Management and outcome of primary spinal ependymomas: A single center experience from Taiwan

Background

Surgical treatment of spinal ependymomas requires careful consideration of the relative risks of neurological worsening from surgery. Our aim was to determine the risk factors of neurological deterioration after surgery for spinal ependymomas.

Material and methods

This 20-year study included 17 patients (seven men and 10 women; 44.65 ± 13.62 years) with histologically confirmed spinal ependymomas. The basic features were reviewed and the functional status was assessed by using the modified McCormick classification. We subdivided the patient population into two groups according to whether neurological deterioration occurred after primary tumor resection (N = 5) or not (N = 12), and compared their clinical characteristics.

Results

The average duration of presenting symptoms in the 17 patients was 23.53 ± 21.45 months. Three (17.6%) patients underwent subtotal or partial resection and 14 (82.4%) patients underwent gross total resection. The incidence of neurological deterioration after primary resection of spinal ependymomas was 29.4%. There were five (100%) and two (16.7%) male patients in the neurological-deterioration and no-deterioration groups, respectively (p = 0.003). The duration of presenting symptoms was 24 months or over in all the patients with neurological deterioration and five of the 12 patients with improved or stabilized function (p = 0.044).

Conclusion

The risk associated with surgical resection of spinal ependymomas should not be overlooked because of the significant incidence of neurological deterioration. The male gender and long-standing symptom (≥24 months) are risk factors of postoperative neurological worsening. Early diagnosis and surgery are therefore critical for successful treatment of spinal ependymomas.     

Serum brain-derived neurotrophic factor predicts responses to escitalopram in chronic posttraumatic stress disorder

Introduction

Some studies have found that antidepressants increase serum brain-derived neurotrophic factor (BDNF) levels in patients with major depression and the expression of BDNF mRNA in limbic structures of rats.

Objectives

This study addressed whether the SSRI escitalopram increases serum BDNF levels in subjects with PTSD and whether BDNF levels are associated with treatment response.

Methods

Medically healthy male subjects (N = 16) with chronic PTSD completed a 12 week open-label trial of flexible dose (5–20 mg/day) escitalopram monotherapy. BDNF levels were obtained at baseline, and at weeks 4, 8 and 12.

Results

PTSD symptoms significantly declined over the course of the 12 week escitalopram treatment. Despite a substantial improvement in PTSD symptoms, there was virtually no change in BDNF levels over time. Nevertheless, mean BDNF levels across the trial were strongly correlated with the slope of PTSD symptoms over the 12 weeks (r = 0.58, p = 0.018). Lower mean BDNF was associated with a greater decrease in PTSD symptoms over the course of the trial.

Conclusions

PTSD subjects with low BDNF levels demonstrated the largest treatment response from an agent with putative neurotrophic effects.     

Evaluation of the prevalence of severe hyperhomocysteinemia in adult patients with thrombosis who underwent screening for thrombophilia

Introduction

Treatment with B-vitamins and betaine reduces the high risk of thrombosis in patients with homocystinuria, a metabolic syndrome that is characterized by severe hyperhomocysteinemia (HHcy). In contrast, there is no clear demonstration that B-vitamins reduce the risk of thrombosis in patients with mild HHcy: for this reason, many question the clinical utility of measuring total Hcy (tHcy) in patients with thrombosis. However, thrombosis may be the first clinical manifestation of homocystinuria in patients reaching adulthood without signs and symptoms of the syndrome.

Aim

1) to measure the prevalence of severe, previously undiagnosed, HHcy among patients with thrombosis 2) to profile these patients on the basis of their characteristics.

Methods

Six Italian Thrombosis Centers completed a first questionnaire, reporting tHcy levels in patients with thrombosis who underwent thrombophilia screening, and a second questionnaire, reporting the characteristics of patients with severe HHcy (tHcy > 100 μmol/L).

Results

Of 19,678 cross-sectionally collected patients with thrombosis who underwent thrombophilia screening in the last 12.5 years (median value, range 6-17), 38 had severe HHcy (0.2%). Their median age at diagnosis was 47 years (range 19-83) and the median level of tHcy was 130 μmol/L (range 101-262). Venous thromboembolism (71%) was more frequent than arterial thromboembolism (26%); recurrent thrombosis occurred in 42% of cases.

Conclusions

Measurement of tHcy in adult patients with thrombosis may reveal the presence of severe HHcy. Since treatment of patients with severe HHcy decreases the risk of thrombosis, measurement of tHcy in patients with thrombosis may prove clinically useful.     

