Saturday, March 30, 2013

Determination of Neurologic Prognosis and Clinical Decision Making in Adult Patients With Severe Tra

imageObjectives: Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable across centers. We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care. Design, Setting, and Participants: We conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers. Intervention: None. Measurements: The main outcome measure was physicians' perceptions of prognosis and recommendations on the level of care. Main Results: Our response rate was 64% (455/712). Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%). In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and one-third disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies. Conclusions: A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.





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Prognosis in Severe Brain Injury

imageBackground: The prediction of neurologic outcome is a fundamental concern in the resuscitation of patients with severe brain injury. Objective: To provide an evidence-based update on neurologic prognosis following traumatic brain injury and hypoxic-ischemic encephalopathy after cardiac arrest. Data Source: Search of the PubMed database and manual review of bibliographies from selected articles to identify original data relating to prognostic methods and outcome prediction models in patients with neurologic trauma or hypoxic-ischemic encephalopathy. Data Synthesis and Conclusion: Articles were scrutinized regarding study design, population evaluated, interventions, outcomes, and limitations. Outcome prediction in severe brain injury is reliant on features of the neurologic examination, anatomical and physiological changes identified with CT and MRI, abnormalities detected with electroencephalography and evoked potentials, and physiological and biochemical derangements at both the brain and systemic levels. Use of such information in univariable association studies generally lacks specificity in classifying neurologic outcome. Furthermore, the accuracy of established prognostic classifiers may be affected by the introduction of outcome-modifying interventions, such as therapeutic hypothermia following cardiac arrest. Although greater specificity may be achieved with scoring systems derived from multivariable models, they generally fail to predict outcome with sufficient accuracy to be meaningful at the single patient level. Discriminative models which integrate knowledge of genetic determinants and biologic processes governing both injury and repair and account for the effects of resuscitative and rehabilitative care are needed.





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Anterior surgical approaches to the cervicothoracic junction: when to use the manubriotomy?

Available online 30 March 2013
Publication year: 2013
Source:The Spine Journal

Background context The cervicothoracic junction (CTJ) is always a difficult area for anterior approaches. Among them, low anterior cervical approach alone or combined with manubriotomy is the most frequently used. Purpose To study the need of manubriotomy. Study design/setting Comparison of last guidelines proposed in literature. Patient sample Seven patients treated between March 2010 and March 2011. Methods All the patients were scanned on with computed tomography and magnetic resonance of the spinal column before surgery. Measurements by Teng and Karikari were applied in all the cases. An illustrative case is showed. Results The anterior approaches to the CTJ are reviewed. The most recent guidelines by Teng and Karikari are easy to apply and careful. The results obtained were the same in all the cases with good outcome. Conclusions Manubriotomy permits a good exposure of the CTJ area with a low rate of complications. Either Teng and Karikari's guidelines can be used to estabilish the need of manubriotomy.






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Aspirin and Aneurysmal Subarachnoid Hemorrhage

Available online 30 March 2013
Publication year: 2013
Source:World Neurosurgery

Objective Recent evidence has suggested a potential beneficial effect of aspirin on the risk of aneurysm rupture. This benefit must be weighed against its potential adverse effects as an anti-platelet agent in the setting of acute aneurysmal subarachnoid hemorrhage (SAH). Methods The authors reviewed a consecutive series of 747 patients with cerebral aneurysms, comparing demographics, aneurysm features, presenting clinical and radiographic grades, vasospasm and outcome at 1 year between patients with aneurysmal SAH taking aspirin on presentation and those who were not. Results The rate of hemorrhagic presentation was significantly greater in patients not taking aspirin (40% vs 28%, p = 0.016). Among 274 patients presenting with aneurysmal SAH, there was no significant difference in presenting clinical (Hunt-Hess) and radiographic (Fisher) grade between patients taking aspirin and those who were not. There was also no significant difference in the rate of subsequent angiographic and delayed cerebral ischemia (DCI). Multivariate analysis of outcome at 1 year found only increasing age (OR 1.19, 95% CI 0.35-4.09), Hunt-Hess (HH) grade (OR 3.01, 95% CI 1.81-5.03), and associated hypertension (OR 3.30, 95% CI 1.39-7.81) to be statistically significant risk factors for poor outcome (death or dependence), while aspirin use was not associated with poor outcome (OR 1.19, 95% CI 0.35-4.09, p = 0.78). Conclusion In this study, patients taking aspirin had a lower rate of hemorrhagic presentation. In addition, taking aspirin did not adversely impact presenting clinical grade or radiographic grade, vasospasm and outcome in the setting of aneurysmal SAH.






