Monday, April 30, 2012

Patients with brain tumor-related epilepsy

Patients with brain tumor-related epilepsy (BTRE) present a complex therapeutic profile and require a unique and multidisciplinary approach. They, in fact, must face two different pathologies at the same time, brain tumor and epilepsy. Therefore, it is necessary to develop a customized treatment plan for each individual with BTRE. This requires a vision of patient management concerned not only with medical therapies related to the oncological disease and to the correct choice of antiepileptic therapies but also with emotional and psychological support for the individual and his/her family. The choice of antiepileptic drugs is challenging for these patients because BTRE is often drug-resistant, has a strong impact on the quality of life, and weighs heavily on public health expenditures. In brain tumor patients, the presence of epilepsy is considered the most important risk factor for long-term disability. The problem of the proper administration of medications and their potential side effects is of great importance, because good seizure control also has a significant impact on the patient's psychological and relational sphere.

  • Content Type Journal Article
  • Category Topic Review
  • Pages 1-6
  • DOI 10.1007/s11060-012-0867-7
  • Authors
    • Marta Maschio, Center for Tumor-Related Epilepsy, Neurology Unit, Department of Neuroscience and Cervical-Facial Pathology, National Institute for Cancer "Regina Elena", Via Elio Chianesi 53, 00144 Rome, Italy
    • Loredana Dinapoli, Center for Tumor-Related Epilepsy, Neurology Unit, Department of Neuroscience and Cervical-Facial Pathology, National Institute for Cancer "Regina Elena", Via Elio Chianesi 53, 00144 Rome, Italy

The relationship between organizational culture and family satisfaction in critical care*

Objectives: Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient. Design: Cross-sectional surveys. Setting: Twenty-three tertiary and community intensive care units within three provinces in Canada. Subjects: One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients. Interventions: None. Measurements and Main Results: Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction. Conclusions: Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

Guidelines for intensive care unit design*

Objective: To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit. Participants: A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit. Scope: The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment. Data Sources and Synthesis: Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations. Conclusions: Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace. (Crit Care Med 2012; 40:–16)

A systematic review and meta-analysis of clinical trials of thyroid hormone administration to brain

Objectives: To review all published clinical studies of thyroid hormone administration to brain-dead potential organ donors. Methods: A search of PubMed using multiple search terms retrieved 401 publications including 35 original reports describing administration of thyroid hormone to brain-dead potential organ donors. Detailed review of the 35 original reports led to identification of two additional publications not retrieved in the original search. The 37 original publications reported findings from 16 separate case series or retrospective audits and seven randomized controlled trials, four of which were placebo-controlled. Meta-analysis was restricted to the four placebo-controlled randomized controlled trials. Results: Whereas all case series and retrospective audits reported a beneficial effect of thyroid hormone administration, all seven randomized controlled trials reported no benefit of thyroid hormone administration either alone or in combination with other hormonal therapies. In four placebo-controlled trials including 209 donors, administration of thyroid hormone (n = 108) compared with placebo (n = 101) had no significant effect on donor cardiac index (pooled mean difference, 0.15 L/min/m2; 95% confidence interval –0.18 to 0.48). The major limitation of the case series and retrospective audits was the lack of consideration of uncontrolled variables that confound interpretation of the results. A limitation of the randomized controlled trials was that the proportion of donors who were hemodynamically unstable or marginal in other ways was too small to exclude a benefit of thyroid hormone in this subgroup. Conclusions: The findings of this systematic review do not support a role for routine administration of thyroid hormone in the brain-dead potential organ donor. Existing recommendations regarding the use of thyroid hormone in marginal donors are based on low-level evidence.

Abrupt clinical onset of Chiari type I/syringomyelia complex: clinical and physiopathological implic

Chiari I malformation (CI) continues to raise great interest among physicians due to the larger and larger number of newly diagnosed cases. The clinical and radiological picture and the management options of such a chronic disease are well acknowledged as well as those of the associated syringomyelia. Little is known, on the other hand, about abrupt clinical onset following decompensation of CI/syringomyelia complex. This review on the sudden onset of these two conditions shows that this is a very rare phenomenon; only 41 cases are being reported in the last three decades. In all these cases, acute onset was referable to CI/syringomyelia and the clinical course quickly precipitated. Motor deficits (36.5 %), respiratory failure (29 %), cranial nerve palsy (17 %), and cardiac arrest (14.5 %) were the most common findings, thus confirming that abrupt onset may have severe and life-threatening consequences. Indeed, sudden or early mortality accounted for 19.5 % of cases. In spite of that, most of the surviving subjects had an excellent outcome following either surgical or medical/rehabilitation treatment. Physiopathology of abrupt onset is attributed to the acute compression of the brainstem/upper cervical spinal cord by ectopic tonsils and syringobulbia/syringomyelia, frequently precipitated by a minor injury, followed by impairment of medullary baroreceptors and midbrain reticular substance (cardiac arrest, syncope), medullary chemoreceptors and phrenic nerve nuclei (respiratory failure), lower cranial nerve nuclei (cardiac arrest, cranial nerve palsy), and pyramidal tracts (motor deficits). About 87 % of patients of this review were asymptomatic prior to their acute onset. The problem of the management of asymptomatic subjects is still open.