Prevalence of depressive symptoms and predictors of treatment among U.S. adults from 2005 to 2010

Objectives

To determine nationally representative estimates of the prevalence of depressive symptoms and factors associated with treatment among those with moderate to severe symptoms.

Methods

A cross-sectional, retrospective analysis of adults age ≥ 18 years in the 2005–2010 National Health and Nutrition Examination Survey data who responded to the Patient Health Questionnaire (PHQ-9) was conducted (n= 13,320). Depressive symptoms and severity were defined by PHQ-9 scores. Depression treatment was defined as either receiving antidepressants or seeing a mental health professional. Multivariable logistic regression analyses using population weights identified factors associated with having depressive symptoms and receipt of any treatment.

Results

The prevalence of depressive symptoms increased from 20.92% to 25.66% over 6 years. Among patients with moderate to severe depression, 38.66% received treatment. Multivariable analyses found that being female, other Hispanic, younger age, having certain chronic comorbidities or previous hospitalization, no health insurance and in poverty status were associated with having depressive symptoms (P< .05). Among patients with moderate to severe depression, being female, white, younger age, having comorbidities (arthritis and hypertension) or previous hospitalization were associated with receipt of treatment (P< .05).

Conclusions

The prevalence of depressive symptoms is high, and only a small portion of patients with moderate to severe depression received treatments. Treatment disparities exist and need improvement.     

Conscious sedation interview for psychogenic pseudosyncope

Objective

We attempted treatment of chronic psychogenic pseudosyncope with serial conscious sedation interviews.

Method

Three conscious sedation interviews were performed.

Results

The patient's symptoms lessened significantly, and improvement lasted for 3 months; however, gradually, her symptoms returned to prior level of severity.

Conclusion

Conscious sedation interviews may improve symptoms of the psychogenic pseudosyncope, but the improvement may be temporary.     

The relationship between actigraphically defined sleep disturbance and REM sleep behaviour disorder in Parkinson's Disease

Aim

In this study, we sought to evaluate the utility of actigraphy for examining symptoms of rapid eye movement sleep behaviour disorder (RSBD).

Methods

Twenty-two patients with idiopathic Parkinson's Disease (mean age = 63.4 years, SD = 7.5) underwent neurological assessment and completed sleep diaries, self-report sleep questionnaires and 2-weeks of actigraphy. They also completed the rapid eye movement sleep behavior disorder questionnaire and were classified as screening negative (RSBD−, n = 9) or positive (RSBD+, n = 13) for RSBD according to published criteria. Key outcome data were the number of wake bouts and duration of arousals during the sleep interval as determined by actigraphy.

Results

Patients classified as RSBD+ demonstrated a higher number of wake bouts than those who were RSBD− (p = 0.011).

Conclusions

These results suggest that actigraphy may be a viable tool to assist in the early identification of RSBD. In turn, this could guide early intervention approaches.     

Influence of attention-deficit/hyperactivity disorder on binge eating behaviors and psychiatric comorbidity profile of obese women

Objective

Previous studies have reported higher prevalence rates of attention-deficit/hyperactivity disorder (ADHD) both in eating disorders (ED) and in obese patients. We compared the psychiatric comorbidity profile of obese ADHD women with non-ADHD obese women and how ADHD symptoms impact in binge eating behaviors.

Design

Cross-sectional study of a clinical sample.

Subjects

171 adult women were evaluated at a specialized clinic in obesity and ED.

Measurements

Participants complete a semi-structured interview and psychopathology rating scales. A hierarchical regression model was employed to predict binge eating behavior.

Results

Obese ADHD patients had a larger number of psychiatric comorbidities (p < 0.001), especially Substance Abuse Disorders, and higher scores on psychopathology rating scales (p < 0.05). The highest prediction for binge eating in the regression model was the presence of depressive symptoms, followed by ADHD inattention symptoms and trait-impulsivity.

Conclusion

ADHD should be routinely evaluated in obese since it is related with more severe psychopathology. Depressive symptoms can predict the presence of binge eating in obese patients.     

Successful treatment with Yokukansan for behavioral and psychological symptoms of Parkinsonian dementia

Objective

To evaluate the efficacy and safety of Yokukansan, a traditional Chinese herbal medicine, for treating behavioral and psychological symptoms of dementia (BPSD) in patients with Parkinson disease (PD; n = 7) and those with PD with dementia (PDD; n = 7).

Background

BPSD are often seen in patients with senile dementia and have serious deleterious effects on the lives of patients and caregivers. Recent studies indicate that the traditional Chinese herbal medicine Yokukansan may be safe and beneficial for the treatment of BPSD patients.

