Saturday, March 31, 2012

Amyloid Markers May Predict Dementia (CME/CE)

(MedPage Today) -- The ratio of two amyloid-β peptides in plasma may prove to be a useful biomarker for the preclinical diagnosis of dementia and Alzheimer's disease, a meta-analysis suggested.





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Friday, March 30, 2012

Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar s

Publication year: 2012
Source:Journal of Clinical Neuroscience
Ralph J. Mobbs, Praveenan Sivabalan, Jane Li
This clinical study prospectively compares the results of open surgery to minimally invasive fusion for degenerative lumbar spine pathologies. Eighty-two patients were studied (41 minimally invasive surgery [MIS] spinal fusion, 41 open surgical equivalent) under a single surgeon (R. J. Mobbs). The two groups were compared using the Oswestry Disability Index, the Short Form-12 version 1, the Visual Analogue Scale score, the Patient Satisfaction Index, length of hospital stay, time to mobilise, postoperative medication and complications. The MIS cohort was found to have significantly less postoperative pain, and to have met the expectations of a significantly greater proportion of patients than conventional open surgery. The patients who underwent the MIS approach also had significantly shorter length of stay, time to mobilisation, lower opioid use and total complication rates. In our study MIS provided similar efficacy to the conventional open technique, and proved to be superior with regard to patient satisfaction, length of hospital stay, time to mobilise and complication rates.






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Genetic Risk And Stressful Early Infancy Join To Increase Risk For Schizophrenia

Working with genetically engineered mice and the genomes of thousands of people with schizophrenia, researchers at Johns Hopkins say they now better understand how both nature and nurture can affect one's risks for schizophrenia and abnormal brain development in general...





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Memory Consolidation Damaged By Sleep Disturbance

Sleep disturbance negatively impacts the memory consolidation and enhancement that usually occurs with a good night's sleep, according to a study published in the open access journal PLoS ONE...





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Surgery for Psychiatric Disorders

Publication year: 2012
Source:World Neurosurgery
Judy Luigjes, Bart P. de Kwaasteniet, Pelle P. de Koning, Marloes S. Oudijn, Pepijn van den Munckhof, P. Richard Schuurman, Damiaan Denys
Surgery in psychiatric disorders has a long history and has regained momentum in the last few decades with deep brain stimulation (DBS). DBS is an adjustable and reversible neurosurgical intervention using implanted electrodes to deliver controlled electrical pulses to targeted areas of the brain. It holds great promise for therapy-refractory obsessive-compulsive disorder (OCD), several double blind controlled and open trails have been conducted and the response rate is estimated around 54%. Open trials have shown encouraging results with DBS for therapy-refractory depression and case reports have shown potential effects of DBS on addiction. Another promising indication is Tourette's syndrome (TS) where potential efficacy of DBS is shown by several case series and few controlled trials. Further research should focus on optimizing DBS with respect to target location and increasing the number of controlled double blinded trials. Additionally, new indications for DBS and new target options should be explored in preclinical research.






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Outcomes for clip ligation and hematoma evacuation associated with 102 patients with ruptured middle

Publication year: 2012
Source:World Neurosurgery
Bradley N. Bohnstedt, Ha Son Nguyen, Charles G. Kulwin, Mohammadali M. Shoja, Gregory M. Helbig, Thomas J. Leipzig, Troy D. Payner, Aaron A. Cohen-Gadol
Objective Few studies have investigated the implications of intracerebral hematoma (ICH) due to rupture of a middle cerebral artery (MCA) aneurysm and patient outcomes. The authors hypothesized that patients with Hunt-Hess (HH) grade IV-V may not benefit from aggressive measures. To evaluate this hypothesis, the authors undertook the following study. Methods A prospectively acquired aneurysm database was examined. We found 144 patients who harbored a ruptured MCA aneurysm and suffered from ICH or intrasylvian hematoma (ISH) with or without SAH. The mean age of our patients was 52.5 years (range, 10–82 years) with 87 women and 57 men. Of these, 122 (84.7%) underwent a combination of interventions, including clip ligation, hematoma evacuation, and/or endosaccular coiling; most patients underwent clip ligation at the same time their hematoma was evacuated. The discharge information was not available for two patients. We examined significant associations among presenting details (age, sex, admission HH grade, etc.) and patients' final outcome. Results The total in-hospital mortality rate was 49% (70 of 142 patients); 42% (51 of 120) for the patients who underwent an intervention and 86.4% (19 of 22) for those who did not undergo any intervention. Among our patients, approximately 52% with an admission HH grade of IV/V died in-hospital following surgery, while 21% with admission HH grade of I-III expired during the same time. In the patient cohort with presenting with HH grade IV and V, 4% (3 of 76) demonstrated Glasgow outcome scale (GOS) 4-5 at discharge, while 15% (12 of 78) displayed GOS 4-5 at 6-month follow-up. Age and sex did not affect outcome. Conclusions Aggressive clip ligation and hematoma evacuation remains a reasonable option for patients suffering from an ICH associated with a ruptured MCA aneurysm. Admission HH grade is the primary prognostic factor for outcome among this patient population as more than half of patients with HH grade IV and V expired during their hospitalization despite aggressive treatment of their hematoma and aneurysm; long-term functional outcome was poor in up to 85% of surviving patients with HH grade IV-V. It may be beneficial to discuss these prognostic factors with the family before implementing aggressive measures.






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Survey on the use of navigation in spine surgery worldwide

Publication year: 2012
Source:World Neurosurgery
Roger Härtl, Khai Sing Lam, Jeffrey Wang, Andreas Korge, Frank Kandziora, Laurent Audigé
Objective Computer-assisted surgery (CAS) can improve the accuracy of screw placement and decrease radiation exposure, yet this is not widely accepted among spine surgeons worldwide. The current viewpoint of the spine surgeon on navigation in their everyday practice is an important issue which has not been studied. A survey-based study assessed opinions on CAS to describe the current global attitudes of surgeons on the use of navigation in spine surgery. Methods A 12-item questionnaire focusing on the number and type of surgical cases, the type of equipment available, and general opinions towards CAS was distributed to 3348 AOSpine surgeons (a speciality group within the AO [Arbeitsgemeinschaft für Osteosynthesefragen] Foundation). Latent class analysis was used to investigate the existence of specific groups based on the respondent opinion profiles. Results A response rate of 20% was recorded. Despite a widespread distribution of navigation systems in North America and Europe, only 11% of surgeons use it routinely. High-volume procedure surgeons, neurological surgeons and surgeons with a busy minimal invasive surgery practice are more likely to use CAS. "Routine users" consider the accuracy, potential of facilitating complex surgery, and reduction in radiation exposure as the main advantages. The lack of equipment, inadequate training, and high costs are the main reasons "non-users" do not use CAS. Conclusion Spine surgeons acknowledge the value of CAS, yet current systems do not meet their expectations in terms of ease of use and integration into the surgical work flow. To increase its use, CAS has to become more cost efficient and scientific data are needed to clarify its potential benefits.






