Wednesday, May 30, 2012

Music is changing your brain

Music -- it's all around us, and in us. Scientists are discovering the remarkable ways that music can give us pleasure, implant itself in our memories, and even alter our brains.





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Neurocritical care education during neurology residency: AAN survey of US program directors

Objective:

Limited information is available regarding the current state of neurocritical care education for neurology residents. The goal of our survey was to assess the need and current state of neurocritical care training for neurology residents.

Methods:

A survey instrument was developed and, with the support of the American Academy of Neurology, distributed to residency program directors of 132 accredited neurology programs in the United States in 2011.

Results:

A response rate of 74% (98 of 132) was achieved. A dedicated neuroscience intensive care unit (neuro-ICU) existed in 64%. Fifty-six percent of residency programs offer a dedicated rotation in the neuro-ICU, lasting 4 weeks on average. Where available, the neuro-ICU rotation was required in the vast majority (91%) of programs. Neurology residents' exposure to the fundamental principles of neurocritical care was obtained through a variety of mechanisms. Of program directors, 37% indicated that residents would be interested in performing away rotations in a neuro-ICU. From 2005 to 2010, the number of programs sending at least one resident into a neuro-ICU fellowship increased from 14% to 35%.

Conclusions:

Despite the expansion of neurocritical care, large proportions of US neurology residents have limited exposure to a neuro-ICU and neurointensivists. Formal training in the principles of neurocritical care may be highly variable. The results of this survey suggest a charge to address the variability of resident education and to develop standardized curricula in neurocritical care for neurology residents.






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US media organisation uses Facebook to build interest in patient harm

ProPublica (www.propublica.org/about/), a not for profit media organisation based in New York, has launched a Facebook page (www.facebook.com/groups/209024949216061/ ) for patients who have been...





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Sunday, May 27, 2012

Magnesium No Help for Brain Bleed (CME/CE)

(MedPage Today) -- An infusion of magnesium does not improve outcomes for patients with an aneurysmal subarachnoid hemorrhage, a randomized trial showed.





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Resolution of Intraventricular Hemorrhage Varies by Ventricular Region and Dose of Intraventricular

Background and Purpose—

The Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR IVH) program is assessing the efficacy of intraventricular recombinant tissue-type plasminogen activator (rtPA) for spontaneous intraventricular hemorrhage (IVH). This subanalysis assesses the effect of dose of rtPA by region on clearance of IVH.

Methods—

Sixty-four patients within 12 to 24 hours of spontaneous IVH were randomized to placebo or 0.3 mg, 1 mg, or 3 mg of rtPA twice daily through an extraventricular drain. Twelve subregions of the ventricles were scored from 0 to 4. Effect of dose on IVH clearance to 50% of baseline score was compared by survival analysis for all regions combined and by subregion. Models including ventricular region, dose, and baseline score were compared by Cox proportional hazards.

Results—

IVH score reduced faster across all regions with increasing rtPA dose (clearance to 50%: log-rank P<0.0001; placebo—11.43 days, 95% CI, 5.68–17.18; 0.3 mg—3.19 days, 1.00–5.38; 1 mg—3.54 days, 0.45–6.64; 3 mg—2.59 days, 1.72–3.46). In the combined models, dose and baseline score were independently associated with reduction in IVH score, which was quickest in the midline ventricles, then the anterior half of the lateral ventricles and slowest in the posterior half of the lateral ventricles (clearance to 50%: P<0.0001; rtPA dose: hazard ratio, 1.47, 1.30–1.67; midline versus anterolateral hazard ratio, 1.71, 1.08–2.71; midline versus posterolateral hazard ratio, 4.05, 2.46–6.65; baseline score hazard ratio, 0.96, 0.91–1.01) with a significant interaction between dose and ventricular region (P=0.005).

Conclusions—

rtPA accelerates resolution of IVH. This effect is dose-dependent, is greatest in the midline ventricles, and least in the posterolateral ventricles.

Clinical Trial Registration—

URL: www.clinicaltrials.gov. Unique identifier: NCT00650858.






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Application of the ABCD2 Score to Identify Cerebrovascular Causes of Dizziness in the Emergency Depa

Background and Purpose—

Dizziness can herald a cerebrovascular event. The ABCD2 score predicts the risk of stroke after transient ischemic attack partly by distinguishing transient ischemic attack from mimics. We evaluated whether this score would also identify cerebrovascular events among emergency department patients with dizziness.

Methods—

We retrospectively identified consecutive adults presenting to a university emergency department with a primary symptom of dizziness, vertigo, or imbalance. Two neurologists independently reviewed medical records to determine whether the presenting symptom was caused by a cerebrovascular event (ischemic stroke, transient ischemic attack, or intracranial hemorrhage). ABCD2 scores were then assigned using clinical information from the medical record. The ability of the score to discriminate between patients with cerebrovascular events and those with other diagnoses was quantified using the c statistic.

Results—

Among 907 dizzy patients (mean age, 59 years; 58% female), 37 (4.1%) had a cerebrovascular cause, the majority of which were ischemic strokes (n=24). The median ABCD2 score was 3 (interquartile range, 3–4). The ABCD2 score predicted ultimate diagnosis of a cerebrovascular event (c statistic, 0.79; 95% CI, 0.73–0.85). Only 5 of 512 (1.0%) patients with a score of ≤3 had a cerebrovascular event compared to 25 of 369 patients (6.8%) with a score of 4 or 5 and 7 of 26 patients (27.0%) with a score of 6 or 7.

