Clinical neurology and neurosurgery

Publisher: Elsevier


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Publications in this journal

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    ABSTRACT: Cyst formation is a well-known complication following radiosurgery for arteriovenous malformations (AVMs). In this retrospective study, the authors studied predictors for AVMs using magnetic resonance imaging (MRI) to assess the mechanism of cyst formation after linac-based radiosurgery (LBRS). From April 1993 to April 2008, LBRS was performed on 109 patients with cerebral AVMs at our institution. Six patients (5.5%) were diagnosed with cyst formation after LBRS, and 5 of them underwent regular MRI follow-up every 3-4 months for 2 years post-LBRS, and every 6-12 months thereafter. Time from initial LBRS until cyst formation ranged from 8 months to 10.5 years. MRI showed contrast changes at the irradiated site and its periphery within a period of 4 months to 7 years after the initial LBRS. Moreover, the emergence of a high-intensity area (HIA) was observed on T2-weighted MRI (T2W-MRI) during the same period when changes were found on contrast-enhanced imaging. The emergence of a low-intensity area on T2W-MRI was observed prior to cyst formation or expansion, which was believed to be due to a subclinical hemorrhage near the irradiated region in all patients. Histological examination of the cyst nodule revealed hemosiderin deposits and microbleeding. Future cyst formation was suggested by the emergence of subclinical hemorrhage (microbleeding) in an irradiated field after gadolinium-enhanced MRI showed contrast changes and T2W-MRI showed a HIA around the irradiated field. MRI follow-up should be conducted on a regular basis in such patients, even after a complete occlusion has been diagnosed.
    Clinical neurology and neurosurgery 06/2014; 121:10-6.
  • Clinical neurology and neurosurgery 06/2014; 121:17-8.
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    ABSTRACT: The 2010 revisions to the McDonald criteria for the diagnosis of multiple sclerosis (MS) were recently published. One objective of the revision was to simplify the MRI criteria. The MRI criteria do not specify magnetic field strength. We studied whether there was any difference in diagnosis between brain 3.0-T and 1.5-T MRI according to the 2010 revisions of the McDonald criteria. We prospectively studied brain 3.0-T and 1.5-T MRI in 22 patients with MS. 1.5-T MRI was performed 24h after 3.0-T MRI, and the scanning protocol included contiguous axial sections of T2-weighted images (T2WI), T1WI, and enhanced T1WI. These two different MRI and neurological assessments were scheduled to be repeated 3 and 6 months after study entry. The regions where MS lesions were better visualized on 3.0-T MRI tended to be in deep white matter on T2WI. Dissemination of lesions in space and time was similar for 3.0-T and 1.5-T MRI. Our study found no difference between brain 3.0-T and 1.5-T MRI. There was no apparent impact of brain 3.0-T MRI on the diagnosis of MS according to the 2010 version of the MRI criteria.
    Clinical neurology and neurosurgery 06/2014; 121:55-8.
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    ABSTRACT: Skull base meningiomas are a neurosurgical challenge due to the involvement of neurovascular structures. In this study, the authors present the first study of the trans-operative use of sodium fluorescein (SF) to enhance skull base meningiomas and perform a quantitative digital analysis of the tumors' pigmentation. The goal of the study was to observe the SF enhancement of skull base meningiomas. A prospective, within-subjects study was designed and performed. This study included twelve patients with skull base meningiomas. After an initial dissection, digital pictures were taken before and after systematic injections of SF using the same light-source used for the surgical microscope. These pictures were analyzed with software that calculated the wavelengths of the sodium fluorescein before and after the injection of the dye. The meningiomas in the sample included the following types: 1 cavernous sinus, 1 olfactory groove, 3 petroclival, 1 tuberculum sellae, 3 sphenoid wings, 1 anterior clinoid, and 2 temporal floor. The SF enhancement in all tumors was strongly positive. The low cost, universal availability and safety of SF indicate that this dye should be examined in further studies, and its applications in skull-base meningioma surgeries should be further assessed.
    Clinical neurology and neurosurgery 05/2014; 120:32-5.
