Whole brain CT perfusion combined with CT angiography in patients with subarachnoid hemorrhage and cerebral vasospasm

Objective

To assess cerebral vasospasm (CVS) and monitor cerebral microcirculatory changes in patients with acute subarachnoid hemorrhage (SAH) via CT angiography (CTA) combined with whole-brain CT perfusion (CTP) techniques.

Methods

Sixty patients with SAH (SAH group) and 10 patients without SAH (control group) were selected for a prospective study. CTP combined with CTA and digital subtraction angiography (DSA) studies were performed on patients with initial onset of SAH less than three days. CTA and DSA as well as the CTP parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), and time-to-peak (TTP) were acquired and analyzed. The relationship of CTA and CTP measurements was assessed in these acute SAH patients.

Results

CTP techniques were used to achieve the perfusion maps of the whole brain in patients with acute SAH. Compared to the control group, mean CBF value was significantly lower while both MTT and TTP values were significantly higher in SAH group (all p < 0.05). Further analysis revealed that mean CBF in patients with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V significantly decreased when compared to patients with nCVS, asCVS, Fisher I–II and Hunt–Hess I–II (p < 0.05). Furthermore both MTT and TTP values were also significantly reduced in patient with CVS, sCVS, Fisher III–IV and Hunt–Hess III–V (p < 0.05).

Conclusion

The study demonstrated that changes of microcirculation in patients with SAH could be assessed by whole-brain CTP. CTP combined with CTA could detect both macroscopic evident vasospasm on CTA and alterations of microcirculation on CTP. Mean CBF was significantly lower in patients with SAH.     

Demographic,circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage

Background

Although, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before.

Objective

For the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH.

Methods

We reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n = 338) or naSAH (n = 46) on clinical and radiological criteria. PMH (n = 32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared.

Results

Aneurysmal SAH occurred most often from 6 am to 12 pm (p < 0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p = 0.008) and smoking (p = 0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p = 0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p < 0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p = 0.0159).

Conclusion

Statistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.     

Stem cell therapy: A clinical trial of stroke

Background

The alarming disability burden and a high prevalence rate of stroke in India has encouraged the researchers to develop regenerative therapies to reduce clinical deficits. This study evaluates safety, feasibility and efficacy of autologous mononuclear and mesenchymal cell transplantation in stroke patients evaluated on clinical scores and functional imaging (fMRI and DTI).

Methods

Forty (n = 40) stroke patients were recruited with the inclusion criteria as: 3 months to 2 years of index event, power of hand muscles of at least 2; Brunnstrom stage: 2–5; conscious and comprehendible. Fugl Meyer (FM), modified Barthel Index (mBI), Medical Research Council (MRC) grade for strength, Ashworth tone scale and functional imaging was used for assessments at baseline, 8 weeks and 24 weeks. 50–60 million cells in 250 ml saline were infused intravenously over 2–3 h.

Results

The safety test profile was normal with no mortality or cell related adverse reactions in stem cell patients. Among outcome parameters, only modified Barthel Index (mBI) showed statistical significant improvement (p < 0.05) in the stem cell group. An increased number of cluster activation in Brodmann areas BA 4, BA 6 was observed post stem cell infusion indicating neural plasticity.

Conclusion

Autologous intravenous stem cell therapy is safe and feasible. Stem cells act as “scaffolds” for neural transplantation and may aid in repair mechanisms in stroke.     

Intravenous rt-PA in patients with ischaemic stroke and renal dysfunction

Objective

Renal dysfunction (RD) increases risk for ischaemic stroke (IS). The impact of RD on the effects of iv-thrombolysis in the Caucasian population has not been fully determined.

Aims

To evaluate the associations between RD and the outcome of iv-thrombolysis in Caucasian patients with IS.

Methods

The observational, multicentre study included 404 patients with IS who were treated with iv-thrombolysis. RD was defined as estimated glomerular filtration rate ≤60 ml/min/1.73 m². Outcome was assessed with modified Rankin Score at 3 months after the stroke onset.