Conclusions—

The ABCD2 score may provide useful information on dizzy emergency department patients at low-risk for having a cerebrovascular diagnosis and may aid frontline providers in acute management if validated prospectively.






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Individual Patient Data Subgroup Meta-Analysis of Surgery for Spontaneous Supratentorial Intracerebr

Background and Purpose—

By 2010 there had been 14 published trials of surgery for intracerebral hemorrhage reported in systematic reviews or to the authors, but the role and timing of operative intervention remain controversial and the practice continues to be haphazard. This study attempted to obtain individual patient data from each of the 13 studies published since 1985 to better define groups of patients that might benefit from surgery.

Methods—

Authors of identified published articles were approached by mail, e-mail, and at conferences and invited to take part in the study. Data were obtained from 8 studies (2186 cases). Individual patient data included patient's age, Glasgow Coma Score at presentation, volume and site of hematoma, presence of intraventricular hemorrhage, method of evacuation, time to randomization, and outcome.

Results—

Meta-analysis indicated that there was improved outcome with surgery if it was undertaken within 8 hours of ictus (P=0.003), or the volume of the hematoma was 20 to 50 mL (P=0.004), or the Glasgow Coma Score was between 9 and 12 (P=0.0009), or the patient was aged between 50 and 69 years (P=0.01). In addition, there was some evidence that more superficial hematomas with no intraventricular hemorrhage might also benefit (P=0.09).

Conclusions—

There is evidence that surgery is of benefit if undertaken early before the patient deteriorates. This work identifies areas for further research. Ongoing studies in subgroups of patients such as the Surgical Trial in Lobar Intracerebral Hemorrhage (STICH II) will confirm whether these interpretations can be replicated.






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Stereotactic radiosurgery for arteriovenous malformations after embolization: a case-control study

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-11, Ahead of Print.
Object In this paper the authors' goal was to define the long-term benefits and risks of stereotactic radiosurgery (SRS) for patients with arteriovenous malformations (AVMs) who underwent prior embolization. Methods Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 120 patients underwent embolization followed by SRS. In this series, 64 patients (53%) had at least one prior hemorrhage. The median number of embolizations varied from 1 to 5. The median target volume was 6.6 cm3 (range 0.2–26.3 cm3). The median margin dose was 18 Gy (range 13.5–25 Gy). Results After embolization, 25 patients (21%) developed symptomatic neurological deficits. The overall rates of total obliteration documented by either angiography or MRI were 35%, 53%, 55%, and 59% at 3, 4, 5, and 10 years, respectively. Factors associated with a higher rate of AVM obliteration were smaller target volume, smaller maximum diameter, higher margin dose, timing of embolization during the most recent 10-year period (1997–2006), and lower Pollock-Flickinger score. Nine patients (8%) had a hemorrhage during the latency period, and 7 patients died of hemorrhage. The actuarial rates of AVM hemorrhage after SRS were 0.8%, 3.5%, 5.4%, 7.7%, and 7.7% at 1, 2, 3, 5, and 10 years, respectively. The overall annual hemorrhage rate was 2.7%. Factors associated with a higher risk of hemorrhage after SRS were a larger target volume and a larger number of prior hemorrhages. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 3 patients (2.5%) after SRS, and 1 patient had delayed cyst formation 210 months after SRS. No patient died of AREs. A larger 12-Gy volume was associated with higher risk of symptomatic AREs. Using a case-control matched approach, the authors found that patients who underwent embolization prior to SRS had a lower rate of total obliteration (p = 0.028) than patients who had not undergone embolization. Conclusions In this 20-year experience, the authors found that prior embolization reduced the rate of total obliteration after SRS, and that the risks of hemorrhage during the latency period were not affected by prior embolization. For patients who underwent embolization to volumes smaller than 8 cm3, success was significantly improved. A margin dose of 18 Gy or more also improved success. In the future, the role of embolization after SRS should be explored.





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Outcome after severe brain trauma due to acute subdural hematoma

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-10, Ahead of Print.
Object In this paper, the authors' goal was to identify factors contributing to outcomes after severe traumatic brain injury (TBI) due to acute subdural hematoma (SDH). Methods Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data regarding accident, treatment, and outcomes were collected. Data sets from patients who had severe TBI (Glasgow Coma Scale score < 9) and acute SDH were selected. Six-month outcomes were classified as "favorable" if the Glasgow Outcome Scale (GOS) scores were 5 or 4, and they were classified as "unfavorable" if GOS scores were 3 or less. The Rotterdam score was used to classify CT findings, and the scores published by Hukkelhoven et al. were used to estimate the predicted rates of death and of unfavorable outcomes. Univariate (Fisher exact test, t-test, chi-square test) and multivariate (logistic regression) statistics were used to identify factors associated with hospital mortality and favorable outcome. Results Of the 738 patients with severe TBI, 360 (49%) had acute SDH. Of these, 168 (46.7%) died in the hospital, 67 (18.6%) survived with unfavorable outcome, and 116 (32.2%) survived with favorable outcome. Long-term outcome was unknown in 9 survivors (2.5%). Mortality rates predicted by the Rotterdam CT score showed good correlation with observed mortality rates. According to the Hukkelhoven scores, observed/predicted ratios for mortality and unfavorable outcome were 1.09 and 1.02, respectively. Conclusions Age, severity of TBI, and neurological status were the main factors influencing outcomes after severe TBI due to acute SDH. Nonoperative management was associated with significantly higher mortality.