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    ABSTRACT: Cervical spinal injuries occur in 2.0-6.6% of patients after blunt trauma and can have devastating neurological sequelae if left unrecognized. Although there is high quality evidence addressing cervical clearance in asymptomatic and symptomatic awake patients, cervical spine clearance in patients with altered level of alertness (i.e., obtunded patients with Glasgow coma scale (GCS) of 14 or less) following blunt trauma has been a matter of great controversy. Furthermore, there are no data on cervical spine clearance in obtunded patients without high impact trauma and these patients are often treated based on evidence from similar patients with high impact trauma. This retrospective study was conducted on this specific subgroup of patients who were admitted to a neurointensive care unit (NICU) with primary diagnoses of intracranial hemorrhage with history of minor trauma; the objective being to evaluate and compare cervical spinal computed tomography (CT) and magnetic resonance imaging (MRI) findings in this particular group of patients. Patients with GCS of 14 or less admitted to neruointensive care unit (NICU) at RUSH University Medical Center from 2008 to 2010 with diagnoses of intracranial hemorrhage (surgical or non-surgical) who had reported or presumed fall (i.e., "found down") were queried from the computer data registry. A group of these patients had cervical spine CT and subsequently MRI for clearing the cervical spine and removal of the cervical collar. Medical records of these patients were reviewed for demographics, GCS score and injury specific data and presence or absence of cervical spine injury. Eighty-three patients were identified from the computer database. Twenty-eight of these patients had positive findings on both CT and MRI (33.73% - Group I); four patients had a negative CT but had positive findings on follow-up MRI (4.82% - Group II); fifty-one patients had both negative CT and MRI (61.44% - Group III). All patients in Group I required either surgical stabilization or continuation of rigid cervical orthosis. All four patients in Group II had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI, but did not have any signs of fracture or ligamentous injury to suggest instability. They eventually underwent surgical decompression of the spinal cord during the same hospital stay. Cervical collars were safely removed in all patients in Group III. In our retrospective study, CT had a sensitivity of 0.875 [0.719-0.950, 95% CI] and a specificity of 1.000 [0.930-1.000, 95% CI] in detecting all cervical spine injuries compared to MRI. However, all patients with missed injuries had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI and were not unstable precluding cervical spine clearance. If only unstable injuries are considered, CT had a sensitivity of 1.00 [0.879-1.000, 95% CI] and a specificity is 1.000 [0.935-1.000, 95% CI] compared to MRI in this particular group of patients. CT is highly sensitive in detecting unstable injuries in obtunded patients with GCS of 14 or less in the absence of high impact trauma. In the absence of high impact trauma, neurosurgeons should be comfortable to discontinue the cervical collar after a negative, high-quality CT in this patient population. In the presence of focal neurological deficits unexplained by associated intracranial injury, an MRI may help diagnose intrinsic spinal cord injuries which necessarily may not be unstable in the presence of a negative CT and does not precludes clearance of cervical spine.
    Clinical neurology and neurosurgery 05/2014; 120:23-6.
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    ABSTRACT: Amyotrophic lateral sclerosis (ALS) or motor neuron disease is an adult-onset progressive neurodegenerative disorder. ALS-CSF has been shown to produce toxic effects on motor neuron cells like aberrant neurofilament phosphorylation and morphological alterations of nuclear and soma size. Our current study was designed to investigate the neuroprotective role of platelet derived growth factor (PDGF) in reverting the adverse effects produced by ALS-CSF. Our present study was carried out to determine the restorative potential of PDGF on the toxic effects of ALS-CSF on NSC motor neuron cells from patients. Therefore the cells were divided in to three groups: (a) normal control (NC) - the cells were not exposed to ALS-CSF; (b) ALS group - the cells were exposed to ALS-CSF; (c) NALS group - the cells were exposed to non ALS CSF. Further each of these groups was supplemented with PDGF. We observed that the mean area of nucleus and cell soma of the differentiated NSC motor neuron cells was significantly reduced in the cells exposed to ALS-CSF. We also observed that subsequent treatment with PDGF restored the soma area and nucleus of the ALS-CSF exposed cells significantly. Taken together, we show that supplementation with PDGF restores the morphological changes induced by ALS-CSF and PDGF may play a significant role in protecting motor neurons from apoptosis in ALS and thereby it promoting the cell survival.
    Clinical neurology and neurosurgery 05/2014; 120:1-5.
