Cardiac-cerebral-renal associations in pediatric traumatic brain injury: Preliminary findings

ObjectiveThe clinical epidemiology of organ outcomes in pediatric traumatic brain injury (TBI) has not been examined. We describe associated markers of cerebral, cardiac and renal injury after pediatric TBI.DesignProspective observational study.PatientsChildren 0–18 years who were hospitalized with TBI.MeasurementsMeasures of myocardial (at least one elevated plasma troponin [cTnI] ≥ 0.4 ng/ml) and multiorgan (hemodynamic variables, cerebral perfusion, and renal) function were examined within the first ten days of hospital admission and within 24 h of each other.Main ResultsData from 28 children who were 11[IQR 10.3] years, male (64.3%), with isolated TBI (67.9%), injury severity score (ISS) 25[10], and admission Glasgow coma score (GCS) 11[9] were examined. Overall, 50% (14 children) had elevated cTnI, including those with isolated TBI (57.9%; 11/19), polytrauma (33.3%; 3/9), mild TBI (57.1% 8/14), and severe TBI (42.9%; 6/11). Elevated cTnI occurred within the first six days of admission and across all age groups, in both sexes, and regardless of TBI lesion type, GCS, and ISS. Age-adjusted admission tachycardia was associated with cTnI elevation (AUC 0.82; p < 0.001). Reduced urine output occurred more commonly in patients with isolated TBI (27.3% elevated cTnI vs. 0% normal cTnI).ConclusionsMyocardial injury commonly occurs during the first six days after pediatric TBI irrespective of injury severity, age, sex, TBI lesion type, or polytrauma. Age-adjusted tachycardia may be a clinical indicator of myocardial injury, and elevated troponin may be associated with cardio-cerebro-renal dysfunction.     

Post-traumatic hydrocephalus after ventricular shunt placement in a Singaporean neurosurgical unit

Ventricular enlargement is a common finding after severe head injury and has a poor prognosis if associated with post-traumatic hydrocephalus (PTH). We retrospectively reviewed our head injury database and identified patients who suffered from severe head injury and subsequently had shunt insertion after a diagnosis of PTH. A total of 871 patients with severe head injury were admitted from April 1999 to December 2006. Twenty-three patients (2.6%) were diagnosed with post-traumatic hydrocephalus and had a shunt inserted. Multiple logistic regression analysis showed that age, and unilateral and bilateral decompressive craniectomy, were significant predictors of PTH. The timing of shunt placement was between 2 weeks and 5 months post–head injury with a mean interval of 70 days. Three patients developed complications after shunt insertion. Seventeen patients (74%) achieved improvement after shunt insertion while the remainder had no significant change in neurological status. Eleven patients (48%) had improvements in their Glasgow Coma Scale (GCS) score of ?2 points, while six patients (26%) had a single-point improvement in their GCS score. At 1 year after shunting, 35% of patients had Glasgow Outcome Scale scores of 3 to 4. PTH is a condition that has an insidious onset with varying clinical and radiological presentations. The incidence is low but there is a significant benefit from ventricular shunt insertion. The use of cerebrospinal fluid dynamic studies, in addition to clinical and radiological findings, has the potential for better diagnosis and management of these patients.     

Re-examining decompressive craniectomy medial margin distance from midline as a metric for calculating the risk of post-traumatic hydrocephalus

Decompressive craniectomy (DC) is a life-saving procedure in severe traumatic brain injury, but is associated with higher rates of post-traumatic hydrocephalus (PTH). The relationship between the medial craniectomy margin’s proximity to midline and frequency of developing PTH is controversial. The primary study objective was to determine whether average medial craniectomy margin distance from midline was closer to midline in patients who developed PTH after DC for severe TBI compared to patients that did not. The secondary objective was to determine if a threshold distance from midline could be identified, at which the risk of developing PTH increased if the DC was performed closer to midline than this threshold. A retrospective review was performed of 380 patients undergoing DC at a single institution between March 2004 and November 2014. Clinical, operative and demographic variables were collected, including age, sex, DC parameters and occurrence of PTH. Statistical analysis compared mean axial craniectomy margin distance from midline in patients with versus without PTH. Distances from midline were tested as potential thresholds. No significant difference was identified in mean axial craniectomy margin distance from midline in patients developing PTH compared with patients with no PTH (n = 24, 12.8 mm versus n = 356, 16.6 mm respectively, p = 0.086). No significant cutoff distance from midline was identified (n = 212, p = 0.201). This study, the largest to date, was unable to identify a threshold with sufficient discrimination to support clinical recommendations in terms of DC margins with regard to midline, including thresholds reportedly significant in previously published research.     