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Tuesday, March 27, 2012

Randomized, placebo-controlled trial of propranolol added to topiramate in chronic migraine

Objective:

To assess the efficacy and safety of adding propranolol to topiramate in chronic migraine subjects inadequately controlled with topiramate alone.

Methods:

This was a double-blind, placebo-controlled, randomized clinical trial conducted through the National Institute of Neurological Disorders and Stroke Clinical Research Collaboration, expected to randomize 250 chronic migraine subjects inadequately controlled (≥10 headaches/month) with topiramate (50–100 mg/day) to either propranolol LA (long acting) (240 mg/day) or placebo. Primary outcome was 28-day moderate to severe headache rate reduction at 6 months (weeks 16 to 24) compared with baseline (weeks –4 to 0).

Results:

A planned interim analysis was performed after 48 sites randomized 171 subjects. The data and safety monitoring board recommended ending the trial after determining that it would be highly unlikely for the combination to result in a significant reduction in 28-day headache rate compared with topiramate alone if all 250 subjects were randomized. No safety concerns were identified. At study closure, 191 subjects were randomized. The 6-month reduction in moderate to severe 28-day headache rate and total 28-day headache rate for combination therapy vs topiramate alone was not significantly different: 4.0 vs 4.5 days (moderate to severe 28-day headache rate; p = 0.57) and 6.2 vs 6.1 days (total 28-day headache rate; p = 0.91).

Conclusions:

This study does not provide evidence that the addition of propranolol LA to topiramate adds benefit when chronic migraine is inadequately controlled with topiramate alone.

Classification of evidence:

This study provides Class II evidence that propranolol LA, added to topiramate, is ineffective in chronic migraine patients who fail topiramate monotherapy.






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Cognitive decline after hospitalization in a community population of older persons

Objective:

To test the hypothesis that hospitalization in old age is associated with subsequent cognitive decline.

Methods:

As part of a longitudinal population-based cohort study, 1,870 older residents of an urban community were interviewed at 3-year intervals for up to 12 years. The interview included a set of brief cognitive tests from which measures of global cognition, episodic memory, and executive function were derived. Information about hospitalization during the observation period was obtained from Medicare records.

Results:

During a mean of 9.3 years, 1,335 of 1,870 persons (71.4%) were hospitalized at least once. In a mixed-effects model adjusted for age, sex, race, and education, the global cognitive score declined a mean of 0.031 unit per year before the first hospitalization compared with 0.075 unit per year thereafter, a more than 2.4-fold increase. The posthospital acceleration in cognitive decline was also evident on measures of episodic memory (3.3-fold increase) and executive function (1.7-fold increase). The rate of cognitive decline after hospitalization was not related to the level of cognitive function at study entry (r = 0.01, p = 0.88) but was moderately correlated with rate of cognitive decline before hospitalization (r = 0.55, p = 0.021). More severe illness, longer hospital stay, and older age were each associated with faster cognitive decline after hospitalization but did not eliminate the effect of hospitalization.

Conclusion:

In old age, cognitive functioning tends to decline substantially after hospitalization even after controlling for illness severity and prehospital cognitive decline.






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Intracerebral Hemorrhage in the Very Old: Future Demographic Trends of an Aging Population [Original

Background and Purpose—

In most European societies and in the United States, the percentage of patients ≥80 years has been rising over the past century. The present study was conducted to observe this demographic change and its impact on patients with intracerebral hemorrhage (ICH).

Methods—

We reviewed patients' data with the diagnosis of ICH from January 2007 to December 2009. All data were collected out of a prospective stroke registry covering the entire state of Hesse, Germany. Incidence rates and absolute numbers of patients with ICH for 2009 to 2050 were calculated.

Results—

Of 3448 patients, 34% had an age ≥80 years. Hospital mortality was 35.9% for patients ≥80 years and 20.0% for patients <80 years. Unfavorable outcome (modified Rankin Scale score >2) was more often found in patients ≥80 years compared with patients <80 years (84.9% versus 74.8%). By the year 2050, the proportion of all patients with ICH ≥80 years will be 2.5-fold higher than in 2009. The total number of ICH cases will increase approximately 35.2% assuming that ICH probability stays the same. The number of patients who die in the hospital will increase approximately 60.2%. The total number of patients with severe disability due to ICH will increase approximately 36.8%.

Conclusions—

If current treatment strategies according to age remain unchanged, an increase of in-hospital mortality and a higher proportion of patients who need lifelong care after ICH can be expected in the coming decades.






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Impact of Emergency Department Transitions of Care on Thrombolytic Use in Acute Ischemic Stroke [Ori

Background and Purpose—

In-hospital mortality is higher for certain medical conditions based on the time of presentation to the emergency department. The primary goal of this study was to determine whether patients with acute ischemic stroke who arrived to the emergency department during a nursing shift change had similar rates of thrombolytic use and functional outcomes compared with patients presenting during nonshift change hours.

Methods—

A retrospective review of patients with acute ischemic stroke presenting to the emergency department of a primary stroke center from 2005 through 2010. The time to notify the stroke team, perform a head CT scan, and to start intravenous or intra-arterial thrombolysis was assessed. Thrombolysis rates, mortality rate, discharge disposition, change in the National Institutes of Health Stroke Scale, and change in modified Barthel Index at 3 and 12 months were assessed.

Results—

Of 3133 patients with acute ischemic stroke, 917 met criteria for inclusion. Arrival during nursing shift change, weekends, and July through September had no impact on process times, thrombolysis rates, and functional outcomes. Arrival at night did result in longer time to intra-arterial but not to intravenous thrombolysis, higher mortality rate, and smaller gain in functional status as measured by the modified Barthel Index at 3 months. The degree of emergency department "busyness" also did not influence tissue-type plasminogen activator treatment times.

Conclusions—

Presentation during a nursing shift change, a time of transition of care, did not delay thrombolytic use in eligible patients with acute ischemic stroke. Presentation with acute ischemic stroke at night did result in delays of care for patients undergoing interventional therapies.