Results

Medians baseline NIHSS score did not differ between groups of patients with and without RD (12.0 vs. 11.0 pts, p = 0.33). Unfavourable outcome was found in 52.1% of patients with and in 41.2% of patients without RD (p = 0.05), mortality was higher in patients with RD (29.9% vs. 14.3%, p < 0.001), and the presence of haemorrhagic transformation (HT) did not differ between the groups (17.1% vs. 17.1% respectively, p = 0.996). A multivariate analysis showed no impact of RD on the unfavourable outcome (OR 0.98; 95%CI 0.88–1.10), mortality (OR 0.92; 95%CI 0.81–1.05) or presence of HT (OR 1.03; 95%CI 0.90–1.18).

Conclusions

We found no impact of RD on the safety and efficacy of iv-thrombolysis in Caucasian patients with IS.     

Treatment of sleep disorders may improve fatigue in multiple sclerosis

Objective

In a previous polysomnographic cross-sectional study we found a significant relationship between sleep disorders and multiple sclerosis (MS) related fatigue. The purpose of this open follow-up observation was to compare the impact of treatment of sleep disorders on MS related fatigue measured with the Modified Fatigue Impact Scale (MFIS).

Methods

Non-randomized follow-up observation: treated versus untreated patients, subgroups according to compliance with sleep medical treatment recommendations (univariate, multivariate analysis, multiple logistic regression). 66 MS patients were followed after polysomnography, 49 patients with relevant sleep disorders and 17 without.

Results

Mean MFIS scores decreased from 41.2 to 26.2 (p = 0.025) in patients with good compliance (GC; n = 18), from 42.4 to 32.1 (p = 0.12) in patients with moderate compliance (MC; n = 12), and from 41.6 to 35.5 (p = 0.17) in non-compliant patients (NC; n = 17). Mean MFIS values increased in patients without sleep disorders from 22.9 to 25.4 (NSD; n = 12, p = 0.56). In multiple logistic regression, treatment of sleep disorders predicted decrease of MFIS-values (GC versus NSD odds ratio 13.4; p = 0.015; 95% confidence interval (CI) 1.7–107.2, MC versus NSD odds ratio 13.8; p = 0.028; 95% CI 1.3–143.3).

Conclusions

Sleep medical treatment may improve MS related fatigue when patients adhere to treatment recommendations.     

Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

Objectives

To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients.

Methods

Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006.

Results

The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59–82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC + AP).Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24 s; p < 0.001). Similarly patients on AC + AP also had higher INR (median 1.9) and aPTT (median 30 s) when compared to those not on AC/AP (p < 0.001).Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm³) when compared to those not on either AC/AP (median 27.2 cm³; p = 0.05). The same was not found for patients using AP (median volume 20.5 cm³; p = 0.813), or both AC + AP (median volume 27.7 cm³; p = 0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04–1.98; p = 0.035).There was no relationship between the use of AC/AP/AC + AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0–3.03; p = 0.05). No relationship was found between use of AP or AC + AP use and mortality.Of the 82 patients with INR > 1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4 U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24 h (median 1.2, IQR 1.1–1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death < 7 days) or functional outcome.

Conclusions

Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.     

Comparison of lumbar drainage and external ventricular drainage for clearance of subarachnoid clots after Guglielmi detachable coil embolization for aneurysmal subarachnoid hemorrhage

Objective

Subarachnoid clots play an important role in development of delayed vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to compare clearance of subarachnoid clots using external ventricular drainage (EVD) or lumbar drainage (LD) after Guglielmi detachable coil (GDC) embolization for aneurysmal SAH.

Methods

The subjects were 51 treated with GDC coil embolization for aneurysmal Fisher group 3 SAH within 72 h of ictus. Software-based volumetric quantification of the subarachnoid clots was performed on CT scans and the hemoglobin (Hb) level was measured in CSF drained from each catheter.

