Saturday, October 27, 2012

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Guia de Neurocirurgia Intensiva

Categoria: Medicina

Atualizado: 04/10/2012

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In Neurocritical Care Patients, Intermediate Glucose Control May Be Better Than Tight

A new study in BioMed Central's open access journal Critical Care suggests that intensive glycemic control does not reduce mortality in neurocritical care patients and could, in fact, lead to more neurological damage. Complicating the picture, poor glucose control also leads to worse recovery and should be avoided...

Stent-assisted coiling in ruptured wide-necked aneurysms: A single-center analysis

Anand Alurkar, Lakshmi Sudha Prasanna Karanam, Suresh Nayak, Sagar Oak

Surgical Neurology International 2012 3(1):131-131

Background: To evaluate the safety and efficacy of stent-assisted coiling of ruptured intracranial wide-necked aneurysms in a setting of acute subarachnoid hemorrhage, without compromising on the antiplatelet regimen. Methods: Forty-two consecutive patients who underwent stent-assisted coiling for ruptured wide-necked intracranial aneurysms from August 2008 to May 2012 were studied. Demographic data like age, sex, Hunt & Hess grade, Fischer scale, and location, and size of the aneurysms were noted. Complications such as aneurysmal rupture, bleeding complications, thromboembolic events, etc. were documented. Also, 30-day and 1-year outcome was measured using modified Rankin scale (mRS). Results: Forty-four wide-necked aneurysms were treated in 42 patients with stent-assisted coiling from August 2008 to May 2012 in our institution, out of a total of 248 aneurysms treated endovascularly in the same period. All these patients presented with subarachnoid hemorrhage (SAH) with varying grades and were treated in the acute phase, i.e. within 1 week of the ictus. There were 24 males and 18 females in the age group ranging from 12 to 78 years, with a mean of 45 years. Technical success was achieved in 39 patients with complete angiographic cure (93%). Intraprocedural stent thrombosis was seen in two patients, which resolved with intra-arterial bolus of tirofiban, and both the patients did not have any neurological deficit. Rebleed occurred in two patients of which one patient succumbed. Six patients required external ventricular drain because of worsening hydrocephalus on computed tomography (CT) scan with clinical deterioration. There was one death in our series due to rebleed. Three other patients died in a period of 1 month due to complications not related to the coiling procedure which include vasospasm, pulmonary embolism, and respiratory infection. All the patients were clinically followed up at 1 month, 3 months, 6 months, and 1 year. Also, angiographic follow- up was done at 1 year in 25 patients (72%). All the patients were maintained on clopidogrel 75 mg per day and ecospirin 150 mg per day for a period of 1 year and were advised to continue ecospirin 150 mg per day lifelong. Conclusion: Even in a setting of acute SAH, stent-assisted coiling can be an effective and safe treatment option with acceptable risks in experienced hands.

Tuesday, October 23, 2012

Venous thromboembolism after trauma: A never event?*

imageObjective: Rates of venous thromboembolism as high as 58% have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. Design: Prospective, observational trial with waiver of consent. Setting: Level I trauma center intensive care unit. Patients: At admission, 534 patients were prescreened with a risk assessment profile. Interventions: Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. Results: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19%). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28%. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23% vs. 8%), operative intervention >2 hrs (77% vs. 46%), complex lower extremity fracture (53% vs. 32%), and pelvic fracture (70% vs. 47%), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33%), unfractionated heparin (29%), dalteparin (40%), or inferior vena cava filters (20%) were not statistically different (p = .764). Conclusions: Medicare's inclusion of venous thromboembolism after trauma as a "never event" should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

Cost Comparison of Endovascular Treatment of Anterior Circulation Aneurysms With the Pipeline Emboli

imageBACKGROUND: The Pipeline embolization device (PED) is a new endovascular option for wide-necked or fusiform anterior circulation aneurysms that were classically treated by coil embolization with adjunctive use of a stent. However, stent-coiling incurs significant equipment and implant costs. OBJECTIVE: To determine whether PED embolization is more economical than stent-assisted coiling. METHODS: Sixty consecutive patients with anterior circulation aneurysms who underwent treatment with the PED (30 patients) or by single-stage stent-assisted coiling (30 patients) were identified from a prospective single-center aneurysm database. The hospital costs of equipment and implants were analyzed and compared for each group. RESULTS: The mean aneurysm size for patients treated with the PED was 9.8 vs 7.3 mm for patients treated by stent-assisted coiling. The total combined costs of proximal access/guide catheters, microcatheters, and microwires were equivalent between the 2 groups. The cost of implants, however, was significantly lower in the PED group ($13 175 ± 726 vs $19 069 ± 2015; P = .013), despite this group having a larger mean aneurysm size. Furthermore, the total procedure cost was significantly lower for the PED group vs the stent-coiling group ($16 445 ± 735 vs $22 145 ± 2022; P = .02), a 25.7% cost reduction. This represents a 27.1% reduction in the cost per millimeter of aneurysm treated in the PED group ($2261 ± 299) vs the stent-coiling group ($3102 ± 193; P = .02). CONCLUSION: Treatment of anterior circulation aneurysms by flow diversion with the PED has lower procedure costs compared with treatment with traditional stent-assisted coiling. ABBREVIATIONS: ICA, internal carotid artery PED, Pipeline embolization device