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    ABSTRACT: Glioblastoma (GBM) is a heterogeneous neoplasm with a small percentage of long-term survivors. Despite aggressive surgical resection and advances in radiotherapy and chemotherapy, the median survival for patients with GBM is 12-14 months. Factors associated with a favorable prognosis include young age, high performance status, gross resection >98%, non-eloquent tumor location and O6-methylguanine methyltransferase (MGMT) promoter methylation. We retrospectively analyzed the relationship of clinical, epidemiologic, genetic and molecular characteristics with survival in patients with GBM. This retrospective analysis of overall survival looked at the outcomes of 480 patients diagnosed with GBM over 14 years at a single institution. Multivariate analysis was performed examining multiple patient characteristics. Median survival time improved from 11.8 months in patients diagnosed from 1995 to 1999 to 15.9 months in those diagnosed from 2005 to 2008. Factors associated with survivor groups were age, KPS, tumor resection, treatment received and early progression. 18 cancer-related genes were upregulated in short-term survivors and five genes were downregulated in short-term survivors. Epidemiologic, clinical, and molecular characteristics all contribute to GBM prognosis. Identifying factors associated with survival is important for treatment strategies as well as research for novel therapeutics and technologies. This study demonstrated improved survival for patients over time as well as significant differences among survivor groups.
    Clinical neurology and neurosurgery 05/2014; 120:103-12.
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    ABSTRACT: The overall benefits of craniectomy must include procedural risks from cranioplasty. Cranioplasty carries a high risk of surgical site infections (SSI) particularly with antibiotic resistant bacteria. The goal of this study was to measure the effect of a cranioplasty bundle on peri-operative complications. The authors queried a prospective, inpatient neurosurgery database at Kaiser Sacramento Medical Center for craniectomy and cranioplasty over a 7 year period. 57 patients who underwent cranioplasties were identified. A retrospective chart review was completed for complications, including surgical complications such as SSI, wound dehiscence, and re-do cranioplasty. We measured cranioplasty complication rates before and after implementation of a peri-operative bundle, which consisted of peri-operative vancomycin (4 doses), a barrier dressing through post-operative day (POD) 3, and de-colonization of the surgical incision using topical chlorhexidine from POD 4 to 7. The rate of MRSA colonization in cranioplasty patients is three times higher than the average seen on ICU admission screening (19% vs. 6%). The cranioplasty surgical complication rate was 22.8% and SSI rate was 10.5%. The concurrent SSI rate for craniectomy was 1.9%. Organisms isolated were methicillin-resistant Staphylococcus aureus (4), methicillin-sensitive S. aureus (1), Propionibacterium acnes (1), and Escherichia coli (1). Factors associated with SSI were peri-operative vancomycin (68.6% vs. 16.7%, p=0.0217). Complication rates without (n=21) and with (n=36) the bundle were: SSI (23.8% vs. 2.8%, p=0.0217) and redo cranioplasty (19% vs. 0%, p=0.0152). Bundle use did not affect rates for superficial wound dehiscence, seizures, or hydrocephalus. The cranioplasty bundle was associated with reduced SSI rates and the need for re-do cranioplasties.
    Clinical neurology and neurosurgery 05/2014; 120:41-4.
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    ABSTRACT: Cervical spondylotic myelopathy (CSM) is typically encountered in the elderly population. Significant inconsistencies currently exist regarding the definition of the disorder, the true incidence of CSM in younger populations, and the established diagnostic criteria. To highlight the lack of standardization in the definition and diagnosis of CSM. A PubMed literature search was conducted spanning the years 2001-2011. The search was limited by the following terms: (1) English language, (2) adults (19-44 years old), and (3) "cervical spondylotic myelopathy." Each article was reviewed to determine if the presence of the definition of CSM existed in the article. The clinical characteristics used to make the diagnosis of CSM were recorded for each article. Cochran's Q statistic was used to determine whether some clinical characteristics were more frequently used than others. Ninety-three papers were reviewed in detail and 16 case reports, reviews, and articles concerning less than 3 patients were excluded, resulting in 77 articles in the final analysis. The most common clinical definitions were gait disturbance (22/77 articles (28.6%)), upper limb paresthesias or sensory disturbance (21/77 (27.3%)), and clumsy hands (15/77 (19.5%)). Hyperreflexia, spasticity, and pathologically increased reflexes were identified as diagnostic criteria in a minority of patients. The literature employs a wide range of neurologic signs and symptoms to make the diagnosis of CSM, with a majority of studies failing to rely on strict diagnostic criteria. The clinician should not discount CSM as an explanation for the aforementioned findings, as it is well-reported in the literature among the ages 18-44.