Results

Clearance of subarachnoid clots was more rapid in patients treated with LD (n = 34) compared to those treated with EVD (n = 17). The Hb level in CSF was significantly higher in the LD group on Days 4–5 after onset of SAH (P < 0.05), but was higher in the EVD group on Days 8–9. The incidence of symptomatic vasospasm did not differ between the two groups. The rate of occurrence of a new low density area on CT scans was higher in patients treated with EVD, but not significantly higher than the rate in the LD group.

Conclusion

GDC embolization followed by lumbar drainage accelerates the reduction of subarachnoid clots, but EVD may contribute to stasis of hemorrhage within subarachnoid spaces.     

Electrophysiological intermediate biomarkers for oxidative stress in schizophrenia

Objective

Diverse electrophysiological abnormalities have been associated with schizophrenia, but the underlying causes remain elusive. We tested whether the altered oxidative stress in schizophrenia contributes to the electrophysiological abnormalities.

Methods

We used an auditory oddball task to measure mismatch negativity (MMN) and gamma band response on 29 schizophrenia patients and 25 normal controls. Oxidative stress was assessed by monomeric glutathione (GSH, reduced form) and glutathione disulfide (GSSG, oxidized form).

Results

Patients had reduced MMN (p = 0.015) and reduced power of gamma band responses at 21–40 Hz and 41–85 Hz (all p < 0.001). GSH was significantly lower (p < 0.001) while %GSSG was higher (p = 0.023) in patients compared with controls. MMN was correlated with GSH in controls; while 21–40 Hz responses were correlated with GSH in patients. Lower GSH and higher GSSG levels were associated with low community functioning (p = 0.018). Multivariate mediation modeling showed that gamma band at 21–40 Hz was a significant mediator for GSH effect on community functions.

Conclusions

High beta/low gamma range (21–40 Hz) responses may be an intermediate biomarker indexing oxidative stress and its effect on clinical functions.

Significance

Electrophysiological abnormalities and associated clinical functional changes may in part be associated with heightened oxidative stress in schizophrenia.     

Fatal aneurysmal subarachnoid haemorrhage: Causes of 30-day in-hospital case fatalities in a large single-centre historical patient cohort

Background

Mortality rates of up to 40% in the early phase following an aneurysmal subarachnoid haemorrhage (SAH) indicate that the overall case-fatality rate is predominantly influenced by the initial phase of the disease. This analysis investigates the in-hospital causes of death (CODs) within 30 days of admission in patients suffering from a SAH.

Methods

Of the 591 consecutive patients with SAHs from ruptured cerebral aneurysms, 85 patients who died within 30 days after admission were analysed. The various CODs were classified as cerebral or non-cerebral events. A Kaplan–Meier survival analysis was performed for the cerebral and non-cerebral CODs to identify the specific chronology of occurrence.

Results

The median cumulative fatality was 4 days. A cerebral oedema as a result of initial brain damage after ictus was the predominant COD (n = 24, 28.2%; median cumulative fatality, 1 day; IQR, 1–4 days; SEM, 0.680), followed by cerebral infarction caused by delayed cerebral ischaemia (DCI) (n = 13, 15.3%; median cumulative fatality, 9 days; IQR, 4–13 days; SEM, 1.379). Renal failure was the predominant non-cerebral COD before cardiac and pulmonary complications (n = 6, 7.1%).

Conclusions

Mortalities after SAHs predominantly occur within the first days after ictus. The dominant cerebral cause of death is early initial cerebral oedema, followed by DCI.     

Are people healthier if their partners are more optimistic? The dyadic effect of optimism on health among older adults

Objective

Optimism has been linked with an array of positive health outcomes at the individual level. However, researchers have not examined how a spouse's optimism might impact an individual's health. We hypothesized that being optimistic (and having an optimistic spouse) would both be associated with better health.

Methods

Participants were 3940 adults (1970 couples) from the Health and Retirement Study, a nationally representative panel study of American adults over the age of 50. Participants were tracked for four years and outcomes included: physical functioning, self-rated health, and number of chronic illnesses. We analyzed the dyadic data using the actor–partner interdependence model.