Pediatric Epilepsy Surgery: Long-term 5-Year Seizure Remission and Medication Use

imageBACKGROUND: It is unclear whether long-term seizure outcomes in children are similar to those in adult epilepsy surgery patients. OBJECTIVE: To determine 5-year outcomes and antiepilepsy drug (AED) use in pediatric epilepsy surgery patients from a single institution. METHODS: The cohort consisted of children younger than 18 years of age whose 5-year outcome data would have been available by 2010. Comparisons were made between patients with and without 5-year data (n = 338), patients with 5-year data for seizure outcome (n = 257), and seizure-free patients on and off AEDs (n = 137). RESULTS: Five-year data were available from 76% of patients. More seizure-free patients with focal resections for hippocampal sclerosis and tumors lacked 5-year data compared with other cases. Of those with 5-year data, 53% were continuously seizure free, 18% had late seizure recurrence, 3% became seizure free after initial failure, and 25% were never seizure free. Patients were more likely to be continuously seizure free if their surgery was performed during the period 2001 to 2005 (68%) compared with surgery performed from 1996 to 2000 (61%), 1991 to 1995 (36%), and 1986 to 1990 (46%). More patients had 1 or fewer seizures per month in the late seizure recurrence (47%) compared with the not seizure-free group (20%). Four late deaths occurred in the not seizure-free group compared with 1 in the seizure-free group. Of patients who were continuously seizure free, 55% were not taking AEDs, and more cortical dysplasia patients (74%) had stopped taking AEDs compared with hemimegalencephaly patients (18%). CONCLUSION: In children, 5-year outcomes improved over 20 years of clinical experience. Our results are similar to those of adult epilepsy surgery patients despite mostly extratemporal and hemispheric operations for diverse developmental etiologies. ABBREVIATION: AED, antiepilepsy drug

Minimally Invasive Surgery for Spontaneous Supratentorial Intracerebral Hemorrhage: A Meta-Analysis

Background and Purpose—

There has been a nonstandard surgical procedure and extensive international controversy in minimally invasive surgery (MIS) for the management of spontaneous supratentorial intracerebral hemorrhage. This meta-analysis assessed the effectiveness of MIS as compared with other treatment options, including conservative medical treatment and conventional craniotomy, in patients with supratentorial intracerebral hemorrhage.


PubMed, Embase, Cochrane Controlled Trials Register (CCTR), Web of Science, European Association for Grey Literature Exploitation (EAGLE), National Technical Information Service (NTIS), Current Controlled Trials, Clinical Trials, International Clinical Trials Registry, Internet Stroke Center, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI) (last searched December 2011) were searched. Randomized controlled trials on MIS in patients with computed tomography-confirmed supratentorial intracerebral hemorrhage were included. We excluded low-quality randomized controlled trials. The death or dependence at the end of follow-up was defined as the primary outcome, and the death at the end of follow-up was defined as the secondary outcome.


The 313 randomized controlled trials met the included criteria. We only analyzed 12 high-quality randomized controlled trials involving 1955 patients. The quality of the included trials was consistently high. OR of the primary outcome and secondary outcome of MIS both showed significant reductions (OR, 0.54, P<0.00001; OR, 0.53, P<0.00001).


Patients with supratentorial intracerebral hemorrhage may benefit more from MIS than other treatment options. The most likely candidates to benefit from MIS are both sexes, age of 30 to 80 years with superficial hematoma, Glasgow Coma Scale score of ≥9, hematoma volume between 25 and 40mL, and within 72 hours after onset of symptoms. Our study could help select appropriate patients for MIS and guide clinicians to optimize treatment strategies in supratentorial intracerebral hemorrhage.

Associations Among Vascular Risk Factors, Carotid Atherosclerosis, and Cortical Volume and Thickness

Background and Purpose—

The purpose of this study was to investigate whether the Framingham Cardiovascular Risk Profile and carotid artery intima-media thickness are associated with cortical volume and thickness.


Consecutive subjects participating in a prospective cohort study of aging and mild cognitive impairment enriched for vascular risk factors for atherosclerosis underwent structural MRI scans at 3-T and 4-T MRI at 3 sites. Freesurfer (Version 5.1) was used to obtain regional measures of neocortical volumes (mm3) and thickness (mm). Multiple linear regression was used to determine the association of Framingham Cardiovascular Risk Profile and carotid artery intima-media thickness with cortical volume and thickness.


One hundred fifty-two subjects (82 men) were aged 78 (±7) years, 94 had a clinical dementia rating of 0, 58 had a clinical dementia rating of 0.5, and the mean Mini-Mental State Examination was 28 ± 2. Framingham Cardiovascular Risk Profile score was inversely associated with total gray matter volume and parietal and temporal gray matter volume (adjusted P<0.04). Framingham Cardiovascular Risk Profile was inversely associated with parietal and total cerebral gray matter thickness (adjusted P<0.03). Carotid artery ntima-media thickness was inversely associated with thickness of parietal gray matter only (adjusted P=0.04). Including history of myocardial infarction or stroke and radiological evidence of brain infarction, or apolipoprotein E genotype did not alter relationships with Framingham Cardiovascular Risk Profile or carotid artery intima-media thickness.


Increased cardiovascular risk was associated with reduced gray matter volume and thickness in regions also affected by Alzheimer disease independent of infarcts and apolipoprotein E genotype. These results suggest a "double hit" toward developing dementia when someone with incipient Alzheimer disease also has high cardiovascular risk.