Methods

We treated 7 PD and 7 PDD patients for 4 weeks with Yokukansan and observed them without Yokukansan for 4 weeks. Changes in behavioral and psychological symptoms were evaluated every 4 weeks according to the Neuropsychiatric Inventory (NPI) scale.

Results

Significant improvements in behavioral and psychological symptoms, particularly in the incidence and duration of hallucinations, were observed in most PD and PDD patients after 4 weeks of Yokukansan treatment. No significant changes were observed in the laboratory tests, cognitive function, activities of daily living, or parkinsonism.

Conclusion

Our results suggest that Yokukansan improves BPSD in both PD and PDD patients without worsening their cognitive function, ability to perform activities of daily living, or parkinsonism.     

Progressive neuropsychiatric manifestations of phenylketonuria in adulthood

Introduction

Neuropsychiatric signs and MRI abnormalities can occur in patients with phenylketonuria in adulthood. We describe clinical and radiological features of phenylketonuric patients and we discuss the advantage of continuing diet in adulthood.

Method

We report late onset neuropsychiatric symptoms of four phenylketonuric patients (33–45 years) diagnosed in infancy and report the case of a patient (33 years) diagnosed with phenylketonuria because of late onset neurological signs. We describe clinical and radiological features of these 5 patients, and their evolution under diet and propose a review of the literature.

Results

The main neurological abnormalities in phenylketonuric patients diagnosed in infancy are: brisk reflexes, spastic paraparesis, psychiatric signs that appear 10.5 years after the diet arrest. A leukoencephalopathy was present in 93% of cases and 91.7% improve clinically after poor phenylalanine diet reintroduction. In 4 patients, neurological abnormalities (spastic paraparesis, dementia, Parkinsonism) led to the late diagnosis. Two of them had a leukoencephalopathy on brain MRI. Patients had high levels of phenylalanine (above 1500 μmol/L) when neuropsychiatric signs occurred. Improvement after diet suggests that hyperphenylalaninemia has a direct toxic effect on the brain.

Discussion/Conclusion

The long-term follow-up of phenylketonuric patients is mandatory to depict and treat neurological complications in time. Diet reintroduction is efficacious in most cases.     

Survival of brain metastatic patients treated with gamma knife radiosurgery alone

Purpose

To evaluate the impact of gamma knife radiosurgery (GKRS) alone on the survival of brain metastasis patients.

Methods

Fifty patients, 17 men and 33 women, with 169 metastatic tumors were retrospectively reviewed. Before therapy, their mean Karnofsky Performance Score was 78. The majority of their primary cancers stemmed from the lung (56%). Thirty-five patients harbored multiple tumors. The mean tumor volume was 3.7 ml. The mean margin dose was 16 Gy. The mean/median clinical follow-up period was 37/25 weeks.

Results

The overall image-proven tumor control rate was 76%, and the median tumor progression-free period was 26 weeks after radiosurgery. The survival rate of the patients was 58% and 30% at 6 and 12 months, respectively, and the overall median post-radiosurgery survival time was 38 weeks. Both uni- and multi-variate Cox analyses demonstrated that patients with KPS ≧ 80 or who were in Recursive Partitioning Analysis Class I survived significantly longer (p < 0.05).

Conclusions

Patients treated with GKRS alone can prolong their median lifespan by a range of 6–10 months if they are in a good pre-GKRS functional state.     

The role of temperament and character in the outcome of depressive mood in eating disorders

Objectives

The aims were to see which temperament and character dimensions were associated with depression, mainly with its outcome at two-year follow up in eating disorders (EDs).

Methods

Participants (N = 151) were 44 Anorexia nervosa (AN), 55 Bulimia nervosa (BN) and 52 Eating disorders not otherwise specified (EDNOS) patients. The Beck Depression Inventory (BDI), State and Trait Anxiety Inventory (STAI), Rosenberg Self Esteem Questionnaire (RSE), Eating Disorder Inventory (EDI-2) and Temperament and Character Inventory (TCI) were administered.

Results

Depression at the beginning (t0) was severe in 22% of the cases. Harm Avoidance and Novelty Seeking had an effect on depressed mood at t0, mediated by Ineffectiveness. Responsibility (SD1) was associated with scores on the BDI at two-year follow up (β = −0.37, 95% CI −2.6, −0.6, p < 0.01).

Conclusion

The evaluation of personality dimension in EDs has therapeutic and prognostic implications: To enhance self-efficacy and self-directness is crucial for good clinical outcome.     

Single- and multi-level anterior decompression and fusion for cervical spondylotic myelopathy – A long term follow-up with a minimum of 5 years

Objective

Cervical spondylotic myelopathy (CSM) is a common disease leading to significant neurological disability. We compared patients suffering from a single- and a multi-level pathology to analyze the influence of the natural course of the disease on the long-term outcome after surgery.