A Predictive Model for Functional Outcome in Patients with Acute Ischemic Stroke Undergoing Endovascular Thrombectomy

IntroductionEndovascular thrombectomy (EVT) is a well-established treatment of acute ischemic stroke. Variability in outcomes among thrombectomy patients results in a need for patient centered approaches to recovery. Identifying key factors that are associated with outcomes can help prognosticate and direct resources for continued improvement post-treatment. Thus, we developed a comprehensive predictive model of short-term outcomes post-thrombectomy.MethodsThis is a retrospective chart review of adult patients who underwent EVT at our institution over the last four years. Primary outcome was dichotomized 90-day mRS (mRS 0–2 v mRS 3–6). Bivariate analyses were conducted, followed by logistic regression modelling via a backward-elimination approach to identify the best fit predictive model.Results326 thrombectomies were performed; 230 cases were included in the model. In the final predictive model, adjusting for age, gender, race, diabetes, and presenting NIHSS, pre-admission mRS = 0–2 (OR 18.1; 95% 3.44–95.48; p < 0.001) was the strongest predictor of a good outcome at 90-days. Other independent predictors of good outcomes included being a non-smoker (OR 5.4; 95% CI 1.53–19.00; p = 0.01) and having a post-thrombectomy NIHSS<10 (OR 9.7; 95% CI 3.90–24.27; p < 0.001). A decompressive hemicraniectomy (DHC) was predictive of a poor outcome at 90-days (OR 0.07; 95% CI 0.01–0.72; p = 0.03). This model had a Sensitivity of 79%, a Specificity of 89% and an AUC=0.89.ConclusionOur model identified low pre-admission mRS score, low post-thrombectomy NIHSS, non-smoker status and not requiring a DHC as predictors of good functional outcomes at 90-days. Future works include developing a prognostic scoring system.     

Simultaneous cranioplasty and ventriculoperitoneal shunt placement in patients with traumatic brain injury undergoing unilateral decompressive craniectomy

Hydrocephalus is a common complication after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). However, the strategy of managing TBI patients with a cranial defect and hydrocephalus remains controversial. Placement of a ventriculoperitoneal shunt (VPS) in patients with a cranial defect and hydrocephalus may aggravate sinking skin flap overlying the cranial defect and result in syndrome of sinking skin flap (SSSF) that causes neurological deterioration. A retrospective analysis of 49 TBI patients who developed hydrocephalus after unilateral DC was undertaken to investigate the safety of simultaneous cranioplasty and VPS placement, and the incidence of SSSF after VPS placement. Among these patients, 17 patients underwent simultaneous cranioplasty and VPS placement, and 32 patients underwent staged cranioplasty and VPS placement. The overall complication rate was 9.3% (3/32) in staged group and 29.4% (5/17) in simultaneous group, respectively. There was no statistically significance between two study groups regarding overall complication (p = 0.11) and reoperation rate (p = 0.47). Two patients with severe brain bulging in staged group developed SSSF after placement of a nonprogrammable VPS. Our study showed that simultaneous cranioplasty and VPS placement may be safe in TBI patients with a cranial defect and hydrocephalus. However, due to the contradictory results about the safety of simultaneous cranioplasty and VPS placement in the literatures, neurosurgeons should carefully consider whether patients are suitable for such treatment. In patients planning to undergo VPS placement first, a programmable shunt may be a better choice for the possibility of SSSF after shunt placement.     