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare b

Publication year: 2012
Source:The Spine Journal
Marjorie C. Wang, Mikesh Shivakoti, Rodney A. Sparapani, Changbin Guo, Purushottam W. Laud, Ann B. Nattinger
Background context Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies. Purpose To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions. Study design Retrospective cohort study. Patient sample Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007. Outcome measures Readmissions within 30 days of discharge, excluding readmissions for rehabilitation. Methods Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software). Results Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions. Conclusions Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.

Acute intracerebral haemorrhage: Grounds for optimism in management

Publication year: 2012
Source:Journal of Clinical Neuroscience
Candice Delcourt, Craig Anderson
Spontaneous intracerebral haemorrhage (ICH) is one of the most devastating types of stroke, which has considerable disease burden in "non-white" ethnic groups where the population-attributable risks of elevated blood pressure are very high. Since the treatment of ICH remains largely supportive and expectant, nihilism and the early withdrawal of active therapy influence management decisions in clinical practice. However, approaches to management are now better defined on the basis of evidence that both survival and speed (and degree) of recovery are critically dependent on the location, size, and degree of expansion and extension into the intraventricular system of the haematoma of the ICH. Although no medical treatment has been shown to improve outcome in ICH, several promising avenues have emerged that include haemostatic therapy and intensive control of elevated blood pressure. Conversely, there is continued controversy over the role of evacuation of the haematoma of ICH via open craniotomy. Despite being an established practice for several decades, and having undergone evaluation in multiple randomised trials, there is uncertainty over which patients have the most to gain from an intervention with clear procedural risk. Minimally invasive surgery via local anaesthetic applied drill-puncture of the cranium and infusion of a thrombolytic agent is an attractive option for patients requiring critical management of the haematoma, not just in low resource settings but arguably also in specialist centres of western countries. With several ongoing clinical trials nearing completion, these treatments could enter routine practice within the next few years, further justifying the urgency of "time is brain" and that active management within well-organized, comprehensive acute stroke care units includes patients with ICH.

Conflict of interest and professional medical associations: the North American Spine Society experie

Publication year: 2012
Source:The Spine Journal
Jerome A. Schofferman, Marjorie L. Eskay-Auerbach, Laura S. Sawyer, Stanley A. Herring, Paul M. Arnold, Eric J. Muehlbauer
Background context Recently the financial relationships between industry and professional medical associations have come under increased scrutiny because of the concern that industry ties may create real or perceived conflicts of interest. Professional medical associations pursue public advocacy as well as promote medical education, develop clinical practice guidelines, fund research, and regulate professional conduct. Therefore, the conflicts of interest of a professional medical association and its leadership can have more far-reaching effects on patient care than those of an individual physician. Purpose Few if any professional medical associations have reported their experience with implementing strict divestment and disclosure policies, and among the policies that have been issued, there is little uniformity. We describe the experience of the North American Spine Society (NASS) in implementing comprehensive conflicts of interest policies. Study design A special feature article. Methods We discuss financial conflicts of interest as they apply to professional medical associations rather than to individual physicians. We describe the current policies of disclosure and divestment adopted by the NASS and how these policies have evolved, been refined, and have had no detrimental impact on membership, attendance at annual meetings, finances, or leadership recruitment. No funding was received for this work. The authors report no potential conflict-of-interest-associated biases in the text. Results The NASS has shown that a professional medical association can manage its financial relationships with industry in a manner that minimizes influence and bias. Conclusions The NASS experience can provide a template for other professional medical associations to help manage their own possible conflicts of interest issues.

Friday, October 19, 2012

Semana Nacional de Ciência e Tecnologia mostra inovações para desenvolvimento sustentável e justo

A nona edição da Semana Nacional de Ciência e Tecnologia (SNCT) vai reunir em eventos por todo o Brasil inovações que podem tornar realidade o desenvolvimento ambientalmente sustentável e socialmente justo. Todos os anos, as ações da semana são promovidas em torno de uma temática de importância social. Para a edição deste ano, o tema escolhido é "Economia verde, sustentabilidade e erradicação

Coma chocolate para ganhar o Nobel

Se fosse tão fácil assim ganhar o prêmio, o Nobel já estaria desmoralizado. Porém também não podemos esquecer a publicação recente que mostra uma correlação entre a média de consumo de chocolate de diferentes países e número de prêmio Nobel. Contudo trata-se de uma publicação na New England Journal of Medicine "Chocolate Consumption, Cognitive Function, and Nobel Laureates" DOI: 10.1056/

New Imaging Technique Could Provide Insight Into Psychiatric Disorders

A new way to take images, monitoring how brain cells organize with each other to delegate certain behaviors, has been discovered by a team of neuroscientists and could potentially identify information on diseases like autism and obsessive-compulsive disorder...

Medical students still suffer mistreatment by faculty, resident doctors, and nurses, US report says

Efforts to report and stop the mistreatment of medical students have not had any effect, concludes a study conducted at the David Geffen School of Medicine of the University of California, Los...