  • Content Type Journal Article
  • Category Review
  • Pages 1-9
  • DOI 10.1007/s10143-012-0391-4
  • Authors
    • Luca Massimi, Institute of Neurosurgery—A. Gemelli Hospital, Largo A. Gemelli, 8, 00168 Rome, Italy
    • Giuseppe M. Della Pepa, Institute of Neurosurgery—A. Gemelli Hospital, Largo A. Gemelli, 8, 00168 Rome, Italy
    • Massimo Caldarelli, Institute of Neurosurgery—A. Gemelli Hospital, Largo A. Gemelli, 8, 00168 Rome, Italy
    • Concezio Di Rocco, Institute of Neurosurgery—A. Gemelli Hospital, Largo A. Gemelli, 8, 00168 Rome, Italy

Sunday, April 29, 2012

Incidental durotomy after spinal surgery: a prospective study in an academic institution

Journal of Neurosurgery: Spine, Volume 0, Issue 0, Page 1-7, Ahead of Print.
Object Incidental durotomies (IDs) are an unfortunate but anticipated potential complication of spinal surgery. The authors surveyed the frequency of IDs for a single spine surgeon and analyzed the major risk factors as well as the impact on long-term patient outcomes. Methods The authors conducted a prospective review of elective spinal surgeries performed over a 15-year period. Any surgery involving peripheral nerve only, intradural procedures, or dural tears due to trauma were excluded from analysis. The incidence of ID was categorized by surgery type including primary surgery, revision surgery, and so forth. Incidence of ID was also examined in the context of years of physician experience and training. Furthermore, the incidence and types of sequelae were examined in patients with an ID. Results Among 3000 elective spinal surgery cases, 3.5% (104) had an ID. The incidence of ID during minimally invasive procedures (3.3%) was similar, but no patients experienced long-term sequelae. The incidence of ID during revision surgery (6.5%) was higher. There was a marked difference in incidence between cervical (1.3%) and thoracolumbar (5.1%) cases. The incidence was lower for cases involving instrumentation (2.4%). When physician training was examined, residents were responsible for 49% of all IDs, whereas fellows were responsible for 26% and the attending for 25%. Among all of the cases that involved an ID, 7.7% of patients went on to experience a neurological deficit as compared with 1.5% of those without an ID. The overall failure rate of dural repair was 6.9%, and failure was almost 3 times higher (13%) in revision surgery as compared with a primary procedure (5%). Conclusions The authors established a reliable baseline incidence for durotomy after spine surgery: 3.5%. They also identified risk factors that can increase the likelihood of a durotomy, including location of the spinal procedure, type of procedure performed, and the implementation of a new procedure. The years of physician training or resident experience did not appear to be a major risk for ID.

Annual rupture risk of growing unruptured cerebral aneurysms detected by magnetic resonance angiogra

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-6, Ahead of Print.
Object In this paper, the authors' goals were to clarify the characteristics of growing unruptured cerebral aneurysms detected by serial MR angiography and to establish the recommended follow-up interval. Methods A total of 1002 patients with 1325 unruptured cerebral aneurysms were retrospectively identified. These patients had undergone follow-up evaluation at least twice. Aneurysm growth was defined as an increase in maximum aneurysm diameter by 1.5 times or the appearance of a bleb. Results Aneurysm growth was observed in 18 patients during the period of this study (1.8%/person-year). The annual rupture risk after growth was 18.5%/person-year. The proportion of females among patients with growing aneurysms was significantly larger than those without growing aneurysms (p = 0.0281). The aneurysm wall was reddish, thin, and fragile on intraoperative findings. Frequent follow-up examination is recommended to detect aneurysm growth before rupture. Conclusions Despite the relatively short period, the annual rupture risk of growing unruptured cerebral aneurysms detected by MR angiography was not as low as previously reported. Surgical or endovascular treatment can be considered if aneurysm growth is detected during the follow-up period.

Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorr

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-5, Ahead of Print.
Object Timing of clinical grading has not been fully studied in patients with aneurysmal subarachnoid hemorrhage (SAH). The primary objective of this study was to identify at which time point clinical assessment using the World Federation of Neurosurgical Societies (WFNS) grading scale and the Glasgow Coma Scale (GCS) is most predictive of poor functional outcome. Methods This study is a retrospective cohort study on the association between poor outcome and clinical grading determined at presentation, nadir, and postresuscitation. Poor functional outcome was defined as a Glasgow Outcome Scale score of 1–3 at 6 months after SAH. Results The authors identified 186 consecutive patients admitted to a teaching hospital between January 2002 and June 2008. The patients' mean age (± SD) was 56.9 ± 13.7 years, and 63% were women. Twenty-four percent had poor functional outcome (the mortality rate was 17%). On univariable logistic regression analyses, GCS score determined at presentation (OR 0.80, p < 0.0001), nadir (OR 0.73, p < 0.0001), and postresuscitation (OR 0.53, p < 0.0001); modified Fisher scale (OR 2.21, p = 0.0013); WFNS grade assessed at presentation (OR 1.92, p < 0.0001), nadir (OR 3.51, < 0.0001), and postresuscitation (OR 3.91, p < 0.0001); intracerebral hematoma on initial CT (OR 4.55, p < 0.0002); acute hydrocephalus (OR 2.29, p = 0.0375); and cerebral infarction (OR 4.84, p < 0.0001) were associated with poor outcome. On multivariable logistic regression analysis, only cerebral infarction (OR 5.80, p = 0.0013) and WFNS grade postresuscitation (OR 3.43, p < 0.0001) were associated with poor outcome. Receiver operating characteristic/area under the curve (AUC) analysis demonstrated that WFNS grade determined postresuscitation had a stronger association with poor outcome (AUC 0.90) than WFNS grade assessed upon admission or at nadir. Conclusions Timing of WFNS grade assessment affects its prognostic value. Outcome after aneurysmal SAH is best predicted by assessing WFNS grade after neurological resuscitation.