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Neurosurgery Blog Apps (iPad, iPhone and Android)

Apps

The Neurosurgery Blog group is developing a series of apps dedicated to medicine and more specifically neuroscience.
This is a space created to divulge our apps. You can found more information about than by clicking in the apps logos.
Let us know about your opinion, critics, suggestions or ideas in the “Contact us” space. With your help we may improve the apps you adquired and create new ones!
We hope you enjoy!
More apps are coming soon!
Now we have more than 14,000 downloads in more than 120 countries !

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Neurosurgery Blog iOS (click here)
Neurosurgery Blog app  Android (Click Here)


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Traumatic Brain Injury (Click here)iPad and iPhone
Traumatismo Cranio-encefalico (Click here) iPad and iPhone
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Neuro Exam App iOS ( Only English and Spanish)


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Neurointensive Care (APPSTORE CLICK HERE English/Portuguese)

Neurointensive Care (English and Portuguese ANDROID) CLICK HERE

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 Epilepsia App (portuguese and English) CLICK HERE iOS


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Neuroinfect App ( Portuguese and English) Click here Android
Neuroinfect App ( Portuguese and English) Click here iOS

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Craniotomy (Portuguese and English) CLICK HERE Android
Craniotomy (Portuguese and English) CLICK HERE  iOS ( COME SOON)

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Anamnesis (English) Click Here iPad and iPhone
Anamnese (Portuguese) Click Here iPad and iPhone

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Sus para concursos (click here) Portuguese Only iPad and iPhone 
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Friday, March 29, 2013

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel ant

Available online 27 March 2013
Publication year: 2013
Source:The Spine Journal

Background context Multilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach. Purpose To elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study. Study design A prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty. Patient sample In total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3–C6 and C3–C7). Outcome measures Self-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales. Methods Comparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables. Results Posterior surgery took an hour shorter (p&lt;.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group. Conclusions Our study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.






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Unruptured Intracranial Arteriovenous Malformations Treated With Radiosurgery

Researchers at the University of Virginia (UVA) Health System recommend radiosurgery for treating unruptured arteriovenous malformations (AVMs), because the procedure has a reasonable benefit-to-risk profile. They base this recommendation on an evaluation of clinical and radiographic outcomes in 444 patients treated with radiosurgery for unruptured AVMs at their institution...





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Quality and quantity of research publications by Iranian neurosurgeons: Signs of scientific progress

