Friday, November 30, 2012

Long term results after cervical anterior fusion using an autologous bone graft (Williams-Isu method

Publication year: 2012
Source:World Neurosurgery
Kyongsong Kim, Toyohiko Isu, Morimoto Daijiro, Atsushi Sugawara, Ryoji Matsumoto, Masanori Isobe, Shiro Kobayashi, Akira Teramoto
Objective Cervical anterior fusion with autologous bone grafts (Williams-Isu method) is a modified, accepted method to treat spinal degenerative disease. Here we report minimum 10-year outcomes. Methods Of 101 patients we treated by cervical anterior fusion using the Williams-Isu method, 50 patients were followed up for a mean of 177 months. Among the 51 patients lost to long-term follow-up 12 were contacted by telephone; they reported their condition as good and none required reoperation. We evaluated their clinical outcomes on the JOA score and assessed radiological findings. Results The average JOA score was 12.5 preoperatively, 15.9 at 2 years after surgery (recovery rate 74.9%), and 15.5 at final follow-up (recovery rate 67.0%). All 5 reoperated patients were treated on the level adjacent to the original lesion. Radiographically, cervical alignment changed from 12.5° to 9.0°, the fused segment angle changed from 5.4° to -0.6°. Although worsening of the fused segment angle did not affect the clinical results, it did affect postoperative cervical sagittal alignment. Cervical alignment and range of motion (ROM) were not different between reoperated (group I) and non-reoperated patients (group II). Fused segment angle worsening was milder than expected in group I. Conclusions The long-term results after the Williams-Isu method were good. The fused segment angle loss of approximately 6° did not affect long-term outcomes although it did affect sagittal cervical alignment. Postoperative worsening of the fused segment angle and hyper ROM changes in the adjacent level were not related to the need for reoperation in our study.






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Continuous hyperosmolar therapy for traumatic brain injury-associated cerebral edema: As good as it

Publication year: 2012
Source:Journal of Clinical Neuroscience
Kristopher T. Kahle, Brian P. Walcott, J. Marc Simard
Cerebral edema is a heterogeneous condition that is present in almost every type of neurological disease process – ranging from tumor, to cerebrovascular disease, to infection, to trauma, among others. It is associated with a high rate of morbidity and mortality. The pathophysiologic mechanisms of edema formation are distinct for the different conditions, thereby defining the various classifications. A relatively new treatment practice for cerebral edema is known as induced, sustained hypernatremia. This practice is highly controversial, is in widespread use, and lacks robust evidence for efficacy. Herein, we review details of the controversy regarding this practice.






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Wednesday, November 28, 2012

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill

imageObjective: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. Methods: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. Recommendations: The article is focused on a suggested glycemic control end point such that a blood glucose ≥150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤70 mg/dL) and to minimize glycemic variability. Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. Conclusions: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.





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The Role of Simulation in Neurosurgical Education: A Survey of 99 United States Neurosurgery Program

Publication year: 2012
Source:World Neurosurgery
Aruna Ganju, Salah G. Aoun, Marc R. Daou, Tarek Y. El Ahmadieh, Alice Chang, Lucy Wang, H. Hunt Batjer, Bernard R. Bendok
Object With the reduction of resident work-hours and the increasing focus on patient safety, it has become evident that simulation has a growing role to play in surgical education. We surveyed the program directors of 99 United States Neurosurgery programs in an effort to better understand how simulation can be implemented in Neurosurgery and to gain insight into key issues that are currently being discussed amongst Neurosurgical educators. Methods A 14-item questionnaire was emailed to 99 Neurosurgery residency program directors. Questions assessed the clinical impact of simulation, the role of simulation in academia, the investments required in time and money, and the model best-suited for simulation. Results The survey response rate was 53.5%. Seventy-two percent of respondents believed that simulation would improve patient outcome, 74% that it could supplement conventional training but only 25% that it could replace it. The majority strongly believed that it could help preparing complex cases and could be of use to attending faculty. Forty-five percent thought that residents should achieve pre-defined levels of proficiency on simulators before working on patients. Seventy-four percent of respondents declared they would make simulator practice mandatory if available, and the majority was willing to invest daily time and considerable funds on simulators. Cadavers were the least preferred models to use compared to virtual simulation and non-cadaveric physical models. Conclusions Simulation should be integrated in Neurosurgery training curricula. The validation of available tools is the next step that will enable the training, acquisition, and testing of neurosurgical skills.






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How much medicine do spine surgeons need to know to better select and care for patients?

Nancy E Epstein

Surgical Neurology International 2012 3(6):329-349

Background: Although we routinely utilize medical consultants for preoperative clearance and postoperative patient follow-up, we as spine surgeons need to know more medicine to better select and care for our patients. Methods: This study provides additional medical knowledge to facilitate surgeons' "cross-talk" with medical colleagues who are concerned about how multiple comorbid risk factors affect their preoperative clearance, and impact patients' postoperative outcomes. Results: Within 6 months of an acute myocardial infarction (MI), patients undergoing urological surgery encountered a 40% mortality rate: similar rates may likely apply to patients undergoing spinal surgery. Within 6 weeks to 2 months of placing uncoated cardiac, carotid, or other stents, endothelialization is typically complete; as anti-platelet therapy may often be discontinued, spinal surgery can then be more safely performed. Coated stents, however, usually require 6 months to 1 year for endothelialization to occur; thus spinal surgery is often delayed as anti-platelet therapy must typically be continued to avoid thrombotic complications (e.g., stroke/MI). Diabetes and morbid obesity both increase the risk of postoperative infection, and poor wound healing, while the latter increases the risk of phlebitis/pulmonary embolism. Both hypercoagluation and hypocoagulation syndromes may require special preoperative testing/medications and/or transfusions of specific hematological factors. Pulmonary disease, neurological disorders, and major psychiatric pathology may also require further evaluations/therapy, and may even preclude successful surgical intervention. Conclusions: Although we as spinal surgeons utilize medical consultants for preoperative clearance and postoperative care, we need to know more medicine to better select and care for our patients.





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Evidence-based guideline update: Steroids and antivirals for Bell palsy: Report of the Guideline Dev

Objective:

To review evidence published since the 2001 American Academy of Neurology (AAN) practice parameter regarding the effectiveness, safety, and tolerability of steroids and antiviral agents for Bell palsy.