Unruptured intracranial aneurysms in the Familial Intracranial Aneurysm and International Study of U

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-5, Ahead of Print.
Object Familial predisposition is a recognized nonmodifiable risk factor for the formation and rupture of intracranial aneurysms (IAs). However, data regarding the characteristics of familial IAs are limited. The authors sought to describe familial IAs more fully, and to compare their characteristics with a large cohort of nonfamilial IAs. Methods The Familial Intracranial Aneurysm (FIA) study is a multicenter international study with the goal of identifying genetic and other risk factors for formation and rupture of IAs in a highly enriched population. The authors compared the FIA study cohort with the International Study of Unruptured Intracranial Aneurysms (ISUIA) cohort with regard to patient demographic data, IA location, and IA multiplicity. To improve comparability, all patients in the ISUIA who had a family history of IAs or subarachnoid hemorrhage were excluded, as well as all patients in both cohorts who had a ruptured IA prior to study entry. Results Of 983 patients enrolled in the FIA study with definite or probable IAs, 511 met the inclusion criteria for this analysis. Of the 4059 patients in the ISUIA study, 983 had a previous IA rupture and 657 of the remainder had a positive family history, leaving 2419 individuals in the analysis. Multiplicity was more common in the FIA patients (35.6% vs 27.9%, p < 0.001). The FIA patients had a higher proportion of IAs located in the middle cerebral artery (28.6% vs 24.9%), whereas ISUIA patients had a higher proportion of posterior communicating artery IAs (13.7% vs 8.2%, p = 0.016). Conclusions Heritable structural vulnerability may account for differences in IA multiplicity and location. Important investigations into the underlying genetic mechanisms of IA formation are ongoing.

Saturday, April 28, 2012

Intelligence Is Overrated: What You Really Need To Succeed - Forbes

Intelligence Is Overrated: What You Really Need To Succeed

Albert Einstein's was estimated at 160,Madonna's is 140, and John F. Kennedy's was only 119, but as it turns out, your IQ score pales in comparison with your EQ, MQ, and BQ scores when it comes to predicting your success and professional achievement.

IQ tests are used as an indicator of logical reasoning ability and technical intelligence. A high IQ is often a prerequisite for rising to the top ranks of business today. It is necessary, but it is not adequate to predict executive competence and corporate success. By itself, a high IQ does not guarantee that you will stand out and rise above everyone else.

Research carried out by the Carnegie Institute of Technology shows that 85 percent of your financial success is due to skills in "human engineering," your personality and ability to communicate, negotiate, and lead. Shockingly, only 15 percent is due to technical knowledge. Additionally, Nobel Prize winning Israeli-American psychologist, Daniel Kahneman, found that people would rather do business with a person they like and trust rather than someone they don't, even if the likeable person is offering a lower quality product or service at a higher price.

With this in mind, instead of exclusively focusing on your conventional intelligence quotient, you should make an investment in strengthening your EQ (Emotional Intelligence), MQ (Moral Intelligence), and BQ (Body Intelligence). These concepts may be elusive and difficult to measure, but their significance is far greater than IQ.

Emotional Intelligence

EQ is the most well known of the three, and in brief it is about: being aware of your own feelings and those of others, regulating these feelings in yourself and others, using emotions that are appropriate to the situation, self-motivation,  and building relationships.

Top Tip for Improvement: First, become aware of your inner dialogue. It helps to keep a journal of what thoughts fill your mind during the day. Stress can be a huge killer of emotional intelligence, so you also need to develop healthy coping techniques that can effectively and quickly reduce stress in a volatile situation.

Moral Intelligence

MQ directly follows EQ as it deals with your integrity, responsibility, sympathy, and forgiveness. The way you treat yourself is the way other people will treat you. Keeping commitments, maintaining your integrity, and being honest are crucial to moral intelligence.

Top Tip for Improvement: Make fewer excuses and take responsibility for your actions. Avoid little white lies. Show sympathy and communicate respect to others. Practice acceptance and show tolerance of other people's shortcomings. Forgiveness is not just about how we relate to others; it's also how you relate to and feel about yourself.

Body Intelligence

Lastly, there is your BQ, or body intelligence, which reflects what you know about your body, how you feel about it, and take care of it. Your body is constantly telling you things; are you listening to the signals or ignoring them? Are you eating energy-giving or energy-draining foods on a daily basis? Are you getting enough rest? Do you exercise and take care of your body? It may seem like these matters are unrelated to business performance, but your body intelligence absolutely affects your work because it largely determines your feelings, thoughts, self-confidence, state of mind, and energy level.

Top Tip For Improvement: At least once a day, listen to the messages your body is sending you about your health. Actively monitor these signals instead of going on autopilot. Good nutrition, regular exercise, and adequate rest are all key aspects of having a high BQ. Monitoring your weight, practicing moderation with alcohol, and making sure you have down time can dramatically benefit the functioning of your brain and the way you perform at work.