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Endovascular Therapy of 623 Patients With Anterior Circulation Stroke [Original Contributions; Clini

Background and Purpose—

Endovascular therapy of acute ischemic stroke has been shown to be beneficial for selected patients. The purpose of this study is to determine predictors of outcome in a large cohort of patients treated with intra-arterial thrombolysis, mechanical revascularization techniques, or both.

Methods—

We prospectively acquired data for 623 patients with acute cerebral infarcts in the carotid artery territory who received endovascular treatment at a single center. Logistic regression analysis was performed to determine predictors of outcome.

Results—

Median National Institutes of Health Stroke Scale (NIHSS) at admission was 15. Partial or complete recanalization was achieved in 70.3% of patients; it was independently associated with hypercholesterolemia (P=0.02), absence of coronary artery disease (P=0.023), and more proximal occlusion site (P<0.0001). After 3 months, 80.5% of patients had survived, and 48.9% of patients reached favorable outcome (modified Rankin scale score 0–2). Good collaterals (P<0.0001), recanalization (P=0.023), hypercholesterolemia (P=0.03), lower NIHSS at admission (P=0.001), and younger age (P<0.0001) were independent predictors for survival. More peripheral occlusion site (P<0.0001), recanalization (P<0.0001), hypercholesterolemia (P=0.002), good collaterals (P=0.002), lower NIHSS (P<0.0001), younger age (P<0.0001), absence of diabetes (P=0.002), and no previous antithrombotic therapy (P=0.036) predicted favorable outcome. Time to treatment was only a predictor of outcome, when collaterals were excluded from the model. Symptomatic intracerebral hemorrhage occurred in 5.5% and was independently predicted by poor collaterals (P=0.004).

Conclusions—

Several independent predictors for outcome and complications were identified. Unlike in intravenous thrombolysis trials, time to treatment was a predictor of outcome only when collaterals were excluded from the model, indicating the important role of collaterals for the time window.






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Monday, March 26, 2012

Hospital Stay Worsens Memory in Elders (CME/CE)

(MedPage Today) -- Elderly patients who are hospitalized are likely to experience worsening of overall cognitive decline along with greater impairments in episodic memory and executive function, a longitudinal study found.





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Surgery after intracranial investigation with subdural electrodes in patients with drug-resistant fo

Abstract  
Video–EEG monitoring with intracranial subdural electrodes is a useful assessment tool for the localization of the epileptogenic zone in patients with drug-resistant focal epilepsy. We aimed at assessing the morbidity related to electrode implantation and the surgical outcome in patients who underwent epilepsy surgery after intracranial EEG monitoring. All patients (N = 58) admitted to our Epilepsy Surgery Centre for drug-resistant focal epilepsy who underwent resective surgery after intracranial monitoring with subdural electrodes and were followed up for at least 2 years were included in the study. Their mean age was 30.4 years (range 8–60 years), 25 (43 %) were female, and 44 (76 %) had a preoperatively detected structural lesion. The mean duration of invasive recording was 2.3 days (range 1–14 days). Extraoperative ECoG allowed the identification of the epileptogenic focus in all cases. The temporal lobe was involved in 21 (36 %) patients, whereas extratemporal foci were identified in 24 (41 %) patients. Thirteen patients (23 %) had multilobar involvement. Functional brain mapping was performed in 15 (26 %) patients. Transient complications related to electrode implantation occurred in three patients. Among patients with evidence of lesion on preoperative MRI, lesionectomy alone was performed in 12 cases (27 %), while it was combined with tailored cortical resection in the remaining cases. Tailored cortical resection was also performed in patients without evidence of lesion on MRI. After resective surgery, transient neurological deficits occurred in five cases, while another patient experienced permanent lateral homonymous hemianopia. At the last follow-up observation, 34 (57 %) patients were seizure-free (Engel class I). This study suggests that invasive EEG recording with subdural electrodes may be useful and fairly safe for many candidates for epilepsy surgery.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-8
  • DOI 10.1007/s10143-012-0382-5
  • Authors
    • Roberta Morace, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Giancarlo Di Gennaro, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Angelo Picardi, Center of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Rome, Italy
    • Pier Paolo Quarato, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Antonio Sparano, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Addolorata Mascia, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Giulio Nicolò Meldolesi, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Liliana Graciela Grammaldo, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Marco De Risi, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy
    • Vincenzo Esposito, Epilepsy Surgery Unit, Department of Neurological Sciences, IRCCS Neuromed, 86077 Pozzilli, Isernia, Italy





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Presurgical planning for arteriovenous malformations using multidetector row CT

Abstract  
Microsurgical resection remains an important treatment for cerebral arteriovenous malformations (AVMs). We developed an accurate method for planning AVM resections using multidetector row CT (MDCT). Between January 2007 and January 2011, 21 consecutive patients with AVMs were enrolled in this study. Sixteen patients were symptomatic, and of these, 15 had a hemorrhagic onset. Preoperative CT angiography (CTA) was performed using an MDCT scanner (GE Lightspeed VCT; GE Healthcare, Milwaukee, WI, USA). In total, 1 to 1.2 mL/kg of iopamidol, a low-osmolar iodinated contrast material, was administered intravenously with the bolus tracking method. In all cases, three-dimensional CTA imaging demonstrated critical arterial feeders and their specific geometric associations with the nidus. Accurate visualization of the architecture of AVMs and surgical trajectory was possible with the volume rendering method, especially when using transparency imaging. Additionally, employing feeder extraction imaging with segmentation post-processing, clear preoperative identification of the feeding arteries around the surrounding structures allowed for not only intraoperative orientation but also planning for presurgical embolization. Moreover, the precise anatomical structures of the brain surface were obtained using fusion imaging with MRI. While it is difficult to scientifically assign a value to a technology, we sought to objectively assess the utility of the currently available CTA. The significant benefits of this modality for presurgical planning include enhanced surgeon confidence and optimization of the sequence of surgical procedures.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-8
  • DOI 10.1007/s10143-012-0383-4
  • Authors
    • Takeshi Mikami, Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, 060-8543 Japan
    • Tohru Hirano, Division of Radiology, Sapporo Medical University Hospital, Sapporo, Japan
    • Toshiya Sugino, Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, 060-8543 Japan
    • Kei Miyata, Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, 060-8543 Japan
    • Satoshi Iihoshi, Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, 060-8543 Japan
    • Masahiko Wanibuchi, Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, 060-8543 Japan
    • Nobuhiro Mikuni, Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, 060-8543 Japan





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Alcohol Intake And Cognitive Functioning

Many observational cohort studies have shown that moderate alcohol use is associated with better cognitive function...





