Monday, February 25, 2013

Patent Watch: A Heart Monitor in Your Phone

Wireless, ultrasonic personal health monitoring system: Instantaneous and personal health information at your fingertips--that is the oft-imagined innovation that could change medicine. Physician-inventor David Albert, chief medical officer of AliveCor, headquartered in San Francisco, first envisioned a portable, easy way to measure personal heart health when Palm Pilots debuted in the late 1990s. Smartphone processors, however, were not powerful enough until the latest generation of devices such as the Droid and the iPhone.

After several clinical trials, the U.S. Food and Drug Administration approved Patent no. 8,301,232 for use last November. The patent describes an electrocardiogram (ECG) device that snaps in place around a smartphone, currently the iPhone 4 or 4S, like a protective cover. The case is embedded with sensors and electronics that measure the electrical activity of the heart. Users can record their heart rate by placing their fingers on the sensors. An ultrasonic signal relays data from the monitor to the smartphone and the AliveECG app. A distant physician can examine the pattern over a secure wireless connection. The readout is not as complete as a typical 12-lead ECG, but the smartphone version provides an accurate proxy in tests.

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Júlio Leonardo B. Pereira
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Spinal ischemic stroke following dialysis: clinical and radiologic findings

Spinal cord ischemia (SCI) is a relatively common cause of noncompressive myelopathy.1 SCI frequently involves the thoracic or lumbar cord manifesting as acute painful paraparesis but may also involve the posterior columns and autonomic fibers.2 Most infarcts affect the central parts of the anterior spinal artery supply.2–4 Outcome depends on the initial severity of the neurologic deficits and may be surprisingly benign especially if proprioception remains intact.1,2 Because hypoperfusion may cause SCI,5,6 our goal was to describe SCI as a potential complication of hemodialysis-associated hypoperfusion.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Site: www.neurocirurgiabr.com
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Randomized controlled trial of trigeminal nerve stimulation for drug-resistant epilepsy

Objective:

To explore the safety and efficacy of external trigeminal nerve stimulation (eTNS) in patients with drug-resistant epilepsy (DRE) using a double-blind randomized controlled trial design, and to test the suitability of treatment and control parameters in preparation for a phase III multicenter clinical trial.

Methods:

This is a double-blind randomized active-control trial in DRE. Fifty subjects with 2 or more partial onset seizures per month (complex partial or tonic-clonic) entered a 6-week baseline period, and then were evaluated at 6, 12, and 18 weeks during the acute treatment period. Subjects were randomized to treatment (eTNS 120 Hz) or control (eTNS 2 Hz) parameters.

Results:

At entry, subjects were highly drug-resistant, averaging 8.7 seizures per month (treatment group) and 4.8 seizures per month (active controls). On average, subjects failed 3.35 antiepileptic drugs prior to enrollment, with an average duration of epilepsy of 21.5 years (treatment group) and 23.7 years (active control group), respectively. eTNS was well-tolerated. Side effects included anxiety (4%), headache (4%), and skin irritation (14%). The responder rate, defined as >50% reduction in seizure frequency, was 30.2% for the treatment group vs 21.1% for the active control group for the 18-week treatment period (not significant, p = 0.31, generalized estimating equation [GEE] model). The treatment group experienced a significant within-group improvement in responder rate over the 18-week treatment period (from 17.8% at 6 weeks to 40.5% at 18 weeks, p = 0.01, GEE). Subjects in the treatment group were more likely to respond than patients randomized to control (odds ratio 1.73, confidence interval 0.59–0.51). eTNS was associated with reductions in seizure frequency as measured by the response ratio (p = 0.04, analysis of variance [ANOVA]), and improvements in mood on the Beck Depression Inventory (p = 0.02, ANOVA).

Conclusions:

This study provides preliminary evidence that eTNS is safe and may be effective in subjects with DRE. Side effects were primarily limited to anxiety, headache, and skin irritation. These results will serve as a basis to inform and power a larger multicenter phase III clinical trial.

Classification of evidence:

This phase II study provides Class II evidence that trigeminal nerve stimulation may be safe and effective in reducing seizures in people with DRE.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthca

Background and Purpose—

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

Methods—

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

Results—

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

Conclusions—

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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One-Year Progression of Moderate Asymptomatic Carotid Stenosis Predicts the Risk of Vascular Events

Background and Purpose—

This study aimed at evaluating whether ultrasound monitoring of moderate asymptomatic carotid stenosis may help in identifying subjects at high risk for vascular events.

Methods—

We included 523 subjects with unilateral asymptomatic carotid stenosis of 50% to 69%. Follow-up carotid ultrasound was performed within 12 months from inclusion to detect the frequency and degree of stenosis progression. Subjects were prospectively evaluated for a median period of 42 months (interquartile range, 38–45) after a second ultrasound evaluation. Outcome measures were any stroke and transient ischemic attack, myocardial infarction, and death.