Sunday, October 14, 2012

Incidence and risk factors of chronic subdural hematoma after aneurysmal clipping

Publication year: 2012
Source:World Neurosurgery
Takayuki Ohno, Koji Iihara, Jun C. Takahashi, Norio Nakajima, Tetsu Satow, Tomohito Hishikawa, Izumi Nagata, Kazuo Yamada, Susumu Miyamoto
Objective Chronic subdural hematoma (CSDH) after aneurysmal clipping is a rare complication, but its incidence and riskfactors are not known in detail. We retrospectively reviewed our cases requiring surgery for CSDH after clipping. Methods Between January 2000 and December 2006, 794 patients (unruptured: 58.0%) underwent clipping surgery for aneurysm of anterior circulation in our hospital. We reviewed incidence and risk factors of CSDH after clipping. For the last two years, we reviewed all CT scans for 163 unruptured cases, and examined the relationship between increase of subdural fluid collection (SFC) and development of CSDH. Results 15 patients (1.9%) developed post clipping CSDH which required evacuation. Among those, 13 were unruptured cases (2.8%), a much higher percentage than for ruptured cases (0.9%). On univariate statistical analysis, risk factors of CSDH were associated with advanced age (p=0.0005), male gender (p=0.04) and unruptured cases (p=0.02). Aneurysmal location was not related to the development of postoperative CSDH. Contralateral CSDH occurred in 3 cases, but no MCA aneurysm developed contralateral CSDH. Increase of postoperative SFC over 1 week was a significant risk factor for CSDH (p=0.001). Conclusion In addition to the classical risk factors, this study showed that clipping for unruptured cases carries higher risk for CSDH as compared to ruptured cases. We suggest that an increase of SFC over 1 week postoperatively can be a factor in predicting CSDH after clipping.

Calculating the Risk Benefit Equation for Aggressive Treatment of Non-convulsive Status Epilepticus

To address the question: does non-convulsive status epilepticus warrant the same aggressive treatment as convulsive status epilepticus?
We used a decision model to evaluate the risks and benefits of treating non-convulsive status epilepticus with intravenous anesthetics and ICU-level aggressive care. We investigated how the decision to use aggressive versus non-aggressive management for non-convulsive status epilepticus impacts expected patient outcome for four etiologies: absence epilepsy, discontinued antiepileptic drugs, intraparenchymal hemorrhage, and hypoxic ischemic encephalopathy. Each etiology was defined by distinct values for five key parameters: baseline mortality rate of the inciting etiology; efficacy of non-aggressive treatment in gaining control of seizures; the relative contribution of seizures to overall mortality; the degree of excess disability expected in the case of delayed seizure control; and the mortality risk of aggressive treatment.
Non-aggressive treatment was favored for etiologies with low morbidity and mortality such as absence epilepsy and discontinued antiepileptic drugs. The risk of aggressive treatment was only warranted in etiologies where there was significant risk of seizure-induced neurologic damage. In the case of post-anoxic status epilepticus, expected outcomes were poor regardless of the treatment chosen. The favored strategy in each case was determined by strong interactions of all five model parameters.
Determination of the optimal management approach to non-convulsive status epilepticus is complex and is ultimately determined by the inciting etiology.

  • Content Type Journal Article
  • Pages 1-12
  • DOI 10.1007/s12028-012-9785-y
  • Authors
    • Matthew Ferguson, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
    • Matt T. Bianchi, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
    • Raoul Sutter, Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
    • Eric S. Rosenthal, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
    • Sydney S. Cash, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
    • Peter W. Kaplan, Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
    • M. Brandon Westover, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA

Saturday, October 13, 2012

Statin May Slow Progressive MS (CME/CE)

LYON (MedPage Today) -- High-dose simvastatin (Zocor) significantly reduced brain atrophy and slowed advancement of disability for 2 years in patients with secondary progressive multiple sclerosis, researchers said here.

Epidemiological trends in the neurological intensive care unit from 2000 to 2008

Publication year: 2012
Source:Journal of Clinical Neuroscience
Brad E. Zacharia, Kerry A. Vaughan, Samuel S. Bruce, Bartosz T. Grobelny, Reshma Narula, Joyce Khandji, Amanda M. Carpenter, Zachary L. Hickman, Andrew F. Ducruet, E. Sander Connolly
Intensive care units (ICU) specializing in the treatment of patients with neurological diseases (Neuro-ICU) have become increasingly common. However, there are few data on the longitudinal demographics of this patient population. Identifying admission trends may provide targets for improving resource utilization. We performed a retrospective analysis of admission logs for primary diagnosis, age, sex, and length of stay, for all patients admitted to the Neuro-ICU at Columbia University Medical Center (CUMC) between 2000 and 2008. From 2000 to 2008, inclusive, the total number of Neuro-ICU admissions increased by 49.9%. Overall mean patient age (54.6±17.4 to 56.2±18.0 years, p =0.041) and gender (55.9–50.3% female, p =0.005) changed significantly, while median length of stay (2 days) did not. When comparing the time period prior to construction of a larger Neuro-ICU (2000–2004) to that after completion (2005–2008), patient age (56.0±17.6 compared to 56.9±17.5 years, p =0.012) and median length of stay (1 compared to 2 days, p <0.001) both significantly increased. Construction of a newer, larger Neuro-ICU at CUMC led to a substantial increase in admissions and changes in diagnoses from 2000 to 2008. Advances in neurocritical care, neurosurgical practices, and the local and global expansion and utilization of ICU resources likely led to differences in lengths of stay.