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Music is changing your brain

Music -- it's all around us, and in us. Scientists are discovering the remarkable ways that music can give us pleasure, implant itself in our memories, and even alter our brains.





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A creative life is a healthy life

The link between creativity and health is well established by research. Creating helps make people happier, less anxious and more resilient.





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Wednesday, May 23, 2012

Steroids Help Unfreeze Bell's Palsy (CME/CE)

(MedPage Today) -- Early treatment with the corticosteroid prednisolone appeared to significantly reduce mild to moderate sequelae in Bell's palsy, according a large Scandinavian trial.





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A New Technology for Detecting Cerebral Blood Flow: A Comparative Study of Ultrasound Tagged NIRS an

Abstract  
There is a need for real-time non-invasive, continuous monitoring of cerebral blood flow (CBF) during surgery, in intensive care units and clinical research. We investigated a new non-invasive hybrid technology employing ultrasound tagged near infrared spectroscopy (UT-NIRS) that may estimate changes in CBF using a cerebral blood flow index (CFI). Changes over time for UT-NIRS CFI and 133Xenon single photon emission computer tomography (133Xe-SPECT) CBF data were assessed in 10 healthy volunteers after an intravenous bolus of acetazolamide. UT-NIRS CFI was measured continuously and SPECT CBF was measured at baseline, 15 and 60 min after acetazolamide. We found significant changes over time in CFI by UT-NIRS and CBF by SPECT after acetazolamide (P ≤ 0.001). Post hoc tests showed a significant increase in CFI (P = 0.011) and SPECT CBF (P < 0.001) at 15 min after acetazolamide injection. There was a significant correlation between CFI and SPECT CBF values (r = 0.67 and P ≤ 0.033) at 15 min, but not at 60 min (P ≥ 0.777). UT-NIRS detected an increase in CFI following an acetazolamide bolus, which correlated with CBF measured with 133Xe-SPECT. This study demonstrates that UT-NIRS technology may be a promising new technique for non-invasive and real-time bedside CBF monitoring.

  • Content Type Journal Article
  • Category Take Notice Technology
  • Pages 1-7
  • DOI 10.1007/s12028-012-9720-2
  • Authors
    • Henrik W. Schytz, Danish Headache Center and Department of Neurology, Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, 2600 Glostrup, Denmark
    • Song Guo, Danish Headache Center and Department of Neurology, Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, 2600 Glostrup, Denmark
    • Lars T. Jensen, Clinical Physiology and Nuclear Medicine, Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
    • Moshe Kamar, Ornim Medical Ltd., Lod, Israel
    • Asaph Nini, Ornim Medical Ltd., Lod, Israel
    • Daryl R. Gress, Department of Neurology and Neurosurgery, University of Virginia, Charlottesville, VA, USA
    • Messoud Ashina, Danish Headache Center and Department of Neurology, Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, 2600 Glostrup, Denmark





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Tired Surgical Residents May Up Error Risk

A small study suggests surgeons in training are still tired enough to raise their risk of making significant errors, despite new guidelines limiting their work hours.
Source: Reuters Health





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New Guide on Stroke Prevention in HF (CME/CE)

(MedPage Today) -- BELGRADE, Serbia -- Unless there are other indications, heart failure patients who don't have atrial fibrillation shouldn't routinely get antithrombotic therapy, European Society of Cardiology groups warned.





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Statin Use Linked to Better Post-Stroke Discharge Status

A new study finds that patients taking a statin before hospitalization, who stay on the drug while in hospital, are more likely to survive and be discharged home.
Medscape Medical News





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Long-term outcome of 114 children with cerebral aneurysms

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 6, Page 636-645, June 2012.
Object Population-based data on pediatric patients with aneurysms are limited. The aim of this study is to clarify the characteristics and long-term outcomes of pediatric patients with aneurysms. Methods All pediatric patients (≤ 18 years old) with aneurysms among the 8996 aneurysm patients treated at the Department of Neurosurgery in Helsinki from 1937 to 2009 were followed from admission to the end of 2010. Results There were 114 pediatric patients with 130 total aneurysms during the study period. The mean patient age was 14.5 years (range 3 months to 18 years). The male:female ratio was 3:2. Eighty-nine patients (78%) presented with subarachnoid hemorrhage. The majority of the aneurysms (116 [89%]) were in the anterior circulation, and the most common location was the internal carotid artery bifurcation (36 [28%]). The average aneurysm diameter was 11 mm (range 2–55 mm) with 16 giant aneurysms (12%). Eighty aneurysms (62%) were treated microsurgically, and 37 (28%) were treated conservatively due to poor medical and neurological status of the patient or due to technical reasons during the early years of the patient series. No connective tissue disorders common to pediatric aneurysm patients were diagnosed in this series, with the exception of 1 patient with tuberous sclerosis complex. The mean follow-up duration was 24.8 years (range 0–55.8 years). At the end of follow-up, 71 patients (62%) had a good outcome, 3 (3%) were dependent, and 40 (35%) had died. Twenty-seven deaths (68%) were assessed to be aneurysm-related. Factors correlating with a favorable long-term outcome were good neurological condition of the patient on admission, aneurysm location in the anterior circulation, complete aneurysm closure, and absence of vasospasm. Six patients developed symptomatic de novo aneurysms after a median of 25 years (range 11–37 years). Fourteen patients (12%) had a family history of aneurysms. There was no increased incidence for cardiovascular diseases in long-term follow-up. Conclusions Most aneurysms were ruptured and of medium size. Internal carotid artery bifurcation was the most frequent location of the aneurysms. There was a male predominance of pediatric patients with aneurysms. Most patients experienced good recovery, with 91% of the long-term survivors living at home independently without assistance and meaningfully employed. Altogether, almost a third of these patients finished high school and one-fifth had a college or university degree. Pediatric patients had a tendency to develop de novo aneurysms.