Methods

We analyzed the records of 52 patients with CSM after surgery. The neurological status of the patients was assessed by the modified Japanese Orthopaedic Association Scale (mJOAS). X-rays were conducted before and after surgery.

Results

52 patients were treated by a single-level (n = 27) or a multi-level approach (n = 25) more than 5 years ago. A significant improvement of the neurological status could be seen even 5 years or more after surgery in both groups without differences. After one year no further improvement could be observed. In the single-level group a trend to a subsequent loss of lordotic correction could be seen. Anterior plates were only used in the multi-level group.

Conclusion

The anterior approach is an effective procedure to improve the symptoms of a CSM for many years. The risk of a multi-level pathology does not appear to exceed the risks of a single-level pathology concerning clinical long-term outcome after surgery. The clinical success is not hindered by a loss of correction in this specific setting.     

Progressive axonal dysfunction and clinical impairment in amyotrophic lateral sclerosis

Objective

To elucidate longitudinal changes in axonal function in amyotrophic lateral sclerosis (ALS) patients, and to relate such changes with motor unit loss and functional impairment.

Methods

37 ALS patients (age, 53.7 ± 1.7 years; 22 males) were studied using axonal excitability techniques at baseline and 12 weeks follow-up.

Results

Longitudinal measurements across excitability parameters suggested increasing K⁺ channel dysfunction, with further increases in depolarising threshold electrotonus (90–100 ms, baseline, 46.8 ± 1.0%; follow-up, 48.7 ± 0.8%; P = 0.02) and superexcitability (baseline, −24.0 ± 1.2%; 12 weeks, −26.0 ± 1.2%; P = 0.04). Patients with preserved compound muscle action potential (CMAP) amplitude at follow-up developed more severe changes in axonal excitability than those in whom CMAP decreased from baseline, suggesting that the most pronounced disease effects were on motor axons immediately prior to axonal loss in ALS patients. Fine motor decline was associated with more severe changes in axonal excitability, suggesting that functional impairment was related to axonal dysfunction.

Conclusions

Longitudinal changes in axonal excitability in ALS patients suggest increasing K⁺ channel dysfunction in motor axons.

Significance

Axonal excitability studies enable investigation of longitudinal changes in axonal ion channel dysfunction, and thereby the processes that potentially contribute to axonal degeneration in ALS.     

A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

Objective

The aim of this study is to conduct a preliminary examination of long-term outcomes on a broad range of affective disorder symptoms treated with a newly developed intervention: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP).

Method

Maintenance of treatment gains at long-term follow-up (LTFU) were explored in patients (N = 15, mean age = 32.27; 60% female) who completed a clinical trial of the UP.

Results

Treatment gains observed at 6-month follow-up (6MFU) on measures of clinical severity, general symptoms of depression and anxiety, and a measure of symptom interference in daily functioning were largely maintained 12 months later (at an average of 18 months posttreatment), and any significant changes from 6MFU to LTFU reflected small increases in symptoms that remained, on average, in the subclinical range.

Conclusions

These findings provide the first initial support for the durability of broad treatment gains following transdiagnostic treatment.     

Treatment of deep vascular orbital malformations

Objective

In this article, we discuss the clinical features and endovascular and/or surgical treatment of deep vascular orbital malformations.

Methods

We report on our treatment of 58 cases of vascular malformations of the orbit between 1991 and 2008.

Results

Arterial low flow lesions, such as cavernomas (n = 44) were the most common finding. These were treated by complete excision. High flow lesions such as angiomas were less common (n = 4). These were treated by the endovascular and/or surgical approach. Venous flow lesions appear as distensible lesions (n = 3) or non-distensible anomalies (n = 4). Deep venous lesions (n = 7) should be treated if they cause severe pain, progressive proptosis, motility disturbances or visual deterioration. No flow lesions include lymphangiomas (n = 3). Surgery may be helpful in specific cases with intracystic haemorrhage and progressive proptosis. Patients with severe visual deterioration do not improve, whereas all other symptoms are potentially reversible.

Conclusions

Treatment of vascular malformations is required in case of progression of symptoms. In cases of visual deterioration, we generally favour early treatment. The least invasive surgical approach, tailored to the individual patient, should be chosen.     

The psychiatric sequelae of burn injury

Objective

To examine factors predicting psychiatric morbidity, taking into account the full range of psychiatric disorders before and after burn injury.