What You Really Need To Succeed

It doesn't matter if you did not receive the best academic training from a top university. A person with less education who has fully developed their EQ, MQ, and BQ can be far more successful than a person with an impressive education who falls short in these other categories.

Yes, it is certainly good to be an intelligent, rational thinker and have a high IQ; this is an important asset. But you must realize that it is not enough. Your IQ will help you personally, but EQ, MQ, and BQ will benefit everyone around you as well. If you can master the complexities of these unique and often under-rated forms of intelligence, research tells us you will achieve greater success and be regarded as more professionally competent and capable.

Keld Jensen is an expert on trust, negotiation, leadership, and communication. To learn more, and sign up for his "Power Bargaining" newsletter.

Friday, April 27, 2012

A inteligência é supervalorizada: o que você realmente precisa para sobreviver

Post de Theolis Bessa

A matéria publicada na Forbes ressalta as qualidades interpessoais como chave para uma carreira de sucesso. O mesmo ocorreria na Ciência? O trato com superiores e colegas no ambiente do laboratório pode certamente pesar na balança na hora de conseguir estágios, ser convidado a participar de projetos ou mesmo emprestar aquele kit crucial para terminar os experimentos para a

IMS 3 Trial of Mechanical Embolectomy in Stroke Stopped

Investigators are disappointed at the move to suspend trial they hoped would demonstrate effectiveness of mechanical embolectomy, a stroke therapy increasingly used even without this evidence.
Medscape Medical News

Effect of Mannitol on Cerebral Blood Volume in Patients With Head Injury

BACKGROUND: Mannitol has traditionally been the mainstay of medical therapy for intracranial hypertension in patients with head injury. We previously demonstrated that mannitol reduces brain volume in patients with cerebral edema, although whether this occurs because of a reduction in brain water, blood volume, or both remains poorly understood. OBJECTIVE: To test the hypothesis that mannitol acts by lowering blood viscosity leading to reflex vasoconstriction and a fall in cerebral blood volume (CBV). METHODS: We used 15O positron emission tomography to study 6 patients with traumatic brain injuries requiring treatment for intracranial hypertension. Cerebral blood flow (CBF), CBV, and cerebral metabolic rate for oxygen (CMRO2) were measured before and 1 hour after administration of 1.0 g/kg 20% mannitol. RESULTS: CBV rose from 4.1 ± 0.4 to 4.2 ± 0.2 mL/100 g (P = .3), while intracranial pressure fell from 21.5± 4.9 to 13.7 ± 5.1 mm Hg (P < .003) after mannitol. Blood pressure, PaCO2, oxygen content, CBF, and CMRO2 did not change. CONCLUSION: A single bolus of 1 g/kg of 20% mannitol does not acutely lower CBV. Another mechanism, such as a reduction in brain water, may better explain mannitol's ability to lower intracranial pressure and reduce mass effect.

Vein of Galen Malformations in Neonates: New Management Paradigms for Improving Outcomes

BACKGROUND: Untreated patients with symptomatic neonatal presentation of vein of Galen aneurismal malformations (VGAMs) carry almost 100% morbidity and mortality. Medical management and endovascular techniques for neonatal treatment have significantly evolved. OBJECTIVE: To evaluate the clinical and angiographic outcomes of modern management of neonates with refractory heart failure from VGAMs. METHODS: From 2005 to 2010, 16 neonatal patients with VGAM presented to our institution. Medical care from the prenatal to perinatal stages was undertaken according to specified institutional guidelines. Nine patients with refractory heart failure required neonatal endovascular intervention. All patients were treated by transarterial deposition of n-butyl cyanoacrylate into fistula sites. Short- and long-term angiographic studies and clinical outcomes were reviewed. RESULTS: Control of heart failure was achieved in 8 patients. One premature baby died shortly after treatment. Long-term angiographic follow-up shows total or near-total angiographic obliteration in all 8 patients. One patient has a mild hemiparesis from treatment. Another has a mild developmental delay. One patient developed a severe seizure disorder and developmental delay. Overall, 66.7% patients have normal neurological development with near-total or total obliteration of the malformation. CONCLUSION: Treatment of refractory heart failure in neonatal VGAM with modern prenatal, neurointensive, neuroanesthetic, and pediatric neuroendovascular care results in significantly improved outcomes with presumed cure and normal neurological development in most.

Low Brain Activity Seen in Chronic Fatigue (CME/CE)

(MedPage Today) -- Patients with chronic fatigue syndrome had significantly less activation of the basal ganglia in response to a known stimulus compared with a control group, investigators reported.

Iatrogenic dural arteriovenous fistula and aneurysmal subarachnoid hemorrhage

Neurosurgical Focus, Volume 32, Issue 5, Page E1, May 2012.
The authors present the case of a patient who presented acutely with aneurysmal subarachnoid hemorrhage (SAH) and a contralateral iatrogenic dural arteriovenous fistula (DAVF). Diagnostic angiography was performed, revealing a right-sided middle cerebral artery (MCA) aneurysm and a left-sided DAVF immediately adjacent to the entry of the ventriculostomy and bur hole site. A craniotomy was performed for clipping of the ruptured MCA aneurysm, and the patient subsequently underwent endovascular obliteration of the DAVF 3 days later. The authors present their treatment of an iatrogenic DAVF in a patient with an aneurysmal SAH, considerations in management options, and a literature review on the development of iatrogenic DAVFs.