Results—

Carotid stenosis progression was associated with the occurrence of vascular events (hazard ratio, 21.57; 95% confidence interval, 11.81–39.39; P<0.001). During follow-up, 96.7% of subjects without progressive carotid stenosis remained free from vascular events. Among patients with progressive stenosis, 53.7% experienced a vascular event and 27.1% experienced an ipsilateral stroke.

Conclusions—

One-year moderate asymptomatic carotid stenosis progression is related to higher risk of vascular events, including ipsilateral stroke.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Reducing Delay of Carotid Endarterectomy in Acute Ischemic Stroke Patients: A Nationwide Initiative

Background and Purpose—

Guidelines recommend carotid endarterectomy (CEA) within 2 weeks from an ischemic event. However, previous studies have shown that only a minority of patients undergo CEA within this period. The aim of this study was to examine the effect of a multidisciplinary nationwide initiative aimed at reducing time to CEA after acute ischemic stroke.

Methods—

We examined a historic population-based observational cohort based on individual patient-level records from the Danish Stroke Registry and the Danish Vascular Registry. The implementation of early ultrasound examination of the carotids (within 4 days from admission) in medical departments coupled with fast CEA after referral to a department of vascular surgery were monitored and audited systematically from 2008 and onward.

Results—

A total of 813 acute ischemic stroke patients underwent CEA during 2007-2010. The percentage of patients undergoing CEA within 2 weeks increased from 13% in 2007 to 47% in 2010 (adjusted odds ratio, 5.8 [95% CI, 3.4–10.1]). The overall median time decreased from 31 days to 16 days. The percentage of relevant acute ischemic stroke patients receiving early ultrasound examination of the carotids increased from 41% in 2008 to 72% in 2010. The time from referral to operation at a vascular department was reduced by 40%.

Conclusions—

Establishing time limits of 4 days to ultrasound examination of the carotids and of 2 weeks to CEA from onset of stroke followed by a systematic multidisciplinary monitoring and auditing of processes was associated with a substantial increase in the proportion of acute ischemic stroke patients who undergo CEA within 2 weeks in Denmark.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Subarachnoid Extension of Primary Intracerebral Hemorrhage is Associated With Poor Outcomes [Clinica

Background and Purpose—

Extension of hemorrhage into the subarachnoid space is observed in primary intracerebral hemorrhage (ICH), yet the phenomenon has undergone limited study and is of unknown significance. The objective of this study is to evaluate the incidence, characteristics, and clinical consequences of subarachnoid hemorrhage extension (SAHE) in ICH on functional outcomes.

Methods—

Patients with primary ICH were enrolled into a prospective registry between December 2006 and June 2012. Patients were managed and serial neuroimaging was obtained per a structured protocol. Presence of any subarachnoid blood on imaging was identified as SAHE by expert reviewers blinded to outcomes. Regression models were developed to test whether the occurrence of SAHE was an independent predictor of functional outcomes as measured with the modified Rankin Scale.

Results—

Of 234 patients with ICH, 93 (39.7%) had SAHE. Interrater agreement for SAHE was excellent (kappa=0.991). SAHE was associated with lobar hemorrhage location (65% of SAHE vs 19% of non-SAHE cases; P<0.001) and larger hematoma volumes (median 23.8 vs 6.7; P<0.001). Fever (69.9% vs 51.1%; P=0.005) and seizures (8.6% vs 2.8%; P=0.07) were more common in patients with SAHE. SAHE was a predictor of death by day 14 (odds ratio, 4.45; 95% confidence interval, 1.88–10.53; P=0.001) and of higher (worse) modified Rankin Scale scores at 28 days (odds ratio, 1.76 per mRS point; 95% confidence interval, 1.01–3.05; P=0.012) after adjustment for ICH score.

Conclusions—

SAHE is associated with worse modified Rankin Scale independent of traditional ICH severity measures. Underlying mechanisms and potential treatments of SAHE require further study.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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The Modified Graeb Score: An Enhanced Tool for Intraventricular Hemorrhage Measurement and Predictio

Background and Purpose—

Simple and rapid measures of intraventricular hemorrhage (IVH) volume are lacking. We developed and validated a modification of the original Graeb scale to facilitate rapid assessment of IVH over time.

Methods—

We explored the relationship between the modified Graeb scale (mGS), original Graeb scale, measured IVH volume, and outcome using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA B (CLEAR B) study. We also explored its reliability. We then evaluated the relationship between mGS and outcome in a large sample of participants with IVH using data contained within the Virtual International Stroke Trials Archive (VISTA). We defined outcome using the modified Rankin scale (>3 signifying poor outcome).