Results

After controlling for several psychological and demographic factors, a person's own optimism and their spouse's optimism predicted better self-rated health and physical functioning (bs = .08–.25, ps < .01). More optimistic people also reported better physical functioning (b = −.11, p < .01) and fewer chronic illnesses (b = −.01, p < .05) over time. Further, having an optimistic spouse uniquely predicted better physical functioning (b = − .09, p < .01) and fewer chronic illnesses (b = − .01, p < .05) over time. The strength of the relationship between optimism and health did not diminish over time.

Conclusions

Being optimistic and having an optimistic spouse were both associated with better health. Examining partner effects is important because such analyses reveal the unique role that spouses play in promoting health. These findings may have important implications for future health interventions.     

Ambulatory assessments of psychological and peripheral stress-markers predict birth outcomes in teen pregnancy

Objective

Pregnant adolescents have high rates of poor birth outcomes, but the causes are unclear. We present a prospective, longitudinal study of pregnant adolescents assessing associations between maternal psychobiological stress indices and offspring gestational age at birth and birthweight.

Method

Healthy nulliparous pregnant adolescents were recruited (n = 205) and followed during pregnancy. Ambulatory assessments over 24 h of perceived psychological stress (collected every 30 min) and salivary cortisol (6 samples) and a summary questionnaire, the Perceived Stress Scale, were collected at three time points (13–16, 24–27, and 34–37 gestational weeks). Corticotropin-releasing hormone, C-reactive protein, and interleukin 6 were assayed from blood taken at the latter 2 sessions. A final sample of 119 participants was selected for analyses.

Results

The ambulatory assessment of perceived psychological stress was positively correlated with the Perceived Stress Scale (r = .20, p = .03) but neither was associated with any of the biological assays (all ps > .20). Based on backward selection regression models that included all stress variables and relevant covariates, the ambulatory assessments of perceived psychological stress and cortisol — though not the Perceived Stress Scale — were negatively associated with gestational age at birth (F(4, 107) = 3.38, p = .01) while cortisol was negatively related to birthweight (F(5, 107) = 14.83, p < .0001).

Conclusions

Targeted interventions to reduce psychological and biological indicators of heightened stress during pregnancy may have positive public health benefits for the offspring given the associations of shortened gestation and lower birthweight with risk for poor mental and physical health outcomes.     

Concomitant and adjuvant temozolomide of newly diagnosed glioblastoma in elderly patients

Objective

The effect of concomitant and adjuvant temozolomide in glioblastoma patients above the age of 65 years lacks evidence. However, after combined treatment became standard at our center all patients were considered for combined therapy. We retrospectively analyzed the effect of temozolomide focused on elderly patients.

Methods

293 patients with newly diagnosed glioblastoma treated single-centered between 1998 and 2010, by radiation alone or concomitant and adjuvant radiochemotherapy, were included. Treatment groups were analyzed by multi- and univariate analysis. Matched pairs for age, by a 5-year-caliper, extent of resection and general state was generated for all patients and elderly subgroups.

Results

103 patients received radiation only and 190 combined treatment. Multivariate and matched pair analysis revealed a benefit due to combined temozolomide (HR 1.895 and 1.752, respectively). For patients older than 65 years median survival was 3.6 (95% CI 3.2–4.7) and 8.7 months (6.3–11.8) for radiotherapy only and combined treatment (HR 3.097, p < 0.0001, n = 90). Over the age of 70 and 75 years median survival was 3.2 (2.3–4.2) vs. 7.5 (5.1–10.9, HR 4.453, p < 0.0001, n = 62) and 3.2 (1.4–3.9) vs. 9.2 months (4.7–13.5; HR 9.037, p < 0.0001, n = 24), respectively. In 8/56 (14%) patients over the age of 70 years temozolomide was terminated due to toxicity.

Conclusion

Retrospective matched pair analysis gives class 2b evidence for prolonged survival due to concomitant and adjuvant temozolomide in elderly glioblastoma patients. Until prospective data for combined radiochemotherapy in elderly patients will be available concomitant and adjuvant temozolomide therapy should not be withheld.     

