stroke. The purpose of the present paper was to review randomized clinical studies concerning the effects of sonothrombolysis associated with tissue plasminogen activator (tPA) on acute ischemic stroke. Methods Systematic searches for literature published between January 1996 and July 2011 were performed for studies regarding sonothrombolysis combined with tPA for acute ischemic stroke. Only randomized controlled trials were included. Data extraction was based on ultrasound variables, patient characteristics, and outcome variables (rate of intracranial hemorrhages and arterial recanalization). Results Four trials were included in this study; 2 trials evaluated the effect of transcranial Doppler (TCD) ultrasonography on sonothrombolysis, and 2 addressed transcranial color-coded duplex (TCCD) ultrasonography. The frequency of ultrasound waves varied from 1.8 to 2 MHz. The duration of thrombus exposure to ultrasound energy ranged from 60 to 120 minutes. Sample sizes were small, recanalization was evaluated at different time points (60 and 120 minutes), and inclusion criteria were heterogeneous. Sonothrombolysis combined with tPA did not lead to an increase in symptomatic intracranial hemorrhagic complications. Two studies demonstrated that patients treated with ultrasound combined with tPA had statistically significant higher rates of recanalization than patients treated with tPA alone. Conclusions Despite the heterogeneity and the limitations of the reviewed studies, there is evidence that sonothrombolysis associated with tPA is a safe procedure and results in an increased rate of recanalization in the setting of acute ischemic stroke when wave frequencies and energy intensities of diagnostic ultrasound systems are used.





No comments:

Obesity-Induced Brain Changes May Be Reason Weight Control Is So Hard

The biggest obstacle to the successful treatment of obesity is the tendency to regain weight lost through diet and exercise, and evidence is increasing that this could be due to physiological causes. Recently, an Australian study reported that after large weight loss, appetite-regulating hormones appear to reset to levels that increase appetite...





No comments:

Friday, December 30, 2011

Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenos

Publication year: 2011
Source: The Spine Journal, Available online 29 December 2011
James Rainville, Lisa A. Childs, Enrique B. Peña, Pradeep Suri, Janet C. Limke, ...
Background contextWalking limitations caused by neurogenic claudication (NC) are typically assessed with self-reported measures, although objective evaluation of walking using motorized treadmill test (MTT) or self-paced walking test (SPWT) has periodically appeared in the lumbar spinal stenosis (LSS) literature.PurposeThis study compared the validity and responsiveness of MTT and SPWT for assessing walking ability before and after common treatments for NC.Study designProspective observational cohort study.Patient sampleFifty adults were recruited from an urban spine center if they had LSS and substantial walking limitations from NC and were scheduled to undergo surgery (20%) or conservative treatment (80%).Outcome measuresWalking times, distances, and speeds along with the characteristics of NC symptoms were recorded for MTT and SPWT. Self-reported measures included back and leg pain intensity assessed with 0 to 10 numeric pain scales, disability assessed with Oswestry Disability Index, walking ability assessed with estimated walking times and distances, and NC symptoms assessed with the subscales from the Spinal Stenosis Questionnaires.MethodsMotorized treadmill test used a level track, and SPWT was conducted in a rectangular hallway. Walking speeds were self-selected, and test end points were NC, fatigue, or completion of the 30-minute test protocol. Results from MTT and SPWT were compared with each other and self-reported measures. Internal responsiveness was assessed by comparing changes in the initial results with the posttreatment results and external responsiveness by comparing walking test results that improved with those that did not improve by self-reported criteria.ResultsMean age of the participants was 68 years, and 58% were male. Neurogenic claudication included leg pain (88%) and buttock(s) pain (12%). Five participants could not safely perform MTT. Walking speeds were faster and distances were greater with SPWT, although the results from both tests correlated with each other and self-reported measures. Of the participants, 72% reported improvement after treatment, which was confirmed by significant mean differences in self-reported measures. Motorized treadmill test results did not demonstrate internal responsiveness to change in clinical status after treatment but SPWT results did, with increased mean walking times (6 minutes) and distances (387 m). When responsiveness was assessed against external criterion, both SPWT and MTT demonstrated substantial divergence with self-reported changes in clinical status and alternative outcome measures.ConclusionsBoth MTT and SPWT can quantify walking abilities in NC. As outcome tools, SPWT demonstrated better internal responsiveness than MTT, but neither test demonstrated adequate external responsiveness. Neither test should be considered as a meaningful substitution for disease-specific measures of function.





No comments:

Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecut

Publication year: 2011
Source: The Spine Journal, Available online 29 December 2011
John T. Street, Brian J. Lenehan, Christian P. DiPaola, Michael D. Boyd, Brian K. Kwon, ...
Background contextTo date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center.PurposeTo determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool.Study designOurs is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study.Patient sampleAll adult patients admitted to the spine service of a quaternary referral center for a 12-month period.Outcome measuresA validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS).MethodsData on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded.ResultsOne hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1–221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%).ConclusionsMajor spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated.