Methods

A cohort of 107 patients consecutively admitted to a Swedish national burn center was examined for lifetime psychiatric morbidity, as well as 94 patients at 1 year postinjury. Sixty-seven individuals, some from that same cohort, were interviewed at 2 to 7 years postinjury. The predictive effects of psychiatric history, personality and other risk factors for psychiatric morbidity following burn were evaluated with multiple regression analyses.

Results

The prevalence of having a psychiatric disorder preburn was 57%. One year postinjury 19% had minor or major depression and 23% had subsyndromal or full posttraumatic stress disorder. At 2 to 7 years, 31% fulfilled the criteria for a psychiatric disorder. The strongest contributing factors were a history of psychiatric morbidity and neuroticism.

Conclusions

Two-thirds of the patients had a lifetime psychiatric disorder, and one-third had a psychiatric diagnosis 2 to 7 years postburn. Mental health problems can have a major impact on daily life and functional abilities. Thus, identification and treatment of a range of psychiatric disorders, taking into account preburn psychiatric disorders and personality, is important for optimal adjustment after burn.     

Additional value of quantitative EEG in acute anterior circulation syndrome of presumed ischemic origin

Objective

The clinical course of acute stroke can be highly variable and for effective management outcome prediction needs to be refined. We investigated whether EEG parameters are of additional diagnostic and prognostic value in the early phase of acute ischemic anterior circulation stroke.

Methods

Ninety-four patients presenting with acute anterior circulation syndrome (ACS) of presumed ischemic origin were incrementally included. Clinical characteristics were correlated with volume of ischemia and EEG parameters. Predictive values for definite stroke, early neurological deterioration, spontaneous early neurological improvement and death within 1 week after ACS were calculated using ROC curves and logistic regression modelling.

Results

In patients with normal or near normal NIHSS score of 0 or 1, the pairwise derived brain symmetry index (pdBSI) was an independent predictor for definite stroke displaying an overall accuracy of 80%. Early neurological deterioration was independently predicted by pdBSI with a correct classification rate of 95%. In ROC analysis, death was predicted by pdBSI with overall accuracy of 97%. Spontaneous neurological improvement was independently predicted by the delta + theta/alpha + beta – ratio with overall accuracy of 75%. Small-vessel stroke was independently predicted by pdBSI with a correct classification rate of 92%.

Conclusions

EEG may be of prognostic value for spontaneous neurological improvement, early neurological deterioration and death in the acute setting of acute anterior circulation syndrome of presumed ischemic origin.

Significance

These findings may have an impact on stroke care.     

Manifestaciones neurológicas de los mixomas cardiacos. Experiencia en un centro de referencia

Introduction

Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma.

Objective

To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years.

Patients and methods

We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012.

Results

Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1 cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths.

Conclusions

Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.     

Long-term neurological and neuropsychological outcome in patients with severe traumatic brain injury

Background

Severe traumatic brain injury (TBI) remains a major cause of death and disability worldwide. The aim of the study was to evaluate predictors for neurological and neuropsychological long-term outcome in patients with severe TBI treated according to an intracranial pressure (ICP-) targeted therapy.

Methods

From 08/2005 to 12/2008, 46 patients with severe TBI and more than 12 h of intensive care treatment were included in this study. Neurological outcome was assessed with the Glasgow Outcome Scale (GOS). Neuropsychological performance assessing 9 different domains was evaluated at long-term follow-up (median 20.5 months; range 10–46). Logistic regression was used to identify favourable outcomes according to the GOS and Fisher's exact tests were used to identify predictors of severe neuropsychological impairments at follow-up.

Results

Twenty-nine patients were available for neuropsychological assessment at long-term follow-up. Only 2 out of 29 patients presented normal or average neuropsychological findings throughout all 9 neuropsychological domains at long-term follow-up. The percentage of a favourable outcome (GOS 4-5) increased from 13.8% at hospital discharge to 75.8% at rehabilitation discharge to 79.3% at long-term follow-up, respectively. Age ≤40 was found to be a strong predictor of favourable outcome at follow-up (OR 5.95, 95% CI 1.41 25.00, p = 0.015). The GOS at hospital discharge was not a predictor for severe impairments in any of the 9 different neuropsychological domains (all p-values were p > 0.268). In contrast, the GOS at rehabilitation discharge was found to be a predictor of severe impairments at follow-up in all but one domain assessed (all p-values less than p < 0.038).

Conclusions

The GOS at rehabilitation discharge should be regarded as a better predictor for neuropsychological impairments at long-term follow-up than the GOS at hospital discharge. Even in patients with favourable GOS after finishing a course of rehabilitation, three quarters of these patients may have at least one severe neuropsychological deficit. Therefore, it remains of paramount importance to provide long-term neuropsychological support to further improve outcome after TBI.