Results—

The CLEAR B study included 360 scans from 36 subjects. The mGS score and IVH volume were highly correlated (R = 0.80, P<0.0001, R2 0.65). Baseline mGS was predictive of poor outcome (area under receiving operating characteristic curve 0.74, 95% confidence interval, 0.57–0.91), whereas the original Graeb scale was not. The VISTA study included 399 participants. Each unit increase in the mGS led to a 12% increase in the odds of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.05–1.19). Measures of reliability (intra- and inter- reader) were good in both studies.

Conclusions—

The mGS, a semiquantitative scale for IVH volume measurement, is a reliable measure with prognostic validity suitable for rapid use in clinical practice and in research.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Site: www.neurocirurgiabr.com
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Minimally Invasive Surgery Plus Recombinant Tissue-type Plasminogen Activator for Intracerebral Hemo

Background and Purpose—

Perihematomal edema (PHE) can worsen outcomes after intracerebral hemorrhage (ICH). Reports suggest that blood degradation products lead to PHE. We hypothesized that hematoma evacuation will reduce PHE volume and that treatment with recombinant tissue-type plasminogen activator (rt-PA) will not exacerbate it.

Methods—

Minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II tested safety and efficacy of hematoma evacuation after ICH. We conducted a semiautomated, computerized volumetric analysis on computed tomography to assess impact of hematoma removal on PHE and effects of rt-PA on PHE. Volumetric analyses were performed on baseline stability and end of treatment scans.

Results—

Seventy-nine surgical and 39 medical patients from minimally invasive surgery and rt-PA in ICH evacuation phase II (MISTIE II) were analyzed. Mean hematoma volume at end of treatment was 19.6±14.5 cm3 for the surgical cohort and 40.7±13.9 cm3 for the medical cohort (P<0.001). Edema volume at end of treatment was lower for the surgical cohort: 27.7±13.3 cm3 than medical cohort: 41.7±14.6 cm3 (P<0.001). Graded effect of clot removal on PHE was observed when patients with >65%, 20% to 65%, and <20% ICH removed were analyzed (P<0.001). Positive correlation between PHE reduction and percent of ICH removed was identified (=0.658; P<0.001). In the surgical cohort, 69 patients underwent surgical aspiration and rt-PA, whereas 10 underwent surgical aspiration only. Both cohorts achieved similar clot reduction: surgical aspiration and rt-PA, 18.9±14.5 cm3; and surgical aspiration only, 24.5±14.0 cm3 (P=0.26). Edema at end of treatment in surgical aspiration and rt-PA was 28.1±13.8 cm3 and 24.4±8.6 cm3 in surgical aspiration only (P=0.41).

Conclusions—

Hematoma evacuation is associated with significant reduction in PHE. Furthermore, PHE does not seem to be exacerbated by rt-PA, making such neurotoxic effects unlikely when the drug is delivered to intracranial clot.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Incidence and Associations of Poststroke Epilepsy: The Prospective South London Stroke Register [Cli

Background and Purpose—

To describe the epidemiology and associations of poststroke epilepsy (PSE) because there is limited evidence to inform clinicians and guide future research.

Methods—

Data were collected from the population-based South London Stroke Register of first strokes in a multiethnic inner-city population with a maximum follow-up of 12 years. Self-completed forms and interviews notified study organizers of epilepsy diagnosis. Kaplan–Meier methods and Cox models were used to assess associations with sociodemographic factors, clinical features, stroke subtype, and severity markers.

Results—

Three thousand three-hundred ten patients with no history of epilepsy presented with first stroke between 1995 and 2007, with a mean follow-up of 3.8 years. Two-hundred thirteen subjects (6.4%) had development of PSE. PSE incidence at 3 months and 1, 5, and 10 years were estimated at 1.5%, 3.5%, 9.0%, and 12.4%, respectively. Sex, ethnicity, and socioeconomic status were not associations, but markers of cortical location, including dysphasia, visual neglect, and field defect, along with stroke severity indices at presentation, including low Glasgow Coma Scale, incontinence, or poor function on Barthel Index, were associated with PSE on univariate analysis. Young age was independently associated with PSE, affecting 10.7% of patients aged <65 years and 1.6% >85 years (P≤0.001) on 10-year estimates. Independent predictors of PSE also included visual neglect, dysphasia, and stroke subtype, particularly total anterior circulation infarcts. Dysarthria was associated with reduced incidence.

Conclusions—

PSE is common, with risk continuing to increase outside the acute phase. Young age, cortical location, larger lesions, and hemorrhagic lesions are independent predictors.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial [Clinical Sciences]

Background and Purpose—

Acute blood pressure (BP) reduction aimed at attenuation of intracerebral hemorrhage (ICH) expansion might also compromise cerebral blood flow (CBF). We tested the hypothesis that CBF in acute ICH patients is unaffected by BP reduction.