Marjan Alimi, Shervin Taslimi, Seyed Mohammad Ghodsi, Vafa Rahimi-Movaghar

Surgical Neurology International 2013 4(1):38-38

Background: This is an analysis of papers published by Iranian neurosurgeons while working in Iran until the year 2010. Methods: We collected bibliometric data and assigned a level of evidence (LOE) for each paper and compared neurosurgical research productivity across three time periods (before 1990, between 1991 and 2000, and after 2000). For further illustration, the annual growth rates of Iranian publications were calculated for all papers published after 1995. Results: We found a total of 1196 papers by 422 Iranian neurosurgeons. Five authors accounted for 22.9% of the papers. The average number of authors for each published manuscript was 3.48 and increased significantly from 2.0 to 4.0 across the three investigated periods ( P < 0.001). 58.9% of Iranian papers were published in local journals only. A total of 74.6% articles were published after 2000, which was a significant increase compared with the decades before ( P < 0.001). Original articles and case reports accounted for 63.8% and 31.1% of the publications, respectively. The proportion of case reports decreased while the proportion of original articles increased across the three time periods ( P < 0.001). The adjusted growth rate for the total number of publications, original articles, case reports, clinical trials, and randomized clinical trials (RCTs) were 14.4%, 16.6%, 10.7%, 13.46%, and 14.7% per year, respectively. Overall, the four most frequently investigated topics were spine (27.3%), trauma (22.3%), tumor (19.1%), and vascular diseases (13.5%). The mean impact factor for journals publishing these studies and average number of citations for each paper (obtained from web of science) were found to be 1.2 and 5.46, respectively. A partitioning of these publications into assigned categories reflecting the LOE of each paper yielded the following LOE distribution for all assessed publications: Ib: 6.02%, Ic: 0.3%, IIa: 0.2%, IIb: 5.4%, IIc: 0.41%, IIIb: 4.8%, IV: 22.5%, and V: 1.2%. The relative number of publications categorized into higher LOE classes increased over the three investigated periods ( P = 0.003). Based on growth curve model, the rate of increase in total numbers of publications following each position change from nonuniversity affiliated neurosurgeon to university affiliated and from university affiliated neurosurgeon to chairman university affiliated neurosurgeon was 81%. Conclusions: A considerable increase in amount and quality of Iranian papers was observed during the past decade as reflected in a higher number of papers categorized in upper LOE classes.





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The Subaxial Cervical Spine Injury Classification System: an external agreement validation study

Available online 29 March 2013
Publication year: 2013
Source:The Spine Journal

Background context In 2007, the Subaxial Cervical Spine Injury Classification (SLIC) system was introduced demonstrating moderate reliability in an internal validation study. Purpose To assess the agreement on the SLIC system using clinical data from a spinal trauma population and whether the SLIC treatment algorithm outcome improved agreement on treatment decisions among surgeons. Study design An external classification validation study. Patient sample Twelve spinal surgeons (five consultants and seven fellows) assessed 51 randomly selected cases. Outcome measures Raw agreement, Fleiss kappa, and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules and latent class modeling were used for accuracy analysis. Methods Fifty-one randomly selected cases with significant injuries of the cervical spine from a prospective consecutive series of trauma patients were assessed using the SLIC system. Neurologic details, plain radiographs, and computed tomography scans were available for all cases as well as magnetic resonance imaging in 21 cases (41%). No funds were received in support of this study. The authors have no conflict of interest in the subject of this article. Results The inter-rater agreement on the most severely affected level of injury was strong (κ=0.76). The agreement on the morphologic injury characteristics was poor (κ=0.29) and agreement on the integrity of the discoligamentous complex was average (κ=0.46). The inter-rater agreement on the treatment verdict after the total SLIC injury severity score was slightly lower than the surgeons' agreement on personal treatment preference (κ=0.55 vs. κ=0.63). Latent class analysis was not converging and did not present accurate estimations of the true classification categories. Based on these findings, no second survey for testing intrarater agreement was performed. Conclusions We found poor agreement on the morphologic injury characteristics of the SLIC system, and its treatment algorithm showed no improved agreement on treatment decisions among surgeons. The authors discuss that the reproducibility of the SLIC system is likely to improve when unambiguous true morphologic injury characteristics are being implemented.






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Monday, March 25, 2013

Outcomes of Carotid Endarterectomy in the Elderly: Report From the National Cardiovascular Data Regi

Background and Purpose—

Benchmark trials of carotid endarterectomy often did not include elderly patients, and the results may not be easily extrapolated to the general population. Using the Carotid Artery Revascularization and Endarterectomy registry, we sought to determine real-world outcomes of carotid endarterectomy in the elderly.

Methods—

This was a retrospective cohort study of patients aged >70 years. We compared outcomes stratified by age among symptomatic and asymptomatic patients.