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Deep Brain Stimulation May Improve Symptoms in Alzheimer's

Deep brain stimulation, a therapy already used to alleviate the symptoms of Parkinson's disease, may also be useful in treating some patients with early signs of Alzheimer's disease.
Medscape Medical News





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Sleep Apnea Hurts Kids' Brain Function (CME/CE, with video)

SAN FRANCISCO (MedPage Today) -- Obstructive sleep apnea in children produces chemical changes in brain areas associated with learning, memory, and executive function, a researcher said here.





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Monday, May 21, 2012

Factors influencing intracranial pressure monitoring guideline compliance and outcome after severe t

Objective: To determine adherence to Brain Trauma Foundation guidelines for intracranial pressure monitoring after severe traumatic brain injury, to investigate if characteristics of patients treated according to guidelines (ICP+) differ from those who were not (ICP-), and whether guideline compliance is related to 6-month outcome. Design: Observational multicenter study. Patients: Consecutive severe traumatic brain injury patients (≥16 yrs, n = 265) meeting criteria for intracranial pressure monitoring. Measurements and Main Results: Data on demographics, injury severity, computed tomography findings, and patient management were registered. The Glasgow Outcome Scale Extended was dichotomized into death (Glasgow Outcome Scale Extended = 1) and unfavorable outcome (Glasgow Outcome Scale Extended 1–4). Guideline compliance was 46%. Differences between the monitored and nonmonitored patients included a younger age (median 44 vs. 53 yrs), more abnormal pupillary reactions (52% vs. 32%), and more intracranial pathology (subarachnoid hemorrhage 62% vs. 44%; intraparenchymal lesions 65% vs. 46%) in the ICP+ group. Patients with a total intracranial lesion volume of ~150 mL and a midline shift of ~12 mm were most likely to receive an intracranial pressure monitor and probabilities decreased with smaller and larger lesions and shifts. Furthermore, compliance was low in patients with no (Traumatic Coma Databank score I −10%) visible intracranial pathology. Differences in case-mix resulted in higher a priori probabilities of dying (median 0.51 vs. 0.35, p < .001) and unfavorable outcome (median 0.79 vs. 0.63, p < .001) in the ICP+ group. After correction for baseline and clinical characteristics with a propensity score, intracranial pressure monitoring guideline compliance was not associated with mortality (odds ratio 0.93, 95% confidence interval 0.47–1.85, p = .83) nor with unfavorable outcome (odds ratio 1.81, 95% confidence interval 0.88–3.73, p = .11). Conclusions: Guideline noncompliance was most prominent in patients with minor or very large computed tomography abnormalities. Intracranial pressure monitoring was not associated with 6-month outcome, but multiple baseline differences between monitored and nonmonitored patients underline the complex nature of examining the effect of intracranial pressure monitoring in observational studies.





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Lifetime Prevalence of Sleepwalking Almost 30%

Use of hypnotic sleeping medications doesn't significantly increase risk for sleepwalking, but comorbid major depression, obsessive-compulsive disorder, or alcohol abuse does.
Medscape Medical News





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Famous 1848 Case Of A Man Who Survived A Terrible Brain Injury Has Modern Parallel

Poor Phineas Gage. In 1848, the supervisor for the Rutland and Burlington Railroad in Vermont was using a 13-pound, 3-foot-7-inch rod to pack blasting powder into a rock when he triggered an explosion that drove the rod through his left cheek and out of the top of his head. As reported at the time, the rod was later found, "smeared with blood and brains...





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Intracellular Signaling Pathways and Size, Shape, and Rupture History of Human Intracranial Aneurysm

BACKGROUND: Size and morphological features are associated with intracranial aneurysm (IA) rupture. The cellular mechanisms of IA development and rupture are poorly known. OBJECTIVE: We studied the expression and phosphorylation of different intracellular signaling molecules in the IA wall compared with IA morphological features to understand better the cellular pathways involved in IA development and wall degeneration. METHODS: Nine ruptured and 17 unruptured human IA samples were collected intraoperatively. The expression levels and phosphorylation state of 3 mitogen-activated protein kinases (c-Jun N-terminal kinase [JNK], p38, extracellular signal-regulated kinase [ERK]), Bcl-2 antagonist of cell death (Bad), mammalian target of rapamycin (mTOR), cyclic AMP response element binding protein (CREB), and Akt were determined by Western blotting. The localization of signaling proteins was determined by immunofluorescence. From 3-dimensional segmentation of computed tomography angiographic data, size and shape indexes were calculated. RESULTS: We found a 5-fold difference in phospho-Bad levels between ruptured and unruptured IAs. Phospho-mTOR was downregulated 2.5-fold in ruptured IAs. Phospho-p54 JNK, phospho-p38, and phospho-Akt levels correlated positively with IA size. Phospho-CREB levels were significantly associated with nonsphericity and ellipticity indexes. Phospho-Akt and phospho-p38 correlated negatively with undulation index. CONCLUSION: The signaling pathway profile (apoptosis, cell proliferation, stress signaling) differs between ruptured and unruptured IAs and is associated with IA geometry. Our results increase the knowledge of IA development and wall degeneration. ABBREVIATIONS: AR, aspect ratio αSMA, α-smooth muscle actin Bad, Bcl-2 antagonist of cell death BF, bottleneck factor CREB, cyclic AMP response element binding protein EI, ellipticity index ERK, extracellular signal-regulated kinase IA, intracranial aneurysm JNK, c-Jun N-terminal kinase MAPK, mitogen-activated protein kinase mTOR, mammalian target of rapamycin NSI, nonsphericity index SMC, smooth muscle cell UI, undulation index VSMC, vascular smooth muscle cell