No comments:

Thursday, December 29, 2011

Neurocirurgia Brasil - Most Popular Posts 2011 (articles)

  Most Popular Posts 2011
 
Diagnosis and treatment of psychogenic parkinsonis...
Nov 8, 2011
123 Pageviews









Subdural Drainage versus Subperiostal Drainage in ...
Nov 17, 2011
114 Pageviews









Craniovertebral junction abnormalities with hindbr...
Nov 21, 2011
103 Pageviews









Dez dicas para Publicar artigos científicos durant...
Nov 5, 2011
99 Pageviews









Apixaban Shines in ARISTOTLE Canadian Cohort (CME/...
Oct 30, 2011
89 Pageviews









Effect of experimental low back pain on neuromuscu...
Nov 7, 2011
79 Pageviews









The effect of call on neurosurgery residents' skil...
Dec 3, 2011
74 Pageviews









The Salary for a Neurosurgeon Resident
Oct 19, 2011
64 Pageviews









Compare the intelligence and grip strength of orth...
Dec 25, 2011
61 Pageviews









All Neurosurgery Free Books (PDF) Links
Oct 22, 2011
No comments:

DASH Guidelines Improve Patient Care

In 2008, about 40 percent of BWH patients presented with delirium, alcohol abuse or dependence or a combination of both. And the number of patients who present with suicidal ideation has increased significantly for the past three years.





No comments:

A Closer Look at Suicide and Antidepressants

Dr. Peter Yellowlees reviews a study examining the association between antidepressants and suicidality. Should the black box warning be directed toward patients of all ages?
Medscape Psychiatry





No comments:

Vasospasm Following Arteriovenous Malformation Rupture

Publication year: 2011
Source: World Neurosurgery, Available online 28 December 2011
Bradley A. Gross, Rose Du
ObjectiveVasospasm and resultant clinical deterioration due to delayed cerebral ischemia (CD-CDI) are a considerable source of morbidity following aneurysmal SAH. Although a relatively common cause of spontaneous SAH, AVM rupture and ensuing vasospasm is infrequently reported.MethodsWe reviewed our own series of 122 patients with AVMs. Seventy-three patients sustaining 84 hemorrhages were analyzed. We additionally performed a review of the literature of vasospasm following AVM rupture.ResultsSeventy of 84 hemorrhages (83%) had an intraparenchymal component, twenty-seven (32%) a subarachnoid component, and fifty-one (61%) had an intraventricular component. No patients experienced CD-DCI, and only one patient experienced mild angiographic vasospasm following 84 hemorrhages (1.1%). Alternatively, this represents 1 in 34 cases (2.9%) that underwent definitive angiography between the fourth and fifteenth day after the hemorrhage. Nineteen additional cases of angiographic vasospasm after AVM rupture are reported in the literature. The mean age of these patients was 33 years; there was a 1.25:1 female to male predominance in this group. Half of these patients had an intraparenchymal hemorrhage, and only 56% of them had SAH. All patients had intraventricular hemorrhage, when assessed. The median time to onset of vasospasm was 9 days. Across 4 series, the rate of angiographic spasm following SAH from an AVM was 6.3% (9/142 cases).ConclusionEven in cases of SAH from AVMs, angiographic vasospasm following AVM rupture is relatively rare. We thus do not recommend empiric delayed angiography to assess for vasospasm in these patients. Nevertheless, it does remain a rare possibility and should be considered in those with CD-DCI.





No comments:

Researchers Discover How The Brain Merges Sights And Sounds

In order to get a better picture of our surroundings, the brain has to integrate information from different senses, but how does it know which signals to combine? New research involving scientists from the Max Planck Institute for Biological Cybernetics, the Bernstein Center for Computational Neuroscience Tubingen, the University of Oxford, and the University of Bielefeld has d...





No comments:

New AAN Guideline on Transverse Myelitis

The American Academy of Neurology has released new guidelines on the evaluation and treatment of transverse myelitis.
Medscape Medical News





No comments:

Silent Strokes May Scatter Memory (CME/CE)

(MedPage Today) -- Subclinical strokes seen on brain imaging may predict memory loss in older age, researchers found.





No comments:

Wednesday, December 28, 2011

Elderly Can Be As Fast As Young In Some Brain Tasks

Both children and the elderly have slower response times when they have to make quick decisions in some settings. But recent research suggests that much of that slower response is a conscious choice to emphasize accuracy over speed...





No comments:

When Viruses Invade the Brain

Neurodegenerative diseases were once considered disorders of the mind, rooted in psychology. Now viruses rank among the environmental factors thought to trigger brain-ravaging diseases such as multiple sclerosis (MS) and Alzheimer's disease. Human herpesvirus-6 (HHV-6), in particular, has been linked to MS in past studies. Neuroscientist Steven Jacobson and his colleagues at the National Institute of Neurological Disorders and Stroke have determined that the virus makes its entry to the human brain through the olfactory pathway, right along with the odors wafting into our nose.

[More]

Add to digg Add to StumbleUpon Add to Reddit Add to Facebook Add to del.icio.us Email this Article





No comments:

Brain Injury Linked to Violent Acts (CME/CE)

(MedPage Today) -- Individuals who've had a severe traumatic brain injury are at subsequent risk for violent behavior, an association not seen for patients with epilepsy, Swedish researchers found.