Results—

There were 4149 patients who underwent carotid endarterectomy; 1376 (33.1%) were symptomatic. Overall mortality rate was 0.5%. The primary outcome of in-hospital death, stroke, and myocardial infarction showed a significant trend and was highest in the age >85 years group (5.6%). Among symptomatic patients, mortality and the primary outcome were not statistically different between those aged >75 years and those aged 70 to 74 years. Among asymptomatic elderly patients, mortality rate was significantly higher in age group >75 years compared with <75 years (0.7% vs 0.0%); however, the combined outcome of stroke, death, and myocardial infarction was not statistically different.

Conclusions—

Elderly patients >85 years of age were at increased risk for death or perioperative complications of stroke, death, and myocardial infarction compared with those who were relatively younger. More elderly patients underwent carotid endarterectomy for asymptomatic carotid stenosis and had higher mortality than the younger counterparts, underlining need for caution in subjecting them to the procedure.








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

In early spring of second year, when I began pediatrics, my first rotation, it would still be dark when I walked to my car at 5:30 in the morning. Except for other cars encountered occasionally at silent intersections, and here and there a figure stumbling out of the shadow of an alley, the streets were empty. Preclinical classes had just ended. Friends and classmates of the last 2 years were suddenly spread out in various rotations or studying for board examinations, never to come back together in quite the same way. Yet, heading north on Broadway as I approached the hospital those mornings, one after another green lights stretched out ahead of me and I would feel, more than at any other point throughout the day, how nice it can be to be alone.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Statins Reduce Neurologic Injury in Asymptomatic Carotid Endarterectomy Patients [Brief Reports]

Background and Purpose—

Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction).

Methods—

A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury.

Results—

Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27–0.96]; P=0.04).

Conclusions—

Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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The Natural History of Depression up to 15 Years After Stroke: The South London Stroke Register [Cli

Background and Purpose—

Evidence on the natural history of depression after stroke is still insufficient to inform prognosis and treatment strategies. This study estimates the incidence, cumulative incidence, prevalence, time of onset, duration, and recurrence rate of depression up to 15 years after stroke.

Methods—

Data from patients registered in the South London Stroke Register between 1995 and 2009 were used (N=4022 at registration. Maximum number of participants for these analyses n=1233). Depression was assessed in all patients with the Hospital Anxiety and Depression Scale (scores >7=depression) 3 months after stroke, 1 year after stroke, and annually thereafter up to 15 years after stroke. Inverse probability weighting was used to calculate the estimates accounting for missing data.

Results—

The poststroke incidence of depression ranged from 7% to 21% in the 15 years after a stroke, with cumulative incidence of 55% and prevalence ranging from 29% to 39%. Most episodes of depression started within a year of stroke, with 33% of the cases starting in the 3 months after a stroke, and none from year 10 onward. Fifty percent of the patients with depression at 3 months had recovered 1 year after stroke. The proportion of recurrent episodes of depression after stroke increased gradually from 38% in year 2 to 100% in years 14 and 15.

Conclusions—

The natural history of depression after stroke is dynamic. Depression affects most of the stroke patients with episodes that have a short duration but a high risk of recurrence in the long term.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Asymptomatic Carotid Artery Stenosis and the Risk of Ischemic Stroke According to Subtype in Patient

Background and Purpose—

Because best medical treatment is improving, the risk of stroke in asymptomatic carotid artery stenosis (ACAS) may decline. We evaluated the risk of ischemic stroke and stratified it according to stroke subtype in patients with ACAS during long-term follow-up.

Methods—

In total, 4319 consecutive patients in the Second Manifestations of Arterial disease study with clinically manifest arterial disease or specific risk factors, but without a history of cerebrovascular disease, were included. Degree of stenosis was evaluated with duplex ultrasound scanning. Strokes during follow-up were classified according to subtype. Cox-proportional hazard-regression models were used to evaluate the relationship between ACAS and future stroke.