Factors predicting the development of new onset post-operative Hydrocephalus following trans-sphenoidal surgery for pituitary adenoma

Background

The aim of this retrospective study was to identify the factors which can predict the development of new onset post-operative Hydrocephalus following transsphenoidal surgery for pituitary adenomas.

Methods

A total of 224 patients with the diagnosis of pituitary adenoma and without preoperative Hydrocephalus were identified from 1995 to 2012. Age, gender, tumor volumes, prior craniotomy and irradiation, outcome, hospital stay, CSF leak, infection and functional status of the tumor were included in the model for analysis.

Results

A total of 13 patients (5.8%) developed new onset post-operative Hydrocephalus. Intraoperative and post-operative CSF leaks were noted in 19 (8.5%) and 17 (7.6%) patients respectively. CSF infection was seen in only 7 (3.1%) patients. Age of the patient (p = 0.010), length of hospital stay (p = 0.012), intraoperative CSF leak (p = 0.000), post-operative CSF leak (p = 0.000) and CSF infection (p = 0.000) had shown significant correlation with the de novo onset of postoperative HC. The independent predictors of post-operative HC were post-operative CSF leak [p = 0.002, OR 27.898, 95% CI 3.350–232.311] and intra-operative CSF leak [p = 0.050, OR 7.687, 95% CI 1.003–58.924].

Conclusion

Age of the patient, intra-operative and post-operative CSF leak, CSF infection and duration of hospital stay were correlated with the development of HC. Post-operative and intra-operative CSF leaks were the independent predictors of new onset HC.     

Association of the manganese superoxide dismutase gene Ala–9Val polymorphism with clinical phenotypes and tardive dyskinesia in schizophrenic patients

Objective

Several recent studies that have investigated the genetic association between the manganese superoxide dismutase (MnSOD) gene Ala–9Val single-nucleotide polymorphism (SNP) and tardive dyskinesia (TD) have produced conflicting results. This study was to investigate whether this SNP was associated with clinical phenotypes and antipsychotic-induced tardive dyskinesia (TD) in schizophrenia in a genetically homogeneous Han Chinese inpatient population.

Methods

Genotyping was performed for the MnSOD gene Ala–9Val SNP in Chinese schizophrenia patients with (n = 176) and without TD (n = 346). The severity of TD was assessed using the abnormal involuntary movement scale (AIMS), and psychopathology using the Positive and Negative Syndrome Scale (PANSS).

Results

The frequencies of genotypes and alleles did not differ significantly between schizophrenic patients with and without TD (both p > 0.05). Also, there was no significant difference in the AIMS total score between the Val/Val and Ala allele carrier groups (p > 0.05). However, the PANSS negative symptom subscore was significantly higher in patients with Val/Val genotype (21.8 ± 7.3) than those with Ala alleles (20.1 ± 7.7) (t = 2.32, p = 0.03).

Conclusion

While the MnSOD gene Ala–9Val polymorphism did not play a major role in the susceptibility to TD in schizophrenic patients, it might be associated with negative symptoms of schizophrenia.     

Botulinum toxin type A versus amitriptyline for the treatment of chronic daily migraine

Objective

To compare the effects of botulinum toxin type A with those of amitriptyline on the treatment of chronic daily migraines.

Methods

Chronic migraine sufferers were randomized into two groups and treated with 25 or 50 mg/day of amitriptyline or 250 U of botulinum toxin type A. A reduction of at least 50% in the number of pain episodes, in the intensity of pain, and in the number of drug doses for pain and reports of improvement by the patient or by the examiner were the main endpoints.

Results

Seventy-two subjects were enrolled in the study. A reduction of at least 50% in the number of days of pain was recorded in 67.8% of the patients in the BTX-A group and 72% (n = 23) of the patients in the AM group (p = 0.78; RR = 0.94; CI = 0.11–8). The reduction in the intensity of pain, as assessed using the visual analogical scale, was 50% in the BXT-A group and 55.6% in the AM group (p = 0.79; RR = 1.11; CI = 0.32–3.8). The reduction in the number of pain drug doses was 77% for the toxin group and 71% for the amitriptyline group (p = 0.76; RR = 0.92; CI = 0.45–1.88).