No comments:

Tuesday, December 27, 2011

Cranial computed tomography scan findings in head trauma patients in Enugu, Nigeria

Samuel C Ohaegbulam, Wilfred C Mezue, Chika A Ndubuisi, Uwadiegwu A Erechukwu, Chinenye O Ani

Surgical Neurology International 2011 2(1):182-182

Background: The choice of radiological investigations in head trauma in Africa is influenced by factors such as cost. Some patients who require computed tomography (CT) scan elsewhere are either managed blindly or do not present for it at the appropriate time. This paper evaluates the CT scan findings as they are obtained in cases of head trauma in a region of Nigeria. Methods: Prospectively recorded data of all head injury patients who presented for CT scan between January 2009 and April 2010 at Memfys Hospital for Neurosurgery (MHN), Enugu, Nigeria, were analyzed. Mobile CereTom 8-Slice CT was used in all cases. New and follow-up cases were included. Results: There were 204 CT scans for head trauma (171 new, 33 follow-up), accounting for about 34% of all head CT scans performed with this unit. The male to female ratio was 3.5:1. About 33.9% of the patients were in the third and fourth decades of life. In 19.9% cases, CT was unremarkable, while 80.1% cases had abnormal CT findings. The CT diagnosis was not in keeping with the indication of head trauma in 7%, and 13% had more than one finding. The most common CT findings were: subdural hematoma 30%, cerebral contusions and edema 30.7%, skull fractures 23.4% and extradural hematoma 8.0%. About 64% of the CT findings required surgical interventions. The overall mortality was 11.1%, but amongst the 137 patients who had abnormal CT findings, it was 13.9%. Conclusion: The high yield and diversity of CT scan findings in head trauma patients support the indication for the appropriate use of CT in diagnosis and management of head trauma even in developing countries.





No comments:

Language Impairment Associated With Arachnoid Cysts: Recovery After Surgical Treatment

Abstract: Supporting data from the literature, we observe that large arachnoid cysts may affect cognitive function. Neuropsychologic assessment plus magnetic resonance imaging allowed for documentation of associations between left temporal arachnoid cysts, language impairment, and other cognitive dysfunctions. Significant cognitive improvements were evident soon after cysto-peritoneal shunting. These observations reinforce the rationale for neuropsychologic assessments of patients with developmental delay and arachnoid cysts, and support the potential benefit of surgical decompression for arachnoid cysts associated with neurologic deficits, even if surgery is performed well after the occurrence of neurologic deficits.





No comments:

Rotavirus Cerebellitis: New Aspects to an Old Foe?

Abstract: Rotavirus infection is a significant cause of childhood morbidity and mortality worldwide. Although infection primarily causes gastroenteritis and dehydration, systemic signs and neurologic manifestations in rotavirus infection are widely recognized. The pathophysiologic origins of neurologic signs in rotavirus infection remain incompletely understood. We present a 4-year-old girl with clinical features of severe cerebellitis in association with abnormalities detected on magnetic resonance imaging. Rotavirus nucleic acid was demonstrated in both serum and cerebrospinal fluid. Severe neurologic sequelae remain after 2 years of follow-up. This report adds further evidence supporting a direct role for rotavirus in neurologic illness.





No comments:

Comparative efficacy of combination drug therapy in refractory epilepsy

Objective:

We retrospectively examined treatment records of developmentally disabled adults with highly refractory epilepsy to determine whether any combinations of 8 of the most commonly used antiepileptic drugs (AEDs) possessed superior efficacy.

Methods:

We obtained the treatment records from 148 developmentally disabled adults with refractory epilepsy cared for in 2 state-run institutions. These records charted monthly convulsive seizure occurrence and AED regimen over 30 years. We studied the effects of 8 commonly used AEDs alone and in combination on seizure frequency in within-patient comparisons.

Results:

Out of the 32 most frequently used AED combinations, we found that only the combination of lamotrigine and valproate had superior efficacy, measured against both an aggregate measure of other AED regimens to which patients were exposed, and in head-to-head comparisons with other AED combinations. We also found that while use of 2 concurrent AEDs provided improved efficacy over monotherapy, use of 3 AEDs at a time provided no further benefit over two.

Conclusions:

These results suggest that at least one AED regimen provides significantly better efficacy in refractory convulsive epilepsy, and that AEDs should be used no more than 2 at a time. Limitations of the study include its retrospective design, lack of randomization, and small sample sizes for some drug combinations. Future prospective trials are needed in this challenging clinical population.






No comments:

Memory after silent stroke: Hippocampus and infarcts both matter

Objective:

Memory decline commonly occurs among elderly individuals. This observation is often attributed to early neurodegenerative changes in the hippocampus and related brain regions. However, the contribution of vascular lesions, such as brain infarcts, to hippocampal integrity and age-associated memory decline remains unclear.

Methods:

We studied 658 elderly participants without dementia from a prospective, community-based study on aging and dementia who received high-resolution structural MRI. Cortical and subcortical infarcts were identified, and hippocampal and relative brain volumes were calculated following standard protocols. Summary scores reflecting performance on tasks of memory, language, processing speed, and visuospatial function were derived from a comprehensive neuropsychological battery. We used multiple regression analyses to relate cortical and subcortical infarcts, hippocampal and relative brain volume, to measures of cognitive performance in domains of memory, language, processing speed, and visuospatial ability.