Women with OSA have higher chances of having metabolic syndrome than men: effect of gender on syndrome Z in cross sectional study

Study objectivesThis study was done to find out prevalence of Metabolic syndrome (MS) in patients with Obstructive Sleep Apnea (OSA) and whether there is any difference in prevalence of syndrome Z in male and female.MethodologyAll consecutive diagnosed patients with OSA between June 2015 and Oct 2019 were screened for metabolic syndrome and factors associated with metabolic syndrome in OSA were analyzed.ResultsDuring study period, 502 patients (357 males; 145 females) were diagnosed with OSA. Mean age was 51.88 ± 12.18 years (females and males:55.91 ± 9.74 and 50.24 ± 12.70 years, respectively). Mean BMI was 31.60 ± 11.09 kg/m² (female: 35.29 ± 7.19 and male: 30.1 ± 12.0 kg/m²) (p < 0.001). Mean AHI was 62.67 ± 35.22. Mild, moderate and severe category of OSA constituted 7.3%, 15.3% and 77.4% respectively. MS was found in 72.7% (365 out of 502) individuals with OSA. MS was found in 75.8%, 68.4 and 48.7% in severe, moderate and mild OSA patients respectively (p < 0.001). Females OSA patients had significantly high percentage (88.27%) of metabolic syndrome compared to males OSA patients (66.38%) {p < 0.001}. Female patients with SZ had higher metabolic score (p = 0.019) and were older (p < 0.001).ConclusionMetabolic syndrome is highly prevalent in OSA population (72.7%) and is much more common in female OSA patients (88%) than males OSA (68%). All OSA patients should be screened for MS so that early intervention can be done in these patients so as to prevent cardiovascular complications.     

Obstructive sleep apnoea in adult patients post-tonsillectomy

BackgroundThe impact of removing the upper airway lymphoid tissue and in particular, tonsillectomy, in adults with OSA has not been demonstrated in large populations.AimsTo compare the severity of OSA and the prevalence of cardiovascular, metabolic and respiratory co-morbidities between patients with OSA who had undergone previous tonsillectomy and those who had not.MethodsThe 19,711 participants in this study came from the European sleep apnea database (ESADA) which comprises data from unselected adult patients aged 18–80 years with a history of symptoms suggestive of OSA referred to sleep centers throughout Europe.ResultsThere were no differences between the two groups in terms of sex ratio and age (146 patients with previous tonsillectomy vs. 19565 patients without). Patients who had undergone tonsillectomy had a lower body mass index (29.3 ± 5.2 kg/m² vs 32.2 ± 6.6 kg/m², p < 0.001), lower subjective sleep latency (17.1 ± 17.8 min vs 25.5 ± 30.4 min, p = 0.001), lower ODI (15.7 ± 18.3 events/hour vs 30.7 ± 26.1 events/hour, p < 0.001), and SpO₂<90% time during sleep (21.8 ± 47.5 min vs 52.6 ± 80.8 min, p < 0.001). OSA patients with tonsillectomy had a lower prevalence of Type II diabetes mellitus (p = 0.001), hypertension (p < 0.001) and a higher prevalence of hyperlipidemia (p < 0.001) and were less likely to be commenced on CPAP (p < 0.001).ConclusionIn a large population of almost 20,000 OSA patients from across Europe, patients who had undergone tonsillectomy presented with less severe OSA at time of diagnosis, and had a lower prevalence of Type II diabetes mellitus and cardiovascular co-morbidities.     