Methods—

Patients with spontaneous ICH <24 hours after onset and systolic BP > 150 mm Hg were randomly assigned to an intravenous antihypertensive treatment protocol targeting a systolic BP of <150 mm Hg (n=39) or <180 mm Hg (n=36). Patients underwent computed tomography perfusion imaging 2 hours postrandomization. The primary end point was perihematoma relative (relative CBF).

Results—

Treatment groups were balanced with respect to baseline systolic BP: 182±20 mm Hg (<150 mm Hg target group) versus 184±25 mm Hg (<180 mm Hg target group; P=0.60), and for hematoma volume: 25.6±30.8 versus 26.9±25.2 mL (P=0.66). Mean systolic BP 2 hours after randomization was significantly lower in the <150 mm Hg target group (140±19 vs 162±12 mm Hg; P<0.001). Perihematoma CBF (38.7±11.9 mL/100 g per minute) was lower than in contralateral homologous regions (44.1±11.1 mL/100 g per minute; P<0.001) in all patients. The primary end point of perihematoma relative CBF in the <150 mm Hg target group (0.86±0.12) was not significantly lower than that in the <180 mm Hg group (0.89±0.09; P=0.19; absolute difference, 0.03; 95% confidence interval –0.018 to 0.078). There was no relationship between the magnitude of BP change and perihematoma relative CBF in the <150 mm Hg (R=0.00005; 95% confidence interval, –0.001 to 0.001) or <180 mm Hg target groups (R=0.000; 95% confidence interval, –0.001 to 0.001).

Conclusions—

Rapid BP lowering after a moderate volume of ICH does not reduce perihematoma CBF. These physiological data indicate that acute BP reduction does not precipitate cerebral ischemia in ICH patients.

Clinical Trial Registration Information—

URL:http://clinicaltrials.gov. Unique Identifier: NCT00963976.








Júlio Leonardo B. Pereira
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Remarkable Decline in Ischemic Stroke Mortality is Not Matched by Changes in Incidence [Clinical Sci

Background and Purpose—

In Western Europe, mortality from ischemic stroke (IS) has declined over several decades. Age–sex-specific IS mortality, IS incidence, 30-day case fatality, and 1-year mortality after hospital admission are essential for explaining recent trends in IS mortality in the new millennium.

Methods—

Data for all IS deaths (1980–2010) in the Netherlands were grouped by year, sex, and age. A joinpoint regression was fitted to detect points in time at which significant changes in the trends occur. By linking nationwide registers, a cohort of patients first admitted for IS between 1997 and 2005 was constructed and age–sex-specific 30-day case fatality and 1-year mortality were computed. IS incidence (admitted IS patients and out-of-hospital IS deaths) was computed by age and sex. Mann–Kendall tests were used for trend evaluation.

Results—

IS mortality declined continuously between1980 and 2000 with an attenuation of decline in the 1990s in some of the age–sex groups. A remarkable decline in IS mortality after 2000 was observed in all age–sex groups, except for young men. An improved decline in 30-day case fatality and in 1-year mortality was also observed in almost all age–sex groups. In contrast, IS incidence remained stable between 1997 and 2005 or even increased slightly.

Conclusions—

The recent remarkable decline in IS mortality was not matched by a decline in the number of incident nonfatal IS events. This is worrying, because IS is already a leading cause of adult disability, claiming a heavy human and economic burden. Prevention of IS is therefore now of the greatest importance.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Predictors for Recurrent Primary Intracerebral Hemorrhage: A Retrospective Population-based Study [C

Background and Purpose—

Underlying comorbidities, previous strokes, and medication may increase the risk for primary intracerebral hemorrhage (PICH) and its recurrence. The aim of this study was to determine the independent predictors for recurrent PICH.

Methods—

We identified 961 subjects with first-ever PICH from 1993 to 2008 among the population of Northern Ostrobothnia, Finland. Hospital and death records were reviewed and data on drug use were obtained from the national register of prescribed medicines. Kaplan–Meier survival curves and Cox proportional hazards models were used to demonstrate predictors for recurrence of PICH.

Results—

Total follow-up time of the 961 patients was 3481 person-years. During the follow-up time, 58 subjects had altogether 68 recurrent PICHs. The annual average incidence of first recurrence was 1.67%. Cumulative 5- and 10-year incidence rates were 9.6% and 14.2%, respectively. In univariable analysis, history of ischemic stroke, diabetes mellitus, and aspirin use were associated with a higher recurrence rate. In multivariable analysis, only previous ischemic stroke (adjusted hazard ratio, 2.22; 95% confidence interval, 1.22–4.05; P=0.009) independently predicted PICH recurrence. Diabetes mellitus tended to increase (adjusted hazard ratio, 2.38; 95% confidence interval, 0.98–5.80; P=0.056), whereas treated hypertension tended to decrease (0.45, 0.20–1.01; P=0.054) the risk for fatal recurrent PICH.