Results:

Presence of brain infarcts was associated with a smaller hippocampus. Smaller hippocampus volume was associated with poorer memory specifically. Brain infarcts were associated with poorer memory and cognitive performance in all other domains, which was independent of hippocampus volume.

Conclusions:

Both hippocampal volume and brain infarcts independently contribute to memory performance in elderly individuals without dementia. Given that age-associated neurodegenerative conditions, such as Alzheimer disease, are defined primarily by impairment in memory, these findings have clinical implications for prevention and for identification of pathogenic factors associated with disease symptomatology.






No comments:

Cerebrospinal fluid markers for differential dementia diagnosis in a large memory clinic cohort

Objective:

To determine how amyloid β 42 (Aβ42), total tau (t-tau), and phosphorylated tau (p-tau) levels in CSF behave in a large cohort of patients with different types of dementia.

Methods:

Baseline CSF was collected from 512 patients with Alzheimer disease (AD) and 272 patients with other types of dementia (OD), 135 patients with a psychiatric disorder (PSY), and 275 patients with subjective memory complaints (SMC). Aβ42, t-tau, and p-tau (at amino acid 181) were measured in CSF by ELISA. Autopsy was obtained in a subgroup of 17 patients.

Results:

A correct classification of patients with AD (92%) and patients with OD (66%) was accomplished when CSF Aβ42 and p-tau were combined. Patients with progressive supranuclear palsy had normal CSF biomarker values in 90%. Patients with Creutzfeldt-Jakob disease demonstrated an extremely high CSF t-tau at a relatively normal CSF p-tau. CSF AD biomarker profile was seen in 47% of patients with dementia with Lewy bodies (DLB), 38% in corticobasal degeneration (CBD), and almost 30% in frontotemporal lobar degeneration (FTLD) and vascular dementia (VaD). PSY and SMC patients had normal CSF biomarkers in 91% and 88%. Older patients are more likely to have a CSF AD profile. Concordance between clinical and neuropathologic diagnosis was 85%. CSF markers reflected neuropathology in 94%.

Conclusion:

CSF Aβ42, t-tau, and p-tau are useful in differential dementia diagnosis. However, in DLB, FTLD, VaD, and CBD, a substantial group exhibit a CSF AD biomarker profile, which requires more autopsy confirmation in the future.






No comments:

Brain Size May Predict Risk For Early Alzheimer's Disease

New research suggests that, in people who don't currently have memory problems, those with smaller regions of the brain's cortex may be more likely to develop symptoms consistent with very early Alzheimer's disease. The study is published in the December 21, 2011, online issue of Neurology®, the medical journal of the American Academy of Neurology...





No comments:

'Rare' Brain Disorder May Be More Common Than Thought, Say Mayo Clinic Scientists

A global team of neuroscientists, led by researchers at Mayo Clinic in Florida, have found the gene responsible for a brain disorder that may be much more common than once believed.





No comments:

Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage

Objective:

Rebleeding of an aneurysm is a leading cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Whereas numerous studies have demonstrated the risk factors associated with rebleeding, few data on complications of rebleeding, including its effect on the development of delayed cerebral ischemia (DCI), are available.

Methods:

A nested case-control study was performed on patients with rebleeding and control subjects matched for modified Fisher scale, Hunt-Hess grade, age, and sex previously entered into a prospective database. Rebleeding was defined as new hemorrhage apparent on repeat CT with or without new symptoms. Incidence and time course of DCI and hospital complications were compared. A secondary analysis of DCI and hospital complications was also performed on subjects surviving to postbleed day 7.

Results:

We identified 120 patients with rebleeding and 359 control subjects from 1996 to 2011. The rebleeding rate was 8.6%. In both the primary and secondary analyses, there was no difference in the incidence of DCI or its time course (29% vs 27%, p = 0.6; 7 ± 5 vs 7 ± 6 days, p = 0.9 for primary analysis; 39% vs 31%, p = 0.1, 7 ± 5 vs 7 ± 6 days, p = 0.6 for the secondary analysis). In a multivariate logistic regression model, rebleeding was associated with the complications of hyponatremia, respiratory failure, and hydrocephalus. Patients with rebleeding had higher rates of mortality, brain death, and poor outcomes.

Conclusions:

Rebleeding after SAH is associated with multiple medical and neurologic complications, resulting in higher morbidity and mortality, but is not associated with change of incidence or timing of DCI.






No comments:

Monday, December 26, 2011

Duration of Anticoagulation After Cerebral Venous Sinus Thrombosis

Abstract  
Cerebral venous sinus thrombosis (CVST) often occurs in young patients and is treated with acute and then long-term oral anticoagulation. It is important to decide when to discontinue anticoagulation, as lifelong anticoagulation exposes the patient to considerable cumulative risk. However, a lack of high quality studies makes choosing a duration of anticoagulation after CVST difficult. In this article, we review the evidence for different treatment durations in several common clinical scenarios of CVST. In addition, when no direct evidence is available, we discuss and extrapolate from the more comprehensively studied situation of systemic venous thromboembolic disease. Recommendations are graded using standard criteria for the level of evidence.