    Clinical neurology and neurosurgery 05/2014; 120C:68-72.
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    ABSTRACT: Monitoring of intracranial pressure (ICP) is important in the optimal treatment of various neurological and neurosurgical diseases. Telemetric ICP monitoring allows long-term measurements in the patient's everyday life and the possibility to perform additional measurements without the procedure related risks of repeated transducer insertions. We identified all patients in our clinic with an implanted Raumedic(®) telemetric ICP probe (NEUROVENT(®)-P-tel). For each patient we identified diagnosis, indication for implantation, surgical complications, duration of ICP reading, number of ICP recording sessions (in relation to symptoms of increased ICP) and their clinical consequence. We included 21 patients in the evaluation (11 female and 10 male). Median age was 28 (2-83) years and median duration of disease was 11 (0-30) years. Eleven patients had various kinds of hydrocephalus, seven patients had idiopathic intracranial hypertension (IIH) and three patients had normal pressure hydrocephalus (NPH). Fifteen patients had a shunt prior to implantation. Median duration of implantation was 248 (49-666) days and median duration from implantation to last recording session was 154 (8-433) days. In total, 86 recording sessions were performed; 29 resulted in surgical shunt revision, 30 in change of acetazolamide dose or programmable valve setting, 20 required no action and 5 resulted in a new recording session. No surgical complications occurred, except for late wound infection at the surgical site in two patients. Telemetric ICP monitoring is useful in patients with complicated CSF dynamic disturbances who would otherwise require repeated invasive pressure monitoring. It seems to be a feasible method to guide adjustment of programmable valve settings and to identify patients with chronic or repeated shunt problems.
    Clinical neurology and neurosurgery 05/2014; 120:36-40.
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    ABSTRACT: The degree of coronary artery calcification has been shown to predict outcomes in coronary artery disease. The impact of intracranial carotid artery calcification on the prognosis of acute ischemic stroke (AIS) is unknown. The authors sought to examine if the degree of intracranial carotid artery calcification influences reperfusion or outcomes in AIS intervention. All anterior circulation large vessel occlusion AIS cases that underwent intra-arterial therapy from January 2009 to July 2012 were reviewed. Clinical and radiographic data were collected. Non-contrast brain CT scans were assigned a Calcium Extent Score (degree of calcification of the carotid wall circumference), Calcium Thickness Score (thickness of the calcified plaque), and total Carotid Siphon Calcium (CSC) Score (8-point scale). One-hundred seventeen patients met inclusion criteria. The mean age was 65.4±15.6 years and 36% were male. Calcification was present in the intracranial carotid artery of 84 patients (71%). Inter-rater agreement for total CSC score was strong (Spearman's rho=0.883, p<0.001). The mean Calcium Extent Score was 1.5±1.3, Calcium Thickness Score 1.3±1.0 and total CSC Score 2.8±2.2. Reperfusion and mRS were not associated with CSC. Multivariate linear regression analysis revealed that older age, history of coronary disease and cervical internal carotid occlusion/near-occlusion were independently associated with higher total CSC scores. Extensive calcification on the intracranial carotid artery does not have impact on reperfusion or clinical outcomes in AIS patients undergoing endovascular therapy. Higher CSC scores are associated with coronary artery disease, increasing age and cervical internal carotid artery occlusion/near-occlusion.
    Clinical neurology and neurosurgery 05/2014; 120:73-7.