Cerebral dural arteriovenous fistulas and aneurysms

Neurosurgical Focus, Volume 32, Issue 5, Page E2, May 2012.
Object The association of aneurysms and cerebral arteriovenous malformations is well established in the literature. Aside from a small number of case reports and small patient series, this association has not been well explored with cerebral dural arteriovenous fistulas (DAVFs). This study was designed to elucidate this relationship in the authors' own patient cohort with DAVFs. Methods Cerebral angiograms of 56 patients with 70 DAVFs were reviewed for the presence of cerebral aneurysms. Background patient demographics, mode of presentation, and DAVF and aneurysm angiographic characteristics were noted. Results Twelve patients (21%) had aneurysms in addition to their DAVF. Three patients had multiple aneurysms. Of a total of 15 aneurysms, 5 (33%) occurred on DAVF feeding arteries and 10 (67%) were in remote locations. These patients more commonly presented with hemorrhage (58% vs 20% for those without aneurysms). Aneurysms were associated with DAVFs in any location (feeding artery or remote), but flow-related feeding artery aneurysms were more likely to be associated with Borden Type III DAVFs. Conclusions Twenty-one percent of patients with cerebral DAVFs also had aneurysms in this patient cohort. It is thus prudent to perform 6-vessel digital subtraction angiography on patients with DAVFs to rule out potential feeding artery and remote aneurysms. This association may be explained by flow-related phenomena, the initial inciting event leading to DAVF formation, as well as a potential genetic component or predisposition to develop these lesions.

Thursday, April 26, 2012

The Relationship Between Intracranial Pressure and Brain Oxygenation in Children With Severe Traumat

BACKGROUND: Intracranial pressure (ICP) monitoring is a cornerstone of care for severe traumatic brain injury (TBI). Management of ICP can help ensure adequate cerebral blood flow and oxygenation. However, studies indicate that brain hypoxia may occur despite normal ICP and the relationship between ICP and brain oxygenation is poorly defined. This is particularly important for children in whom less is known about intracranial dynamics. OBJECTIVE: To examine the relationship between ICP and partial pressure of brain tissue oxygen (PbtO2) in children with severe TBI (Glasgow Coma Scale score ≤8) admitted to Red Cross War Memorial Children's Hospital, Cape Town. METHODS: The relationship between time-linked hourly and high-frequency ICP and PbtO2 data was examined using correlation, regression, and generalized estimating equations. Thresholds for ICP were examined against reduced PbtO2 using age bands and receiver-operating characteristic curves. RESULTS: Analysis using more than 8300 hourly (n = 75) and 1 million high-frequency data points (n = 30) demonstrated a weak relationship between ICP and PbtO2 (r = 0.05 and r = 0.04, respectively). No critical ICP threshold for low PbtO2 was identified. Individual patients revealed a strong relationship between ICP and PbtO2 at specific times, but different relationships were evident over longer periods. CONCLUSION: The relationship between ICP and PbtO2 appears complex, and several factors likely influence both variables separately and in combination. Although very high ICP is associated with reduced PbtO2, in general, absolute ICP has a poor relationship with PbtO2. Because reduced PbtO2 is independently associated with poor outcome, a better understanding of ICP and PbtO2 management in pediatric TBI seems to be needed.

Ventricular Catheter Location and the Clearance of Intraventricular Hemorrhage

BACKGROUND: There is no consensus regarding optimal position of an external ventricular drain (EVD) with regard to clearance of intraventricular hemorrhage (IVH). OBJECTIVE: To assess the hypothesis that EVD laterality may influence the clearance of blood from the ventricular system with and without administration of thrombolytic agent. METHODS: The EVD location was assessed in 100 patients in 2 Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR IVH) phase II trials assessing the safety and dose optimization of thrombolysis through the EVD to accelerate the clearance of obstructive IVH. Laterality of catheter was correlated with clearance rates. RESULTS: Clearance of IVH over the first 3 days was significantly greater when thrombolytic compared with placebo was administered regardless of catheter laterality (P < .005; 95% confidence interval, −14.0 to −4.14 for contralateral EVD and −24.7 to −5.44 for ipsilateral EVD). When thrombolytic was administered, there was a trend toward more rapid clearance of total IVH through an EVD placed on the side of dominant intraventricular blood compared with an EVD on the side with less blood (P = .09; 95% confidence interval, −9.62 to 0.69). This was not true when placebo was administered. Clearance of third and fourth ventricular blood was unrelated to EVD laterality. CONCLUSION: It is possible that placement of EVD may be optimized to enhance the clearance of total IVH if lytic agents are used. Catheters on either side can clear the third and fourth ventricles with equal efficiency.

Cancer Drug Effective in Relapsing MS (CME/CE)

NEW ORLEANS (MedPage Today) -- Alemtuzumab (Lemtrada, Campath) dramatically reduced multiple sclerosis relapses in patients with long-term disease -- with just once-a-year treatment, researchers reported here.

Caffeine May Relieve Dry Eye Syndrome

Caffeine increases tear volume, particularly in people with certain genetic polymorphisms.
Medscape Medical News

Tuesday, April 24, 2012

Cresce valorização da divulgação científica

Copio abaixo uma reportagem muito interessante da Agencia FAPESP:

Por Fábio de Castro

Agência FAPESP – Editor de Ciência do Financial Times há duas décadas, o jornalista britânico Clive Cookson acredita que os temas científicos têm se tornado mais familiares e mais valorizados para o público, graças a uma cobertura jornalística que se revela pouco a pouco mais profunda e mais

Follow-up imaging to detect recurrence of surgically treated pediatric arteriovenous malformations

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 5, Page 497-504, May 2012.
Object The true postoperative incidence of arteriovenous malformation (AVM) recurrence in the pediatric population remains largely unreported. Some literature suggests that delayed imaging studies should be obtained at 6 months to 1 year after negative findings on a postoperative angiogram. The aim of this study was to describe the timing of AVM recurrences after resection and the neuroimaging modalities on which the recurrences were detected. Methods This study was performed in a retrospective cohort of all pediatric patients treated surgically for AVM resection by a single neurosurgeon between 2005 and 2010. Patients were followed after resection with MR angiography (MRA) or conventional angiography, when possible, at various time points. A visual scale for compactness of the initial AVM nidus was used, and the score was correlated with probability of recurrence after surgery. Results A total of 28 patients (13 female, 15 male) underwent an AVM resection. In 18 patients (64.3%) an intraoperative angiogram was obtained. In 4 cases the intraoperative angiogram revealed residual AVM, and repeat resections were performed immediately. Recurrent AVMs were found in 4 children (14.3%) at 50, 51, 56, and 60 weeks after the initial resection. Recurrence risk was 0.08 per person-year. No patient with normal results on an angiogram obtained at 1 year developed a recurrence on either a 5-year angiogram or one obtained at 18 years of age. All patients with recurrence had a compactness score of 1 (diffuse AVM); a lower compactness score was associated with recurrence (p = 0.0003). Conclusions All recurrences in this cohort occurred less than 15 months from the initial resection. The authors recommend intraoperative angiography to help ensure complete resection at the time of the surgery. Follow-up vascular imaging is crucial for detecting recurrent AVMs, and conventional angiography is preferred because MRA can miss smaller AVMs. One-year follow-up imaging detected these recurrences, and no one who had negative results on an angiogram obtained at 1 year had a late recurrence. However, not all of the patients have been followed for 5 years or until 18 years of age, so longer follow-up is required for these patients. A lower compactness score predicted recurrent AVM in this cohort.

Nonprogrammable and programmable cerebrospinal fluid shunt valves: a 5-year study

Journal of Neurosurgery: Pediatrics, Volume 9, Issue 5, Page 462-467, May 2012.
Object Programmable valves (PVs) for shunting CSF have increasingly replaced nonprogrammable valves (NPVs). There have been only a few longer-term studies (≥ 5 years) conducted that have compared the effectiveness of NPVs with that of PVs for children with hydrocephalus, and only 1 study has reported NPVs as being favorable over PVs. The objective of this retrospective study was to compare the long-term survival of these 2 types of shunt valves. Methods The authors collected data for all patients who underwent CSF shunt insertion or revision between January 1, 2000, and December 31, 2008. Patients underwent follow-up for a minimum of 2 years postoperatively. Statistical analyses were done using chi-square, Kaplan-Meier survival curve, and multivariate analyses. Results A total of 616 valves were implanted, of which 313 were PVs and 303 were NPVs. Of these, 253 were original shunt implantations and 363 were revisions. The proportion of 5-year survival for NPVs (45.8%) was significantly higher than that for PVs (19.8%) (p = 0.0005, log-rank). The NPVs that survived longer than 6 months also survived through the 5th year better than the PVs (p = 0.0001). Conclusions The authors' data suggest that NPVs survive longer than PVs in children, but there is a need for prospective, case-control studies to confirm these data.

Brain dead mom gives birth to twins

A Michigan woman gives birth to twin boys after being declared brain dead due to aneurysms.

Monday, April 23, 2012

Lack of Increase in Intracranial Pressure After Epidural Blood Patch in Spinal Cerebrospinal Fluid L

Background and Importance  
Epidural blood patch (EBP) is one therapeutic measure for patients suffering from spontaneous intracranial hypotension (SIH) or post-lumbar puncture headaches. It has been proposed that an EBP may directly seal a spinal cerebrospinal fluid (CSF) fistula or result in an increase in intracranial pressure (ICP) by a shift of CSF from the spinal to the intracranial compartment. To the best of our knowledge this is the first case of a patient with SIH and neurological deterioration in whom ICP was measured before, during, and after spinal EBP.
Clinical Presentation  
This 52-year old previously healthy man presented with holocephal headaches. MRI showed a left hemispheric subdural fluid collection causing a significant mass effect. Myelography revealed a CSF leak with epidural contrast at the left side of the L-2 level. To seal the CSF leak, we performed an EBP procedure targeted at left L-2 level and recorded ICP. After applying the epidural blood patch (15 cc) the patient improved rapidly, ICP however remained unchanged before, during, and after the procedure. One day post-treatment, he had a GCS score increase from 12 to 15 and no headache or neurological deficits.
A shift of CSF from the spinal to the cranial compartment with a subsequent rise in ICP might not be a beneficial therapeutic mechanism of spinal epidural blood patching.