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Sunday, March 25, 2012

Parental recognition of shunt failure: a prospective single-institution study

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 4, Page 363-371, April 2012.
Object Because there is no gold standard for preoperative diagnosis of shunt failure, understanding the sensitivity, specificity, and predictive values of symptoms, signs, and diagnostic tests enables practitioners to make logical clinical decisions. Parents of children with shunts undergo educational instruction to enable them to recognize shunt failure. The authors prospectively investigated parental ability to recognize shunt failure. Methods Data were prospectively collected on 205 consecutive encounters in 153 children with shunted hydrocephalus presenting to the emergency department or clinic, or as an inpatient consultation, to the Children's Hospital of Alabama between April and October 2010. Regardless of the complaint, all parents were asked if they believed the shunt was in failure. Six children were excluded from analysis because a parental response was lacking. Using the Shunt Design Trial definitions, shunt failure was diagnosed intraoperatively or ruled out if the child did not undergo shunt revision within 1 week of presentation. Sensitivity, specificity, predictive values, and accuracy were calculated using the parental response and shunt failure diagnosis. Secondarily, parents were compared based on their experience with shunt failure in their children; experienced parents were defined as having experienced at least 3 shunt failures. Post hoc analysis evaluated diagnostic test characteristics among hydrocephalus causes and compared parental recognition of shunt failure to head CT and shunt series diagnostic test characteristics. Parents also completed a standardized shunt failure survey regarding their shunt teaching education and symptom tracking. Results Children enrolled were a mean age of 6.9 years old, 92 (46%) of the encounters were with male patients, and most patients were Caucasian (69%) and had undergone an average of 2.8 previous shunt revisions. Seventy-one children (36%) were diagnosed with shunt failure. Parental response diagnostic test characteristics were: positive predictive value (PPV) of 41%, negative predictive value (NPV) of 79%, sensitivity of 83%, specificity of 34%, and accuracy of 52% for shunt failure. Sixty-three parents were considered experienced and responded with a PPV of 29%, NPV of 92%, sensitivity of 94%, specificity of 23%, and accuracy of 41%. One hundred thirty-six parents were considered inexperienced and responded with a PPV of 48%, NPV of 75%, sensitivity of 80%, specificity of 41%, and accuracy of 57%. When statistically compared, experienced parents had significantly lower PPV (29% vs 48%, respectively; p = 0.035) and accuracy (41% vs 57%, respectively; p = 0.049) than inexperienced parents. On post hoc analysis, parental recognition of shunt failure was inferior to head CT and shunt series diagnostic tests with a lower specificity (20% vs 88%, respectively; p < 0.0005), PPV (44% vs 84%, respectively; p < 0.0005), NPV (61% vs 85%, respectively; p = 0.006), and accuracy (47% vs. 85%, respectively; p < 0.0005). Conclusions The overall parental response had the greatest value in ruling out shunt failure, reflected in the high NPV, particularly in experienced parents. The head CT and shunt series provide more favorable diagnostic test characteristics than the parental response. Although educational interventions have decreased shunt-related deaths, parents have difficulty differentiating shunt failure from alternative diagnoses.





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Hyperacute cerebral aneurysm rerupture during CT angiography

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-7, Ahead of Print.
Object The object of this study was to identify the clinical features and outcomes of a subgroup of patients with aneurysmal subarachnoid hemorrhage (SAH) who had active contrast extravasation from a ruptured aneurysm during initial cerebral CT angiography (CTA). Methods The authors performed a retrospective study of spontaneous SAH cases involving patients treated at their institute. They identified 9 cases in which active contrast extravasation was evident on the initial CT angiogram. Another 12 similar cases were also identified in a literature review and data was gathered from these cases to evaluate the outcomes. Results Analysis of all 21 cases revealed that the overall outcomes in cases characterized by active aneurysmal bleeding during CTA were poor. Seventy-six percent of patients had unfavorable results. Patients who showed poor neurological status at presentation died no matter what kind of treatment they received. In contrast, patients who presented with good neurological status initially had a chance of favorable outcome. Among the patients with good initial neurological status, most demonstrated rapid deterioration of their condition during the CTA examination; only those who received immediate and effective decompressive surgery and aneurysm obliteration had good results. Conclusions Active aneurysmal rebleeding during CTA is an uncommon but devastating event. Though the mortality of this distinct group of patients remains high, a clinical subgroup may benefit from immediate surgery. Patients with good initial neurological status who show rapid neurological deterioration may still have a favorable outcome if they undergo timely and successful decompressive surgery and proper aneurysm obliteration. Patients who present with poor neurological status do badly, and there is no effective treatment for such patients.





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Creatine metabolism and psychiatric disorders: Does creatine supplementation have therapeutic value?

Publication year: 2012
Source:Neuroscience & Biobehavioral Reviews
Patricia J. Allen
Athletes, body builders, and military personnel use dietary creatine as an ergogenic aid to boost physical performance in sports involving short bursts of high-intensity muscle activity. Lesser known is the essential role creatine, a natural regulator of energy homeostasis, plays in brain function and development. Creatine supplementation has shown promise as a safe, effective, and tolerable adjunct to medication for the treatment of brain-related disorders linked with dysfunctional energy metabolism, such as Huntington's Disease and Parkinson's Disease. Impairments in creatine metabolism have also been implicated in the pathogenesis of psychiatric disorders, leaving clinicians, researchers and patients alike wondering if dietary creatine has therapeutic value for treating mental illness. The present review summarizes the neurobiology of the creatine-phosphocreatine circuit and its relation to psychological stress, schizophrenia, mood and anxiety disorders. While present knowledge of the role of creatine in cognitive and emotional processing is in its infancy, further research on this endogenous metabolite has the potential to advance our understanding of the biological bases of psychopathology and improve current therapeutic strategies.






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Subdural hematoma of the posterior fossa due to posterior communicating artery aneurysm rupture

Myoung Soo Kim, Jong Rak Jung, Sang Won Yoon, Chae Heuck Lee

Surgical Neurology International 2012 3(1):39-39

Background: We describe an unusual presentation of a ruptured aneurysm of the posterior communicating artery with an acute subdural hematoma (SDH) located in the posterior fossa. We also reviewed the literature, focusing on the location of this intracranial hematoma. Case Description: An 83-year-old woman was admitted to our institution with recent sudden headache and dizziness. Magnetic resonance imaging showed a thin collection of blood in the subdural space adjacent to the clivus, along the wall of the posterior fossa, and at the cervical spine level. A right posterior communicating artery aneurysm was diagnosed using computed tomography angiography and digital subtraction angiography. The aneurysm had two lobes, one of which was attached to the right dorsum sellae. The aneurysm was occluded by stent-assisted coil embolization. The patient was discharged 3 weeks after admission with absence of neurological deficit. Conclusion: A ruptured aneurysm of the posterior communicating artery may cause an acute SDH.