Conclusions—

Previous ischemic stroke independent of confounding factors may increase the risk for PICH recurrence.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
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Friday, February 22, 2013

Free New #Neurosurgery Blog App - Apps Android Google Play #neurology #medicine # medstudent

New App Free !!! Neurosurgery Blog 
You can note yours surgery on cloud. 


Júlio Leonardo B. Pereira
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Thursday, February 21, 2013

Stroke after Alzheimer disease: I have more bad news

A rather dark joke has it that a doctor is speaking with his patient, Mr. Jones, after examining him.








Júlio Leonardo B. Pereira
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How do we fashion better trials for neurostimulator studies in migraine?

Numerous investigators make tremendous and respectable efforts so that well-designed and -executed prospective, double-blind, randomized, controlled trials can determine definitively whether therapies of interest are indeed safe and effective. In this issue of Neurology®, Schoenen et al.1 report the results of such a trial conducted at 5 tertiary headache centers in Belgium. They determined whether migraine attacks can be prevented by trigeminal neurostimulation with a supraorbital transcutaneous stimulator: Cefaly. This stimulation device is fashionably designed and its frame resembles a lightweight tiara or sporty sunglasses.








Júlio Leonardo B. Pereira
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Emerging Subspecialties in Neurology: Global health

Global health is the study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.1 In contrast to the public health concerns of a particular country or region, global health looks at populations irrespective of borders. One of the key elements in advancing the field of global health was the establishment of the WHO in 1948. Since its inception, the WHO has helped coordinate global efforts toward eradication of diseases such as smallpox and polio as well as elimination of onchocerciasis. It now assumes responsibility for the International Classification of Diseases. More recently, the field of global health has received considerable attention from world leaders, philanthropists, and academics. In 2009, President Obama introduced his Global Health Initiative that proposed spending $63 billion over 6 years to support global health programs specifically targeting areas such as HIV/AIDS, malaria, tuberculosis, nutrition, and reproductive health. On his first day of work as NIH Director, Francis Collins announced global health as one of his 5 themes of "exceptional opportunity" that would receive special priority during his tenure.2 The Fogarty International Center is a branch of the NIH that helps to support global health research for US and foreign researchers, often in resource-limited settings. The research initiatives encompass a diverse range of disciplines within the field of medicine.








Júlio Leonardo B. Pereira
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Surgical Treatment of Ruptured Anterior Circulation Aneurysms: Comparison of Pterional and Supraorb

imageBACKGROUND: Recent advancements in microsurgical techniques and instrumentation have allowed the development of the keyhole approach in aneurysm surgery. OBJECTIVE: To compare the safety, efficacy, and 1-year clinical outcome of supraorbital keyhole and standard pterional approaches for ruptured anterior circulation aneurysms. METHODS: A total of 87 patients underwent surgical clipping, 40 through the pterional and 47 through the supraorbital keyhole approach. Baseline demographics, operative time, procedural complications, and 1-year patient outcome were retrospectively compared. RESULTS: The 2 groups were comparable with respect to baseline characteristics, with the exception of a higher proportion of small aneurysms (<7 mm) in the supraorbital group (70.2% vs 37.5%, P = .002). Total operative time was significantly shorter in the supraorbital group (205 minutes, P < .001) compared with the pterional group (256 minutes). The rate of procedural complications was lower in patients treated through the pterional (17.5%) vs the supraorbital approach (23.4%, P = .4). Intraoperative aneurysm ruptures occurred more frequently in the supraorbital group (10.6% vs 2.5%). No patient experienced early or late rebleeding in either group. One year after treatment, 75% (30/40) of patients achieved a favorable outcome (Glasgow Outcome Scale IV or V) in the pterional group vs 76.6% (36/47) in the supraorbital group (P = .8). CONCLUSION: The rate of procedural complications may be higher with the supraorbital keyhole approach, but overall patient outcomes appear to be comparable. The pterional approach is a simple, reliable, and efficient procedure. The keyhole approach may be an acceptable alternative for neurosurgeons who have gained sufficient experience with the technique, especially for small noncomplex aneurysms.







Júlio Leonardo B. Pereira
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Brain Lesions Can Predict Alzheimer's Diagnosis

Damage to small blood vessels in the brain could be a secondary risk factor leading to Alzheimer's Disease, a new study in JAMA Neurology suggests. A part of this blood vessel damage is known as white matter hyperintensities, seen in the brains of Alzheimer's patients and appearing to increase the risk for the disease, making it a secondary factor...