  • Content Type Journal Article
  • Category Practical Pearl
  • Pages 1-6
  • DOI 10.1007/s12028-012-9702-4
  • Authors
    • Jens Fichtner, Department of Neurosurgery, Bern University Hospital, Publications Office, 3010 Bern, Switzerland
    • Christian Fung, Department of Neurosurgery, Bern University Hospital, Publications Office, 3010 Bern, Switzerland
    • Werner Z`Graggen, Department of Neurosurgery, Bern University Hospital, Publications Office, 3010 Bern, Switzerland
    • Andreas Raabe, Department of Neurosurgery, Bern University Hospital, Publications Office, 3010 Bern, Switzerland
    • Jürgen Beck, Department of Neurosurgery, Bern University Hospital, Publications Office, 3010 Bern, Switzerland

Feliz 103 anos Rita Levi-Montalcini

Fotografia da página oficial do Prêmio Nobel (aqui).

Post de Aldina Barral

Hoje a Dra. Rita Levi-Montalcini, recebedora do Nobel em 1986, completa 103 anos. Os seus cem anos foram comemorados pelo Totum  (Uma mulher admirável).

Ela não está em casa descansando… Ela continua trabalhando no European Brain Research Institute, Rita Levi-Montalcini Foundation e acaba de publicar mais um

Decompressive Hemicraniectomy in Malignant Middle Cerebral Artery Infarct: A Randomized Controlled T

Decompressive hemicraniectomy (DHC) has proven efficacious for the treatment of malignant middle cerebral artery infarction (mMCAI) only in patients less than 60 years. This study aimed to assess the effectiveness of DHC in patients up to 80.
This is a prospective, randomized, controlled trail comparing the outcomes with or without DHC in patients aged 18–80 with mMCAI (ChiCTR–TRC–11001757). The primary outcome measure was the modified Rankin Scale (mRS) scores at 6 months. The secondary outcome measures included the 6- and 12-month mortality and the mRS scores after 1 year. The prognosis of patients was evaluated independently by two blinded investigators. In addition, subgroup analyses were done for those above 60 years of age. All analyses were by intention-to-treat.
A significant reduction in the poor outcome (mRS > 4) following DHC was reached after 36 patients had completed the follow-up period of 6 months. The trial was then terminated when 47 participants (24 in the surgical group vs. 23 in the medical group) had been recruited. The final analysis, based on the outcome data of the 47 patients, showed that DHC significantly reduced mortality at 6 and 12 months (12.5 vs. 60.9 %, P = 0.001 and 16.7 vs. 69.6 %, P < 0.001, respectively), and significantly fewer patients had a mRS score >4 after surgery (33.3 vs. 82.6 %, P = 0.001 and 25.0 vs. 87.0 %, P < 0.001, respectively). Similar results were present in the subgroup analyses of elderly participants
For patients up to 80 years who suffered mMCAI, DHC within 48 h of stroke onset not only is a life-saving treatment, but also increases the possibility of surviving without severe disability (mRS = 5).

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-11
  • DOI 10.1007/s12028-012-9703-3
  • Authors
    • Jingwei Zhao, Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
    • Ying Ying Su, Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
    • Yan Zhang, Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
    • Yun Zhou Zhang, Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
    • Ruilin Zhao, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
    • Lin Wang, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
    • Ran Gao, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
    • Weibi Chen, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
    • Daiquan Gao, Division of Neurocritical Care, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China

Brain Freeze Might Help Solve Migraine Mysteries

Image courtesy of iStockphoto/Neurostockimages

Eager eaters know that gulping a Slurpee or inhaling a sundae can cause that brief seizing sensation known in the not-so-technical literature as "brain freeze" or " ice cream headache ."


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Friday, April 20, 2012

Magnetic resonance imaging and aneurysm clips

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-11, Ahead of Print.
The problem of implanted metals causing tissue damage by movement in patients exposed to MRI fields has produced a confusing welter of erroneous, pseudoscientific publications about magnetics, metals, medical equipment, and tissue compatibility. Quite simply, among the devices made for implantation, only those fabricated of stainless steel have the ferromagnetic properties capable of causing such accidents. The author, who introduced the basic design of the modern aneurysm clip in the late 1960s and then a cobalt nickel alloy as an improvement over steel, while chairing the neurosurgical committee assigned to the task of establishing neurosurgical standards at American Society for Testing and Materials, exposes this flawed information and offers clear guidelines for avoiding trouble.

New Physics and Future Medicine

Physicists have been struggling for decades to unify quantum mechanics, which corrals the particle flock, with Einstein's general theory of relativity, which sculpts space and time. They've come at it with various approaches, including string theory, but it remains stubbornly intractable. Yet--taking a common tactic that physicists use to break apart complex challenges--what if we simplified the problem?


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CNS Drugs Most Often Prescribed Off-Label

Anticonvulsants, antipsychotics, and antidepressants are most likely to be prescribed off-label, a new study finds.
Medscape Medical News

Exercise Lowers Alzheimer's Risk, Even If You Start Late

Doing exercise every day can considerably reduce your risk of developing Alzheimer's disease, even if you start becoming physically active after 80 years of age, researchers from Rush University Medical Center reported in the journal Neurology. Increased physical activity may include becoming involved in daily chores, such as housework, the authors added. Lead author, Dr. Aron S...