Intracranial Supraclinoid ICA Dissection Causing Cerebral Infarction and Subsequent Subarachnoid Hem

Intracranial arterial dissection usually leads to cerebral infarction or subarachnoid hemorrhage (SAH). It is rare to see both complications in one clinical scenario.
Case report and review of the literature.
A 48-year-old woman suffered a left middle cerebral infarct from a dissection of the left supraclinoid ICA. As she was recovering from the ischemic stroke 5 days later she suffered a SAH. The SAH was caused by rupture of a dissecting pseudoaneurysm, which only became evident on repeat catheter angiography. The dissecting pseudoaneurysm was treated with coil occlusion.
Intracranial ICA dissections are typically associated with either ischemic or hemorrhagic presentation. We report an unusual case of a patient who suffered a SAH a few days after an ischemic stroke from the dissection. This case contradicts the long-held dogma that intracranial dissection can have either an ischemic or a hemorrhagic presentation, but not both.

  • Content Type Journal Article
  • Category Practical Pearl
  • Pages 1-5
  • DOI 10.1007/s12028-012-9781-2
  • Authors
    • Naif M. Alotaibi, Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
    • Jennifer E. Fugate, Department of Neurology, Mayo Clinic, Rochester, MN, USA
    • Timothy J. Kaufmann, Department of Radiology, Mayo Clinic, Rochester, MN, USA
    • Alejandro A. Rabinstein, Department of Neurology, Mayo Clinic, Rochester, MN, USA
    • Eelco F. M. Wijdicks, Department of Neurology, Mayo Clinic, Rochester, MN, USA
    • Giuseppe Lanzino, Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

Decompressive surgery for malignant middle cerebral artery syndrome

Publication year: 2012
Source:Journal of Clinical Neuroscience
Sai-Cheung Lee, Yi-Chou Wang, Yin-Cheng Huang, Po-Hsun Tu, Shih-Tseng Lee
Decompressive craniectomy has been considered the most attractive option for surgical treatment of malignant middle cerebral artery (MCA) infarction. We retrospectively reviewed the clinical and radiological records of 78 patients with malignant MCA infarction who underwent decompressive craniectomy with dura augmentation over a 6-year period. Twenty-six patients had undergone additional anterior temporal resection during decompressive craniectomy. The overall mortality at 30days after surgery was 25.6% while the mortality rate at 6months after surgery was 30.8%. At 6months after surgery, 30.8% of the patients were considered to have good outcomes, while 69.2% had a poor outcome (16.7% suffered from severe disability, 21.8% remained in a vegetative state, and 30.8% died). Ipsilateral surgery was performed on 48 patients with infarction on the dominant side and on 30 patients with lesions on the non-dominant side. No significant difference was noted between these two groups at the 30-day mortality rate. Although no patient with an infarction on the dominant side recovered effective verbal ability during the 6months of follow-up, there was no significant difference between the two groups in clinical outcome at 6months after surgery. The 30-day survival rate in the 26 patients who underwent additional anterior temporal lobectomy was significantly higher (84.6%) than that in patients who underwent decompressive craniectomy and duroplasty only (69.2%) (p <0.05). However, in patients who survived, this additional procedure does not appear to improve the functional outcome.

A novel technique for ventriculoperitoneal shunting by flat panel detector CT-guided real-time fluor

Shinya Kobayashi, Tatsuya Ishikawa, Tatsushi Mutoh, Kentaro Hikichi, Akifumi Suzuki

Surgical Neurology International 2012 3(1):119-119

Background: Surgical placement of a ventriculoperitoneal shunt (VPS) is the main strategy to manage hydrocephalus. However, the failure rate associated with placement of ventricular catheters remains high. Methods: A hybrid operating room, equipped with a flat-panel detector digital subtraction angiography system containing C-arm cone-beam computed tomography (CB-CT) imaging, has recently been developed and utilized to assist neurosurgical procedures. We have developed a novel technique using intraoperative fluoroscopy and a C-arm CB-CT system to facilitate accurate placement of a VPS. Results: Using this novel technique, 39 consecutive ventricular catheters were placed accurately, and no ventricular catheter failures were experienced during the follow-up period. Only two patients experienced obstruction of the VPS, both of which occurred in the extracranial portion of the shunt system. Conclusion: Surgical placement of a VPS assisted by flat panel detector CT-guided real-time fluoroscopy enabled accurate placement of ventricular catheters and was associated with a decreased need for shunt revision.

Tuesday, October 9, 2012

Nobel de Medicina 2012 para células tronco

Saiu hoje o resultado do Premio Nobel de Medicina 2012.


Do site da Nobel Organization:


The Nobel Prize recognizes two scientists who discovered that mature, specialised cells can be reprogrammed to become immature cells capable of developing into all tissues of the body. Their findings have revolutionised our understanding of how cells and organisms develop.

John B. Gurdon

Ventriculoperitoneal Shunt Strategy for Cerebrospinal Fluid Rhinorrhea Repair: A Case Report and Rev

Abstract: We present a 10-year-old boy with a greater than 5-year history of cerebrospinal fluid rhinorrhea. He experienced nine episodes of bacterial meningitis and underwent four surgical repairs, including two endoscopic repairs via the lateral nasal cavity, a craniotomy repair via forehead epidural, and endoscopic repair in combination with a ventriculoperitoneal shunt. The first three surgeries failed, but the fourth was successful, with no recurrence during 2.5 years of follow-up. We suggest that ventriculoperitoneal shunts be considered for refractory recurrent cerebrospinal fluid rhinorrhea, particularly in patients after multiple failures of conventional surgical repair, to reduce intracranial hypertension caused by long-term chronic cerebrospinal fluid compensatory production.