  • Content Type Journal Article
  • Category Review Article
  • Pages 1-8
  • DOI 10.1007/s12028-011-9661-1
  • Authors
    • Frances Caprio, Department of Neurology, Stroke Program, Feinberg School of Medicine of Northwestern University, 710 North Lake Shore Drive, Abbott Hall 11th Floor, Chicago, IL 60611, USA
    • Richard A. Bernstein, Department of Neurology, Stroke Program, Feinberg School of Medicine of Northwestern University, 710 North Lake Shore Drive, Abbott Hall 11th Floor, Chicago, IL 60611, USA





No comments:

Laminectomy and extension of instrumented fusion improves two-year pain, disability, and quality of

Publication year: 2011
Source: World Neurosurgery, Available online 24 December 2011
Owoicho Adogwa, Scott L. Parker, Stephen K. Mendenhall, David N. Shau, Oran Aaronson, ...
ObjectiveAdjacent Segment Disease (ASD) may occur as a long-term consequence of spinal fusion and is associated with significant back and leg pain. Surgical management of symptomatic ASD consists of neural decompression and extension of fusion. However, conflicting results have been reported with respect to the long-term clinical effectiveness of revision surgery in this setting. We set out to comprehensively assess the long-term clinical outcome after revision surgery and determine its effectiveness in the treatment of adjacent segment disease.MethodsFifty patients undergoing revision surgery for ASD-associated back and leg pain were included in this study. Baseline and two-year VAS-BP, VAS-LP, Oswestry Disability Index (ODI), physical and mental quality of life (SF-12 PCS & MCS) and health-state utility [EuroQol (EQ-5D)] were assessed.ResultsA sustained improvement in VAS-BP(8.72 ± 1.85 vs. 3.92 ± 2.84, p=0.001), VAS-LP(6.30 ± 3.90 vs. 3.02 ± 3.03, p=0.001), ODI(28.72 ± 9.64 vs. 18.48 ± 11.31, p=0.001), SF-12 PCS (26.89 ± 8.85 vs. 35.58 ± 11.97, p=0.001) and SF-12 MCS(44.66 ± 12.85 vs. 53.16 ± 9.46, p=0.001) was observed two years after revision surgery, with a cumulative mean two-year gain of 0.76 QALYs(EQ-5D). Median [IQR] time to narcotic independence and return to work was 1.7 [1.0-8.0] months and 2.0 [1.0-4.75] months, respectively.ConclusionsPatients undergoing decompression and extension of fusion for adjacent segment disease-associated back and leg pain reported long-term improvement in pain, disability and both physical and mental quality of life, suggesting that revision surgery is a highly effective treatment strategy in this patient population.





No comments:

Complications necessitating a return to the operating room following intradural spine surgery

Publication year: 2011
Source: World Neurosurgery, Available online 24 December 2011
Jason M. Hoover, Michelle J. Clarke, Nicholas M. Wetjen, Jay Mandrekar, Ross C. Puffer, ...
ObjectiveTo determine the incidence of and risk factors for cerebrospinal fluid, wound, and hematoma-related complications following intradural spine surgery.BackgroundComplications of intradural spinal surgery requiring a return to the operating room lengthen hospital stay and increase cost as well as patient risk. Here we present our experience with complications in intradural spinal surgery.MethodsFrom 1993 and 2010, 528 pediatric and adult patients who underwent biopsy and/or resection of intramedullary or extramedullary spinal lesions at Mayo Clinic-Rochester were evaluated.ResultsThe overall complication rate in this series was 4.9%, Complications, such as neurological worsening due to an etiology not able to be treated surgically, or medical complications, such as deep venous thrombosis, were not included in this study. The overall complication rates that were CSF-related, wound-related, hematoma-related and miscellaneous were 3.0%, 1.1%, 0.6%, and 0.2% respectively. Complication rates decreased with age from 15.4% in 0-10 year-olds to 4.1% in 61-90 year-olds. Tumors represented the majority of pathology at 90.5%. The complication rate for patients who had prior treatment was higher at 6.9% compared with 4.7% in those that had no prior treatment (p=.5). Intramedullary tumors had a complication rate of 7.1% vs. 3.6% for extramedullary tumors (p=.14). 5.7% of patients had coexisting intracranial tumors at the time of their surgery but none had complications with intradural spine surgery.ConclusionsComplications of intradural spine surgery are most commonly CSF-related, may decrease with increasing age of the patient, and are higher with intramedullary tumors.





No comments:

Coexistence of extra-axial cavernous malformation and cerebellar developmental venous anomaly in the

Publication year: 2011
Source: World Neurosurgery, Available online 24 December 2011
Bo Wu, Weidong Liu, Yuan Zhao
BackgroundThe coexistence of cavernous malformations (CMs) and developmental venous anomalies (DVAs) in the cerebellopontine angle (CPA) is exceedingly rare. To the authors' knowledge, only 1 case of CPA CM with concurrence of a neighboring DVA has been reported to date.Case DescriptionThe authors presented such vascular malformations in a 36-year-old man with progressive CPA syndrome over 6 weeks. Preoperative neuroimaging suggested the diagnosis of an extra-axial hemorrhagic lesion in the CPA cistern with a cerebellar DVA in the close vicinity. The lesion was totally removed with the DVA untouched and was confirmed to be extra-axial in intimate contact with only the VII-VIII complex and the draining veins of DVA. Pathology revealed a CM. The patient underwent partial improvement in neurological function postoperatively. The radiographic follow-up at 1 year revealed no recurrence.ConclusionCMs should be considered in the differential diagnosis of any extra-axial hemorrhagic mass, especially with a DVA in the proximity. The coexistence of CM and DVA in CPA, although maybe just a coincidence, suggests the possibility of a new subtype of extra-axial CPA CM secondary to a preexisting DVA. A long-term follow-up is justified in discovering the potential mechanism and biology of such uncommon vascular malformations.





No comments:

Sunday, December 25, 2011

Compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists

Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study

BMJ

BMJ 2011; 343 doi: 10.1136/bmj.d7506 (Published 15 December 2011)


Objective To compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists.
Design Multicentre prospective comparative study.
Setting Three UK district general hospitals in 2011.
Participants 36 male orthopaedic surgeons and 40 male anaesthetists at consultant or specialist registrar grade.
Main outcome measures Intelligence test score and dominant hand grip strength.
Results Orthopaedic surgeons had a statistically significantly greater mean grip strength (47.25 (SD 6.95) kg) than anaesthetists (43.83 (7.57) kg). The mean intelligence test score of orthopaedic surgeons was also statistically significantly greater at 105.19 (10.85) compared with 98.38 (14.45) for anaesthetists.
Conclusions Male orthopaedic surgeons have greater intelligence and grip strength than their male anaesthetic colleagues, who should find new ways to make fun of their orthopaedic friends.
No comments:

Resolution of extra-axial collections after decompressive craniectomy for ischemic stroke

Publication year: 2011
Source: Journal of Clinical Neuroscience, Available online 23 December 2011
Alexander E. Ropper, Stephen V. Nalbach, Ning Lin, Ian F. Dunn, William B. Gormley
Extra-axial fluid collections are known consequences of decompressive hemicraniectomy. Studies have examined these collections and their management. We retrospectively reviewed 12 consecutive patients who underwent decompressive hemicraniectomy for the treatment of malignant cerebral edema after infarction and evaluated the evolution, resolution and treatment of post-operative extra-axial fluid collections. All patients underwent standard-sized frontotemporoparietal hemicraniectomy with duraplasty as treatment for medically intractable malignant cerebral edema at an average of 3 days after the stroke (median 2 days). Their 30-day mortality was 25%. Three patients developed some extra-axial fluid collections after craniectomy: two patients developed the collections early in their post-operative course, 3 days and 5 days after the craniectomy. Both experienced spontaneous resolution of the collections without corrective cranioplasty or shunt placement at 34 days and 58 days after surgery. The third patient developed a collection 55 days after the operation related to a subgaleal bacterial infection. In the final analysis, 18% of patients developed extra-axial collections and all resolved spontaneously. The incidence of extra-axial collections after decompressive hemicraniectomy following ischemic stroke was lower in our retrospective series than has been reported by others. The collections resolved spontaneously, suggesting that early anticipatory, corrective treatment with cerebrospinal fluid diversion or cranioplasty may not be warranted.





No comments:

Commentary: Development and validation of the Asian Migraine Criteria (AMC)

Publication year: 2011
Source: Journal of Clinical Neuroscience, Available online 23 December 2011
Richard J. Stark
Precise and manageable diagnostic criteria are vital for researchers and clinicians dealing with headache. The lack of clear and accessible markers of the biological distinctions between different types of headache means that criteria are determined by expert consensus. The International Classification of Headache Disorders (ICHD) criteria are the current benchmark and are evolving. They are effective for research as they exclude questionable cases from consideration, but in clinical practice they are used inconsistently by neurologists, and rarely by general practitioners, because of complexity. In this issue of theJournal of Clinical Neuroscience, Ghandehari et al. have proposed a new set of criteria, the Asian Migraine Criteria (AMC). These criteria perform well against the gold-standard ICHD, but are almost as complex. They do not have the simplicity of the ID Migraine tool. Nevertheless, they are welcome: any tool that general practitioners may be attracted to use that increases the accuracy of headache diagnosis is to be applauded.





No comments:

Saturday, December 24, 2011

Occipito-Cervical Fusion in an Infant with Atlanto-Occipital Dislocation: Technical Report

Publication year: 2011
Source: World Neurosurgery, Available online 24 December 2011
Edward C. Benzel, Donald H. Zhang, Christopher Iannotti, Daniel Refai, Paul Ruggieri, ...
BackgroundFor children who survive traumatic AOD, early surgical stabilization and arthrodesis of the occipito-atlanto-axial complex is typically performed. Due to the unique and crowded anatomy of the occipito-cervical junction, the creation of a fusion construct that is both safe and biomechanically sound is extremely challenging, especially in infants. We present a technical report of infantile type I AOD with gross instability, who underwent surgical stabilization consisting occiput to C2 arthrodesis using autologous rib, augmented with BMP-2, Mersiline suture, and Ethibond suture as 'cross connectors'.Technical DescriptionThe patient is a 12 month-old female who was involved in a high-speed motor vehicle accident and sustained a type I atlanto-occipital dislocation (AOD). Definitive surgical stabilization consisting of arthrodesis from the occiput to C2 using autologous rib augmented with BMP-2, Mersiline suture, and Ethibond suture as 'cross connectors' was performed. There were no intraoperative complications. A follow-up cervical spine CT obtained 12 weeks post-operatively demonstrated excellent occipito-cervical alignment, with evidence of modest bony fusion from the occiput to C2. The neurological examination demonstrated modest, but progressive, improvement, with partial resolution of bilateral sixth nerve palsies, and improvement in upper and lower extremity muscle strength and tone.ConclusionSignificant surgical challenges exist regarding occipito-cervical fusion in infants with AOD and gross instability. This case report illustrates the successful application of BMP-2-augmented occipito-cervical fusion using autologous rib, in combination with Mersiline and ethibond suture, in the treatment of an infant with type I AOD with gross instability.





No comments:

Decompressive hemicraniectomy, strokectomy, or both in the treatment of malignant middle cerebral ar

Publication year: 2011
Source: World Neurosurgery, Available online 24 December 2011
Dean B. Kostov, Richard H. Singleton, David Panczykowski, Hilal A. Kanaan, Michael B. Horowitz, ...
ObjectiveWe sought to evaluate the impact of acraniotomy forstrokectomy (CS) with bone replacement,decompressivehemicraniectomy (DHC), or DHC with astrokectomy (DHC+S) on outcome after malignant supratentorial infarction.MethodsWe conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n=18), DHC (n=17), or DHC+S (n=33) at our institution from 2002-2008. End-points included functional outcome measured by the modified Rankin Scale (mRS) and incidence of mortality at 1 year.ResultsMean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At one year, the median mRS was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (p=0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome.ConclusionIn patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.





No comments:

Friday, December 23, 2011

Mortality of Cerebral Venous-Sinus Thrombosis in a Large National Sample [Original Contributions; Br

Background and Purpose—

The purpose of this study was to evaluate the mortality rates associated with cerebral venous–sinus thrombosis in a large national sample.

Methods—

A cohort of patients with cerebral venous–sinus thrombosis was identified from the National Inpatient Sample database for the years 2000 to 2007. According to the International Classification of Diseases, 9th Revision, Clinical Modification codes, cerebral venous–sinus thrombosis is categorized into pyogenic and nonpyogenic groups. Multivariate logistic regression analysis was used to assess covariates associated with hospital mortality.

Results—

Among 3488 patients, the overall mortality rate was 4.39%, which was nonsignificantly higher among the pyogenic group (4.55% versus 3.52%; OR, 0.76; 95% CI, 0.47–1.23). In the pyogenic cerebral venous–sinus thrombosis group, hematologic disorders were the most frequent predisposing condition (16.2%); whereas systemic malignancy followed by hematologic disorders were most common in the nonpyogenic group (14.08% and 10.04%, respectively). Predictors of mortality included age, intracerebral hemorrhage as well as the predisposing conditions of hematologic disorders, systemic malignancy, and central nervous system infection.

Conclusions—

Compared with arterial stroke, CVST harbors a relatively low mortality rate. Death is determined by age, the presence of intracerebral hemorrhage, and certain predisposing conditions.






No comments:

Improved Prediction of Poor Outcome After Thrombolysis Using Conservative Definitions of Symptomatic

Background and Purpose—

Direct comparison of symptomatic intracerebral hemorrhage (sICH) rates among different thrombolysis studies is complicated by the variability of definitions of sICH. The prediction of outcome still remains unclear.

Methods—

Baseline data and clinical courses of patients treated with thrombolytic therapy were collected in a prospective database. The 3-month outcome was evaluated using the modified Rankin Scale. Results of 24-hour follow-up imaging were reevaluated by at least 2 independent raters. Four common definitions of sICH (National Institute of Neurological Disorders and Stroke [NINDS], European Cooperative Acute Stroke Study [ECASS] 2, Safe Implementation of Thrombolysis in Stroke [SITS], ECASS 3) were applied. Kappa interrater statistics were calculated. Our objective was to find the sICH definition with the highest predictive value for mortality, poor (modified Rankin Scale 5 or 6) and unfavorable (modified Rankin Scale ≥3) clinical outcome after 90 days.

Results—

The data of 314 patients were analyzed. The NINDS definition revealed the highest sICH rate (7.7%); the lowest rate was found for the ECASS 3 definition (3.2%) of sICH. The highest interrater agreement was found for the ECASS 2 definition ( 0.85) and the lowest for the NINDS definition ( 0.57). Patients with sICH according to the SITS definition had the highest risk for death (OR, 14.4) and poor outcome (OR, 26.6).

Conclusions—

None of the different definitions contains an optimal combination of prediction of mortality and outcome and a high interrater agreement rate. For the clinical evaluation of mortality, we recommend using the SITS definition; for studies needing a high interrater agreement rate, we recommend using the ECASS 2 definition. Due to the lack of 1 single optimal definition, future thrombolytic trials should preferably use different definitions.






No comments:

Statin Use During Ischemic Stroke Hospitalization Is Strongly Associated With Improved Poststroke Su

Background and Purpose—

Statins reduce infarct size in animal models of stroke and have been hypothesized to improve clinical outcomes after ischemic stroke. We examined the relationship between statin use before and during stroke hospitalization and poststroke survival.

Methods—

We analyzed records from 12 689 patients admitted with ischemic stroke to any of 17 hospitals in a large integrated healthcare delivery system between January 2000 and December 2007. We used multivariable survival analysis and grouped-treatment analysis, an instrumental variable method that uses treatment differences between facilities to avoid individual patient-level confounding.

Results—

Statin use before ischemic stroke hospitalization was associated with improved survival (hazard ratio, 0.85; 95% CI, 0.79–0.93; P<0.001), and use before and during hospitalization was associated with better rates of survival (hazard ratio, 0.59; 95% CI, 0.53–0.65; P<0.001). Patients taking a statin before their stroke who underwent statin withdrawal in the hospital had a substantially greater risk of death (hazard ratio, 2.5; 95% CI, 2.1–2.9; P<0.001). The benefit was greater for high-dose (>60 mg/day) statin use (hazard ratio, 0.43; 95% CI, 0.34–0.53; P<0.001) than for lower dose (<60 mg/day) statin use (hazard ratio, 0.60; 95% CI, 0.54–0.67; P<0.001; test for trend P<0.001), and earlier treatment in-hospital further improved survival. Grouped-treatment analysis showed that the association between statin use and survival cannot be explained by patient-level confounding.

Conclusions—

Statin use early in stroke hospitalization is strongly associated with improved poststroke survival, and statin withdrawal in the hospital, even for a brief period, is associated with worsened survival.






No comments:

Smoking Cessation 1 Year Poststroke and Damage to the Insular Cortex [Original Contributions; Clinic

Background and Purpose—

Hospitalization as a result of stroke provides an opportunity to stop smoking that is often not taken up. The present study analyzes sociodemographic, psychological, and lesion-related variables to identify associated factors for smoking cessation during the first year after stroke.

Methods—

We conducted a prospective longitudinal study with a 1-year follow-up of a cohort of 110 patients with acute stroke who were smokers at the time of diagnosis and were admitted consecutively between January 2005 and July 2007.

Results—

On hospital release, 69.1% had given up smoking but at 1 year, only 40% had stopped smoking. Of the 110 patients, 27 (24.5%) had an acute stroke lesion in the insular cortex, of which 19 (70.3%) were nonsmokers at 1 year. Strongly associated factors in giving up smoking were the location of the lesion in the insular cortex (OR, 5.42; 95% CI, 1.95–15.01; P=0.001) and having the intention of giving up before the stroke, comparing precontemplating patients (without intention of giving up in the near future) with contemplating and prepared patients (intention of stopping in the near future; OR, 7.29; 95% CI, 1.89–28.07; P=0.004).

Conclusions—

Of patients with stroke who were smokers, only 4 of 10 patients had stopped smoking 1 year after admission. Our results show that the variables best predicting smoking cessation in patients with a stroke diagnosis 1 year after hospital discharge are insular damage and the prestroke intention to stop.






No comments:

Angiographic Reconstructions From Whole-Brain Perfusion CT for the Detection of Large Vessel Occlusi

Background and Purpose—

Multimodal CT imaging consisting of nonenhanced CT, CT angiography (CTA), and whole-brain volume perfusion CT is increasingly used for acute stroke imaging. In these patients, presence of vessel occlusion is an important factor governing treatment decisions and possible endovascular therapy. The goal of this study was to assess the value and diagnostic accuracy of angiographic thin-slice volume perfusion CT reconstructions for the detection of intracranial large vessel occlusion in patients with stroke.

Methods—

Fifty-eight patients with acute stroke received nonenhanced CT, CTA, and volume perfusion CT. All images were obtained on a 128-slice multidetector CT scanner. CT angiographic axial and coronal maximum-intensity projections of the head were reconstructed from conventional CTA and from the peak arterial scan of the volume perfusion CT data set (4-dimensional CTA). Images were assessed for the presence of intracranial vessel occlusion. The distribution of ischemic lesions was analyzed on perfusion parameter maps.

Results—

On CTA, 30 patients (52%) had a total of 33 occluded intracranial artery segments. Twenty-eight occlusions were identified on 4-dimensional CTA, resulting in an 85% sensitivity with a positive predictive value of 97%. When combined with an analysis of the perfusion parameter maps, sensitivity of 4-dimensional CTA increased to 94% with a positive predictive value of 100%.

Conclusions—

In acute stroke, angiographic volume perfusion CT reconstructions may be a feasible option to detect intracranial arterial occlusion and evaluate patients for endovascular therapy. Sensitivity for detection of intracranial arterial occlusion can be increased by simultaneous assessment of perfusion parameter maps. Future studies should assess whether time-resolved 4-dimensional CTA may offer additional diagnostically relevant information compared with single-phase CTA.






No comments:
Subscribe to: Posts (Atom)