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    ABSTRACT: The purpose of this study is to validate the efficacy of intensive statin therapy for patients with atherosclerotic intracranial arterial stenosis (AICAS). In this study, we performed a single-center, randomized, single-blind, parallel-group clinical trial. A total of 120 Chinese patients with AICAS were enrolled and randomly divided into three groups [low-dose atorvastatin therapy (LAT, 10mg/day), standard-dose atorvastatin therapy (SAT, 20mg/day), and intensive-dose atorvastatin therapy (IAT, 40mg/day) groups] in a 1:1:1 ratio. Evaluation variables, including changes in serum lipid profiles, degree of stenosis, and perfusion-related parameters derived from computed tomography perfusion (CTP) imaging from baseline to weeks 26 and 52, as well as the occurrence of cerebrovascular events during the study period, were used to compare the benefits of these three statin therapies. After 52 weeks of treatment, improvement of serum lipid profiles, degree of stenosis, and perfusion-related parameters were all significantly better in the IAT group. In addition, the cumulative probability of cerebrovascular events at 52 weeks was significantly lower in the IAT group than in the LAT group, although there was no statistical difference between the IAT group and the SAT group. The proportion of patients experiencing any adverse event was similar among the three treatment groups. Adverse events caused by IAT were generally mild; no serious adverse events occurred throughout the entire period of study. In conclusion, long-term use of IAT appears to be a safe and effective treatment at least for Chinese patients with AICAS.
    Clinical neurology and neurosurgery 05/2014; 120:6-13.
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    ABSTRACT: The present study tested the hypothesis of whether antiplatelet agents (APA) induce chronic subdural hematoma (CSDH) recurrence via a platelet aggregation inhibitory effect. We examined risk factors for CSDH recurrence, focusing on APA, in 719 consecutive patients who admitted to three tertiary hospitals and underwent burr-hole craniostomy and irrigation for CSDH. This was a multicenter, retrospective, observational study. Age, sex, history of diabetes mellitus, hypertension, chronic renal failure, alcohol consumption habits, consciousness disturbance on admission, or preoperative CT density was not associated with recurrence. Subdural drainage was significantly associated with less recurrence. Preoperative oral APA administration was significantly associated with more recurrence. The recurrence rate of CSDH in non-APA group was 11% if surgery was performed on admission. However, if surgery was performed immediately after discontinuation of oral APA administration, the recurrence rate in APA group significantly increased to 32% (p value<0.0001; odds ratio, 3.77; 95% confidence interval, 1.72-8.28). The effect of APA on CSDH recurrence gradually diminished as the number of days until initial surgery, after stopping APA, increased. Antiplatelet therapy significantly influences the recurrence of CSDH.
    Clinical neurology and neurosurgery 05/2014; 120:49-54.
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    ABSTRACT: The number of patients who need cranioplasty after decompressive craniectomy has increased. In most cases, autologous bone flaps are used for cranioplasty, and there have been reports of the complication of bone flap resorption. Based on these facts, we analysed patients who underwent cranioplasty in our institution to learn about potential risk factors of cranioplasty. We performed a retrospective study and analysed 58 patients who underwent cranioplasty between 2006 and 2013. We found that patients with a defect size >120cm(2) whose reimplantation was delayed tended to have a risk of bone flap resorption. Patients with delayed reimplantation and a defect size >120cm(2) show a tendency of aseptic bone flap resorption. In these cases, a patient-specific implant (PSI) could be the first choice material for this procedure to reduce the rate of this complication.
    Clinical neurology and neurosurgery 05/2014; 120:64-7.
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    ABSTRACT: The objective of this study is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. 48 Patients with CTS were enrolled in our prospective trial. Participants were classified in 2 groups: 24 patients underwent open surgery technique and 24 underwent endoscopic carpal tunnel decompression. Carpal canal shape and volume, configuration and position of contents, were analyzed by using imaging techniques. Preoperative carpal canal volume in endoscopic patient group averaged 5.7±1.4 cc and 7.3±2.9 cc at 6 weeks postoperatively (28%±7%, p=0.018). In contrast preoperative carpal canal volume in open carpal tunnel release group averaged 4.9±1.1 cc (and increased to 6.2±1.7 cc at 6-week follow up investigation (36%±5%, p=0.002). Preoperative carpal arch width calculation in endoscopic carpal tunnel release group averaged 21.7±1.1mm and 21.5±1.9mm in open carpal tunnel release patients (p=0.6575). Postoperative carpal arch width measurements in endoscopic carpal tunnel decompression group averaged 22.6±4.1mm and 22.1±2.9mm in open carpal tunnel release patient population at 6-week follow-up investigation (p=0.628). Endoscopic approach causes an increment in carpal canal volume comparable to open technique and provides equivalent anatomic outcomes and will produce at least equivalent long-term clinical relief.
    Clinical neurology and neurosurgery 05/2014; 120:96-8.
  • Clinical neurology and neurosurgery 04/2014;