Conclusions

Botulinum toxin type A was as effective as amitriptyline for the prophylactic treatment of chronic daily migraines.     

Parent artery occlusion with bypass surgery for the treatment of internal carotid artery aneurysms: Clinical and hemodynamic results

Objective

Parent artery occlusion with/without bypass surgery is one of the treatment choices for the internal carotid artery (ICA) aneurysm difficult to treat by clipping or coiling. There have been few reports regarding postoperative cerebral blood flow (CBF) changes after surgery. This study evaluated the present bypass selection strategy based on balloon test occlusion (BTO) in terms of clinical and hemodynamic outcomes.

Methods

Twenty-one consecutive patients with ICA aneurysms underwent parent artery occlusion. High flow bypass (n = 9), superficial temporal artery–middle cerebral artery bypass (n = 10), or no bypass (n = 2) was performed depending on the changes in clinical symptoms and CBF during BTO. Quantitative CBF measurement with acetazolamide challenge was performed in the chronic stage.

Results

Overall outcome at discharge was good recovery 18, moderate disability 2, and severe disability 1. Two patients suffered symptomatic embolic or perforator infarction associated with the surgical manipulations. Preoperative cranial nerve pareses improved completely or partially in all patients except one. CBF in the chronic stage (n = 18) demonstrated no significant difference between the surgical and non-surgical cerebral hemispheres. No cerebral ischemic event was observed during the follow-up period (mean 2.9 years).

Conclusion

The present surgical strategy based on preoperative BTO provides a reliable tool to achieve acceptable clinical and hemodynamic outcomes in patients with complex ICA aneurysms to be treated by parent artery occlusion.     

Intracerebral metastases of malignant melanoma and their recurrences—A clinical analysis

Introduction

Brain metastases (BM) commonly occur in patients with metastatic malignant melanoma (MM). Prognosis is poor even with maximal therapy. The aim of the current study was to retrospectively evaluate patients with BM of MM who were treated neurosurgically with respect to clinical presentation, recurrent disease, survival and factors affecting survival.

Patients and methods

Thirty-four patients (19 f/15 m) with BM of MM were treated in our hospital between 2000 and 2010. Patient data were analysed, survival was examined using Kaplan–Meier-estimates and factors affecting prognosis were evaluated using uni- and multivariate analysis.

Results

Twenty-two patients (64.7%) had a single BM, whereas twelve patients (35.3%) revealed two or more lesions. Median survival for patients with a single BM was 13.0 months (95%-CI 9.3–16.7 months), this was significantly (p = 0.014) better than for patients with two or more BM (median 5.0, 95%-CI 3.4–14.6 months).Nineteen patients (55.9%) developed an intracranial relapse after microsurgical resection of a first lesion. Patients with an isolated intracerebral relapse survived significantly (p = 0.003) longer than those with systemic progression (median 6.0, 95%-CI 0.0–15.3 months vs median 3.0, 95%-CI 1.7–4.3 months). Similarly, patients with a high performance status showed significantly (p = 0.001) prolonged survival (median 7.0, 95%-CI 0.0–19.9 months vs median 1.0, 95%-CI 0.0–2.2 months). Eleven out of nineteen patients (57.9%) underwent either another microsurgical resection (n = 6) or stereotactic radiosurgery (n = 5). These patients remained on a high performance status even after aggressive therapy.

Discussion

Even though the prognosis for patients with BM of MM is generally poor, patients with a single BM can benefit from microsurgical resection. However, there is a high risk of intracranial relapse. In selected patients with a good performance status and recurrent intracranial disease, recurrent local therapy can be justified and useful.     

Cerebral microbleeds predict first-ever symptomatic cerebrovascular events

Objective

Cerebral microbleeds (CMB) on gradient-echo T2*-weighted magnetic resonance image (MRI) are frequently seen in patients with cerebral diseases. In this observational study we assessed whether CMB are a predictive factor for first-ever cerebrovascular events.