Failure of an effective physiologic threshold compliance tool to demonstrate benefit in a clinical trial of traumatic brain injury patients

BackgroundBetter physiologic threshold compliance holds promise for improving outcomes in neurocritical care patients.MethodsOur group developed a threshold compliance tool. This software computes and displays the proportion of values out of range in real time. We captured intracranial pressure (ICP) measures in our patients before and after implementation of this technology. Ten months after the threshold compliance tool was introduced we initiated a randomized controlled trial involving acute traumatic brain injury (TBI) patients to assess whether the tool was effective at reducing out-of-range ICP values.ResultsA total of 54 patients with ICP monitors were included in our analysis, 42 of whom sustained a TBI. Implementation of the threshold compliance tool was associated with an 85.3% reduction in ICP values exceeding 22 mmHg in neurocritical care patients (p = 0.004) and a 76.8% reduction in patients with TBI (p = 0.043). Out-of-range values in an area-under-the-curve analysis were reduced by 78.8% in all patients (p = 0.009) and in TBI patients by 77.9% (p = 0.051). Out-of-range values were not further reduced during our randomized controlled trial examining the threshold compliance tool, and a difference between treatment groups was not suggested.ConclusionsImplementation of a threshold compliance tool was associated with a marked and significant reduction in out-of-range ICP values. Benefit was, however, not evident in a randomized controlled trial. Our analysis provides a unique perspective on our failure to detect an apparent true difference and may provide insights into other neurotrauma trial failures.     

Sleep assessment in cystic fibrosis patients using a minimal-impact biomotion system

PurposeIn our study we aimed to analyze sleep variability and activity in patients with cystic fibrosis (CF) during their hospital stay.MethodsForty-three CF patients were recruited and have been divided into two subgroups: exacerbated (n = 18) and non-exacerbated (n = 25). During the course of their hospital stay we used VitaLog, a minimal-impact biomotion device, in order to determine total sleep time (TST), time in bed (TIB), sleep efficiency (SE) and intra patient standard deviation (IPSD) of TST.ResultsTST was 5.1 h ± 1.5 h and ranged from 0.6h to 7.9 h.TIB was 17.7 h ± 3.8 h and ranged from 5.6h to 23.9 h. SE was 70.0% ± 17.0% and ranged from 13.6% to 98.5%. TST was higher in non-exacerbated patients (5.3 h ± 1.4 h vs. 4.8 h ± 1.6 h, p = 0.008) whereas TIB was lower in non-exacerbated patients (17.0 h ± 3.7 h vs. 18.5 h ± 3.8 h, p = 0.002). We also found that SE was better in non-exacerbated patients (73.1% ± 14.6% vs. 66.6% ± 18.8%, p = 0.002). Furthermore, we observed that IPSD of TST was higher in exacerbated patients (1.3 h ± 0.5 h vs. 0.9 h ± 0.4 h, p = 0.004).ConclusionIn general, in CF patients TST was short and SE poor during the night. Furthermore, in the course of their hospital stay patients showed low activity. In exacerbated patients sleep quality was lower compared to non-exacerbated patients.     

Sleep disorders in Wilson's disease

Background/objectivesWilson's disease (WD) is a rare genetic disorder that leads to copper overload, mainly in the liver then, in the brain. Patients with WD often complain about sleep disorders. We aimed to explore them.Patients/methodsSleep complaints and disease symptoms were compared in 40 patients with WD (20 patients with hepatic phenotype matched to 20 neurologic one) and 40 age, sex and BMI matched healthy controls.ResultsPatients with WD had more frequently (32.5 vs 10.0%, p < 0.05) and more severe (10.5 ± 6.0 vs 7.6 ± 4.8, p < 0.01) insomnia than controls and insomnia was more severe in neurologic than hepatic form of the disease (12.25 ± 5.89 vs 8.73 ± 5.8, p < 0.05). Insomnia severity was correlated with the severity of depressive symptoms (r = 0.53, p < 0.001). Compared to controls, patients reported more difficulties staying asleep and more consequences of insomnia on their quality of life. REM sleep behavior disorder was more frequent in WD (20 vs 0%, p = 0.005) than controls. Patients complained more frequently of nycturia (22.8 vs 7.6%, p = 0.003) than controls. Patients did not differ from controls for sleepiness, restless legs syndrome and obstructive sleep apnea syndrome. Patients did not report cataplexia.ConclusionIn patients with WD, insomnia and REM sleep behavior disorder are the two main sleep complaints. Insomnia is more frequent in neurologic than hepatic form of the disease. Severity of insomnia is associated with the severity of depressive symptoms.     