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Shortfalls in published neurosurgical literature

Publication year: 2012
Source:Journal of Clinical Neuroscience
Mohammad Sami Walid, Joe Sam Robinson, Joe Sam Robinson
Expenditure related to neurosurgery has increased unevenly since the early 1990s. In this study we explored the literature by which clinical evidence is obtained to better direct neurosurgical practice. We searched different types of neurosurgery literature and four major neurosurgical procedures (excision of brain lesion, cerebral aneurysm clipping/coiling, discectomy, spine fusion) written in English on PubMed from 1996, the year of its launch, using the keyword "cost". Only a small and static portion of the neurosurgical literature was indexed as level I clinical evidence (randomized controlled trials), with a lack of cost appraisal in the outcome analysis of neurosurgical interventions. By way of rectification, a major increase in funding of grade I studies with cost analysis, and the requirement by peer-reviewed journals of a cost–benefit analysis, would promote the quality of clinical research yielding unquestionable advantage on national healthcare practice.






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The Cognitive Effects Of Head Impacts In Athletics Investigated By Researchers

Dartmouth faculty and students played prominent roles in a recent study on the cognitive effects of head impacts among student athletes. Tested at the beginning and end of one season, 22 percent of those students who participated in contact sports scored significantly lower in memory and learning skills than expected, as opposed to only 4 percent of non-contact sport athletes...





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Sunday, May 20, 2012

Brain MRI abnormalities in Brazilian patients with neuromyelitis optica

Publication year: 2012
Source:Journal of Clinical Neuroscience
Cíntia Elias Pires, Christianne Martins Correa da Silva, Fernanda Cristina Rueda Lopes, Fabiola Rachid Malfetano, Valéria C.S.R. Pereira, Tadeu Kubo, Paulo R.V. Bahia, Soniza Vieira Alves-Leon, Emerson L. Gasparetto
Brain abnormalities in neuromyelitis optica (NMO) have been reported previously, but the pathophysiological mechanism and clinical relevance of these abnormalities are poorly understood. We assessed the prevalence and patterns of brain MRI abnormalities in a Brazilian cohort of patients with NMO. Conventional brain MRI and medical records from 24 Brazilian patients with NMO were retrospectively evaluated. Brain MRI were classified into four subgroups: normal, non-specific lesions, multiple sclerosis (MS)-like lesions, and typical lesions. Brain lesions were detected in 19 patients (79.2%). Fourteen patients (58.3%) had non-specific lesions, three (12.5%) had MS-like lesions, and two (8.3%) had typical lesions. Differences between these subgroups with respect to the Expanded Disability Status Scale (EDSS) scores (p =0.86) were not significant. This study demonstrates a high prevalence of brain abnormalities in Brazilian patients with NMO; however, we did not find a significant relationship between these abnormalities and EDSS scores.






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Saturday, May 19, 2012

Stroke Victims Use Minds to Control Robotic Arms (CME/CE, with video)

(MedPage Today) -- Controlling robotic limbs with neural impulses appears possible, according to preliminary results in two patients left with no functional control of their arms after a brainstem stroke.





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Tertiary mechanisms of brain damage: a new hope for treatment of cerebral palsy?

Publication year: 2012
Source:The Lancet Neurology, Volume 11, Issue 6
Bobbi Fleiss, Pierre Gressens
Cerebral palsy is caused by injury or developmental disturbances to the immature brain and leads to substantial motor, cognitive, and learning deficits. In addition to developmental disruption associated with the initial insult to the immature brain, injury processes can persist for many months or years. We suggest that these tertiary mechanisms of damage might include persistent inflammation and epigenetic changes. We propose that these processes are implicit in prevention of endogenous repair and regeneration and predispose patients to development of future cognitive dysfunction and sensitisation to further injury. We suggest that treatment of tertiary mechanisms of damage might be possible by various means, including preventing the repressive effects of microglia and astrocyte over-activation, recapitulating developmentally permissive epigenetic conditions, and using cell therapies to stimulate repair and regeneration Recognition of tertiary mechanisms of damage might be the first step in a complex translational task to tailor safe and effective therapies that can be used to treat the already developmentally disrupted brain long after an insult.






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Can Twitter predict disease outbreaks?

In March 2011 the most powerful earthquake and tsunami in Japan's history caused horrifying devastation on the country's northeastern coast. Along with a massive loss of life, the entire...





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Stereotactic Radiosurgery for Arteriovenous Malformations Located in Deep Critical Regions

BACKGROUND: Radiosurgery is widely used to treat deep eloquent arteriovenous malformations (AVMs). OBJECTIVE: To evaluate how anatomic location, AVM size, and treatment parameters define outcome. METHODS: Retrospective analysis of 356 thalamic/basal ganglia and 160 brainstem AVMs treated with gamma knife radiosurgery. RESULTS: Median volume was 2 cm3 (range, 0.02-50) for supratentorial and 0.5 cm3 (range, 0.01-40) for brainstem AVMs; the marginal treatment doses were 17.5 to 25 Gy. After single treatment, obliteration was achieved in 65% of the brainstem, in 69% of the supratentorial, and 40% of the peritectal AVMs. Obliteration of lesions <4 cm3 was better in the brainstem (70%) and in the supratentorium (80%), but not in the peritectal region (40%). Complications were rare (6%–15%) and mild (≤modified Rankin scale [MRS] 2). Rebleed rate increased with size, but was not higher than before treatment. AVMs >4 cm3 in the brainstem were treated with unacceptable morbidity and low cure rate. Obliteration of large supratentorial AVMs was 65% to 47% with more complications ≥MRS3. Repeat radiosurgical treatment led to obliteration in 66% of the cases with minor morbidity. CONCLUSION: Deep eloquent AVMs <4 cm3 can be treated safely and effectively with radiosurgery. Obliteration of peritectal AVMs is significantly lower after a single treatment. However, morbidity is low, and repeat treatment leads to good obliteration. Radiosurgical treatment >4 cm3 in the brainstem is not recommended. Supratentorial deep AVMs >8 cm3 can be treated with radiosurgery with higher risk and lower obliteration rate. However, these lesions are difficult to treat with other treatment modalities, and a 50% success rate makes radiosurgery a good alternative even in this challenging group. ABBREVIATIONS: AVM, arteriovenous malformations MRS, modified Rankin scale





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Cerebral Bypasses for Complex Aneurysms and Tumors: Long-term Results and Graft Management Strategi

BACKGROUND: Various techniques of cerebral bypasses are used to treat aneurysms and tumors. OBJECTIVE: To study long-term clinical and radiological outcome of various bypass types and to analyze techniques used in the management of long-term graft problems. METHODS: A consecutive series of patients who underwent revascularization during a 5-year period were analyzed for indications, graft patency, and neurological outcomes. Potential risk factors for bypass problems and the management of bypass stenosis were studied. RESULTS: A total of 80 patients (69 with aneurysms and 11 with tumors) underwent 88 bypasses (59 extracranial-to-intracranial [EC-IC] bypasses [10 low flow, 49 high flow], 9 intracranial-to-intracranial [IC-IC] bypasses [3 long, 6 short], and 20 local bypasses), with mean radiological follow-up of 32 months (range, 1-53 months). At late follow-up, 5 of 9 (56%) IC-IC (5 short, 0 long grafts), 8 of 9 (90%) EC-IC low-flow, 44 of 48 (92%) EC-IC high-flow, and all local bypasses were patent. Four patients with EC-IC high-flow bypass occlusions were asymptomatic, but transient ischemic attacks were noted in 3 of 6 patients with graft stenosis. None of the risk factors evaluated were significantly predictive of EC-IC graft occlusions or stenosis. EC-IC HF graft stenoses were permanently corrected by microsurgery (n = 4) or endovascular surgery (n = 1). CONCLUSION: The EC-IC and local bypasses have higher long-term patency rates (91% and 100%) compared with IC-IC bypasses (66%, 0% long graft). Some EC-IC bypasses may occlude asymptomatically (9%) or develop graft stenosis (13%) over the long term. Microsurgical and endovascular surgical techniques have been developed to treat graft stenosis. ABBREVIATIONS: CTA, computed tomographic angiogram EC-IC, extracranial to intracranial bypass HF, high flow IADSA, intra-arterial digital subtraction angiogram IC-IC, intracranial to intracranial bypass ICA, internal carotid artery LF, low flow MCA, middle cerebral artery mRS, modified Rankin Scale OA, occipital artery PCA, posterior cerebral artery PCOM, posterior communicating artery PICA, posterior inferior cerebellar artery RAG, radial artery graft STA, superficial temporal artery SVG, saphenous vein graft TIA, transient ischemic attack





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Terminal Myelocystocele: Surgical Observations and Theory of Embryogenesis

BACKGROUND: The structural complexity of terminal myelocystocele (TMC) precludes a recognizable link to spinal cord development and therefore a plausible embryogenetic theory. OBJECTIVE: To demystify TMC using clinical, imaging, surgical, electrophysiological, and histopathological data and to propose a theory of embryogenesis. METHODS: Our series consisted of 4 newborns and 6 older children. All had preoperative magnetic resonance imagings and surgical repair of the myelocystocele with electrophysiological monitoring. RESULTS: TMC can be deconstructed into essential and nonessential features. Essential features are present in all TMCs and constitute the core malformation, comprising an elongated spinal cord extending extraspinally into a cerebrospinal fluid--filled cyst that is broadly adherent to the subcutaneous fat. The functional conus resides in the proximal cyst or within the intraspinal cord, and the caudal myelocystocele wall is nonfunctional fibroneural tissue. Nonessential features include variable measures of hydromyelia, caudal meningocele, and fat, present in only some patients. The core structure of TMC strikingly resembles a transitory stage of late secondary neurulation in chicks in which the cerebrospinal fluid--filled bleblike distal neural tube bulges dorsally to fuse with the surface ectoderm, before focal apoptosis detaches it from the surface and undertakes its final dissolution. We theorize that TMC results from a time-specific paralysis of apoptosis just before the dehiscence of the cystic distal cord from the future skin, thereby preserving the embryonic state. CONCLUSION: Besides tethering, the myelocystocele may show early rapid expansion causing precipitous deterioration. We recommend early repair with resection of the nonfunctional caudal cyst wall, reconstruction of the proximal neural placode, and duraplasty. ABBREVIATIONS: HH, Hamburger-Hamilton OEIS, omphalocele, bladder exstrophy, imperforate anus, and spinal anomaly TM, terminal myelocystocele TUNEL, terminal deoxynucleotidyl transferase--mediated deoxyuridine triphosphate nick-end labeling





