BACKGROUND: After an initial computed tomography (CT) scan revealing intracranial hemorrhage resulting from traumatic brain injury, a standard of care in many trauma centers is to schedule a repeat CT scan to rule out possible progression of bleed. OBJECTIVE: To evaluate the utility of routine follow-up CT in changing the management of mild head injury patients despite clinical stability, although repeat imaging is indicated to assess a deteriorating patient. METHODS: The trauma database at our institution was retrospectively reviewed and the literature was searched to identify patients after mild head injury with positive initial CT finding and scheduled repeat scan. Patients were divided into 2 groups for comparison. Group A included patients who had intervention based on neurological examination changes. Group B comprised patients requiring a change in management according to CT results exclusively. The meta-analysis of the present cohort and included articles was performed with a random-effects model. RESULTS: Overall, 15 studies and 445 patients met our eligibility criteria, totaling 2693 patients. Intervention rates of groups A and B were 2.7% (95% confidence interval, 1.7-3.9; P = .003) and 0.6% (95% confidence interval, 0.3-1; P = .21), respectively. The statistical difference between both intervention rates was clinically significant with P < .001. CONCLUSION: The available evidence indicates that it is unnecessary to schedule a repeat CT scan after mild head injury when patients are unchanged or improving neurologically. In the absence of supporting data, we question the value of routine follow-up imaging given the associated accumulative increase in cost and risks. ABBREVIATIONS: CI, confidence interval ICH, intracranial hemorrhage
A 69-year-old man developed acute-onset confusion and hypertension with systolic pressures in the 160s 1 day after carotid endarterectomy for right facial droop from left hemispheric lacunar infarcts. CT perfusion (figure, A–D) demonstrated findings consistent with cerebral hyperperfusion syndrome (CHS) following revascularization. CHS is caused by loss of autoregulation, hypertension, and ischemia-reperfusion injury resulting in increased regional blood flow and vascular congestion.1 CHS following revascularization may present as ipsilateral headache, focal seizure, or neurologic deficit. Nonperfusion imaging may show intraparenchymal hemorrhage or edema. Labetalol and clonidine are used for aggressive blood pressure control until cerebral autoregulation is restored.2
Original Article: http://www.neurology.org/cgi/content/short/81/4/e25?rss=1
Dementia affects a staggering proportion of individuals, imposing a huge cost to our society. There are currently no disease-modifying treatments for dementia, making lifestyle factors that influence dementia risk of utmost importance. One such lifestyle factor that has shown promise in delaying dementia onset is engagement in cognitively stimulating activities, such as reading, writing, and playing games.1,2 However, the mechanisms by which these activities exert protective effects remain unclear (figure).
Original Article: http://www.neurology.org/cgi/content/short/81/4/308?rss=1
In his Global Perspectives article, Dr. Chin1 reported on the resource constraints related to the provision of stroke care in Africa. This was based on his experience visiting Mulago Hospital, Uganda's primary tertiary care referral center. He appropriately points out the very limited data related to stroke prevention and treatment in the region, and issued an urgent call for investment in optimizing preventive interventions.
Original Article: http://www.neurology.org/cgi/content/short/81/4/403-a?rss=1
A 5-year-old boy was operated on for a non-metastatic medulloblastoma of the fourth ventricle (figure 1). Chemotherapy and bifractionated craniospinal radiotherapy were administered. Four years later, T1-weighted MRI with contrast revealed abnormal vessels in the right sylvian fissure that gradually increased during follow-up; angiography confirmed an arteriovenous malformation (AVM) (figure 2). Even though it was asymptomatic, its location and growth prompted us to treat (embolization then excision of the residual nidus). This very rare case of supposed radiation-induced AVM suggests that when abnormal vasculature imaging occurs in follow-up1,2 further investigation with angiography is warranted, with consideration of further treatment.
Original Article: http://www.neurology.org/cgi/content/short/81/4/398?rss=1
Neurosurgery BlogO Neurosurgery Blog e seus aplicativos tem a função de expandir e aprofundar o entendimento em neurocirurgia.FAN PAGE NEUROSURGERY BLOG:NEUROSURGERY BLOG APP FREEPara fazer o download, seguem os links:
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BACKGROUND: 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
Nature Reviews Neuroscience 14, 520 (2013). doi:10.1038/nrn3554
Author: Monica Hoyos Flight
The mechanisms of action of most antidepressants are unclear. A study in Nature Medicine now shows that therapeutic concentrations of the antidepressants amitriptyline and fluoxetine reduced the activity of acid sphingomyelinase (ASM), an enzyme that releases ceramide from sphingomyelin, in both cultured neurons and
Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/APK53uJVxDY/nrn3554
Nature Reviews Neuroscience 14, 565 (2013). doi:10.1038/nrn3538
Authors: David A. Oakley & Peter W. Halligan
Hypnosis uses the powerful effects of attention and suggestion to produce, modify and enhance a broad range of subjectively compelling experiences and behaviours. For more than a century, hypnotic suggestion has been used successfully as an adjunctive procedure to treat a wide range of clinical
Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/1_uFNi-U0-8/nrn3538
Objectives:To assess the feasibility and reliability of systematic evaluations of analgesia, sedation level, and delirium features in the neurologically critically ill and to determine whether delirium features are linked to clinical outcomes in this population. Design:Multicentered prospective observational study. Setting:Neurological, Neurosurgical, Neurosciences or Surgical Trauma ICUs from three hospitals (two in Canada and one in the United States). Patients:A convenience sample of adult NICU or neurologic, neurosurgical, neurosciences, or surgical trauma ICU patients admitted for greater than 12 hours from November 2011 to April 2012. Interventions:Systematic assessments were simultaneously and independently performed by a neurologist, intensivists, or trauma surgeon, and a nurse in three multispecialty ICUs. Pain was evaluated with the numeric rating scale or behavioral pain scale. Sedation was assessed using the Richmond Agitation-Sedation Scale. Patients with Richmond Agitation-Sedation Scale greater than or equal to −4 were screened for features of delirium with the Intensive Care Delirium Screening Checklist. Intraclass correlation coefficient was used to evaluate inter-rater reliability between the nurse and the physician for pain and sedation scales, and the kappa coefficient was calculated for concordance of the Intensive Care Delirium Screening Checklist items. Measurements and Main Results:151 patients had 439 assessments. Pain and sedation were always assessable with excellent inter-rater reliability (numeric rating scale intraclass correlation coefficient, 0.92; behavior pain scale intraclass correlation coefficient, 0.83; and Richmond Agitation-Sedation Scale intraclass correlation coefficient, 0.92). Patients were sufficiently alert for delirium screening 3/4 of the time; Intensive Care Delirium Screening Checklist items had good concordance (kappa coefficients between 0.58 and 0.91 for the eight Intensive Care Delirium Screening Checklist items). Nonevaluable items were most often orientation, hallucinations, and speech or mood content. Furthermore, each additional Intensive Care Delirium Screening Checklist item present in proportion to the total evaluable Intensive Care Delirium Screening Checklist score was associated with a 10% increase in ICU length of stay. Conclusions:Pain and sedation can be systematically assessed in the neurologically critically ill; the majority can also be screened for delirium features with excellent inter-rater reliability. Increased proportion of Intensive Care Delirium Screening Checklist items is associated with worse outcomes.
Objectives:Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU. Data Sources:Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012. Study Selection:Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU. Data Extraction:Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool. Data Synthesis:The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians. Conclusions:Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation. (Crit Care Med 2013; 41:2015–2029)