Substance use on admission toxicology screen is associated with peri-injury factors and six-month outcome after traumatic brain injury: A TRACK-TBI Pilot study

Substance use is commonly associated with traumatic brain injury (TBI). We investigate associations between active substance use, peri-injury factors, and outcome after TBI across three U.S. Level I trauma centers. TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) with Marshall computed tomography (CT) score 1–3, no neurosurgical procedure/operation, and admission urine toxicology screen (tox+/−) were extracted. Associations between tox+/−, comorbidities, hospital variables, and six-month functional (GOSE) and neuropsychiatric (PCL-C, BSI18, RPQ-13, SWLS) outcomes were analyzed. Multivariable regression was performed for associations significant on univariate analysis with odds ratios (mOR) presented. Significance assessed at p < 0.05. In 133 subjects, tox+/tox− were 29.1%/72.9%. Tox+ was younger (35.5/43.6-years, p = 0.018), trended toward male sex (80.6%/63.9%, p = 0.067), was associated with history of seizures (27.8%/10.3%, p = 0.012), self-reported substance use (44.4%/17.5%, p = 0.001), prior TBI (58.8%/34.1%, p = 0.009), GCS < 15 (69.4%/48.4%, p = 0.031) and blood alcohol level >0.08-mg/dl (55.6%/30.8%, p = 0.022). In CT-negative subjects, tox+ was associated with increased hospital admission (95.7%/66.7%, p = 0.034). At six-months, tox+ was associated with screening positive for post-traumatic stress disorder (PCL-C: 40.0%/15.9%; mOR = 8.24, p = 0.022) and psychiatric symptoms (BSI18: 40.0%/14.3%, mOR = 11.06, p = 0.023). Active substance use in TBI may confound GCS assessment, triage to higher level of care, and be associated with increased six-month neuropsychiatric symptoms. Substance use screening should be integrated into standard emergency/acute care TBI protocols to optimize management and resource utilization. Clinicians should be vigilant in providing education, counselling, and follow-up for TBI patients with substance use.     

Increased thickness of lumbar spine ligamentum flavum in wild-type transthyretin amyloidosis

BackgroundWild-type transthyretin (ATTRwt) amyloid deposits have been found in the ligamentum flavum of patients undergoing surgery for spinal stenosis. The relationship between ATTRwt and ligamentum flavum thickness is unclear. We used pre-operative magnetic resonance imaging (MRI) to analyze ligamentum flavum thickness in lumbar spinal stenosis patients with and without ATTRwt amyloid.MethodsWe retrospectively identified 178 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 253 specimens was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and ATTRwt was confirmed using mass-spectrometry and gene sequencing.ResultsTwenty four of the 178 patients (13.5%) were found to have ATTRwt in the ligamentum flavum. Forty ATTRwt specimens and 213 non-ATTRwt specimens were measured. Mean ligamentum flavum thickness was 4.92 (±1.27) mm in the ATTRwt group and 4.00 (±1.21) mm in the non-ATTRwt group (p < 0.01). The ligamentum flavum was thickest at L4-L5, with a thickness of 5.15 (±1.27) mm and 4.23 (±1.29) mm in the ATTRwt and non-ATTRwt group, respectively (p = 0.007). There was a significant difference in ligamentum flavum thickness between ATTRwt and non-ATTRwt case for both patients younger than 70 years (p = 0.016) and those older than 70 years (p = 0.004). ATTRwt patients had greater ligamentum flavum thickness by 0.83 mm (95% confidence interval (CI): 0.41–1.25 mm, p < 0.001) when controlled for age and lumbar level.ConclusionPatients with ATTRwt had thicker ligamentum flavum compared to patients without ATTRwt. Further studies are needed to investigate the pathophysiology of ATTRwt in ligamentum flavum thickening.     