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Stent-Assisted Coiling of Wide-Necked Aneurysms in the Setting of Acute Subarachnoid Hemorrhage: Ex

BACKGROUND: Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications. OBJECTIVE: To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms. METHODS: A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade ≥ III received a ventriculostomy before endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required periprocedural thrombolysis. RESULTS: Of the aneurysms, 66.2% arose within the anterior circulation; 69.2% of patients presented with hydrocephalus or a Hunt and Hess grade ≥ III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1% of patients, and the overall mortality rate was 16.9%. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7%) or intraoperative in-stent thrombosis (5 patients, 7.7%). Three (4.6%) patients had a fatal hemorrhage. CONCLUSION: Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms. ABBREVIATIONS: ACT, activated clotting time GOS, Glasgow outcome scale MCA, middle cerebral artery SAH, subarachnoid hemorrhage





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Role of Fever in Ventriculoperitoneal Shunt Placement After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND: Central fever is common after aneurysmal subarachnoid hemorrhage (aSAH) and may delay ventriculoperitoneal shunt (VPS) placement. OBJECTIVE: We hypothesize that drain-dependent aSAH patients with central fever or persistent fever after treatment of an identifiable cause are not at an increased risk of infectious VPS failure. METHODS: Patient demographics, radiographic characteristics, temperature, incidence of infection, and shunt failure were prospectively recorded in a consecutive cohort of aSAH patients. Central fever was defined as temperature higher than 38.3°C with no identifiable cause. RESULTS: Of 580 patients, 61 (11%) were drain dependent. Central fever developed in 18, 35 had fever of known etiology, and 8 remained afebrile. There was no shunt failure at discharge, and 2 failures (3.2%) at follow-up were attributed to infection. One patient with central fever (6%), none with fever of identifiable etiology, and 1 (13%) with no fever had infectious shunt failures at a median follow-up of 10.2 ± 3.6 months (P > .05). Nine patients with central fever (50%) and 6 (17%) who were treated for fever of known etiologies had persistent fever at shunt placement. Patients who were febrile on the day of surgery had similar infectious shunt failure rates at discharge compared with those who were afebrile (0% vs 0%; P = 1.0). Similarly, febrile and afebrile patients at VPS insertion had comparable rates of infectious shunt failure at follow-up (7% vs 2%; P = .43). CONCLUSION: aSAH patients with central fever or persistent fever after treatment of fever of identifiable etiology are not at an increased risk of infectious VPS failure. ABBREVIATIONS: aSAH, aneurysmal subarachnoid hemorrhage CXR, chest radiography EVD, external ventricular drain IVH, intraventricular hemorrhage NICU, neurological intensive care unit SAH, subarachnoid hemorrhage VPS, ventriculoperitoneal shunt





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Coagulopathy After Traumatic Brain Injury

Traumatic brain injury has long been associated with abnormal coagulation parameters, but the exact mechanisms underlying this phenomenon are poorly understood. Coagulopathy after traumatic brain injury includes hypercoagulable and hypocoagulable states that can lead to secondary injury by either the induction of microthrombosis or the progression of hemorrhagic brain lesions. Multiple hypotheses have been proposed to explain this phenomenon, including the release of tissue factor, disseminated intravascular coagulation, hyperfibrinolysis, hypoperfusion with protein C activation, and platelet dysfunction. The diagnosis and management of these complex patients are difficult given the lack of understanding of the underlying mechanisms. The goal of this review is to summarize the current knowledge regarding the mechanisms of coagulopathy after blunt traumatic brain injury. The current and emerging diagnostic tools, radiological findings, treatment options, and prognosis are discussed. ABBREVIATIONS: aPC, activated protein C FFP, fresh-frozen plasma INR, international normalized ratio PT, thromboplastin time PTT, partial thromboplastin time TBI, traumatic brain injury TF, tissue factor tPA, tissue-type plasminogen activator





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The Impact of Provider Volume on the Outcomes After Surgery for Lumbar Spinal Stenosis