Methods:

We searched Medline and the Cochrane Database of Controlled Clinical Trials for studies published since January 2000 that compared facial functional outcomes in patients with Bell palsy receiving steroids/antivirals with patients not receiving these medications. We graded each study (Class I–IV) using the AAN therapeutic classification of evidence scheme. We compared the proportion of patients recovering facial function in the treated group with the proportion of patients recovering facial function in the control group.

Results:

Nine studies published since June 2000 on patients with Bell palsy receiving steroids/antiviral agents were identified. Two of these studies were rated Class I because of high methodologic quality.

Conclusions and Recommendations:

For patients with new-onset Bell palsy, steroids are highly likely to be effective and should be offered to increase the probability of recovery of facial nerve function (2 Class I studies, Level A) (risk difference 12.8%–15%). For patients with new-onset Bell palsy, antiviral agents in combination with steroids do not increase the probability of facial functional recovery by >7%. Because of the possibility of a modest increase in recovery, patients might be offered antivirals (in addition to steroids) (Level C). Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is likely that it is modest at best.






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Randomized Controlled Trial of Symptomatic Middle Cerebral Artery Stenosis: Endovascular Versus Medi

Background and Purpose—

To investigate the efficacy and safety of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic middle cerebral artery stenosis compared with standard medical treatment in a low-risk Chinese population.

Methods—

A prospective, randomized, controlled, single-center clinical trial was conducted comparing PTAS with medical treatment for symptomatic middle cerebral artery stenosis (≥70%). Patients were enrolled according to 1:1 enroll ratio (PTAS: medical). The PTAS group received stenting or balloon angioplasty, whereas the medical treatment group received standard medical treatment (aspirin 100mg plus clopidogrel 75mg/d), and all the patients were under strict control of the risk factors. The end point events were any kind of ipsilateral stroke or transient ischemic attack, or death from any origin during 1-year follow-up.

Results—

The enrollment was stopped after 70 patients were enrolled from August 2007 to December 2010, with a 30-day rate of end point events of 8.3% versus 5.9% (P=0.69) for PTAS and medical group, respectively, and 1-year rate of end point events of 19.4% versus 17.6% (P=0.85), respectively. There was no significant difference in baseline characteristics between the 2 groups. The mean follow-up time, which was ongoing, was 9.9 ± 3.9 and 9.7 ± 4.4 months, respectively. Among the risk factors, hypertension was the independent related to the outcome (P=0.015).

Conclusions—

This study showed that endovascular treatment is as safe but not better than medical treatment for symptomatic middle cerebral artery stenosis in a low-risk Chinese population. History of hypertension increases the risk of recurrent ischemic events.






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Reliability of Real-Time Video Smartphone for Assessing National Institutes of Health Stroke Scale S

Background and Purpose—

Telestroke reduces acute stroke care disparities between urban stroke centers and rural hospitals. Current technologies used to conduct remote patient assessments have high start-up costs, yet they cannot consistently establish quality timely connections. Smartphones can be used for high-quality video teleconferencing. They are inexpensive and ubiquitous among health care providers. We aimed to study the reliability of high-quality video teleconferencing using smartphones for conducting the National Institutes of Health Stroke Scale (NIHSS).

Methods—

Two vascular neurologists assessed 100 stroke patients with the NIHSS. The remote vascular neurologist assessed subjects using smartphone videoconferencing with the assistance of a bedside medical aide. The bedside vascular neurologist scored patients contemporaneously. Each vascular neurologist was blinded to the other's NIHSS scores. We tested the inter-method agreement and physician satisfaction with the device.

Results—

We demonstrated high total NIHSS score correlation between the methods (r=0.949; P<0.001). The mean total NIHSS scores for bedside and remote assessments were 7.93±8.10 and 7.28±7.85, with ranges, of 0 to 35 and 0 to 37, respectively. Eight categories had high agreement: level of consciousness (questions), level of consciousness (commands), visual fields, motor left and right (arm and leg), and best language. Six categories had moderate agreement: level of consciousness (consciousness), best gaze, facial palsy, sensory, dysarthria, and extinction/inattention. Ataxia had poor agreement. There was high physician satisfaction with the smartphone.

Conclusions—

Smartphone high-quality video teleconferencing is reliable, easy to use, affordable for telestroke NIHSS administration, and has high physician satisfaction.






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Racial and Ethnic Disparities in the Treatment of Unruptured Intracranial Aneurysms: A Study of the

Background and Purpose—

Minorities in the United States have less access to healthcare system resources, especially preventative treatments. We sought to determine whether racial and sex disparities existed in the treatment of unruptured intracranial aneurysms.

Methods—

Using the Nationwide Inpatient Sample, hospitalizations for clipping and coiling of intracranial aneurysms from 2001 to 2009 were identified by cross-matching International Classification of Diseases, 9th Revision codes for diagnosis of unruptured aneurysm and subarachnoid hemorrhage (SAH) with procedure codes for clipping or coiling of cerebral aneurysms. Demographic information analyzed included age (<50, 50–64, 65–79, and ≥80 years), race (white, black, Hispanic, Asian/Pacific Islander), sex, income quartile, primary payer (Medicare, Medicaid, private insurance, self-pay, no charge, other), and Charlson comorbidity index.

Results—

When compared with patients treated for SAH, those treated for unruptured intracranial aneurysm were significantly more likely to be women (75.0% versus 69.0%; P<0.0001). In all, 9.7% of patients receiving treatment for SAH were self-payers versus 3.0% of patients being treated for unruptured intracranial aneurysm (P<0.0001). In all, 62.2% of patients receiving treatment for SAH were white compared with 76.4% of patients being treated for unruptured intracranial aneurysm (P<0.0001). There was a higher proportion of black, Hispanic, and Asian patients in the SAH treatment group when compared with the unruptured aneurysm treatment group (P<0.0001 for all groups).

Conclusions—

When compared with patients undergoing treatment for SAH, patients undergoing surgical and endovascular treatment for unruptured intracranial aneurysm are generally from higher socioeconomic strata and are more likely to be insured, women, and white. Future studies are needed to determine the underlying causes and solutions for this disparity.