Impact of smoking cessation on the risk of subarachnoid haemorrhage: a nationwide multicentre case c

Background and purpose

Subarachnoid haemorrhage (SAH) is the most devastating cerebrovascular disease. Cigarette smoking is one of the established risk factors for SAH, but the risk of SAH has not been properly elucidated in relation to smoking cessation.


We performed a nationwide multicentre case control study involving 33 hospitals in Korea. A total of 426 SAH cases and 426 age and sex matched controls were enrolled. We obtained detailed information on lifestyle, medical history and, in particular, smoking habits from participants using structured questionnaires.


148 SAH patients (37.4%) were current smokers compared with 103 (24.2%) controls, giving an adjusted OR of 2.84 (95% CI, 1.63 to 4.97) after controlling for possible confounders. Based on cumulative dose of smoking (pack years), the risk of SAH was found to increase in a dose–responsive fashion. Smoking cessation (≥5 years) caused a reduction in SAH to 59% (p<0.05). However, participants with a history of heavy smoking (≥20 cigarettes per day) had a 2.3 times increased risk of SAH compared with participants who had never smoked (p<0.05).


We have demonstrated that cigarette smoking increases the risk of SAH, but smoking cessation decreases the risk in a time dependent manner, although this beneficial effect may be diminished in previous heavy smokers. To forestall tragic SAH events, our results call for more global and vigorous efforts for people to stop smoking.

Post-traumatic amnesia predicts intelligence impairment following traumatic brain injury: a meta-ana


Worldwide, millions of patients with traumatic brain injury (TBI) suffer from persistent and disabling intelligence impairment. Post-traumatic amnesia (PTA) duration is a promising predictor of intelligence following TBI.


To determine (1) the impact of TBI on intelligence throughout the lifespan and (2) the predictive value of PTA duration for intelligence impairment, using meta-analytic methods.


Electronic databases were searched for peer reviewed articles, published until February 2012. Studies reporting intelligence following TBI and injury severity by PTA duration were included. Meta-analytic methods generated effect sizes for full scale IQ (FSIQ), performance IQ (PIQ) and verbal IQ (VIQ), following mild TBI (PTA duration 1–24 h) and severe TBI (PTA duration >7 days), during the subacute phase of recovery (≤6 months post-injury) and the chronic phase (>6 months post-injury). Meta-regression elucidated the predictive value of PTA duration for intelligence impairment.


Patients with severe TBI exhibited large depressions in FSIQ in the subacute phase of recovery (d=–1.07, 95% CI to 1.52 to –0.62; p<0.001), persisting into the chronic phase (d=–0.78, 95% CI –1.06 to –0.51; p<0.001). PIQ was more severely affected than VIQ in the subacute phase (Q(1) =3.85; p<0.05) but not in the chronic phase (Q(1) =0.03, p=0.87). Most importantly, longer PTA duration strongly predicted greater depressions of FSIQ and PIQ in the subacute phase (–0.76 ≤ βs ≤ –0.73, Ps<0.01) and FSIQ, PIQ and VIQ in the chronic phase (–0.80 ≤ βs ≤ –0.61, Ps<0.05).


PTA duration is a valuable predictor of intelligence impairment following TBI. Results support the routine assessment of PTA duration in clinical settings.

Why do some patients after head injury deteriorate over the long term?

When asked to see a patient who is deteriorating rather than getting better over time since a head injury, the clinician will need to rule out complications of the head injury, such as a subdural haematoma. The neuropsychiatrist will assess whether, for example, a depressive illness, anxiety disorder, psychosis or substance abuse explains the deterioration. But oftentimes there is no obvious explanation for the deterioration. This finding tallies with studies that find increasing cognitive impairment over time since injury in a proportion of patients.1 Explanations for this include accelerated cerebral atrophy2 and/or chronic inflammation3 or depleted cerebral reserve bringing forward age-related cognitive decline.4

Two papers with very different methodologies, one strong and one rather weaker, address the question of the long-term outcome after a head injury. Wang et al,5 interrogated a clinical database containing the medical insurance records of...

Why do some patients after head injury deteriorate over the long term?

When asked to see a patient who is deteriorating rather than getting better over time since a head injury, the clinician will need to rule out complications of the head injury, such as a subdural haematoma. The neuropsychiatrist will assess whether, for example, a depressive illness, anxiety disorder, psychosis or substance abuse explains the deterioration. But oftentimes there is no obvious explanation for the deterioration. This finding tallies with studies that find increasing cognitive impairment over time since injury in a proportion of patients.1 Explanations for this include accelerated cerebral atrophy2 and/or chronic inflammation3 or depleted cerebral reserve bringing forward age-related cognitive decline.4

Two papers with very different methodologies, one strong and one rather weaker, address the question of the long-term outcome after a head injury. Wang et al,5 interrogated a clinical database containing the medical insurance records of...

Marijuana Pill Relieves MS Symptoms (CME/CE)

(MedPage Today) -- Marijuana extract pills may ease painful muscle stiffness for some patients with multiple sclerosis, a randomized trial affirmed.

Saturday, October 6, 2012

Apps | Neurosurgery Blog


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!