Non-Surgical Test For Brain Cancer In The Pipeline

In a breakthrough for the way brain cancer is diagnosed and monitored, a team of researchers, lead by Anna M. Krichevsky, PhD, of the Center of Neurologic Diseases at Brigham and Women's Hospital (BWH), have demonstrated that brain tumors can be reliably diagnosed and monitored without surgery...

Monday, April 16, 2012

Treating Head Injury Without Surgery By Monitoring Pressure

The pressure inside patient's skull can rise due to brain tumors and head trauma, including concussion. The elevated pressure inside the brain can destroy brain tissue or cut off the brain's blood supply. Being able to monitor the pressure inside the brains of affected people could help physicians in establishing the best possible treatment...

Long-term outcome of surgical management of adult Chiari I malformation

Chiari I malformation continues to inspire controversy. Debate still exists about surgical options. The aim of this study is to evaluate the long-term outcome of posterior fossa decompression procedure (PFD) in the treatment of adult Chiari I malformation, focusing on some factors or technical aspects which might influence the outcome. Forty-six adult patients with Chiari I malformation operated by PFD are the subject of this study. The group included 21 males and 25 females, with mean age of 37.4 years. Patients were divided into two groups: group I (32 cases) with syringomyelia and group II (14 cases) without syringomyelia. Group I was further subdivided into three subgroups according to the surgical procedure adopted: group Ia (12 cases) operated by PFD only, group Ib (14 cases) operated by PFD with fourth ventricular shunt, and group Ic (six cases) operated by PFD and syringosubarachnoid shunt. All cases included in group II were operated by PFD only. In group I, symptoms improved in 14 cases (43.8 %) and stabilized in 18 cases (56.3 %), whereas in group II, symptoms resolved in ten cases (71.4 %) and improved in four cases (28.6 %). Postoperative magnetic resonance imaging showed that the syrinx was resolved in 21 cases (65.6 %), improved in seven cases (21.9 %), and unchanged in four cases (12.5 %). Among the mean follow-up period (5.8 years), recurrence of symptoms occurred in five cases (10.9 %), all of them are included in group I, and were reoperated again. Posterior fossa decompression is recommended as the treatment of choice in adult Chiari I malformation with or without syringomyelia. The presence of syringomyelia predicts a less favorable response to surgical intervention. Syringosubarachnoid shunting did not improve the long-term outcome either clinically or radiologically. Implanting a fourth ventricular shunt in cases of syringomyelia associated with adhesions at the foramen of Magendie decreases the long-term incidence of recurrence significantly. For recurrent cases, re-exploration of the initial posterior fossa decompression is recommended before any consideration is given for direct management of the syrinx.

  • Content Type Journal Article
  • Category Original Article
  • Pages 1-11
  • DOI 10.1007/s10143-012-0387-0
  • Authors
    • Nasser M. F. El-Ghandour, Department of Neurosurgery, Faculty of Medicine, Cairo University, 81 Nasr Road, Nasr City, Cairo, Egypt

Friday, April 13, 2012

Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective ther

Publication year: 2012
Source:Journal of Clinical Neuroscience, Volume 19, Issue 5
José E. Cohen, Samuel Moscovici, John M. Gomori, Ron Eliashar, Jeffrey Weinberger, Eyal Itshayek
Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized with n-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1±8.6days, including an average 5.2±3.4days after embolization. Average follow-up after discharge was 21.3±25.7months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.

Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompress

Publication year: 2012
Source:Journal of Clinical Neuroscience, Volume 19, Issue 5
Po-Hsun Tu, Zhuo-Hao Liu, Chi-Cheng Chuang, Tao-Chieh Yang, Chieh-Tsai Wu, Shih-Tseng Lee
Decompressive hemicraniectomy (DC) can save the lives of patients with malignant middle cerebral artery (MCA) infarction. We proposed that postoperative midline shift is important for the long-term outcome of patients with MCA infarction. We conducted a retrospective study of DC in 38 patients with malignant MCA infarction. The long-term outcome was assessed one year after surgery using the modified Rankin Scale (mRS) score. Patients who had midline shift less than the optimal diagnostic cut-off point on the fourth postoperative day were classified as having a successful decompression and the remaining patients were classified in the failed decompression group. The successful decompression group mRS score was 4.20±0.89 one year after surgery and the failed decompression group mRS score was 5.11±0.76 (p <0.0001). Successful decompression, resulting in postoperative midline shift of less than 5mm, was a key factor for beneficial, long-term functional outcomes in patients with malignant MCA infarction.

Characteristics of cavernomas of the brain and spine

Publication year: 2012
Source:Journal of Clinical Neuroscience, Volume 19, Issue 5
Juri Kivelev, Mika Niemelä, Juha Hernesniemi
The incidence of cavernomas in the general population ranges from 0.3% to 0.5%. They frequently occur in young adults, usually being detected between the second and fifth decade of life, in both sporadic and familial forms. Patients with inherited cavernomas are typically affected by multiple lesions, whereas sporadic forms mostly present with a single lesion. Three genes responsible for development of cavernomas identified to date include CCM1, CCM2, and CCM3. The natural history of brain cavernomas is relatively benign and up to 21% of patients are asymptomatic. The most frequent manifestations of the disease are seizures, focal neurological deficits, and hemorrhage. We review the current literature data on the characteristics of brain and spinal cavernomas.