Júlio Leonardo B. Pereira
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Porque as revistas pagas devem acabar

A discussão sobre revistas de acesso aberto (open access) x revistas de acesso fechado (as disponíveis somente para quem faz assinatura de conteúdo) está em voga. Neste blog, temos apresentado alguns argumentos a favor do acesso aberto. Esses argumentos, no entanto, vem sendo apresentados por pesquisadores, em sua maioria. No entanto, ontem me deparei com este post, publicado no The student







Júlio Leonardo B. Pereira
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Vascular Development May Be An Important New Factor In Normal And Abnormal Brain Development

A new study by Columbia Engineering researchers finds that the infant brain does not control its blood flow in the same way as the adult brain. The paper, which the scientists say could change the way researchers study brain development in infants and children, is published in the February 18 Early Online edition of Proceedings of the National Academy of Sciences (PNAS)...







Júlio Leonardo B. Pereira
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Deep Brain Stimulation Fights Disease Deep Inside The Brain

Some 90,000 patients per year are treated for Parkinson's disease, a number that is expected to rise by 25 percent annually. Deep Brain Stimulation (DBS), which consists of electrically stimulating the central or peripheral nervous system, is currently standard practice for treating Parkinson's, but it can involve long, expensive surgeries with dramatic side effects...







Júlio Leonardo B. Pereira
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Download the AAN Annual Meeting App

The 2013 AAN Annual Meeting mobile app for iPhone®, iPad®, and Android® devices is now available for download at the App Store or Google Play.







Júlio Leonardo B. Pereira
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Saturday, February 16, 2013

Whole-brain magnetic resonance spectroscopic imaging measures are related to disability in ALS

Objective:

To demonstrate the sensitivity of a recently developed whole-brain magnetic resonance spectroscopic imaging (MRSI) sequence to cerebral pathology and disability in amyotrophic lateral sclerosis (ALS), and compare with measures derived from diffusion tensor imaging.

Methods:

Whole-brain MRSI and diffusion tensor imaging were undertaken in 13 patients and 14 age-similar healthy controls. Mean N-acetylaspartate (NAA), fractional anisotropy, and mean diffusivity were extracted from the corticospinal tract, compared between groups, and then in relation to disability in the patient group.

Results:

Significant reductions in NAA were found along the course of the corticospinal tracts on whole-brain MRSI. There were also significant changes in fractional anisotropy (decreased) and mean diffusivity (increased) in the patient group, but only NAA showed a significant relationship with disability (r = 0.65, p = 0.01).

Conclusion:

Whole-brain MRSI has potential as a quantifiable neuroimaging marker of disability in ALS. It offers renewed hope for a neuroimaging outcome measure with the potential for harmonization across multiple sites in the context of a therapeutic trial.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Biomarkers for PD: How can we approach complexity?

By the time patients present with motor symptoms of Parkinson disease (PD), two-thirds of their dopaminergic neurons will have died and at least some of the remaining dopaminergic neurons may already be affected by the molecular mechanisms that will eventually lead to their death. It is plausible to assume that any neuroprotective therapy for PD might be much more effective if individuals at risk could be started on such therapy while they are still in the premotor stage of the disease. Excellent epidemiologic combined with long-time clinical follow-up studies have unequivocally established that individuals with common but nonspecific symptoms, such as autonomic dysfunction including constipation, erectile and urinary dysfunction, and neuropsychiatric symptoms like depression or hyposmia, are at increased risk of developing PD.1 Other premotor manifestations of PD, in particular REM sleep behavioral disorder (RBD), are much more characteristic for premotor PD, but comparatively rare. Any attempt to base the identification of premotor PD on clinical observation only is therefore limited by low specificity (as would be the case for constipation) or sensitivity (as for RBD). Moreover, low specificity of some markers alludes to another major drawback in the search of biomarkers: the heterogeneity of PD. To evaluate markers reliably, it is therefore important to assess cohorts in whom homogenous pathogenesis can be assumed. This is the case in individuals who share the same genetically determined risk. Monogenetic forms of PD are, however, rare, and it is therefore difficult to recruit such genetically determined cohorts.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Women With Brain Aneurysms At No Greater Risk Of Rupture During Pregnancy And Delivery

For women with aneurysms involving the brain blood vessels, pregnancy and delivery don't appear to increase the risk of aneurysm rupture, reports a paper in the February issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health...