Anamnesis (English) Click Here iPad and iPhone

Anamnese (Portuguese) Click Here iPad and iPhone

Traumatic Brain Injury (Click here)iPad and iPhone

Traumatismo Cranio-encefalico (Click here)iPad and iPhone

Traumatic Brain Injury (Click here) Android

Traumatismo Cranio-encefalico (Click here) Android



Hedache apps (Click here) iPad and iPhone

Dor de cabeça ( Click here) iPad and iPhone

Hedache apps (Click here) Android 

Dor de cabeça ( Click here) Android


Sus para concursos (click here) Portuguese Only iPad and iPhone 

Sus para concursos (click here) Portuguese Only  Android

Neuroexame (click here) Portuguese Only iPad and iPhone

Neurosurgery Blog app Only Android (Click Here)


Neurointensive Care



Neurons Made From Adult Cells In The Brain

Finding ways to make new brain cells are important steps in the search for treatments for brain-wasting diseases such as Alzheimer's and Parkinson's. Now a German-led team has discovered how to make new human neurons from another type of adult cell found in the brain. The researchers write about their work in the 5 October online issue of Cell Stem Cell...

Friday, October 5, 2012

"Smart" Surgical Tool For Superhuman Precision

Even the most skilled and steady surgeons experience minute, almost imperceptible hand tremors when performing delicate tasks. Normally, these tiny motions are inconsequential, but for doctors specializing in fine-scale surgery, such as operating inside the human eye or repairing microscopic nerve fibers, freehand tremors can pose a serious risk for patients...

Evaluation and management of combat-related spinal injuries: a review based on recent experiences

Publication year: 2012
Source:The Spine Journal, Volume 12, Issue 9
Andrew J. Schoenfeld, Ronald A. Lehman, Joseph R. Hsu
Background context The current approach to the evaluation and treatment of military casualties in the Global War on Terror is informed by medical experience from prior conflicts and combat encounters from the last 10 years. In an effort to standardize the care provided to military casualties in the ongoing conflicts, the Department of Defense (DoD) has published Clinical Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal injury. However, the combat experience with spine injuries in the present conflicts remains incompletely described. Purpose To describe the CPGs for the care of the combat casualty with suspected spine injuries and discuss them in light of the published military experience with combat-related spinal trauma. Study design Literature review. Methods A literature review was conducted regarding published works that discussed the incidence, epidemiology, and management of combat-related spinal trauma. The CPGs, established by the DoD, are discussed in light of actual military experiences with spine trauma, the present situation in the forward surgical teams and combat support hospitals treating casualties in theater, and recent publications in the field of spine surgery. Results In the conventional wars fought by the United States between 1950 and 1991 (Korea, Vietnam, Gulf War I), the incidence of spine injuries remained close to 1% of all combat casualties. However, in the Global War on Terror, the enemy has relied on implements of asymmetric warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices. The increase in explosive mechanisms of injury has elevated the number of soldiers exposed to blunt force trauma and, consequently, recent publications reported the highest incidence of combat-related spinal injuries in American military history. Wounded soldiers are expeditiously evacuated through the echelons of care but typically do not receive surgical management in theater. The current CPGs for the care of soldiers with combat-related spinal injuries should be re-examined in light of data regarding the increasing number of spine injuries, new injury patterns, such as lumbosacral dissociation and low lumbar burst fractures, and recent reports within the field of spine surgery as a whole. Conclusions American and coalition forces are sustaining the highest spine combat casualty rates in recorded history and previously unseen injuries are being encountered with increased frequency. While the CPGs provide useful direction in terms of the evaluation and management of combat casualties with spine injuries, such recommendations may warrant periodic re-evaluation in light of recent combat experiences and evolving scientific evidence within the spine literature.

Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts

Publication year: 2012
Source:The Spine Journal, Volume 12, Issue 9
Ronald A. Lehman, Haines Paik, Tobin T. Eckel, Melvin D. Helgeson, Patrick B. Cooper, Carlo Bellabarba
Background context The most common location for burst fractures occurs at the thoracolumbar junction, where the stiff thoracic spine meets the more flexible lumbar spine. With our current military conflicts in Iraq and Afghanistan, we have seen a disproportionate number of low lumbar burst fractures. Purpose To report our institutional experience in the management of low lumbar burst fractures. Study design Retrospective review. Methods We performed a retrospective review of medical records and radiographs for all patients treated at our institution with combat-related injuries and thoracolumbar fractures. We included all patients who had sustained a burst fracture from T12 to L5 and had at least 1-year clinical follow-up. Results Thirty-two patients sustained burst fractures. Nineteen patients (59.4%) had low lumbar (L3–L5) burst fractures, and 12 patients (37.5%) had thoracolumbar junction (T12–L2) burst fractures as their primary injury. Additionally, seven patients sustained less severe burst fractures at an additional level. One patient sustained burst fractures at both upper and lower lumbar levels. Of the low lumbar fractures, 52.6% had evidence of neurologic injury, two of which were complete. Similarly, in the upper lumbar group, 58.2% sustained a neurologic injury, two of which were complete. Twenty-two patients underwent surgical intervention, complicated by infection in 18%. At most recent follow-up, all but one patient with presenting neurologic injury had persistent deficits. Conclusion Low lumbar burst fractures are the predominant combat-related spine injury in our current military conflicts. The rigidity offered by current body armor may effectively lower the transition zone that normally occurs at the thoracolumbar junction, thereby, transferring forces into the lower lumbar spine. Increased awareness of this fracture pattern is warranted by all surgeons because of unique clinical challenges associated with its treatment. Although the incidence is increased in the military population, other surgeons may be involved with long-term care of these patients on completion of their military service.