BACKGROUND: Investigation into the provider volume-outcomes association for patients undergoing spine surgery has been limited. OBJECTIVE: To examine the impact of surgeon and hospital volume on the outcomes after decompression with or without fusion for lumbar spinal stenosis. METHODS: Data from the Nationwide Inpatient Sample (2005-2008) were retrospectively extracted. Multivariate logistic regression analyses were performed to calculate the adjusted odds of in-hospital mortality and the development of a postoperative complication with increasing surgeon or hospital volume. Provider volume was evaluated continuously and categorically, divided by percentiles into quintiles. Very-low-volume surgeons performed < 15 procedures over 4 years. All analyses were adjusted for differences in patient age, sex, comorbidities, and primary payer, as well as hospital bed size, teaching status, and location (urban vs rural). RESULTS: A total of 48 971 admissions were examined. In-hospital mortality did not differ significantly with increasing provider volume. When examined continuously, greater surgeon volume was associated with a significantly lower adjusted odds of developing a complication (odds ratio, 0.72; 95% confidence interval, 0.65-0.78; P < .001). Patients who underwent surgery by very-low-volume surgeons (odds ratio, 1.38; 95% confidence interval, 1.19-1.60; P = .001), but not those treated by low-, medium-, or high-volume surgeons, had a significantly higher complication rate compared with those who underwent surgery by very high-volume surgeons. After adjustment for surgeon volume, hospital volume was not significantly associated with in-hospital mortality or complications. CONCLUSION: In this nationwide study, patients treated by very-low-volume surgeons had a significantly higher complication rate compared with those treated by very high-volume surgeons. ABBREVIATIONS: CI, confidence interval ICD-9-CM, International Classification of Diseases, 9th revision, clinical modification NIS, Nationwide Inpatient Sample OR, odds ratio





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Wednesday, May 16, 2012

Clinical presentation and treatment of distal anterior inferior cerebellar artery aneurysms

Abstract  
Aneurysms located at the distal portion of the anterior inferior cerebellar artery (AICA) are rare, and their clinical features are not fully understood. We report the clinical features and management of nine distal AICA aneurysms in nine patients treated during the past decade at Kagoshima University Hospital and affiliated hospitals. Our series includes seven women and two men. Of their nine aneurysms, eight were ruptured and one was unruptured; six were saccular and three were dissecting aneurysms. The most prevalent location was the meatal loop (n = 5) followed by the postmeatal (n = 3) and premeatal segment (n = 1) of the AICA, suggesting hemodynamic stress as an etiology of these distal AICA aneurysms. Of the nine patients, five presented with angiographic features suggestive of increased hemodynamic stress to the AICA and the common trunk of the posterior inferior cerebellar artery, with vertebral artery stenosis, marked laterality, and a primitive hypoglossal artery. We addressed eight aneurysms (eight patients) surgically; one aneurysm in one patient disappeared in the course of 3 months without surgical treatment. Of the eight surgically treated aneurysms, seven were ruptured and one was unruptured, five were clipped via lateral suboccipital craniotomy, two were trapped via lateral suboccipital craniotomy, and one was embolized. Good outcomes were obtained in six of the eight patients who underwent operation (75 %). We consider increased hemodynamic stress attributable to anatomic variations in the AICA and related posterior circulation to be the predominant contributor to the development of distal AICA aneurysms. Direct clipping and trapping yielded favorable outcomes in our series.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-8
  • DOI 10.1007/s10143-012-0390-5
  • Authors
    • Hiroshi Tokimura, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Takashi Ishigami, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Hitoshi Yamahata, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Hajime Yonezawa, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Shunichi Yokoyama, Division of Neurosurgery, Nanpuh Hospital, Kagoshima, Japan
    • Akihiro Haruzono, Division of Neurosurgery, Fujimoto Hospital, Miyakonojo City, Miyazaki, Japan
    • Soichi Obara, Division of Neurosurgery, Obara Hospital, Kagoshima, Japan
    • Yosuke Nishimuta, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Tetsuya Nagayama, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Kazuho Hirahara, Division of Neurosurgery, Kagoshima City Hospital, Kagoshima, Japan
    • Takashi Kamezawa, Division of Neurosurgery, Kaseda Hospital, Kagoshima, Japan
    • Sei Sugata, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan
    • Kazunori Arita, Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8544, Japan





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The Brain's Neuronal Circuit Excitability May Be Altered By Mild Traumatic Brain Injury, Lead To Bra

Even mild head injuries can cause significant abnormalities in brain function that last for several days, which may explain the neurological symptoms experienced by some individuals who have experienced a head injury associated with sports, accidents or combat, according to a study by Virginia Commonwealth University School of Medicine researchers...





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This Is Your Brain on Drugs

In the 1954 foundational text of the Age of Aquarius, The Doors of Perception , Aldous Huxley describes his encounters with mescaline, a psychoactive substance derived from the peyote cactus and traditionally used by Native Americans for religious purposes. Huxley's experiences include profound changes in the visual world, colors that induce sound, the telescoping of time and space, the loss of the notion of self, and feelings of oneness, peacefulness and bliss more commonly associated with religious visions or an exultant state: "A moment later a clump of Red Hot Pokers, in full bloom, had exploded into my field of vision. So passionately alive that they seemed to be standing on the very brink of utterance, the flowers strained upwards into the blue.... I looked down at the leaves and discovered a cavernous intricacy of the most delicate green lights and shadows, pulsing with undecipherable mystery." Yet remarkably these enhanced percepts are not grounded in larger but in reduced brain activity, as a recent experiment reports. More on that in a moment.

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How Neuroscientists and Magicians Are Conjuring Brain Insights

Apollo Robbins (right) in action removing the wristwatch of Mariette DiChristina. (Credit: Flip Phillips.)

I see you have a watch with a buckle. Standing at my side, Apollo Robbins held my wrist lightly as he turned my hand over and back.

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