Spontaneous improvement in both obstructive sleep apnea and cognitive impairment after stroke

BackgroundKnowledge available about the relationship between obstructive sleep apnea (OSA) and cognitive impairment after stroke is limited. The evolution of OSA and cognitive performance after stroke is not sufficiently described.MethodsWe prospectively enrolled and examined acute stroke patients without previously diagnosed OSA. The following information was collected: (1) demographics, (2) sleep cardio-respiratory polygraphy (PG) at 72 h, day seven, month three, and month 12 after stroke, (3) post-stroke functional disability tests at entry and at months three and 12, and (4) cognition (attention and orientation, memory, verbal fluency, language, and visual-spatial abilities) using the revised Addenbrooke's Cognitive Examination (ACE-R) at months three and 12.ResultsOf 68 patients completing the study, OSA was diagnosed in 42 (61.8%) patients. The mean apnea/hypopnea index (AHI) at study entry of 21.0 ± 13.7 spontaneously declined to 11.6 ± 11.2 at month 12 in the OSA group (p < 0.0005). The total ACE-R score was significantly reduced at months three (p = 0.005) and 12 (p = 0.004) in the OSA group. Poorer performance on the subtests of memory at months 3 (p = 0.039) and 12 (p = 0.040) and verbal fluency at months 3 (p < 0.005) and 12 (p < 0.005) were observed in the OSA group compared to non-OSA group. Visual-spatial abilities in both the OSA (p = 0.001) and non-OSA (p = 0.046) groups and the total ACE-R score in the OSA (p = 0.005) and non-OSA (p = 0.002) groups improved.ConclusionsA high prevalence of OSA and cognitive decline were present in patients after an acute stroke. Spontaneous improvements in both OSA and cognitive impairment were observed.     

Hemispheric Differences in Cerebral Autoregulation in Children with Moderate and Severe Traumatic Brain Injury

Introduction  To examine hemispheric differences in cerebral autoregulation in children with traumatic brain injury (TBI). After IRB approval and consent, subjects underwent static cerebral autoregulation testing during the first 9 days after PICU admission. Cerebral autoregulation was quantified using the autoregulatory index (ARI). Results  Forty-two (27 M:15 F) children (10 ± 5 years) with TBI and admission Glasgow coma scale score (5 ± 2) were enrolled. Seven (54%) of the 13 children with focal TBI and 8 (28%) of 29 children with diffuse TBI had impairment or absence of cerebral autoregulation of atleast one hemisphere. In patients with isolated focal TBI, ARI was lower (0.40 ± 0.40 vs. 0.67 ± 0.40; P = 0.03) in the side of TBI than in the unaffected hemisphere, but cerebral autoregulation was often impaired on the side without TBI or shift (5/13) on head CT. There was no difference in ARI between hemispheres in children with diffuse TBI, with or without superimposed focal lesions (P = 0.17). Patients with bilateral intact cerebral autoregulation tended to have higher 6 month Glasgow Outcome Score (GOS) than patients with either unilateral or bilateral cerebral autoregulation impairment (GOS 4.0 ± 0.60 vs. 3.6 ± 0.80; P = 0.08). Conclusions  Hemispheric differences in cerebral autoregulation were common in children with isolated focal TBI. Absence of TBI on CT was not always associated with intact cerebral autoregulation. Patients with bilaterally intact cerebral autoregulation tended to have better outcomes.     

Quantitative pupillometry in patients with traumatic brain injury and loss of consciousness: A prospective pilot study