Patients and methods

This study consisted of 698 subjects without a history of symptomatic cerebrovascular events, who received gradient-echo T2*-weighted MRI for 3 months between November 2003 and January 2004 in Kishiwada City Hospital, Osaka, Japan. These subjects were then observed as outpatients for over 3.5 years.

Results

The prevalence of CMB at baseline was 17.0% (119/698) in this population, and the follow-up rate was 51%. A total of 36 first-ever symptomatic cerebrovascular events were observed during the 3 and a half-year follow-up period. First-ever symptomatic cerebrovascular events occurred significantly more frequently in subjects with CMB (15 cases) than those without CMB (21 cases) (p = 0.001). Even after adjusting for age, sex and hypertension, it was revealed that the presence of CMB was an independent predictor for the first-ever symptomatic cerebrovascular event by using the Cox proportional hazards model (hazard ratio, 2.87; 95% CI, 1.27–6.48; p = 0.01).

Conclusion

The presence of CMB is an independent predictor of first-ever symptomatic cerebrovascular diseases.     

Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon's training level of minimally invasive spine surgery

Purpose

To evaluate the differences of learning curve for PELD depending on the surgeon’ s training level of minimally invasive spine surgery.

Methods

We retrospectively reviewed the medical records of 120 patients (surgeon A with his first 60 patients, surgeon B with his first 60 patients) with sciatica and single-level L4/5 disk herniation who underwent PELD by the two surgeons with different training level of minimally invasive spine surgery (Group A: surgeon with little professional training of PELD; Group B: surgeon with 2 years of demonstration teaching of PELD).

Results

Significant differences were observed in the operation time (p = 0.000), postoperative hospital stay (p = 0.026) and reoperation rate (p = 0.050) between the two groups. In the operation time, significant differences were observed between the 1–20 patients group and 41–60 patients group in Group B (p = 0.041), but there were no significant differences among the 1–20 patients group, 21–40 patients group and 41–60 patients group in Group A. In the postoperative hospital stay, the significant differences were observed in the 1–20 patients group between Group A and Group B (p = 0.011). Significant differences were observed between preoperative and postoperative VAS back score, VAS leg score and JOA score. Higher improvement in the VAS leg score was observed in Group B than Group A (p = 0.031). In the rate of reoperation, the significant difference was observed between the 1–20 patients group and 41–60 patients group in Group A (p = 0.028) but there were no significant differences among the 1–20 patients group, 21–40 patients group and 41–60 patients group in Group B.

Conclusions

The surgeons’ training level of minimally invasive spine surgery was an important factor for the success of PELD, especially the demonstration teaching of PELD for the new minimally invasive spine surgeons.     

Exercise training improves depressive symptoms in people with multiple sclerosis: Results of a meta-analysis

Objective

There is a high prevalence, yet under-treatment of depressive disorder and symptoms by conventional therapy in people with multiple sclerosis (MS). We conducted a meta-analysis examining the overall effect of exercise training on depressive symptoms in MS.

Methods

We searched PubMed for randomized controlled trials (RCT) of exercise training and depression as an outcome in samples with MS. There were 13 RCTs that met inclusion criteria and yielded data for effect size (ES) generation (Cohen's d). An overall ES was calculated using a random effects model and expressed as Hedge's g.

Results

The weighted mean ES was small, but statistically significant (Hedge's g = 0.36, SE = 0.09, 95% CI = 0.18–0.54, z = 3.92, p < .001) indicating the exercise training resulted in an improvement in depressive symptoms compared to control. The overall effect was not heterogeneous (Q = 16.46, df = 12, p = 0.17, I² = 27.08); and post-hoc, exploratory analyses only identified depression symptom scale as a potential moderator variable (p = 0.04).

Conclusion

The cumulative evidence indicates that exercise training can yield a small, yet statistically significant and reliable reduction in depressive symptoms for people with MS.