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Delaying Surgical Repair After Traumatic Brain Injury Reduced Secondary Brain Swelling, Damage In TB

Immediate skull reconstruction following trauma that penetrates or creates an indentation in the skull can aggravate brain damage inflicted by the initial injury, a study by a University of South Florida research team reports...





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Minimally invasive surgical treatment of lumbar spinal stenosis: Two-year follow-up in 54 patients

Sylvain Palmer, Lisa Davison

Surgical Neurology International 2012 3(1):41-41

Objective: Minimally invasive surgery has seen increasing application in the treatment of spinal disorders. Treatment of degenerative spinal stenosis, with or without spondylolisthesis, with minimally invasive technique preserves stabilizing ligaments, bone, and muscle. Satisfactory results can be achieved without the need for fusion in most cases. Methods: Fifty-four consecutive patients underwent bilateral decompressions from a unilateral approach for spinal stenosis using METRx instrumentation. Visual Analog Scale (VAS) pain scores were recorded preoperatively and patients were interviewed, in person or by phone, by our office nurse practitioner (LD) to assess postoperative VAS scores, and patient satisfaction with the clinical results 21-39 months postoperatively (median 27 months). Results: Fifty-four patients underwent decompression at 77 levels (L4/5 = 43, L3/4 = 22, L5/S1 = 8, L1/2 = 4, L2/3 = 4), (single = 35, double = 16, triple = 2, quadruple = 1). There were 39 females and 15 males. The average age was 67 years. The average operative time was 78 minutes and the average blood loss was 37 ml per level. Twenty-seven patients had preoperative degenerative spondylolisthesis (Grade 1 = 26, Grade 2 = 1). Eight patients had discectomies and four had synovial cysts. Patient satisfaction was high. Use of pain medication for leg and back pain was low, and VAS scores improved by more than half. There were three dural tears. There were no deaths or infections. One patient with an unrecognized dural tear required re-exploration for repair of a pseudomeningocele and one patient required a lumbar fusion for pain associated with progression of her spondylolisthesis. Conclusions: Minimally invasive bilateral decompression of acquired spinal stenosis from a unilateral approach can be successfully accomplished with reasonable operative times, minimal blood loss, and acceptable morbidity. Two-year outcomes in this series revealed high patient satisfaction and only one patient progressed to lumbar fusion.





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Ability to Learn Is Affected by the Timing of Sleep

Sleep has many functions--including facilitating learning.

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Will living alone make you depressed?

It's long been known that elderly people are more prone to depression and other mental-health problems if they live on their own. New research suggests the same pattern may also be found in younger, working-age adults.





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Thursday, March 22, 2012

Intracranial relapse rates and patterns, and survival trends following post-resection cavity radiosu

Abstract  
The objective of this study is to evaluate the patterns of relapse and survival trends in patients with single brain metastases treated with post-operative adjuvant Gamma knife stereotactic radiosurgery (GKS) without whole brain radiotherapy (WBRT). Retrospective analysis of all consecutive patients who underwent GKS to the tumor cavity following resection of solitary brain metastasis was performed at a single institution. Between March 2001 and June 2010, 56 patients underwent GKS to the resection cavity following resection of intracranial metastases; no patient received pre- or post-operative WBRT as an adjuvant (salvage WBRT was permissible). The mean marginal dose was 17.1 Gy (range 14–20 Gy). The mean follow-up period was 24 months (range 3–99 months). Five patients (8.9%) had local recurrence in the immediate vicinity of the resection cavity, qualifying as "local failures", and 21 (37.5%) recurred at distant intracranial sites. Median intracranial recurrence free survival was 13 months. Median overall survival was 20.5 months. Salvage interventions were required in 26 patients, and included repeat radiosurgery in 17 patients, further surgery in two patients, and salvage WBRT in eight (14.3%; two of whom had also been locally salvaged with repeat radiosurgery) patients. As expected, avoidance of WBRT results in a high rate of intracranial failure (26/56 patients, 46%), even in well-selected patients with only single brain metastases. As anticipated, the majority of failures (21, 37.5%) are "distant intracranial", and in this well-selected cohort the local failure rate is low (5/56 patients, <9%). All patients failing intracranially (46%) are potential candidates for salvage therapies, but WBRT as salvage was utilized in only 14.3% of patients. The median intracranial relapse-free was 13 months and overall survival was 20.5 months.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-6
  • DOI 10.1007/s11060-012-0808-5
  • Authors
    • Hideki Ogiwara, Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA
    • Kapila Kalakota, Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
    • Sunpreet S. Rakhra, Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
    • Irene B. Helenowski, Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
    • Maryanne H. Marymont, Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
    • John A. Kalapurakal, Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
    • Minesh P. Mehta, Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
    • Robert B. Levy, Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA
    • James P. Chandler, Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA





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Box 1: Creating an eye-catching poster: Simple guidelines for poster presentation

Mais dicas para fazer do seu poster um sucesso em congressos!!Fonte: Nature JobsPresentations: Billboard scienceKendall PowellNature 483 , 113-115 (2012) doi:10.1038/nj7387-113aPublished online 29 February 2012This article was originally published in the journal NatureLeia o artigo completo aquiChoose landscape (horizontal) over portrait (vertical) orientations.Follow the recommended dimensions





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Wednesday, March 21, 2012

How Memories Are Encoded In Our Brains

University of Alberta led research may have discovered how memories are encoded in our brains. Scientists understand memory to exist as strengthened synaptic connections among neurons. However components of synaptic membranes are relatively short-lived and frequently re-cycled while memories can last a lifetime...





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Survive Cancer, Lessen Alzheimer's Risk

Could there be an inverse relationship between cancer and neurodegeneration? A new analysis of data from the Framingham Heart Study suggests this possibility.
Medscape Medical News





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Surgery of the Mind, Mood, and Conscious State: an Idea in Evolution

Publication year: 2012
Source:World Neurosurgery
R. Aaron Robison, Alexander Taghva, Charles Y. Liu, Michael L.J. Apuzzo
Since the beginning of recorded history, mankind has sought a physical means of altering disordered behavior and consciousness. This quest has spawned numerous innovations in neurosurgery and the neurosciences, from the earliest prehistoric attempts at trepanation, to the electrocortical and anatomic localization of cerebral function that emerged in the 19th century. At the start of the 20th century, the overwhelming social impact of psychiatric illness intersected with the novel but imperfect understanding of frontal lobe function, establishing a decades-long venture into the modern origin of psychosurgery, the prefrontal lobotomy. The subsequent social and ethical ramifications of the widespread overuse of transorbital lobotomies drove psychosurgery to near extinction. However, as the pharmacologic treatment of psychiatric illness was established, numerous concomitant technical and neuroscientific innovations permitted the incremental development of a new paradigm of treating the disordered mind. In this paper, we retrospectively examine these early origins of psychosurgery, and then look to the recent past, present and future for emerging trends in surgery of the psyche. Recent decades have seen a revolution in minimalism, non-invasive imaging, and functional manipulation of the human cerebrum that have created new opportunities and treatment modalities for disorders of the human mind and mood. Early contemporary efforts were directed at focal lesioning of abnormal pathways, but deep brain stimulation now aims to reversibly alter and modulate those neurologic activities responsible for not only psychiatric disorders, but also to modulate and even to augment consciousness, memory and other elements of cerebral function. As new tools become available, the social and medical impact of psychosurgery promises to revolutionize not only neurosurgery, but also mankind's capability for positively impacting life and society.






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The Role of Adjuvant Radiation Therapy in the Management of High-Grade Gliomas

The purpose of this article is to update the neurosurgical community on the role of adjuvant radiation therapy in the management of patients with high-grade glioma. This information guides clinicians in the multidisciplinary management of these patients via a review of the literature describing current treatment paradigms as well as new avenues of investigation.





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Tuesday, March 20, 2012

A Neuroscientist's Quest to Reverse Engineer the Human Brain

What makes us who we are? Where is our personal history recorded, or our hopes? What explains autism or schiziphrenia or remarkable genius? Sebastian Seung argues that it's all in the connections our neurons make. In his new book, Connectome , he argues that technology has now reached a point where it is conceivable to start mapping at least portions of the connectome. It's a daunting task, he says, but without it, neuroscience will be stuck. He answered questions from Mind Matters editor Gareth Cook.

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Flow-Diverting Stent for Ruptured Intracranial Dissecting Aneurysm of Vertebral Artery

BACKGROUND: The treatment of ruptured dissecting aneurysms of the intracranial vertebral artery (VA) with parent vessel preservation is a challenge for neurosurgeons and interventional neuroradiologists. OBJECTIVE: To propose an indication for flow-diverting treatment for reconstruction of a dissecting VA with acute subarachnoid hemorrhage. METHODS: Two male patients transferred after acute subarachnoid hemorrhage and dissecting aneurysm on the V4 segment of the dominant VA. An occlusion test was not performed because of their poor clinical state. A flow-diverting stent represented by the Pipeline embolization device was suggested to both patients. RESULTS: Three Pipeline embolization devices were deployed in each VA. One dissecting aneurysm was excluded immediately after 3 stents, and 1 patient had complete exclusion demonstrated at the 48-hour control. No morbidity directly related to the procedure was observed. No recanalization and no rebleeding occurred during the 3 months of follow-up. CONCLUSION: A flow-diverting stent may be considered an option to treat ruptured dissecting aneurysms of the VA, providing remodeling of the parent vessel and complete exclusion of the aneurysm.





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Sex Disparities in Postoperative Outcomes After Neurosurgical Intervention: Findings From the UMEND

BACKGROUND: Little is known about the relationship between sex and the risk of complications after neurosurgical intervention. Improved understanding of this relationship may assist clinicians in advising patients of the risks and benefits of neurosurgical intervention and managing their patients after surgery. OBJECTIVE: To determine the independent relationship between sex and morbidity after neurosurgical intervention. METHODS: Data were collected for 918 neurosurgical cases at the University of Michigan Hospitals. Bivariate χ2 tests and analysis of variance were used to assess relationships between sex, demographics, case type, medical comorbidities, postoperative complication risk, and postoperative hospital and intensive care unit stay. We fit a multivariable logistic regression model of 30-day complication risk by sex adjusted for potential confounders and used multifactor analysis of variance to assess the relationship between sex and hospital as well as intensive care unit stay, adjusted for potential confounders. RESULTS: The percentages of patients experiencing complications within 30 days of surgery were 20.3% for male and 11.3% for female patients. In multivariable regression models, male sex predicted postoperative complications compared with female sex (odds ratio: 2.0, 95% confidence interval: 1.4-3.0). By multifactor analysis of variance, male sex was associated with longer hospital stay (P < .01), but was not associated with neurosurgical intensive care unit stay. CONCLUSION: Our findings suggest male sex is an independent predictor of postoperative complication risk and increased hospital stay after neurosurgical intervention. This finding may be used clinically to help identify those patients at increased risk of a complicated recovery. Future research might consider mechanisms relating sex and postoperative outcomes.





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Extent of Surgical Resection Predicts Seizure Freedom in Low-Grade Temporal Lobe Brain Tumors

BACKGROUND: Achieving seizure control in patients with low-grade temporal lobe gliomas or glioneuronal tumors remains highly underappreciated, because seizures are the most frequent presenting symptom and significantly impact patient quality-of-life. OBJECTIVE: To assess how the extent of temporal lobe resection influences seizure outcome. METHODS: We performed a quantitative, comprehensive systematic literature review of seizure control outcomes in 1181 patients with epilepsy across 41 studies after surgical resection of low-grade temporal lobe gliomas and glioneuronal tumors. We measured seizure-freedom rates after subtotal resection vs gross-total lesionectomy alone vs tailored resection, including gross-total lesionectomy with hippocampectomy and/or anterior temporal lobe corticectomy. RESULTS: Included studies were observational case series, and no randomized, controlled trials were identified. Although only 43% of patients were seizure-free after subtotal tumor resection, 79% of individuals were seizure-free after gross-total lesionectomy (OR = 5.00, 95% confidence interval [CI]: 3.33-7.14). Furthermore, tailored resection with hippocampectomy plus corticectomy conferred additional benefit over gross-total lesionectomy alone, with 87% of patients achieving seizure freedom (OR = 1.82, 95% CI: 1.23-2.70). Overall, extended resection with hippocampectomy and/or corticectomy over gross-total lesionectomy alone significantly predicted seizure freedom (OR = 1.18, 95% CI: 1.11-1.26). Age <18 years and mesial temporal location also prognosticated favorable seizure outcome. CONCLUSION: Gross-total lesionectomy of low-grade temporal lobe tumors results in significantly improved seizure control over subtotal resection. Additional tailored resection including the hippocampus and/or adjacent cortex may further improve seizure control, suggesting dual pathology may sometimes allow continued seizures after lesional excision.





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Surgical Mortality and Selected Complications in 273 Consecutive Craniotomies for Intracranial Tumor

BACKGROUND: In order to weigh the risks of surgery against the presumed advantages, it is important to have specific knowledge about complication rates. Contemporary reports on complications following craniotomy for tumor resection in pediatric patients are scarce. OBJECTIVE: To study the surgical mortality and rate of hematomas, infections, meningitis, infarctions, and cerebrospinal fluid (CSF) leaks, as well as neurological morbidity, after craniotomy for pediatric brain tumors in a large, contemporary, single-institution consecutive series. METHODS: All pediatric patients (< 18 years) from a well-defined population of 3.0 million inhabitants who underwent craniotomies for intracranial tumors at Oslo University Hospital, Rikshospitalet, during 2003 to 2009 were included. The patients were identified from our prospectively collected database, and all charts were reviewed to validate the database entries. RESULTS: Included in the study were 273 craniotomies, performed on 211 patients. Mean age was 8.5 years (range, 0-18). Follow-up was 100%. One hundred ninety-nine cases (72.9%) were primary craniotomies, while 74 cases (27.1%) were secondary craniotomies. Surgical approach was supratentorial in 194 (71.1%) and infratentorial in 79 (28.9%). Surgical mortality within 30 days was 0.4% (n = 1). Complication rates were intracerebral hemorrhage 0.4%, chronic subdural hematoma 1.1%, meningitis 1.8%, cerebral infarctions 1.5%, and postoperative CSF leak 7.3%. Neurological deficit rates were no change or improvement 87.2%, minor or moderate new deficits 9.5%, and severe new neurological deficits 2.9%. CONCLUSION: Overall, the complication rates are low and compare favorably with similar data from adult series. The authors' data could be used as a baseline for future studies.





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Prognostic Value of Intraventricular Bleeding in Spontaneous Intraparenchymal Cerebral Hemorrhage of

BACKGROUND: The literature is controversial on whether intraventricular bleeding has a negative impact on the prognosis of spontaneous intracerebral hemorrhage. Nevertheless, an association between intraventricular bleeding and spontaneous intracerebral hemorrhage volumes has been consistently reported. OBJECTIVE: To evaluate the prognostic value of intraventricular bleeding in deep intraparenchymal hypertensive spontaneous hemorrhage with a bleeding volume <30 cm3. METHODS: Of the 320 patients initially evaluated, 33 met the inclusion criteria and were enrolled in this prospective study. The volume of intraparenchymal hemorrhage was calculated by brain computed tomography (CT) image analysis, and the volume of intraventricular bleeding was calculated by the LeRoux scale. Clinical data, including neurological complications, were collected daily during hospitalization. Neurological outcome was evaluated 30 days after the event by using the Glasgow outcome scale. Patients were assigned to 1 of 3 groups according to intraventricular bleeding: Control, no intraventricular bleeding; LR 1, intraventricular bleeding with LeRoux scale scores of 1 to 8; or LR 2, intraventricular bleeding with LeRoux scale scores >8. RESULTS: There were no significant differences among groups concerning age, mean blood pressure, and time from onset to brain CT scan. Patients with greater intraventricular bleeding presented lower initial Glasgow coma scale scores, increased ventricular index and width of temporal horns, increased number of clinical and neurological complications, and longer hospitalization. Furthermore, their relative risk for unfavorable clinical outcome was 1.9 (95% confidence interval 1.25-2.49). CONCLUSION: Intraventricular bleeding with a LeRoux scale score >8 appears to have a negative effect on deep spontaneous intraparenchymal cerebral hemorrhage of small volume.





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Extent of Surgical Resection Predicts Seizure Freedom in Low-Grade Temporal Lobe Brain Tumors

BACKGROUND: Achieving seizure control in patients with low-grade temporal lobe gliomas or glioneuronal tumors remains highly underappreciated, because seizures are the most frequent presenting symptom and significantly impact patient quality-of-life. OBJECTIVE: To assess how the extent of temporal lobe resection influences seizure outcome. METHODS: We performed a quantitative, comprehensive systematic literature review of seizure control outcomes in 1181 patients with epilepsy across 41 studies after surgical resection of low-grade temporal lobe gliomas and glioneuronal tumors. We measured seizure-freedom rates after subtotal resection vs gross-total lesionectomy alone vs tailored resection, including gross-total lesionectomy with hippocampectomy and/or anterior temporal lobe corticectomy. RESULTS: Included studies were observational case series, and no randomized, controlled trials were identified. Although only 43% of patients were seizure-free after subtotal tumor resection, 79% of individuals were seizure-free after gross-total lesionectomy (OR = 5.00, 95% confidence interval [CI]: 3.33-7.14). Furthermore, tailored resection with hippocampectomy plus corticectomy conferred additional benefit over gross-total lesionectomy alone, with 87% of patients achieving seizure freedom (OR = 1.82, 95% CI: 1.23-2.70). Overall, extended resection with hippocampectomy and/or corticectomy over gross-total lesionectomy alone significantly predicted seizure freedom (OR = 1.18, 95% CI: 1.11-1.26). Age <18 years and mesial temporal location also prognosticated favorable seizure outcome. CONCLUSION: Gross-total lesionectomy of low-grade temporal lobe tumors results in significantly improved seizure control over subtotal resection. Additional tailored resection including the hippocampus and/or adjacent cortex may further improve seizure control, suggesting dual pathology may sometimes allow continued seizures after lesional excision.





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Clinical Factors Associated With Outcome in Chronic Subdural Hematoma: A Retrospective Cohort Study

BACKGROUND: Chronic subdural hematoma (CSDH) is commonly seen in neurosurgical practice, and the incidence is increasing. Treatment results are highly variable with respect to recurrences and complications. OBJECTIVE: To report our single-center experience with the surgical treatment of CSDH in patients on preoperative corticosteroids and to assess possible predictors of outcome. METHODS: The medical reports of 496 consecutive patients with CSDHs treated with burr hole craniostomy were analyzed retrospectively. Patient demographics, medication, hematoma, treatment characteristics, and laboratory values were scored in relation to outcome. Data were analyzed with the χ2 test, independent t test, and multivariate backward regression. RESULTS: Mean age was 71.5 ± 13.3 years (range, 18.6-95.4 years); the male-to-female ratio was 3:1. A decreased Glasgow Coma Scale (GCS) was observed in 63.1%, and GCS motor score on admission was < 6 in 25.2%. Recurrence and mortality rates were 11.9% and 5.3%, respectively. Multivariate analysis showed a longer period of preoperative dexamethasone administration (odds ratio [OR], 0.93 per day; P = .02), GCS motor score within 1 week after surgery of 6 (OR, 0.54; P = .02), postoperative complications (OR, 5.3; P < .001), and a left-sided hematoma (OR, 0.42; P = 0.010) to be significantly related to recurrence risk. CONCLUSION: The present data suggest that in surgical treatment of CSDH with burr hole craniostomy, extended preoperative corticosteroid administration is associated with a lower recurrence rate. The use of corticosteroids does not seem to be related to a higher incidence of complications and treatment-related death compared with the current literature.





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Decompressive Craniectomy in Children: Single-Center Series and Systematic Review

BACKGROUND: Decompressive craniectomy (DC) is performed as a life-saving procedure in patients with intractably increased intracranial pressure after traumatic brain injury, bleeding, cerebral infarction, or brain swelling of other causes. However, the application of DC is as controversial in the pediatric population as it is in adults. OBJECTIVE: To find factors influencing the outcome in pediatric patients who underwent DC because of sustained high intracranial pressure. METHODS: Between April 2000 and December 2009, 34 pediatric patients (age 0-18 years) underwent DC. Patients were stratified according to the indication for DC. Outcome was assessed according to the modified Rankin Scale score at 6 months. MEDLINE was searched for published studies or reports of DC in pediatric patients to gain a larger population. Two reviewers independently extracted data. RESULTS: Literature data, including the current series, revealed a total of 172 pediatric patients. Overall, a favorable outcome was achieved in 106 of 172 patients (62%). A favorable outcome was achieved in 25 of 36 patients without traumatic brain injury vs 81 of 136 patients with traumatic brain injury (69% vs 60%). Patients without signs of cerebral herniation had a better outcome than patients with unilateral or bilateral dilated pupils (73% vs 60% vs 45%, respectively). CONCLUSION: The current data indicate that DC in children with traumatic or nontraumatic brain swelling might be warranted, regardless of the underlying cause. Despite mydriasis, a favorable outcome might be achieved in a significant number of pediatric patients. Nevertheless, careful individual decision making is needed for each patient, especially when signs of cerebral herniation have persisted for a long time.





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Endoscopic Treatment of Isolated Fourth Ventricle: Clinical and Radiological Outcome

BACKGROUND: Treatment of an isolated fourth ventricle should be considered when clinical symptoms or a significant mass effect occur. OBJECTIVE: To report clinical and radiographic outcomes after endoscopic transaqueductal or transcisternal stent placement into the fourth ventricle. METHODS: In 19 patients (age, 34th week of gestation-20 years; median age, 17.5 months), 22 endoscopic procedures were performed. Either an aqueductoplasty or, in cases with a supratentorially extended fourth ventricular component, an interventricular fenestration was performed. In all patients, a stent connected to the cerebrospinal fluid--diverting shunt was placed through the fenestration. Surgical complications and radiological and clinical outcomes are reported. RESULTS: All 19 patients had a mean follow-up of 26.9 ± 18.2 months. No persisting neurological complications were observed; 27.3% of patients experienced complete resolution of presenting symptoms, whereas 68.3% demonstrated partial resolution. Symptoms with short duration (< 4 weeks) resolved completely, whereas long-standing symptoms partially improved. Short-term shunt complications (n = 2; insufficient catheter placement and subdural hygroma) and a need for long-term stent revisions (n = 3; stent retraction and shunt revision for other causes) were observed. The mean fourth ventricular volume was reduced after surgery (44.2 ± 25.8 to 23.1 ± 21.9 mL; P < .01). Pontine diameter increased from 0.9 ± 0.3 to 1.2 ± 0.3 cm (P < .01) after surgery. Both effects were still demonstrated on later radiological follow-up of 24.4 ± 14.2 months (fourth ventricular size, 24.7 ± 28.1 mL; P < .01; pontine diameter, 1.3 ± 0.3 cm; P < .01). CONCLUSION: The clinical and radiological outcomes after endoscopic aqueductoplasty and interventriculostomy in children with an isolated fourth ventricle indicate that this procedure is feasible, effective, and safe.





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Quality of Life, Anxiety, and Depression in Patients With an Unruptured Intracranial Aneurysm With o

BACKGROUND: Awareness of having an unruptured intracranial aneurysm can affect quality of life and provoke feelings of anxiety and depression, even in treated patients, because of fear of recurrence of aneurysms. OBJECTIVE: To assess quality of life and feelings of anxiety and depression in patients with an unruptured aneurysm with or without aneurysm occlusion. METHODS: We sent postal questionnaires (Medical Outcomes Study Short Form-36, EuroQol-5D, Hospital Anxiety and Depression Scale) to 229 patients with an unruptured aneurysm and no history of subarachnoid hemorrhage identified from our database. Group mean scores and corresponding 95% confidence intervals (CIs) were compared between the no intervention group and the intervention group and with a reference population using the Student t test and χ2 test. RESULTS: In total, 173 questionnaires (76%) were returned. There were no statistically significant differences in quality of life and anxiety and depression levels between patients with and those without aneurysm occlusion. Patients in the no intervention group compared with the reference population had a significantly reduced quality of life in the physical function (−10.7; 95% CI, −16.2 to −5.1), role physical (−15.8; 95% CI, −25.5 to −6.0), role emotional (−9.9; 95% CI, −18.7 to −1.1), vitality (−7.2; 95% CI, −12.1 to −2.4), and general health (−11.6; 95% CI, −16.2 to −6.9) domains. Results were comparable in the intervention group except for the role emotional domain, which was not statistically significantly reduced. CONCLUSION: Patients with an unruptured aneurysm have a reduced quality of life compared with the reference population, mainly in physical domains, but without an apparent effect on mood or anxiety. The extent of reduction in quality of life is similar in patients with and without aneurysm occlusion.





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NICE backs new oral anticoagulant for stroke prevention

The National Institute for Health and Clinical Excellence (NICE) has recommended the oral anticoagulant dabigatran etexilate (Pradaxa) for the prevention of stroke and systemic embolism in patients...





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