ObjectiveLoss of consciousness (LOC) is a hallmark feature in Traumatic Brain Injury (TBI), and a strong predictor of outcomes after TBI. The aim of this study was to describe associations between quantitative infrared pupillometry values and LOC, intracranial hypertension, and functional outcomes in patients with TBI.MethodsWe conducted a prospective study of patients evaluated at a Level 1 trauma center between November 2019 and February 2020. Pupillometry values including the Neurological Pupil Index (NPi), constriction velocity (CV), and dilation velocity (DV) were obtained.ResultsThirty-six consecutive TBI patients were enrolled. The median (range) age was 48 (range 21–86) years. The mean Glasgow Coma Scale score on arrival was 11.8 (SD = 4.0). DV trichotomized as low (<0.5 mm/s), moderate (0.5–1.0 mm/s), or high (>1.0 mm/s) was significantly associated with LOC (P = .02), and the need for emergent intervention (P < .01). No significant association was observed between LOC and NPi (P = .16); nor between LOC and CV (P = .07).ConclusionsOur data suggests that DV, as a discrete variable, is associated with LOC in TBI. Further investigation of the relationship between discrete pupillometric variables and NPi may be valuable to understand the clinical significance of the pupillary light reflex findings in acute TBI.     

Endoscopic third ventriculostomy for malfunction in previously shunted infants

Introduction  The usage of endoscopic third ventriculostomy (ETV) as an alternative to shunt revision in the management of shunt malfunction is gaining popularity. Methods  We review the clinical data of 45 patients who underwent ETV because of ventriculopritoneal shunt malfunction at Hacettepe University School of Medicine Department of Neurosurgery between January 2002 and August 2007. Medical records of the patients were retrospectively studied. Results  Male-to-female ratio was 23/22. The cause of the hydrocephalus was aqueduct stenosis in 21 (46.9%) patients, newborn meningitis in nine (20%) patients, tumor in six (13.3%) patients, newborn intraventricular hemorrhage in four (8.8%) patients, myelomeningocele in three (6.6%), and trauma in two (2.2%) patients. Of the patients, 27 (60%) had triventricular and 18 (40%) had tetraventricular hydrocephalus at their radiologic evaluation. On admission, all patients had at least one episode of shunt dysfunction prior to ETV. Follow-up duration after surgery was 1–5 years (mean 2.46 ± 1.64 years). Postoperative cerebrospinal fluid flow studies using the cine-PC MR imaging were performed on all patients. The overall success rate for ETV after shunt malfunction was 80% with 36 patients and failure rate was 20% with nine patients. All of these nine patients had undergone shunt insertion within 10 days–1 month after unsuccessful ETV. Conclusion  Endoscopic third ventriculostomy is an effective treatment for shunt malfunction.     

Distraction Osteogenesis Maxillary Expansion (DOME) for adult obstructive sleep apnea patients with narrow maxilla and nasal floor

ObjectivesThis study correlates objective and subjective measurements associated with obstructive sleep apnea (OSA) to define the efficacy of Distraction Osteogenesis Maxillary Expansion (DOME) to treat adult OSA patients with narrow maxilla and nasal floor.MethodsThis is a retrospective study reviewing cases from September 2014 through April 2018 with 75 eligible subjects. Inclusion criteria required OSA confirmed by attended polysomnography (PSG). Pre- and Post-operative clinical data were measured at the Stanford Sleep Medicine and Stanford Sleep Surgery Clinics. DOME is a two-step process starting with insertion of custom-fabricated maxillary expanders anchored to the hard palate by mini-implants followed by minimally invasive osteotomies. After maxillary expansion was complete, orthodontic treatment to restore normal occlusion was initiated. Perioperative Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Nasal Obstruction Symptom Evaluation (NOSE), and Oxygen Desaturation Index (ODI) were measured for 43, 72, 72, and 34 subjects respectively. Statistical analysis was performed using paired T-test with significance set at p-value < 0.05.ResultsThe mean age of test subjects was 30.5 ± 8.5 years with a gender distribution of 57 males and 18 females. There was a significant reduction in pre and post-operative NOSE score (10.94 ± 5.51 to 3.28 ± 2.89, p < 0.0001), mean ESS score (10.48 ± 5.4 to 6.69 ± 4.75, p < 0.0001), and AHI (17.65 ± 19.30 to 8.17 ± 8.47, p < 0.0001) with an increased percentage of REM sleep (14.4 ± 8.3% to 22.7 ± 6.6%, p = 0.0014). No significant adverse effects were identified.ConclusionsDOME treatment reduced the severity of OSA, refractory nasal obstruction, daytime somnolence, and increased the percentage of REM sleep in this selected cohort of adults OSA patients with narrow maxilla and nasal floor.     

Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective,Propensity Score Matched Study

Background and Purpose: Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. Methods: We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. Results: In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. Conclusions: In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.     

Improvements of central respiratory events,Cheyne–Stokes respiration and oxygenation in patients hospitalized for acute decompensated heart failure

BackgroundSleep-disordered breathing (SDB), and Cheyne–Stokes respiration (CSR) in particular, are associated with reduced survival in patients with acute decompensated heart failure (ADHF). CSR cycle length (CL) has been shown to mirror heart failure severity and therefore may be a predictor of outcome. However, studies characterizing CSR in ADHF are rare and no study has investigated changes in CSR from admission to discharge in ADHF patients.MethodsConsecutive patients admitted to our Academic Medical Center with ADHF were eligible. Study patients underwent two multichannel cardiorespiratory polygraphy (PG) recordings, one on admission and another during recompensation.Results105 patients (age 71.5 ± 12.1 years, 66.7% male, NYHA class 3.2 ± 0.6, left ventricular ejection fraction 38.5 ± 13.3%, brain natriuretic peptide 1299 ± 1290 pg/ml); 77 had two fully analyzable PG recordings. CSA prevalence on the first PG was 77%. Based on the apnea-hypopnea index (AHI), CSA was mild, moderate or severe in 21%, 39% and 40% of patients, respectively. During ADHF treatment, AHI decreased non-significantly from 54 ± 17/h to 48 ± 9/h (p = 0.06), central hypopnea index from 20.9 ± 14/h to 17.1 ± 6.2/h (p < 0.01), and time spent in CSR from 65.5 ± 28.4 to 63.7 ± 17.8 min (p < 0.01); oxygenation improved from 91.4 ± 2.6% to 92.0 ± 1.5% (p < 0.05). There was no significant change in CL.ConclusionsPatients with ADHF have a high prevalence of central respiratory events, which decreased during cardiac recompensation. Cardiac recompensation also non-significantly improved the AHI and time spent in CSR and oxygenation, but had no clear impact on CSR CL, which leaves clinical account open to further investigation.     

Investigation on sleep and mental health of patients with Parkinson's disease during the Coronavirus disease 2019 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic is adversely affecting sleep quality and mental health, especially in individuals with chronic disease such as Parkinson's disease (PD).MethodsWe conducted a quantitative study, which included 119 Chinese PD patients who had been treated in an outpatient neurology clinic in Wuhan and 169 age- and sex-matched healthy controls. The questionnaire survey focused on the impact of the COVID-19 pandemic on sleep, mental status, symptoms, and daily life and medical treatment of PD patients.ResultsCompared to healthy controls, PD patients had significantly higher scores in both the Pittsburgh Sleep Quality Index (PSQI) (8.13 vs 5.36, p < 0.001) and the Hospital Anxiety and Depression Scale (HADS) -Depression (4.89 vs 3.82, p = 0.022), as well as a higher prevalence of sleep disturbances with PSQI > 5 points (68.9% vs 44.4%, p < 0.001). Sleep disturbance was identified in 68.9% of PD patients. A logistic regression analysis showed that sleep disturbance of PD patients was independently associated with exacerbation of PD symptoms (OR = 3.616, 95%CI= (1.479, 8.844), p = 0.005) and anxiety (OR = 1.379, 95%CI= (1.157, 1.642), p < 0.001). Compared to male PD patients, female ones had higher PSQI scores (9.28 ± 4.41 vs 7.03 ± 4.01, p = 0.009) and anxiety (32.8% vs 0.1%, p = 0.002) and depression prevalence (34.5% vs 11.5%, p = 0.003).ConclusionThe findings of the present study emphasize the importance of mental and sleep health interventions in PD patients during the COVID-19 pandemic. Additional attention should be paid to the difficulty encountered by PD patients in seeking medical treatment.