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Genetic Heritability of Ischemic Stroke and the Contribution of Previously Reported Candidate Gene a

Background and Purpose—

The contribution of genetics to stroke risk, and whether this differs for different stroke subtypes, remainsuncertain. Genomewide complex trait analysis allows heritability to be assessed from genomewide association study (GWAS) data. Previous candidate gene studies have identified many associations with stoke but whether these are important requires replication in large independent data sets. GWAS data sets provide a powerful resource to perform replication studies.

Methods—

We applied genomewide complex trait analysis to a GWAS data set of 3752 ischemic strokes and 5972 controls and determined heritability for all ischemic stroke and the most common subtypes: large-vessel disease, small-vessel disease, and cardioembolic stroke. By systematic review we identified previous candidate gene and GWAS associations with stroke and previous GWAS associations with related cardiovascular phenotypes (myocardial infarction, atrial fibrillation, and carotid intima-media thickness). Fifty associations were identified.

Results—

For all ischemic stroke, heritability was 37.9%. Heritability varied markedly by stroke subtype being 40.3% for large-vessel disease and 32.6% for cardioembolic but lower for small-vessel disease (16.1%). No previously reported candidate gene was significant after rigorous correction for multiple testing. In contrast, 3 loci from related cardiovascular GWAS studies were significant: PHACTR1 in large-vessel disease (P=2.63e–6), PITX2 in cardioembolic stroke (P=4.78e–8), and ZFHX3 in cardioembolic stroke (P=5.50e–7).

Conclusions—

There is substantial heritability for ischemic stroke, but this varies for different stroke subtypes. Previous candidate gene associations contribute little to this heritability, but GWAS studies in related cardiovascular phenotypes are identifying robust associations. The heritability data, and data from GWAS, suggest detecting additional associations will depend on careful stroke subtyping.






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Postcraniotomy superficial temporal artery pseudoaneurysm in the setting of triple H therapy: A case

Sergei Terterov, Nancy McLaughlin, Neil A Martin

Surgical Neurology International 2012 3(1):139-139

Background: Superficial temporal artery (STA) pseudoaneurysm after a craniotomy is very rare with only five cases reported in the literature, none manifesting in the setting of cerebral vasospasm treatment with triple H therapy. Case Description: A 31-year-old male was admitted after a syncopal episode. Imaging documented a ruptured anterior communicating artery aneurysm. He was taken to the operating room for aneurysm clipping, but the procedure was aborted due to intraoperative aneurysm re-rupture, at which point the patient underwent emergent coil embolization of the aneurysm. The postoperative course was complicated by severe cerebral vasospasm requiring prolonged triple H therapy. On postoperative day 22, a growing left temporal mass with a bruit was noted. The suspected diagnosis of STA pseudoaneurysm was confirmed by femoral angiography, and it was treated with coils and Onyx embolization. Conclusion: We report the first case of a postcraniotomy STA pseudoaneurysm in the setting of induced hypertension for the treatment of cerebral vasospasm. Endovascular embolization is a viable option for the treatment of an STA pseudoaneurysm.





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Self-monitoring of oral anticoagulation reduces thromboembolic events and does not increase risk of

Commentary on: Heneghan C, Ward A, Perera R, et al..Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data. Lancet2012;379:322–34.

Context

Although oral anticoagulation with vitamin K antagonists reduces major thromboembolism in high-risk patients, it requires frequent laboratory monitoring to prevent over-anticoagulation which can result in serious bleeding or under anticoagulation which increases the risk for thromboembolism. This monitoring typically occurs in clinical settings, but with marketing of accurate and reliable portable devices, it can now be done more conveniently by the patient at home. Several clinical trials have evaluated the safety and efficacy of patient self-monitoring: either patient self-management (patient tests and adjusts the dose as needed) or patient self-testing with clinical dosing (dosing changes determined by clinicians). Heneghan et al present a systematic review and meta-analysis of individual patient data from 11 of these trials.

Methods

A systematic review of published...






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Tuesday, November 27, 2012

Management of abdominal pseudocyst in shunt-dependent hydrocephalus

Sung-Joo Yuh, Michael Vassilyadi

Surgical Neurology International 2012 3(1):146-146

Background: Abdominal pseudocyst (APC) is an uncommon manifestation of a ventriculoperitoneal (VP) shunt that is attributed to an inflammatory response, usually the result of infection. Case Description: A 13-year-old girl with a VP shunt presented with progressive abdominal distention, pain and vomiting. The shunt was inserted at infancy for congenital hydrocephalus. A shunt infection was treated with externalization of the shunt, antibiotics and subsequent shunt replacement. At the age of four, the shunt was revised for a distal malfunction. Nine years later, abdominal CT and ultrasound demonstrated large multiseptated cysts. The shunt was externalized and 1.8 L of sterile, xanthochromic peritoneal fluid was drained. The cerebrospinal fluid was clear, colorless, acellular and sterile with normal protein and glucose levels. Two days later, the distal portion of the shunt was replaced back into the pleural cavity. Five months later a pleural effusion formed. Thoracentesis was performed and there was no evidence of infection. The shunt was subsequently converted to a ventriculoatrial system. The patient has remained well for over 3.5 years. Conclusion: APC represents an important complication of VP shunts, with an unclear etiology that can occur nine years after shunt surgery. This paper presents an update on the management of APCs.





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Monday, November 26, 2012

Video Neuroanatomia: Ossos do Crânio e Face (Básico)


Video Aula de Neuroanatomia: Ossos do Crânio e Face 

1- http://www.facebook.com/pages/Neuroexame-App/478799325487946?ref=ts&fref=ts
2- http://www.facebook.com/pages/Guia-de-Neurocirurgia-Intensiva-App/240989362693510
3- http://www.facebook.com/pages/Traumatismo-Craniano-App/348238591932724
4- http://www.facebook.com/pages/Anamnese-App/430712956964529
5- http://www.facebook.com/dordecabecaapp
6- http://www.facebook.com/pages/SUS-para-concursos-app/292210890879923
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Wednesday, November 21, 2012

Listening To Music Helps Prevent Insomnia

Warm milk, melatonin pills, or even prescription pills are all used to avoid a dreaded condition known as insomnia. Each of these methods have different degrees of side effects and success...





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Efficacy and Safety of Oberlin's Procedure in the Treatment of Brachial Plexus Birth Palsy

imageBACKGROUND: In brachial plexus injuries, when there are no available roots to use as a source for graft reconstruction, nerve transfers emerge as an elective technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. Despite the high rate of good to excellent results in adults, this technique is seldom used in children. OBJECTIVE: To evaluate the efficacy and safety of Oberlin's procedure in the surgical treatment of brachial plexus birth palsy. METHODS: Striving to restore elbow flexion, we performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. After follow-up of at least 19 months, primary outcomes were the strength of elbow flexion (modified British Medical Research Council Scale), hand function measured using Al-Qattan's Scale, and comparative x-rays of both hands to detect altered growth. RESULTS: Good to excellent results related to biceps contraction were obtained in 14 patients (82.3%) (3/MRC3, 11/MRC4). The preoperative Al-Qattan Scale score for the hand was maintained at final follow-up. Comparing the treated and normal limb, no difference was observed in hand development by x-ray. CONCLUSION: Oberlin's procedure is an effective and safe option for the surgical treatment of upper brachial plexus birth palsy. ABBREVIATION: mBMRC, modified British Medical Research Council Grading System





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Safety and Efficacy of Intraoperative Angiography in Craniotomies for Cerebral Aneurysms and Arterio

imageBACKGROUND: In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial. OBJECTIVE: To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision. METHODS: Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas. RESULTS: In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P < .001), ruptured aneurysm (P < .001), and increasing number of vessels injected (P < .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity. CONCLUSION: IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in > 8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy. ABBREVIATIONS: AVF, arteriovenous fistula AVM, arteriovenous malformation ICGA, indocyanine green fluorescence angiography IOA, intraoperative angiography





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Levels of Evidence in the Neurosurgical Literature: More Tribulations Than Trials

imageBACKGROUND: The importance of evidence-based medicine has been well documented and supported across various surgical subspecialties. OBJECTIVE: To quantify the levels of evidence across publications in the neurosurgical literature, to assess the change in evidence over time, and to indicate predictive factors of higher-level evidence. METHODS: We reviewed the levels of evidence across published clinical studies in 3 neurosurgical journals from 2009 to 2010. Randomized trials were evaluated by use of the Detsky Quality of Reporting Scale. Levels-of-evidence data for the same journals in 1999 were obtained from the literature, and regression analysis was performed to identify predictive factors for higher-level evidence. RESULTS: Of 660 eligible articles, 14 (2.1%) were Level I, 54 (8.2%) were Level II, 73 (11.1%) were Level III, 287 (43.5%) were Level IV, and 232 (35.2%) were Level V. The number of Level I studies decreased significantly between 1999 and 2010 (3.4% vs 2.1%, respectively; P = .01). Seven randomized clinical trials were identified, and 1 trial had significant methodological limitations (Mean Detsky Index = 16.3; SD = 1.8). Publications with larger sample size were significantly associated with higher levels of evidence (Levels I and II; odds ratio, 1.7; 95% confidence interval, 1.45-2.05; P = .001). The ratio of higher levels of evidence to lower levels was 0.11. CONCLUSION: Higher levels of evidence (Levels I and II) represent only 1 in 10 neurosurgical clinical papers in the top neurosurgical journals. Increased awareness of the need for better evidence in the field through education and adoption of the levels of evidence may improve the conduct and publication of prospective studies. ABBREVIATIONS: EBM, evidence-based medicine RCT, randomized controlled trial





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Long-term Results of Gamma Knife Surgery for Partially Embolized Arteriovenous Malformations

imageBACKGROUND: The effectiveness and risk of Gamma Knife surgery (GKS) in the management of partially embolized cerebral arteriovenous malformations (AVMs) remain to be elucidated. OBJECTIVE: To evaluate the long-term imaging and clinical outcomes of GKS in AVM patients who had undergone previous partial embolization and compare the results with patients treated with GKS alone. METHODS: A total of 215 embolized AVMs were analyzed. The mean patient age was 32.9 years. The mean volume of the nidus was 4.6 mL (range, 0.1-29.4 mL), and the mean prescription dose was 19.6 Gy (range, 4-28 Gy). This group was compared with 729 nonembolized AVMs. RESULTS: After embolization and GKS, angiographically confirmed total obliteration of the AVMs was significantly lower (33%) compared with patients in whom GKS was used alone (60.9%; P < .001). However, the mean nidus size was larger and the Spetzler-Martin grade was higher for the embolized AVMs compared with the nonembolized AVMs. Radiation-induced changes occurred more often in the embolized (43.4%) than the nonembolized (33.4%) AVMs (P = .028). Permanent neurological deficits associated with radiation-induced changes occurred in 2.7% of the embolized compared with 1.3% of the nonembolized patients (P = .14). CONCLUSION: In our retrospective and historical series, the long-term results suggest that the obliteration rate is significantly lower in embolized AVMs compared with nonembolized AVMs, also because of the fact that the combined treatment is applied to higher grade AVMs; the percentage of grade III-V AVMs was 58.6% and 48.8% for nonembolized AVMs. ABBREVIATIONS: AVM, arteriovenous malformation GKS, Gamma Knife surgery n-BCA,N-butyl-2-cyanoacrylate RIC, radiation-induced change





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Tuesday, November 20, 2012

Semiologia Neurologica parte II - Aplicativo Neuroexame ( Neurologia )


Aula com noções basicas de semiologia neurologica. Parte II Retirada do Aplicativo Neuroexame. 
O objetivo do aplicativo NEUROEXAME é relacionar de forma resumida noções de semiologia neurológica, as várias alterações do exame neurológico e as doenças a elas relacionadas.
Desenvolvido pela MedPhone e a Equipe de Neurocirurgia da Santa Casa de BH, Dr. Gervásio Carvalho, Dr. Júlio Pereira, Dr. Mauro Borgo, Dr. Marcello Penholatte, Dr. Lucas Alverne e Dr. José Lopes.

Júlio Leonardo B. Pereira
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Semiologia Neurologica parte I - Aplicativo Neuroexame ( Neurologia )


Aula com noções basicas de semiologia neurologica. Parte I Retirada do Aplicativo Neuroexame. 
O objetivo do aplicativo NEUROEXAME é relacionar de forma resumida noções de semiologia neurológica, as várias alterações do exame neurológico e as doenças a elas relacionadas.
Desenvolvido pela MedPhone e a Equipe de Neurocirurgia da Santa Casa de BH, Dr. Gervásio Carvalho, Dr. Júlio Pereira, Dr. Mauro Borgo, Dr. Marcello Penholatte, Dr. Lucas Alverne e Dr. José Lopes.
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Saturday, November 17, 2012

Can We "Talk" to Vegetative Patients Via fMRI?



Can We "Talk" to Vegetative Patients Via fMRI?
BEST OF SCIENCE | NOVEMBER 14, 2012
http://pulse.me/s/fmegm


### **The Claim** Asking a persistently vegetative patient a question while his head is in a brain-scan machine, doctors can interpret his answer fr... Read more

--
Sent via Pulse/
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Friday, November 16, 2012

Seizures Do Not Increase In-Hospital Mortality After Intracerebral Hemorrhage in the Nationwide Inpa

Abstract
Background  
Seizures are common after intracerebral hemorrhage (ICH) but their impact on outcome is uncertain and prophylactic anti-convulsant use is controversial. We hypothesized that seizures would not increase the risk of in-hospital mortality in a large administrative database.
Methods  
The study population included patients in the 2006 Nationwide Inpatient Sample over the age of 18 with a principal diagnosis of ICH (ICD9 = 431). Subjects with a secondary diagnosis of aneurysm, arterio-venous malformation, brain tumor, or traumatic brain injury were excluded. Seizures were defined by ICD9 codes (345.0x–345.5x, 345.7x–345.9x, 780.39). Logistic regression was used to quantify the relationship between seizures and in-hospital mortality. Pre-specified subgroups included age strata, length of stay, and invasive procedures.
Results  
13,033 subjects met all eligibility criteria, of which 1,430 (11.0 %) had a secondary diagnosis of seizure. Subjects with seizure were younger (64 vs. 70 years, p < 0.001), more likely to get craniectomy (2.1 vs. 1.2 %, p = 0.006), ventriculostomy (8.5 vs. 6.0 %, p < 0.001), intubation (32.2 vs. 25.9 %, p < 0.001), and tracheostomy (6.4 vs. 4.2 %, p < 0.001). Seizure patients had lower in-hospital mortality (24.3 vs. 28.0 %, p = 0.003). In a multivariable model incorporating patient and hospital level variables, seizures were associated with reduced odds of in-hospital death (OR = 0.62, 95 % CI 0.52–0.75).
Conclusions  
A secondary diagnosis of seizure after ICH was not associated with increased in-hospital death overall or in any of the pre-specified subgroups; however, there may be residual confounding by severity. These findings do not support a need for routine prophylactic anti-epileptic drug use after ICH.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-6
  • DOI 10.1007/s12028-012-9791-0
  • Authors
    • Michael T. Mullen, Department of Neurology, University of Pennsylvania, 3400 Spruce Street, 3 W Gates Building, Philadelphia, PA 19104, USA
    • Scott E. Kasner, Department of Neurology, University of Pennsylvania, 3400 Spruce Street, 3 W Gates Building, Philadelphia, PA 19104, USA
    • Steven R. Messé, Department of Neurology, University of Pennsylvania, 3400 Spruce Street, 3 W Gates Building, Philadelphia, PA 19104, USA





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Clinical Prediction Models for Aneurysmal Subarachnoid Hemorrhage: A Systematic Review

Abstract
Background  
Clinical prediction models can enhance clinical decision-making and research. However, available prediction models in aneurysmal subarachnoid hemorrhage (aSAH) are rarely used. We evaluated the methodological validity of SAH prediction models and the relevance of the main predictors to identify potentially reliable models and to guide future attempts at model development.
Methods  
We searched the EMBASE, MEDLINE, and Web of Science databases from January 1995 to June 2012 to identify studies that reported clinical prediction models for mortality and functional outcome in aSAH. Validated methods were used to minimize bias.
Results  
Eleven studies were identified; 3 developed models from datasets of phase 3 clinical trials, the others from single hospital records. The median patient sample size was 340 (interquartile range 149–733). The main predictors used were age (n = 8), Fisher grade (n = 6), World Federation of Neurological Surgeons grade (n = 5), aneurysm size (n = 5), and Hunt and Hess grade (n = 3). Age was consistently dichotomized. Potential predictors were prescreened by univariate analysis in 36 % of studies. Only one study was penalized for model optimism. Details about model development were often insufficiently described and no published studies provided external validation.
Conclusions  
While clinical prediction models for aSAH use a few simple predictors, there are substantial methodological problems with the models and none have had external validation. This precludes the use of existing models for clinical or research purposes. We recommend further studies to develop and validate reliable clinical prediction models for aSAH.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-11
  • DOI 10.1007/s12028-012-9792-z
  • Authors
    • Blessing N. R. Jaja, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Michael D. Cusimano, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Nima Etminan, Heinrich Heine University, Düsseldorf, Germany
    • Daniel Hanggi, Heinrich Heine University, Düsseldorf, Germany
    • David Hasan, University of Iowa, Iowa, IA, USA
    • Don Ilodigwe, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Hector Lantigua, Columbia University, New York, NY, USA
    • Peter Le Roux, University of Pennsylvania, Philadelphia, PA, USA
    • Benjamin Lo, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Ada Louffat-Olivares, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Stephan Mayer, Columbia University, New York, NY, USA
    • Andrew Molyneux, Oxford University, Oxford, UK
    • Audrey Quinn, Leeds Teaching Hospitals NHS Trust, Leeds, UK
    • Tom A. Schweizer, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Thomas Schenk, King's College London, London, UK
    • Julian Spears, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • Michael Todd, University of Iowa, Iowa, IA, USA
    • James Torner, University of Iowa, Iowa, IA, USA
    • Mervyn D. I. Vergouwen, University Medical Center Utrecht, Utrecht, Netherlands
    • George K. C. Wong, Chinese University of Hong Kong, Hong Kong, China
    • Jeff Singh, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
    • R. Loch Macdonald, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada





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Outcome Prediction in Moderate and Severe Traumatic Brain Injury: A Focus on Computed Tomography Var

Abstract
Background  
With this study we aimed to design validated outcome prediction models in moderate and severe traumatic brain injury (TBI) using demographic, clinical, and radiological parameters.
Methods  
Seven hundred consecutive moderate or severe TBI patients were included in this observational prospective cohort study. After inclusion, clinical data were collected, initial head computed tomography (CT) scans were rated, and at 6 months outcome was determined using the extended Glasgow Outcome Scale. Multivariate binary logistic regression analysis was applied to evaluate the association between potential predictors and three different outcome endpoints. The prognostic models that resulted were externally validated in a national Dutch TBI cohort.
Results  
In line with previous literature we identified age, pupil responses, Glasgow Coma Scale score and the occurrence of a hypotensive episode post-injury as predictors. Furthermore, several CT characteristics were associated with outcome; the aspect of the ambient cisterns being the most powerful. After external validation using Receiver Operating Characteristic (ROC) analysis our prediction models demonstrated adequate discriminative values, quantified by the area under the ROC curve, of 0.86 for death versus survival and 0.83 for unfavorable versus favorable outcome. Discriminative power was less for unfavorable outcome in survivors: 0.69.
Conclusions  
Outcome prediction in moderate and severe TBI might be improved using the models that were designed in this study. However, conventional demographic, clinical and CT variables proved insufficient to predict disability in surviving patients. The information that can be derived from our prediction rules is important for the selection and stratification of patients recruited into clinical TBI trials.

  • Content Type Journal Article
  • Category Original Research
  • Pages 1-11
  • DOI 10.1007/s12028-012-9795-9
  • Authors
    • Bram Jacobs, Department of Neurology (935), Radboud University Nijmegen Medical Centre (RUNMC), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
    • Tjemme Beems, Department of Neurosurgery (931), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
    • Ton M. van der Vliet, Department of Radiology, RUNMC, Nijmegen, The Netherlands
    • Arie B. van Vugt, Department of Emergency Medicine, RUNMC, Nijmegen, The Netherlands
    • Cornelia Hoedemaekers, Department of Intensive Care Medicine (632), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
    • Janneke Horn, Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
    • Gaby Franschman, Department of Anesthesiology, VU University Medical Centre, Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
    • Ian Haitsma, Department of Neurosurgery, Erasmus Medical Centre, Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
    • Joukje van der Naalt, Department of Neurology, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
    • Teuntje M. J. C. Andriessen, Department of Neurology (935), Radboud University Nijmegen Medical Centre (RUNMC), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
    • George F. Borm, Department of Epidemiology, Biostatistics and HTA (133), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
    • Pieter E. Vos, Department of Neurology (935), Radboud University Nijmegen Medical Centre (RUNMC), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands





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Video game-based coordinative training improves ataxia in children with degenerative ataxia

Objective:

Degenerative ataxias in children present a rare condition where effective treatments are lacking. Intensive coordinative training based on physiotherapeutic exercises improves degenerative ataxia in adults, but such exercises have drawbacks for children, often including a lack of motivation for high-frequent physiotherapy. Recently developed whole-body controlled video game technology might present a novel treatment strategy for highly interactive and motivational coordinative training for children with degenerative ataxias.

Methods:

We examined the effectiveness of an 8-week coordinative training for 10 children with progressive spinocerebellar ataxia. Training was based on 3 Microsoft Xbox Kinect video games particularly suitable to exercise whole-body coordination and dynamic balance. Training was started with a laboratory-based 2-week training phase and followed by 6 weeks training in children's home environment. Rater-blinded assessments were performed 2 weeks before laboratory-based training, immediately prior to and after the laboratory-based training period, as well as after home training. These assessments allowed for an intraindividual control design, where performance changes with and without training were compared.

Results:

Ataxia symptoms were significantly reduced (decrease in Scale for the Assessment and Rating of Ataxia score, p = 0.0078) and balance capacities improved (dynamic gait index, p = 0.04) after intervention. Quantitative movement analysis revealed improvements in gait (lateral sway: p = 0.01; step length variability: p = 0.01) and in goal-directed leg placement (p = 0.03).

Conclusions:

Despite progressive cerebellar degeneration, children are able to improve motor performance by intensive coordination training. Directed training of whole-body controlled video games might present a highly motivational, cost-efficient, and home-based rehabilitation strategy to train dynamic balance and interaction with dynamic environments in a large variety of young-onset neurologic conditions.

Classification of evidence:

This study provides Class III evidence that directed training with Xbox Kinect video games can improve several signs of ataxia in adolescents with progressive ataxia as measured by SARA score, Dynamic Gait Index, and Activity-specific Balance Confidence Scale at 8 weeks of training.






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Migraine headache is present in the aura phase: A prospective study

Objectives:

Migraine aura is commonly considered to be a distinct phase of a migraine attack that precedes headache. The objective of the study was to examine a large number of prospectively recorded attacks of migraine with aura and determine the timing of headache and other migraine symptoms relative to aura.

Methods:

As part of a clinical trial we collected prospective data on the time course of headache and other symptoms relative to the aura. Patients (n = 267) were enrolled from 16 centers, and asked to keep a headache diary for 1 month (phase I). They were asked to record headache symptoms as soon as possible after aura began and always within 1 hour of aura onset. A total of 456 attacks were reported during phase I by 201 patients. These patients were then randomized and included in phase II, during which a total of 405 attacks were reported in 164 patients. In total, we present data from 861 attacks of migraine with aura from 201 patients.

Results:

During the aura phase, the majority of attacks (73%) were associated with headache. Other migraine symptoms were also frequently reported during the aura: nausea (51%), photophobia (88%), and photophobia (73%). During the first 15 minutes within the onset of aura, 54% of patients reported headache fulfilling the criteria for migraine.

Conclusion:

Our results indicate that headaches as well as associated migraine symptoms are present early, during the aura phase of the migraine attack in the majority of patients.






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Apoio ao Projeto de Lei 4411/2012 “Ciência & Pesquisa: Importações sem Fronteiras”

Caros colegas,



Está em tramitação na Câmara dos Deputados, agora na Comissão de Seguridade Social e Família (CSSF), o Projeto de Lei no. 4411/2012, de autoria do Deputado Romário, o ex-jogador de futebol, que "propõe a eliminação da burocracia de importação de mercadorias destinadas à  pesquisa científica e tecnológica através da criação, pelo CNPq, de um cadastro nacional de pesquisadores que





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Saturday, November 10, 2012

Hemicraniectomy in the management of space-occupying ischemic stroke

Publication year: 2012
Source:Journal of Clinical Neuroscience
Julia Flechsenhar, Johannes Woitzik, Klaus Zweckberger, Hemasse Amiri, Werner Hacke, Eric Jüttler
A space-occupying mass effect is a common finding in several stroke subtypes. A large, intracranial mass is a potentially life-threatening complication, irrespective of its underlying origin, with transtentorial or transforaminal herniation being the common endpoint and often the cause of death. Prompt and adequate intervention is therefore required. Although sufficient data on the management of large haematomas are lacking, there is good evidence from randomized trials that in younger patients with life-threatening, space-occupying, so-called "malignant" middle cerebral artery (MCA) infarctions, early hemicraniectomy decreases mortality without increasing the number of severely disabled survivors. Yet many questions concerning hemicraniectomy in malignant MCA infarction remain open: the definition of a malignant MCA infarct within the first hours, optimal timing of surgery, quality of life and acceptance of remaining disability, the role of aphasia in patients with dominant hemispheric infarcts, the effect of age, and the influence of the pre-morbid status on decision making. The joint efforts of neurologists, neurosurgeons, intensive care physicians, and rehabilitation physicians are needed to design and conduct studies that might answer these questions.






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Friday, November 9, 2012

Synoptic Philosophy in a Neurosurgical Residency: A Book and Cinema Club

Publication year: 2012
Source:World Neurosurgery
Rishi Wadhwa, Jai Deep Thakur, Raul Cardenas, Jeri Wright, Anil Nanda
Introduction of a book and cinema club in our department has helped combine an education in humanities with neurosurgical training. We feel the involvement of teaching in humanities adds to our specialty and helps in fulfilling the ACGME's six core competencies. Our goal is to encourage synoptic philosophy and impart creative ways of interacting with the world. Medical and non-medical based books and movies were selected and reviewed in an open forum. Efforts were made to integrate the ACGME six core competencies into the discussions. Residents then anonymously addressed a questionnaire pertaining to the usefulness of the book club in residency. 13 residents attended the sessions and responded to the questionnaire. 61.5% of residents felt the topics were pertinent to their everyday life. 77% felt that the club had helped them somehow in residency. The majority (7/13) felt the club should not be included as part of the curriculum in an 80 hour work week. Institution of a book and movie club appears to be an effective way of integrating humanities within a neurosurgical residency.






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Current Situation of Neurosurgery of Central America An analysis and Suggestions for improvement

Publication year: 2012
Source:World Neurosurgery
M. Ena Isabel Miller, R. Rafael De la Riva, D. Jorge Eduardo Ortega, Francisco Sansivirini Valle, Ricardo Lungo Esquivel, Marvin F. Salgado Perez, José Antonio Perez Berrios
Neurosurgery in the Central American Region continues to grow and develop despite other public health challenges that have been prioritized. In resource deficient countries there are many other issues that are also addressed by the World Health Organization (WHO), Pan American Health Organization, World Bank, etc. such as mal-nutrition, sanitation, control of infectious diseases, maternal morbidity/mortality issues, trauma etc. We can identify at least three areas of concern where improvement will alleviate some of the issues that relate to the present situation: A. Training of more personnel (paramedical and medical) B. Technical support in diagnostic and treatment facilities C. Proper distribution of A and B in underserved regions. In an effort to inform other neurosurgeons of the world (World Neurosurgery) as to the status of our specialty and the kind of care that is available in the Central American Region the active members of ASOCAN (Association of Central American Societies of Neurosurgery) have come together and have summarized some of the important variables. ASOCAN was founded in the city of Copan (archeological site of Mayan the status of neurosurgery in the Central American Region. The health problems are similar, and the availability of resources is alike in the majority of the countries that comprise the region. At present there are 165 neurosurgeons in the Central American region.






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Treatment of Status Epilepticus: An International Survey of Experts

Abstract
Background  
As part of the development of the Neurocritical Care Society (NCS) Status Epilepticus (SE) Guidelines, the NCS SE Writing Committee conducted an international survey of SE experts.
Methods  
The survey consisted of three patient vignettes (case 1, an adult; case 2, an adolescent; case 3, a child) and questions regarding treatment. The questions for each case focused on initial and sequential therapy as well as when to use continuous intravenous (cIV) therapy and for what duration. Responses were obtained from 60/120 (50%) of those surveyed.
Results  
This survey reveals that there is expert consensus for using intravenous lorazepam for the emergent (first-line) therapy of SE in children and adults. For urgent (second-line) therapy, the most common agents chosen were phenytoin/fosphenytoin, valproate sodium, and levetiracetam; these choices varied by the patient age in the case scenarios. Physicians who care for adult patients chose cIV therapy for RSE, especially midazolam and propofol, rather than a standard AED sooner than those who care for children; and in children, there is a reluctance to choose propofol. Pentobarbital was chosen later in the therapy for all ages.
Conclusion  
There is close agreement between the recently published NCS guideline for SE and this survey of experts in the treatment of SE.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-8
  • DOI 10.1007/s12028-012-9790-1
  • Authors
    • James J. Riviello Jr., NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, Division of Pediatric Neurology, Department of Neurology, New York University School of Medicine, 223 East 34th Street, New York, NY 10016, USA
    • Jan Claassen, Columbia University, New York, NY, USA
    • Suzette M. LaRoche, Emory University, Altanta, GA, USA
    • Michael R. Sperling, Thomas Jefferson University, Philadelphia, PA, USA
    • Brian Alldredge, University of California, San Francisco, CA, USA
    • Thomas P. Bleck, Rush University Medical Center, Chicago, IL, USA
    • Tracy Glauser, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
    • Lori Shutter, University of Cincinnati Medical Center, Cincinnati, OH, USA
    • David M. Treiman, Arizona State University, Tempe, AZ, USA
    • Paul M. Vespa, University of California, Los Angeles, CA, USA
    • Rodney Bell, Thomas Jefferson University, Philadelphia, PA, USA
    • Gretchen M. Brophy, Virginia Commonwealth University, Richmond, VA, USA
    • The Neurocritical Care Society Status Epilepticus Guideline Writing Committee





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Intracranial arterial stenoses: current viewpoints, novel approaches, and surgical perspectives

Abstract  
Ten percent of all strokes occurring in the USA are caused by intracranial arterial stenosis (IAS). Symptomatic IAS carries one of the highest rates of recurrent stroke despite intensive medical therapy (25 % in high-risk groups). Clinical results for endovascular angioplasty and stenting have been disappointing. The objectives of this study were to review the contemporary understanding of symptomatic IAS and present potential alternative treatments to resolve factors not addressed by current therapies. We performed a literature review on IAS pathophysiology, natural history, and current treatment. We present an evaluation of the currently deficient aspects in its treatment and explore the role of alternative surgical approaches. There is a well-documented interrelation between hemodynamic and embolic factors in cerebral ischemia caused by IAS. Despite the effectiveness of medical therapy, hemodynamic factors are not addressed satisfactorily by medications alone. Collateral circulation and severity of stenosis are the strongest predictors of risk for stroke and death. Indirect revascularization techniques, such as encephaloduroarteriosynangiosis, offer an alternative treatment to enhance collateral circulation while minimizing risk of hemorrhage associated with hyperemia and endovascular manipulation, with promising results in preliminary studies on chronic cerebrovascular occlusive disease. Despite improvements in medical management for IAS, relevant aspects of its pathophysiology are not resolved by medical treatment alone, such as poor collateral circulation. Surgical indirect revascularization can improve collateral circulation and play a role in the treatment of this condition. Further formal evaluation of indirect revascularization for IAS is a logical and worthy step in the development of intracranial atherosclerosis treatment strategies.

  • Content Type Journal Article
  • Category Review
  • Pages 1-11
  • DOI 10.1007/s10143-012-0432-z
  • Authors
    • Nestor R. Gonzalez, Department of Neurosurgery, David Geffen School of Medicine at UCLA, 10833 LeConte Ave., Rm 18-251 Semel, Los Angeles, CA 90095-7039, USA
    • David S. Liebeskind, UCLA Stroke Center, Los Angeles, CA, USA
    • Joshua R. Dusick, Department of Neurosurgery, David Geffen School of Medicine at UCLA, 10833 LeConte Ave., Rm 18-251 Semel, Los Angeles, CA 90095-7039, USA
    • Fernando Mayor, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
    • Jeffrey Saver, UCLA Stroke Center, Los Angeles, CA, USA





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Doctors versus Big Pharma : is it justifiable to judge research by its authors?

Doctors use different standards to judge scientific research depending on who funded it. They judge research funded by industry as less rigorous, have less confidence in the results, and are less likely to prescribe new drugs than when the funding source is either the NIH or unknown - even when the apparent quality of the research is the same.Those were the results of a study published by Harvard researchers Dr. Aaron Kesselheim and colleagues in the New England Journal of Medicine last month. The story has received a fair amount of coverage since then, including being analyzed by the Scientific American Guest Blog , the Los Angeles Times , and the New York Times . [More]

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Quatro Heranças - Genética Médica Populacional

Video interessante elaborado pelo INCT de Genética Medica Populacional.
O video explora quatro situações da herança genética no Brasil.



Quatro Heranças - Genética Médica Populacional from VERTE filmes on Vimeo.





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Predictors of in-stent stenosis and occlusion after endovascular treatment of intracranial vascular

Publication year: 2012
Source:Journal of Clinical Neuroscience
Xiao-Biao Lai, Ming-Hua Li, Hua-Qiao Tan, Ben-Yan Luo, Yue-Qi Zhu, Jue Wang, Yong-Dong Li
Covered stent placement has emerged as a promising therapeutic option for intracranial vascular lesions. However, in-stent stenosis and occlusion continue to be important concerns with the use of a covered stent, which is more thrombogenic than other types of stents. The purpose of this study was to determine predictors of in-stent stenosis and occlusion for covered stents used in the treatment of intracranial vascular diseases. Clinical, procedural and angiographic data of 46 patients with 49 intracranial vascular lesions treated with the Willis covered stent (Micro-Port, Shanghai, China) between April 2005 and October 2010 were collected and analyzed retrospectively. Univariate analysis and multivariate logistic regression analysis were performed to determine the factors predictive of in-stent stenosis and/or occlusion of the stents. In-stent stenosis and/or occlusion were documented at angiography in six patients with six lesions, and no stenoses or occlusions were seen at angiography in the remaining 40 patients with 43 lesions. Univariate analysis revealed that hypertension, post-procedure irregular antiplatelet therapy and cerebrovascular arteriosclerosis were associated with in-stent stenosis and/or occlusion. By multivariate logistic regression analysis, post-procedure irregular antiplatelet therapy (odds ratio [OR]=15; 95% confidence interval [CI], 1.172–192.004; p =0.037) and cerebrovascular arteriosclerosis (OR=19; 95% CI, 1.374–262.659; p =0.028) were independent predictors of in-stent stenosis and/or occlusion. Thus, post-procedure irregular antiplatelet therapy and coexistent cerebrovascular arteriosclerosis appear to increase the risk of in-stent stenosis and/or occlusion of covered stents in the treatment of intracranial vascular disease.






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Stop the silent misdiagnosis: patients' preferences matter

In recent decades, rapid advances in the biosciences have delivered an explosion of treatment options. This is good news for patients, but it makes medical decision making more complicated. Most...





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Thursday, November 8, 2012

Decompressive Hemicraniectomy, Strokectomy, or Both in the Treatment of Malignant Middle Cerebral Ar

Publication year: 2012
Source:World Neurosurgery, Volume 78, Issue 5
Dean B. Kostov, Richard H. Singleton, David Panczykowski, Hilal A. Kanaan, Michael B. Horowitz, Tudor Jovin, Brian T. Jankowitz
Objective We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction. Methods We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year. Results Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome. Conclusion In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.






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