Results—

We identified 293 (6.8%) patients with ACAS 50% to 99%, of whom 193 had 70% to 99% stenosis. In these subgroups, mean follow-up was 6.2 and 6.0 years, respectively. In total, 94 ischemic strokes occurred, of which 8 in ACAS 50% to 99% patients. The any territory annual ischemic stroke risk was 0.4% in 50% to 99% ACAS and 0.5% per year for 70% to 99% ACAS patients. The risk of ischemic stroke was not significantly increased in patients with ACAS 70% to 99% (hazard ratio, 1.5; 95% confidence interval, 0.7–3.5). Patients with ACAS 50% to 99% and ACAS 70% to 99% tended to have nonsignificantly more large vessel disease strokes (hazard ratio, 1.5; 95% confidence interval, 0.5–4.2 and hazard ratio, 1.7; 95% confidence interval, 0.5–5.6).

Conclusions—

Patients with clinically manifest arterial disease or type 2 diabetes mellitus have a low risk of developing ischemic stroke, irrespective of its subtype and independent of the degree of ACAS stenosis.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Independent Risk Factors for Intracranial Aneurysms and Their Joint Effect: A Case-Control Study [Cl

Background and Purpose—

Three percent of the population has an unruptured intracranial aneurysm (UIA). We aimed to identify independent risk factors from lifestyle and medical history for the presence of UIAs and to investigate the combined effect of well-established risk factors.

Methods—

We studied 206 patients with an UIA who never had a subarachnoid hemorrhage and 574 controls who were randomly retrieved from general practitioner files. All participants filled in a questionnaire on potential risk factors for UIAs. With logistic regression analysis, we identified independent risk factors for UIA and assessed their combined effect.

Results—

Independent risk factors were current smoking (odds ratio [OR], 3.0; 95% confidence interval [CI], 2.0–4.5), hypertension (OR, 2.9; 95% CI, 1.9–4.6), family history of stroke other than subarachnoid hemorrhage (OR, 1.6; 95% CI, 1.0–2.5), hypercholesterolemia (OR, 0.5; 95% CI, 0.3–0.9), and regular physical exercise (OR, 0.6; 95% CI, 0.3–0.9). The joint risk of smoking and hypertension was higher (OR, 8.3; 95% CI, 4.5–15.2) than the sum of the risks independently.

Conclusions—

Current smoking, hypertension, and family history of stroke increase the risk of UIA, with smoking and hypertension having an additive effect, whereas hypercholesterolemia and regular physical exercise decrease this risk. A healthy lifestyle probably reduces the risk of UIA and thereby possibly also that of aneurysmal subarachnoid hemorrhage. Whether smoking and hypertension increase the risk of aneurysmal subarachnoid hemorrhage only through an increased risk of aneurysm formation or also through an increased risk of rupture remains to be established.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Sunday, March 24, 2013

Prediction of Alzheimer disease in subjects with amnestic and nonamnestic MCI

Objective:

To compare the predictive accuracy of β-amyloid (Aβ)1–42 and total tau in CSF, hippocampal volume (HCV), and APOE genotype for Alzheimer disease (AD)-type dementia in subjects with amnestic mild cognitive impairment (aMCI) and nonamnestic mild cognitive impairment (naMCI).

Methods:

We selected 399 subjects with aMCI and 226 subjects with naMCI from a multicenter memory clinic–based cohort. We measured CSF Aβ1–42 and tau by ELISA (n = 231), HCV on MRI (n = 388), and APOE 4 (n = 523). Follow-up was performed annually up to 5 years. Outcome measures were progression to AD-type dementia and cognitive decline.

Results:

At least 1 follow-up was available for 538 subjects (86%). One hundred thirty-two subjects with aMCI (38%) and 39 subjects with naMCI (20%) progressed to AD-type dementia after an average follow-up of 2.5 years. CSF Aβ1–42, tau, Aβ1–42/tau ratio, HCV, and APOE 4 predicted AD-type dementia in each MCI subgroup with the same overall diagnostic accuracy. However, CSF Aβ1–42 concentration was higher and hippocampal atrophy less severe in subjects with naMCI compared with aMCI. This reduced the sensitivity but increased the specificity of these markers for AD-type dementia in subjects with naMCI.

Conclusions:

AD biomarkers are useful to predict AD-type dementia in subjects with aMCI and naMCI. However, biomarkers might not be as sensitive for early diagnosis of AD in naMCI compared with aMCI. This may have implications for clinical implementation of the National Institute on Aging and Alzheimer's Association criteria.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Residency Training: Teaching communication: Residency is not too late

Resident Dr. A is called to speak with the family of a patient in the neuro-intensive care unit who has malignant left middle cerebral artery syndrome and is close to brain death. Resident Dr. A has many competing obligations that day, but realizes how important the discussion will be. As he stood outside the family conference room where anxious loved ones waited, he contemplated what he was going to say and how. Having done this before, he felt confident that he could do it well. What he did not realize was that on the other side of the door were 20 frightened family members who speak a different language, have many different beliefs, and have no idea that their family member is dying. Resident Dr. A's confidence was based on sufficient knowledge of the patient's illness and prognosis, but despite decades of formal education, he was never taught how to effectively communicate with patients and their families in this situation.








Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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BP Control May Help Slow Alzheimer's (CME/CE)

(MedPage Today) -- Genetics and high blood pressure appear to interact to increase deposits in the brain of a protein involved in the pathology of Alzheimer's disease, researchers reported.







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Incidence, risk factors, and outcome of postoperative pneumonia after microsurgical clipping of rupt

Amey Savardekar, Tenzin Gyurmey, Ritesh Agarwal, Subrata Podder, Sandeep Mohindra, Sunil K Gupta, Rajesh Chhabra

Surgical Neurology International 2013 4(1):24-24

Background: Occurrence of pneumonia challenges the medical management of patients who have undergone surgery for aneurysmal subarachnoid hemorrhage, and is associated with significant mortality and morbidity. There are very few studies evaluating the incidence and outcome of postoperative pneumonia in patients undergoing microsurgical clipping of ruptured intracranial aneurysms. The aim of this study was to determine the incidence, risk factors, and outcome of postoperative pneumonia in patients undergoing surgery for ruptured intracranial aneurysms. Methods: All patients operated for intracranial aneurysms, over a period of 9 months, were included prospectively. They were studied for risk factors predisposing them to pneumonia and their outcomes were noted at discharge. Patients with predisposing chronic lung disease, preexisting pneumonia, and chronic smoking habits were excluded. Results: One hundred and three patients [Mean age: 46.01 years; M:F - 58:45] underwent microsurgical clipping of aneurysm during the study period. Of these, 28 patients (27.2%) developed postoperative pneumonia. The variables associated with postoperative pneumonia were: [Preoperative] age >50 years, Glasgow Coma Scale (GCS) at presentation <15 and Hunt and Hess grade before surgery >2; [postoperative] duration of surgery >3 hours, GCS <15 after complete reversal from anesthesia, duration of intubation in the postoperative period >48 hours, tracheostomy, postoperative ventilation, intensive care unit (ICU) stay >5 days. Predictive factors for postoperative pneumonia by multivariate analysis were: Postoperative endotracheal intubation >48 hours, tracheostomy and ICU stay >5 days. Conclusions: There is a high incidence of postoperative pneumonia and mortality associated with pneumonia (27.2% and 9.7%, respectively in our study) in patients of ruptured intracranial aneurysms undergoing microsurgical clipping at our center, with Acinetobacter species being the predominant causative organism.







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Randomized trial demonstrates that extended-release epidural morphine may provide safe pain control

Sarah C Offley, Ellen Coyne, MaryBeth Horodyski, Paul T Rubery, Seth M Zeidman, Glenn R Rechtine

Surgical Neurology International 2013 4(3):51-57

Background: Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia. This has not been studied in open spinal surgery. Methods: Ninety-eight patients having complex posterior lumbar surgery were enrolled in a partially randomized clinical trial (PRCT) of low to moderate doses of EREM. Surgery included levels from L3 to S1 with procedures involving combinations of decompression, instrumented arthrodesis, and interbody grafting. The patients were randomized to receive either 10 or 15 mg of EREM through an epidural catheter placed under direct vision at the conclusion of surgery. Multiple safety measures were employed to prevent or detect respiratory depression. Postoperative pain scores, narcotic utilization, and adverse events were recorded. Results: There were no significant differences between the two groups as to supplemental narcotic requirements, pain scores, or adverse events. There were no cases of respiratory depression. The epidural narcotic effect persisted from 3 to 36 hours after the injection. Conclusion: By utilizing appropriate safety measures, EREM can be used safely for postoperative pain control in lumbar surgery patients. As there was no apparent advantage to the use of 15 mg, the lower 10 mg dose should be used.







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Subarachnoid Hemorrhage With Negative Initial Catheter Angiography: A Review of 254 Cases Evaluatin

imageBACKGROUND: Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial. OBJECTIVE: To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging. METHODS: Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram. RESULTS: Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of short-term and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients. CONCLUSION: Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH. ABBREVIATIONS: CTA, computed tomographic angiography DSA, digital subtraction angiography HH, Hunt and Hess MRA, magnetic resonance angiogram NPM, nonperimesencephalic PM, perimesencephalic SAH, subarachnoid hemorrhage







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Cavernous Malformation of Brainstem, Thalamus, and Basal Ganglia: A Series of 176 Patients

imageBACKGROUND: Cavernous malformations (CMs) in deep locations account for 9% to 35% of brain malformations and are surgically challenging. OBJECTIVE: To study the clinical features and outcomes following surgery for deep CMs and the complication of hypertrophic olivary degeneration (HOD). METHODS: Clinical records, radiological findings, operative details, and complications of 176 patients with deep CMs were reviewed retrospectively. RESULTS: Of 176 patients with 179 CMs, 136 CMs were in the brainstem, 27 in the basal ganglia, and 16 in the thalamus. Cranial nerve deficits (51.1%), hemiparesis (40.9%), numbness (34.7%), and cerebellar symptoms (38.6%) presented most commonly. Hemorrhage presented in 172 patients (70 single, 102 multiple). The annual retrospective hemorrhage rate was 5.1% (assuming CMs are congenital with uniform hemorrhage risk throughout life); the rebleed rate was 31.5%/patient per year. Surgical approach depended on the proximity of the CM to the pial or ependymal surface. Postoperatively, 121 patients (68.8%) had no new neurological deficits. Follow-up occurred in 170 patients. Delayed postoperative HOD developed in 9/134 (6.7%) patients with brainstem CMs. HOD occurred predominantly following surgery for pontine CMs (9/10 patients). Three patients with HOD had palatal myoclonus, nystagmus, and oscillopsia, whereas 1 patient each had limb tremor and hemiballismus. At follow-up, 105 patients (61.8%) improved, 44 (25.9%) were unchanged, and 19 (11.2%) worsened neurologically. Good preoperative modified Rankin Score (98.2% vs 54.5%, P = .001) and single hemorrhage (89% vs 77.3%, P < .05) were predictive of good long-term outcome. CONCLUSION: Symptomatic deep CMs can be resected with acceptable morbidity and outcomes. Good preoperative modified Rankin Score and single hemorrhage are predictors of good long-term outcome. ABBREVIATIONS: AOVM, angiographically occult vascular malformation CM, cavernous malformation HOD, hypertrophic olivary degeneration mRS, modified Rankin Score SRS, stereotactic radiosurgery







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Noninvasive Language Mapping in Patients With Epilepsy or Brain Tumors

imageBACKGROUND: Functional magnetic resonance imaging (fMRI) has become part of routine brain mapping in patients with epilepsy or tumor undergoing resective surgery. However, robust localization of crucial functional areas is required. OBJECTIVE: To establish a simple, short fMRI task that reliably localizes crucial language areas in individual patients who undergo respective surgery. METHODS: fMRI was measured during an 8-minute auditory semantic decision task in 28 healthy controls and 35 consecutive patients who had focal epilepsy or a brain tumor. Nineteen underwent resective surgery. Group and individual analyses were performed. Results in patients were compared with postsurgical language outcome and electrocortical stimulation when available. RESULTS: fMRI activations concordant with the anterior and posterior language areas were found in 96% and 89% of the controls, respectively. The anterior and posterior language areas were both activated in 93% of the patients. These results were concordant with electrocortical stimulation results in 5 patients. Transient postsurgical language deficits were found in 2 patients in whom surgery was performed in the vicinity of the fMRI activations or who had postsurgical complications implicating areas of fMRI activations. CONCLUSION: The proposed fast fMRI language protocol reliably localized the most relevant language areas in individual subjects. It appears to be a valuable complementary tool for surgical planning of epileptogenic foci and of brain tumors. ABBREVIATIONS: ECS, electrocortical stimulation FLI, frontal lateralization index fMRI, functional magnetic resonance imaging FWE, family-wise error LI, lateralization index MNI, Montreal Neurological Institute SD, standard deviation SEM, standard error of the mean TPLI, temporoparietal lateralization index







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Incidence of Neurosurgical Wrong-Site Surgery Before and After Implementation of the Universal Proto

imageBACKGROUND: Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals. OBJECTIVE: To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute. METHODS: The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation. RESULTS: Fifteen WSS events were found with an overall incidence of 0.07% and Poisson 95% confidence interval of 8.4 to 25. All but one of these were wrong-level spine surgeries (14/15). There was only 1 recorded case of wrong-side surgery and this occurred after implementation of the UP. A statistically greater number of WSS events occurred before (n = 12) in comparison with after (n = 3) UP implementation (P < .001). CONCLUSION: A statistically significant reduction in overall WSS was seen after implementation of the UP. This reduction can be attributed to less frequent wrong-level spine surgery. There was no case of wrong procedure or patient surgery and the 1 case of wrong-side surgery occurred after UP implementation. ABBREVIATIONS: JC, Joint Commission UP, Universal Protocol WSS, wrong-site surgery







Júlio Leonardo B. Pereira
Phone: (+1) 424-2301706
Linkedin:http://www.linkedin.com/in/juliommais 
Site: www.neurocirurgiabr.com
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Wingspan Stenting for Intracranial Atherosclerotic Stenosis: Clinical Outcomes and Risk Factors for

imageBACKGROUND: Intracranial atherosclerotic stenosis (ICAS) is responsible for 9% to 37% of ischemic strokes. OBJECTIVE: To evaluate the clinical outcome and risk factors for in-stent restenosis (ISR) after treatment of ICAS with a Wingspan stent. METHODS: Seventy-seven patients with 79 total target ICAS > 60% (mean, 79.9 ± 8.4%; symptomatic ICAS, 96.2%) underwent attempted treatment with Wingspan stenting between March 2010 and March 2011. A retrospective review of the prospectively registered data was conducted to assess the risk factors for ISR and the clinical outcomes of these patients. RESULTS: The 30-day transient ischemic attack/stroke and death rates were 5.3% (95% confidence interval [CI], 0.1-10.5) and 0%, respectively. All patients but 1 were followed up clinically for a mean of 18.9 months (range, 12-23 months). During the period, cumulative transient ischemic attack/stroke and death rates were 8.1% (95% CI, 1.7-14.5) and 0%, respectively. Only 1 patient suffered a disabling stroke (subarachnoid hemorrhage), which was associated with retreatment of an ISR with a drug-eluting balloon-expandable stent. Follow-up angiography was available in 69 treated vessels (89.6%) at 3 to 24 months (median, 12 months). Binary ISR rate was 24.6%, of which 17.6% (3 of 17 cases) was symptomatic. Rapid balloon inflation (95% CI, 5.490-530.817) and longer length of stenosis (95% CI, 1.093-1.891) were independent risk factors for ISR. CONCLUSION: Wingspan stenting may be effective for appropriately selected ICAS patients. Rapid balloon inflation and longer lengths of stenosis were independent risk factors for ISR. ABBREVIATIONS: CI, confidence interval ICA, internal carotid artery ICAS, intracranial atherosclerotic stenosis ISR, in-stent restenosis PTAS, percutaneous transluminal angioplasty and stenting SAMMPRIS, Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial TIA, transient ischemic attack WASID, Warfarin-Aspirin Symptomatic Intracranial Disease







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