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Novel Methods to Predict Increased Intracranial Pressure During Intensive Care and Long-Term Neurolo

imageObjective: Intracranial pressure monitoring is standard of care after severe traumatic brain injury. Episodes of increased intracranial pressure are secondary injuries associated with poor outcome. We developed a model to predict increased intracranial pressure episodes 30 mins in advance, by using the dynamic characteristics of continuous intracranial pressure and mean arterial pressure monitoring. In addition, we hypothesized that performance of current models to predict long-term neurologic outcome could be substantially improved by adding dynamic characteristics of continuous intracranial pressure and mean arterial pressure monitoring during the first 24 hrs in the ICU. Design: Prognostic modeling. Noninterventional, observational, retrospective study. Setting and Patients: The Brain Monitoring with Information Technology dataset consisted of 264 traumatic brain injury patients admitted to 22 neuro-ICUs from 11 European countries. Interventions: None. Measurements: Predictive models were built with multivariate logistic regression and Gaussian processes, a machine learning technique. Predictive attributes were Corticosteroid Randomisation After Significant Head Injury-basic and International Mission for Prognosis and Clinical Trial design in TBI-core predictors, together with time-series summary statistics of minute-by-minute mean arterial pressure and intracranial pressure. Main Results: Increased intracranial pressure episodes could be predicted 30 mins ahead with good calibration (Hosmer-Lemeshow p value 0.12, calibration slope 1.02, calibration-in-the-large −0.02) and discrimination (area under the receiver operating curve = 0.87) on an external validation dataset. Models for prediction of poor neurologic outcome at six months (Glasgow Outcome Score 1–2) based only on static admission data had 0.72 area under the receiver operating curve; adding dynamic information of intracranial pressure and mean arterial pressure during the first 24 hrs increased performance to 0.90. Similarly, prediction of Glasgow Outcome Score 1–3 was improved from 0.68 to 0.87 when including dynamic information. Conclusion: The dynamic information in continuous mean arterial pressure and intracranial pressure monitoring allows to accurately predict increased intracranial pressure in the neuro-ICU. Adding information of the first 24 hrs of intracranial pressure and mean arterial pressure monitoring to known baseline risk factors allows very accurate prediction of long-term neurologic outcome at 6 months.







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Hematoma Attack Cuts Edema in Brain Bleed (CME/CE)

(MedPage Today) -- Hematoma evacuation was associated with a significant reduction in perihematomal edema, according to results of the phase II MISTIE trial.







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Post-traumatic hydrocephalus after ventricular shunt placement in a Singaporean neurosurgical unit

Available online 13 February 2013
Publication year: 2013
Source:Journal of Clinical Neuroscience

Ventricular enlargement is a common finding after severe head injury and has a poor prognosis if associated with post-traumatic hydrocephalus (PTH). We retrospectively reviewed our head injury database and identified patients who suffered from severe head injury and subsequently had shunt insertion after a diagnosis of PTH. A total of 871 patients with severe head injury were admitted from April 1999 to December 2006. Twenty-three patients (2.6%) were diagnosed with post-traumatic hydrocephalus and had a shunt inserted. Multiple logistic regression analysis showed that age, and unilateral and bilateral decompressive craniectomy, were significant predictors of PTH. The timing of shunt placement was between 2weeks and 5months post–head injury with a mean interval of 70days. Three patients developed complications after shunt insertion. Seventeen patients (74%) achieved improvement after shunt insertion while the remainder had no significant change in neurological status. Eleven patients (48%) had improvements in their Glasgow Coma Scale (GCS) score of ⩾2 points, while six patients (26%) had a single-point improvement in their GCS score. At 1year after shunting, 35% of patients had Glasgow Outcome Scale scores of 3 to 4. PTH is a condition that has an insidious onset with varying clinical and radiological presentations. The incidence is low but there is a significant benefit from ventricular shunt insertion. The use of cerebrospinal fluid dynamic studies, in addition to clinical and radiological findings, has the potential for better diagnosis and management of these patients.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Music Lessons Early In Life Increase Brain Development

Playing the recorder in kindergarten, piano lessons in first grade, clapping to the rhythm throughout elementary school music class, all of these can contribute to developing the brain. The new findings, published in the Journal of Neuroscience, reveal that musical training earlier than the age of seven has a significant impact on the development of the brain...







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Deep Brain Therapy Benefits May Linger After Device Turned Off In Some Dystonia Cases

Two patients freed from severe to disabling effects of dystonia through deep brain stimulation therapy continued to have symptom relief for months after their devices accidentally were fully or partly turned off, according to a report published online in the journal Movement Disorders...







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Prognosis of acute subdural haematoma from intracranial aneurysm rupture

Background

Acute subdural haematoma (aSDH) is a rare complication of aneurysmal subarachnoid haemorrhage (SAH) and is associated with poor clinical condition on admission and poor outcome.

Objective

The aim of this study was to assess whether aneurysmal aSDH is an independent risk factor for poor outcome.

Methods

In a series of 1632 patients retrieved from our prospectively collected single centre SAH database and fulfilling prespecified inclusion criteria, we found 53 patients with aSDH on the initial CT scan. From the same series, we collected 660 patients in whom aSDH was ruled out by reviewing the initial CT scan. We compared the risk of poor outcome at discharge and at 3 months between patients with and without aSDH by calculating crude risk ratios (RRs) with corresponding 95% CIs, and adjusting for age, sex, location and treatment modality of the aneurysm that bled, clinical condition on admission, intracerebral haemorrhage, intraventricular haemorrhage and hydrocephalus, with Poisson regression.

Results

Patients with aSDH had a higher risk of poor outcome at discharge (crude RR 1.59; 95% CI 1.35 to 1.86) and at 3 months (crude RR: 2.17, 95% CI 1.79 to 2.62) than patients without aSDH. After simultaneous adjustment for five characteristics that affected the crude RR, the RR for poor outcome for patients with aSDH at discharge was 1.15 (95% CI 0.97 to 1.37) and at 3 months 1.30 (95% CI 1.04 to 1.62).

Conclusions

The presence of aSDH in patients with aneurysmal SAH is an independent risk factor for poor outcome at 3 months.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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History of Psychosurgery: Psychiatrist's Perspective

Available online 15 February 2013
Publication year: 2013
Source:World Neurosurgery

Interest in using neuromodulation to treat psychiatric disorders is rapidly increasing. The development of novel tools and techniques, such as Deep Brain Stimulation (DBS), increases precision and minimizes risk. This article reviews the history of psychosurgical interventions and recent developments of DBS to provide a framework for understanding current options and future goals. We begin by discussing early approaches to psychosurgery, focusing on the widespread used of lobotomy and the subsequent backlash from the public and professionals in the field. Next, we discuss the development of stereotaxis. This technique allows for more targeted, precise interventions that produce discrete subcortical lesions. We focus on four stereotactic procedures that were developed using this technique: cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy. We subsequently review contemporary theory and approaches with relevance to psychosurgery. We discuss the systems and neurocircuitry that are thought to be involved in psychiatric illness and provide targets for intervention. This discussion includes presentation of basal ganglia thalamocortical pathophysiology including cortico-striato-thalamo-cortical (CSTC) loops. We focus the discussion on two psychiatric disorders that have been targets of neurosurgical interventions: Obsessive-Complusive Disorder (OCD) and mood disorders such as Major Depressive Disorder (MDD). Evidence from studies of DBS in psychiatric disorders, including efficacy and tolerability, is reviewed. Finally, we look to the future, exploring the possibilities for these approaches to increase understanding, transform societal views of mental illness, and improve treatment.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Brain Location For Stem Cell Transplantation Crucial For Cell Survival

Researchers at the Johns Hopkins University in Baltimore, Md., and the Mossakowski Medical Research Centre in Warsaw, Poland, have found that nonself-donated cells (allografts) better survive implantation into the brains of immunocompetent research mice when the grafts are injected into the striatum (STR) of the brain rather than injected into the forceps minor (FM) region...







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Monday, February 11, 2013

Alzheimer's - Let's Focus On Early Stages, FDA Proposes

In an effort to treat and identify Alzheimer's patients early on during the disease, the FDA says it may relax the guidelines on Alzheimer's early-stage trials. The Agency has issued a proposal designed to help researchers and developers find new treatments for patients before the onset of overt (noticeable) dementia...







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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Complications Associated with Surgical Treatment of Traumatic Spinal Fractures: A Review of the Scol

Available online 8 February 2013
Publication year: 2013
Source:World Neurosurgery

Objective Traumatic spinal fracture is a common indication for surgery with an associated high incidence of perioperative complications. The literature provides a wide range in the incidence of complications. We seek to assess the perioperative morbidity and mortality of surgery for traumatic spinal fractures and to identify predictors of their occurrence. Methods We performed a retrospective analysis of all traumatic spinal fracture cases submitted by members of the Scoliosis Research Society from 2004 to 2007. Results A total of 108,478 cases were submitted from 2004 through 2007, with 6,706 (6.2%) performed for treatment of traumatic fracture. Twenty two percent of patients had preoperative neurological deficits. Intraoperative neuromonitoring was used in 58% of cases. The overall incidence of complications was 6.9%. The perioperative mortality was 0.5%. There were 59 (0.9%) new postoperative neurological deficits. Multivariate analysis demonstrated preoperative neurological deficit [P=0.001; OR 1.449, 95% CI (1.156-1.817)] and fusion [P=0.001; OR 1.12, 95% CI (1.072-1.168)] as predictors of complications and use of intraoperative neuromonitoring [P=0.016; OR1.949, 95% CI (1.13-3.361)] and preoperative neurological deficit [P<0.001; OR 2.964, 95% CI (1.667-5.271)] as predictors of new postoperative neurological deficits (P<0.001). Conclusions Overall, surgery for the treatment of spinal fractures was performed with relatively low incidences of perioperative complications (6.9%) and mortality (0.5%). These data may prove useful for patient counseling and ongoing efforts to improve the safety of operative care for patients with spinal fracture.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
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