An Endoscopic Scoring System for Extraparenchymal Neurocysticercosis

Publication year: 2012
Source:World Neurosurgery
J. Humberto Tapia-Pérez, Jaime G. Torres-Corzo, Juan C. Chalita-Williams, Roberto Rodríguez-Della Vecchia, José Juan Sánchez-Rodríguez, Martín Sánchez-Aguilar
Objective In our previous study, we had suggested the usefulness of cerebral endoscopy as a therapeutic option for hydrocephalus due to neurocysticercosis (NCC). Now, we propose a scoring system for the assessment of the inflammatory alterations caused by NCC inside the ventricular cavities and the basal subarachnoid space. Methods We assessed the video recordings of the endoscopic procedures in patients with hydrocephalus due to NCC in a two-phase study. In the first phase (n=10), each patient's assigned score was correlated with the cerebrospinal fluid (CSF) values obtained by lumbar and ventricular puncture. Reproducibility was determined using an intraclass correlation coefficient (ICC). In the second phase (n=30), we tested the prognostic value of our score by comparing it to the patient's Karnofsky performance score (KPS) 3 months after endoscopy. Results The score included 4 main components: ependymal findings, number of involved sites, abnormalities in the subarachnoid space, and other alterations. These values were summed to produce a total score that correlated strongly with both protein and cell counts from ventricular CSF. The ICC of the global score was 0.85. In the second phase, the scores were divided into mild, moderate, and severe categories (6, 15, and 9 patients, respectively). The initial KPS was similar between the groups (p=0.56); however, when measured 3 months later, there were significant differences (p=0.02). The logistic regression analysis of patients with a score in the severe range (OR=0.09, 95% CI, 0.06–0.64) showed a reduced chance for achieving a good outcome (KPS > 90) after 3 months. Conclusions Our scoring system enables an endoscopic classification of the damage caused by NCC in the ventricular and basal subarachnoid space. The score has a biological basis and a good internal reproducibility. Furthermore, the score seems to be useful for determining the short-term prognosis, and patients with high scores would require additional therapeutic measures for improving their outcomes.

Deep Brain Stimulation in the Treatment of Obsessive-Compulsive Disorder

Publication year: 2012
Source:World Neurosurgery
Patric Blomstedt, Rickard L. Sjöberg, Maja Hansson, Owe Bodlund, Marwan I. Hariz
Objective Deep brain stimulation (DBS) has emerged as a treatment for severe cases of therapy refractory obsessive compulsive disorder (OCD) and promising results have been reported. The literature might however be somewhat unclear, considering the different targets used, and due to repeated inclusion of individual patients in multiple publications. The aim of the present paper was to review the literature on DBS for OCD. Method The modern literature concerning studies conducted on DBS in the treatment of OCD was reviewed. Results The results of DBS in OCD have been presented in 25 papers with 130 patients, of which however only 90 constituted of individual patients. Five of these papers included at least five individual patients not presented elsewhere. Sixty-eight of these patients were implanted in the region of the internal capsule/ventral striatum, including the nucleus Accumbens. The target in this region has varied between groups and over time, but the latest results from bilateral procedures in this area have demonstrated a 50 % reduction of OCD-scores, depression and anxiety. The Subthalamic nucleus has been suggested as an alternative target. Even if beneficial effects have been demonstrated the efficacy of this procedure cannot be decided, since only results after 3 months of active stimulation have been presented so far. Conclusion DBS is a promising treatment for therapy-refractory OCD, but the published experience is limited and the method is at present an experimental therapy.

Re-irradiation in recurrent malignant glioma: prognostic value of [18F]FET–PET

The aim of the present study is to determine new positron emission tomography (PET) imaging-related factors predictive of progression-free survival as well as survival in patients with recurrent malignant glioma (MG) prior to and after re-irradiation. Fifty-six patients with recurrent MG who underwent re-irradiation treatment and pretherapeutic dynamic [18F]-fluoroethyl-l-tyrosine (FET)–PET scan were retrospectively analyzed. The prognostic value of different parameters, such as biological tumor volume, maximal tumor uptake (SUVmax/BG), mean tumor uptake (SUVmean/BG), as well as uptake kinetics, was evaluated. [18F]FET uptake kinetics was classified according to a five-point rating as category G1–2 (strongly/mainly increasing kinetics), G3 (mixed 1:1), or G4–5 (mainly/strongly decreasing kinetics). Patients within the pretherapeutic kinetic group G4–5 had significantly worse survival than the other two groups (p = 0.01). Multivariate analysis revealed that histologic grade, Karnofsky Performance Score (KPS), and kinetic group were independent significant predictors for survival after re-irradiation. The uptake kinetics of [18F]FET–PET is an independent determinant of overall and to a lesser extent also progression-free survival. Thus, [18F]FET–PET kinetics may provide valuable additional prognostic information for treatment decisions.

  • Content Type Journal Article
  • Category Clinical Study
  • Pages 1-7
  • DOI 10.1007/s11060-012-0980-7
  • Authors
    • Maximilian Niyazi, Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Nathalie Jansen, Department of Nuclear Medicine, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Ute Ganswindt, Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Silke Birgit Schwarz, Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Julia Geisler, Department of Nuclear Medicine, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Oliver Schnell, Department of Neurosurgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Karen Büsing, Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
    • Sabina Eigenbrod, Department of Neuropathology, Ludwig-Maximilians-University Munich, Feodor-Lynen-Str. 23, 81377 Munich, Germany
    • Christian la Fougère, Department of Nuclear Medicine, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
    • Claus Belka, Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany