Ultrastructural analysis of vascular features in cerebral cavernous malformations

Objective

Investigation of the structure of vascular malformations highlights the pathogenic mechanisms underlying their clinical behavior. One of the vascular malformations is called cerebral cavernous malformation (CCM). However, the ultrastructural features of the vascular malformations are not defined in detail.

Methods

We aimed to investigate the ultrastructural features of CCMs using transmission (TEM), scanning (SEM) electron microscopy, and also immunohistochemistry methods with antibodies against CCM proteins such as CCM2 and CCM3. CCM tissues (n = 6) microsurgically excised from patients for conventional indications.

Results

CCM2 and CCM3 were strongly detected in the vascular endothelium. However, there was a very weak immunostaining in stroma. SEM observations revealed that there were ruptures and damages in the luminal endothelium, possibly due to the damage of intercellular junctions. TEM observations also showed a few ruptures and detachments between the endothelium and basal lamina as observed with partially damages and disconnections. The architecture of pericytes showed protrusions and shrinkages. Our results suggest that the thin vessel walls of CCMs were lacking of subendothelial support and intact basal lamina underlying the endothelial cells.

Conclusion

This study is so far the first study attempting to show human CCM lesions with SEM. We believe that an understanding of the ultrastructural features of these lesions by light and electron microscopy techniques would help to understand the pathology of these diseases.     

Outcome of surgical decompression of spinal mass lesions in non-Hodgkin's lymphoma and plasmacytoma

Objective

Surgical treatment for spinal mass lesions due to non-Hodgkin's lymphoma (NHL) or plasmacytoma is necessary only in rare instances. The purpose of this study was to investigate long-term outcome and quality of life of surgery combined with postoperative chemotherapy or radiochemotherapy.

Methods

The data of patients, who underwent spinal surgery for mass lesions in a 10-year periods were reviewed, identifying 10 patients with a histopathological diagnosis of NHL or plasmacytoma. Functional outcome were assessed by the Karnofsky Performance Score (KPS), quality of life by the Short Form-36 (SF-36) Health Survey Questionnaire, and pain by the Visual Analog Scale (VAS).

Results

Clinical presentations included pain (n = 10), paresis (n = 5), and sensory deficits (n = 5). Surgical treatment included removal of the mass lesion (total, n = 5; subtotal, n = 5) for decompression, interbody fusion (n = 3), and corporectomy followed by stabilization (n = 1). Histopathological findings revealed NHL in five patients and plasmacytoma/multiple myeloma in five other patients. Postoperatively, all patients underwent chemotherapy or radiochemotherapy. Mean follow-up time was 38 months. At the last follow-up, 2 patients had succumbed to progression of disease. Pain intensity remained significantly reduced as compared to preoperatively (p = 0.049). The KPS was 90–100% in five patients still alive, 70% in two, and 60% in one. SF-36 subscores were lower as compared to age-matched healthy controls.

Conclusions

This retrospective study shows that surgical decompression of spinal mass lesions is a valuable option in selected patients with NHL or plasmacytoma to improve neurological deficits and control pain. Long-term outcome after postoperative adjuvant therapy confirms prolonged stability of quality of life.     

Interhemispheric approach to tumors of the posterior gyrus cinguli

Objective

Posterior gyrus cinguli tumors are a well-defined group of tumors that pose considerable challenges in creating surgical access and manipulating adjacent eloquent areas (visual and motor). Here we report our 5-year experience in the surgical treatment of these tumors and describe tumor characteristics, surgical steps, critical aspects, and prognostic factors.

Methods

This series comprises 37 patients operated on for glioma (high-grade in 28, low-grade in 9), often presenting with motor impairment (n = 20), intracranial hypertension (n = 15), seizures (n = 11), and/or hemianopia (n = 9). Preoperative assessment was performed with magnetic resonance imaging. Half of the tumors were more than 4 cm in size, and the majority presented secondary extension into the fronto-parieto-occipital area, the temporo-mesial area, and/or the corpus callosum. Positioning and assisted surgery were optimized in each patient based on preoperative planning.

Results

The ipsilateral interhemispheric approach was elected in all cases. Tumor size and extension were significantly associated with the degree of tumor removal. Total removal was achieved in 25 patients (65%); 4 (10%) had persistent morbidity (visual or motor deficits). The occurrence of local and systemic complications was negligible.

Conclusions

Surgical treatment of posterior gyrus cinguli tumors can be safely approached via the interhemispheric route as it permits several beneficial operative maneuvers in selected cases.     

Surgical resection of osteolytic calvarial lesions: Clinicopathological features

Objective

Osteolytic calvarial lesions are infrequent findings. Some cases are found incidentally during cancer staging or subsequent to unspecific symptoms. There are no standardized algorithms for the treatment of such lesions. Thus, the aim of this study was to describe the clinicopathological features and surgical outcome in various osteolytic calvarial lesions.

Material and methods

The clinical presentation, radiological imaging findings, surgical treatment and histopathological findings of 36 patients who underwent surgery for an osteolytic calvarial lesion at our institution between 1998 and 2008 were reviewed.

Results

Thirty-six osteolytic calvarial lesions were identified in 20 men and 16 women. Mean age at diagnosis was 37 years. Ten patients were children younger than 15 years. Five lesions were detected during cancer staging. Complete removal of the calvarial lesions was achieved in all patients without complications. The most common histopathological diagnosis was metastasis (n = 9), Langerhans-cell histiocytosis (n = 9), and intraosseous hemangioma (n = 5). In two asymptomatic patients, histopathological findings revealed metastases of a previously unknown tumor. In two other patients known to suffer from cancer, histopathological findings indicated intraosseous hemangioma and intraosseous meningioma, respectively. Reconstruction of the calvarial defect was performed in 24 cases with poly-methyl-methacrylate and with titanium mesh in 1 case.

Conclusions

Osteolytic calvarial lesions can be found in any age group. The histopathological examination reveals various entities, and in some instances it was not concurrent with a primary malignancy. Because surgical morbidity is low, we recommend complete resection of osteolytic calvarial lesions with reconstruction when feasible.     

Impaired ability to shift weight onto the non-paretic leg in right-cortical brain-damaged patients

Background

: Stroke patients experience postural instability that can impede functional improvements in their gait. However, the precise functions of the dominant and non-dominant hemispheres in controlling static standing posture and weight-bearing remain unclear.

Objective

: To investigate differences in balancing ability between right-handed patients with right and left hemispheric lesions.

Methods

: Weight shifting was quantitatively evaluated to determine the ability of patients to control their balance in a static posture and during conscious weight shifting onto the paretic or non-paretic leg. Participants were enrolled from a consecutive series of stroke patients attending a rehabilitation program (n = 49; 31 male, 18 female; mean age 69.3 ± 9.4 years). Age-matched normal controls were recruited as volunteers (n = 12; 4 male, 8 female; mean age 67.9 ± 4.9 years).

Results

: Patients with cortical lesions in the right hemisphere were able to shift less weight onto the non-paretic leg than patients with cortical lesions in the left hemisphere (p < 0.05). There were no correlations between the existence of unilateral spatial neglect and the percentage of weight shifted onto the non-paretic leg, static standing posture (r = 0.27, p = 0.40) or dynamic standing posture (r = −0.37, p = 0.24). In contrast, there was a significant correlation between the percentage of weight consciously shifted onto the non-paretic leg and the existence of anosognosia (r = 0.74, p = 0.006), but not between static standing posture and anosognosia (r = −0.15, p = 0.63).

Conclusion

: Patients with right cortical hemispheric lesions were able to shift less body weight onto their non-paretic leg. These patients should be encouraged to practice shifting their weight towards their non-paretic leg to improve their balance.     

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.     

Does glycated hemoglobin have clinical significance in ischemic stroke patients?

Objectives

It has been suggested that patients with an elevated hemoglobin A1c (HbA1c) level have an increased risk of cardiovascular disease regardless of the presence of diabetes. However, an association between HbA1c and stroke has not yet been determined. In this study, our purpose was to examine whether HbA1c was independently associated with various types of cerebral vascular lesions in stroke patients.

Methods

A consecutive series of acute ischemic stroke patients were included for this analysis from October, 2002, to March, 2006. HbA1c was examined on admission, and MR imaging was performed for analysis of large artery diseases (LADs) and small artery diseases (SADs). Symptomatic or asymptomatic LAD was diagnosed by MR angiography, and SAD was classified as leukoaraiosis, microbleeds, or old lacunar infarctions.

Results

A total of 639 stroke patients were analyzed (diabetics, n = 247; non-diabetics, n = 392). There was no relationship between the level of HbA1c and any type of cerebrovascular lesion in the non-diabetic patients. In contrast, HbA1c showed a significant negative association with symptomatic LAD and leukoaraiosis in the diabetic patients using univariate analysis (p = 0.01 and p < 0.05, respectively). These associations did not remain significant, however, after adjustment for age and hypertension. This was, in part, because the HbA1c level in our diabetic population decreased gradually with age (p = 0.03).

Conclusions

Our results indicate that HbA1c is not associated with risk for various types of cerebrovascular lesions in ischemic stroke patients. The negative association between age and HbA1c in diabetic patients should be further investigated.     

Higher heart rate increments on head-up tilt in control subjects are not associated with autonomic dysfunction

Objective

To determine whether there is altered autonomic function associated with elevated heart rate increments on head-up tilt (HUT) in younger individuals.

Methods

A total of 149 subjects were enrolled in this study. Subjects underwent the autonomic reflex screen including HUT and completed the Autonomic Symptom Profile.

Results

Heart rate increment on HUT did not show a correlation with Composite Autonomic Severity Score (CASS) and the individual CASS scores were low (score 0/10, n = 103; score 1/10, n = 27; score 2/10, n = 1; score 3/10, n = 2). There was no correlation with multiple autonomic domains assessed by the Autonomic Symptom Profile. However, there were significant inverse correlations between heart rate increment and total COMPASS score including male sexual dysfunction (r = −0.318; p = 0.011; n = 64), bladder (r = −0.209; p = 0.014; n = 138), pupillomotor (r = −0.235; p = 0.006; n = 138) and male sexual dysfunction (r = −0.554; p < 0.0001; n = 64). These domains showed a positive correlation with age and a significant effect of age but not heart rate increment with regression analysis (except pupillomotor domain).

Conclusions

These results argue against a reduction in autonomic function underlying the higher heart rate increments seen on HUT in younger individuals.

Significance

These findings argue that the development of Postural Tachycardia Syndrome involves mechanisms that potentially occur independently of heart rate increment.     

CT perfusion-guided versus time-guided mechanical recanalization in acute ischemic stroke patients

Objective

Perfusion studies are increasingly used to triage acute stroke patients for endovascular recanalization therapies. We compare the safety and efficacy of CT perfusion (CTP)-guided to time-guided mechanical recanalization in acute ischemic stroke (AIS) patients.

Methods

A review was conducted on 132 patients, 94 undergoing CTP-guided and 38 undergoing time-guided (maximum 8 h from symptom onset) mechanical recanalization at our institution.

Results

The rate of partial-to-complete recanalization did not differ between the CTP and the non-CTP group (78.7% vs. 81.6%, respectively, p = 0.71). ICH occurred respectively in 18.1% in the CTP group versus 31.6% in the non-CTP group (p = 0.06). The overall in-hospital mortality rate was significantly lower in the CTP group (15.9% vs. 36.8%, p = 0.04). In multivariable analysis, CTP-guided patient selection was an independent negative predictor of in-hospital mortality (OR = 3.2; p = 0.01). CTP-guided patient selection, however, was not a predictor of favorable outcome (Modified Rankin Scale 0–2 or 0–3).

Conclusions

CTP-based patient selection was associated with lower ICH and mortality rates. Favorable outcomes, however, did not differ between the 2 groups. These results may suggest a possible benefit in terms of in-hospital mortality with CTP-guided triage of AIS patients for endovascular treatment.     

Noninvasive measurement of human brain temperature adjacent to arteriovenous malformation using 3.0 T magnetic resonance spectroscopy

Object

The brain temperature at rest is determined by the balance between heat produced by cerebral energy turnover, which is identical to cerebral metabolism, and heat that is removed, primarily by cerebral blood flow. The present study investigated whether brain temperature measured by proton magnetic resonance (MR) spectroscopy can detect cerebral hemodynamic impairment in patients with arteriovenous malformations (AVMs) as shown by single photon emission computed tomography (SPECT).

Methods

Brain temperature, cerebral blood flow, and cerebrovascular reactivity were measured using proton MR spectroscopy and SPECT in five healthy volunteers and six patients with AVMs. Regions of interest were selected adjacent to the AVMs and in the corresponding contralateral region.

Results

Brain temperature around AVMs was calculated in all subjects using MR spectroscopy. The mean brain temperature in volunteers was 37.1 ± 0.41 °C. A significant correlation was observed between brain temperature ratio (affected side/contralateral side) and cerebrovascular reactivity ratio (affected side/contralateral side) (r = −0.82, p = 0.0480).

Conclusion

Brain temperature measured by proton MR spectroscopy can detect cerebral hemodynamic impairment in patients with AVMs. Further investigations regarding the relationships between brain temperature and clinical feature in patients with AVMs are needed.     

Endovascular recanalisation therapy for prolonged basilar artery occlusion based on clinical-diffusion MRI mismatch

Objectives

Clinical-diffusion magnetic resonance imaging (MRI) mismatch (CDM) in patients with anterior circulation occlusions is an optional method used to select patients for recanalisation outside the 3-h time window. A similar concept has not been reported with posterior circulation occlusions.

Methods

CDM was defined as a Glasgow Coma Scale (GCS) score <8 with DWI lesions not located in the dorsal pons, midbrain or thalamus at the time of admission. Eligible patients were treated with endovascular recanalisation therapy (ERT). The treatment included intra-arterial rt-PA thrombolysis and angioplasty and stenting performed separately or combined. The recanalisation result was assessed by angiography immediately after the treatment according to the trial reports in the Thrombolysis in Myocardial Infarction Criteria (TIMI). The complications and outcome 3 months later were recorded.

Results

Nine patients with a mean age of 66.6 years were included in the study (7 men and 2 women). The median durations of clinical presentation and coma were 31 h (range 25–53 h) and 6 h (range 2–13 h). The median GCS score at admission was 6 (range 4–7). Occlusions were located in the proximal basilar artery (BA) (n = 2) and the middle BA (n = 7). ERT was successful in 8 patients (TIMI 2, n = 2 and TIMI 3, n = 6) but failed in 1 patient because recanalisation was not possible (TIMI 0). No intracranial haemorrhage or dissections occurred during treatment. The recanalised patients recovered consciousness within 9–27 h after treatment. The median GCS score upon discharge was 14 (range 3–15). Three months later, 6 patients had a good outcome (modified Rankin Score (mRS) 0–2), and 2 patients had a moderate outcome (mRS 3). The patient who did not undergo recanalisation died in the rehabilitation hospital 21 days later.

Conclusions

CDM may be a valid method for selecting patients with prolonged basilar artery occlusion (BAO) who are eligible for recanalisation treatment. ERT was feasible for patients with BAO. A good clinical outcome was achieved with successful recanalisation.     

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.     

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.     

Usefulness of stereotactic biopsy and neuroimaging in management of HIV-1 Clade C associated focal brain lesions with special focus on cerebral toxoplasmosis

Background

Focal brain lesions (FBL) in HIV/AIDS frequently pose a diagnostic dilemma as the etiology varies from infective (tuberculoma, toxoplasmosis and tuberculous abscesses) to neoplastic lesions like lymphoma. For determining etiology, advanced neuroimaging techniques, serological and molecular biological tests have been evolved with varying sensitivities/specificities. Stereotactic biopsy (STB) of the lesions is reserved for lesions unresponsive to appropriate therapy.

Objective and methods

In this study, the diagnostic yield of neuroimaging [cranial CT (n = 25), MRI (n = 24), and Th201/99Tc SPECT scan (n = 18)] is compared with histopathological diagnosis obtained by STB (n = 21) or autopsy (n = 4) in 25 HIV-1 subtype C seropositive individuals with FBL identified by neuroimaging with special reference to cerebral toxoplasmosis in an eighteen month study period (2006–2007).

Results and conclusion

Cerebral toxoplasmosis was the most frequent cause of FBL (21/25, 84%), followed by one case each of tuberculoma, progressive multifocal leukoencephalopathy (PML), primary central nervous system lymphoma (PCNSL) and measles inclusion body encephalitis (MIBE), the last two diagnosed at autopsy. Of the 21 cases of cerebral toxoplasmosis, definitive diagnosis with histopathological confirmation was available in 14/21 (66.6%), with indirect evidence suggesting probable toxoplasmosis in seven, all of whom responded to antitoxoplasma therapy. CT and MRI had comparable specificities (75%), while MRI had marginally higher sensitivity (85% versus 80.9%) in detecting multiple lesions. The positive predictive value of both CT and MRI was identical (94.4%), suggesting that CT maybe a cost effective screening tool in resource restricted settings, for evaluating FBL. Sensitivity of 99Tc SPECT scan for diagnosing inflammatory lesions was 75% but failed to differentiate PCNSL from toxoplasmosis. This study is the first of its kind from India analyzing FBL with specific focus on cerebral toxoplasmosis in the setting of HIV-1 subtype C.     

Electroconvulsive therapy in pregnant patients

Objectives

In this study, the aim was to evaluate the clinical characteristics of patients that received electroconvulsive therapy (ECT) during pregnancy due to psychiatric disorders, evaluate the safety and efficacy of ECT in pregnant women, and evaluate the overall status of mothers and babies during the postpartum period.

Methods

The study included 33 patients who were admitted as inpatients with the indication of ECT due to pregnancy and concurrent psychiatric disorders.

Results

Upon ECT administration, a complete response to treatment was seen in 84.21% of patients with major depression (n= 16), a partial response to treatment in 15.78% of patients (n= 3), a complete response to treatment in 91.66% of patients with bipolar disorder (n= 11), a partial response to treatment in 8.33% of the patients(n= 1), and a full response to treatment in 50% of patients with schizophrenia (n= 1) and a partial response to treatment in 50% of patients with schizophrenia (n= 1) were obtained. We had after birth information of 27 infants from total 33. It was learned that two of them had disease, one was stillbirth and 24 of them did not have any health problems.

Conclusions

ECT administration during pregnancy to treat psychiatric disorders was found to be an effective treatment method. No risk of preterm birth in mothers treated with ECT during pregnancy was detected.     

Diagnostic impact of baseline cerebral blood flow in patients with acute ischemic stroke prior to intravenous recombinant tissue plasminogen activator therapy

Objective

To determine whether severe cerebral perfusion defects measured by SPECT prior to rt-PA therapy attribute to severe intracerebral hemorrhage (SICH).

Methods

We measured baseline cerebral blood flow (CBF) using technetium-99m-labeled hexamethylpropyleneamine oxime (99mTc-HMPAO) SPECT qualitatively prior to rt-PA therapy, in 52 consecutive patients (range 38–93 years). The degree and extent of the asymmetry of local CBF were analyzed semi-quantitatively. We did not administrate rt-PA in patients with severe perfusion defects. Clinical outcome and the incidence of SICH were studied.

Results

Three (5.8%) patients had severe perfusion defects that were undetected by CT and/or DWI. The other 49 (94.2%) patients had mild perfusion defects. The asymmetry of local CBF was 0.08 ± 0.08 (n = 3) and 0.3 ± 0.15 (n = 49) in the two groups, respectively. The percentages of the ipsilateral hemisphere in which perfusion was impaired severely were 17.5 ± 9.5% (n = 3) and 0.43 ± 0.87% (n = 49). Two patients were found petechial hemorrhage, but there was no patient who developed SICH in the former group following conventional antithrombotic therapy. In the latter group, SICH occurred in 1/49 (2.0%) patient following rt-PA therapy.

Conclusion

These results suggest that rt-PA therapy for patients with severe cerebral perfusion defects may cause SICH and baseline CBF may contribute to identify patients at high risk for SICH after intravenous rt-PA therapy.     

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.     

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.     

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.     

Endovascular treatment of distal intracranial aneurysms with Onyx 18/34

Objective

Surgical clipping and coil embolization of distally located intracranial aneurysms can be challenging. The goal of this study was to assess the feasibility, safety and efficacy of treatment of distal aneurysms with the liquid embolic agent Onyx 18/34.

Methods

Sixteen patients were treated with Onyx 18/34 for distally located aneurysms in our institution between March 2009 and September 2012. The technique consists of occluding the aneurysm as well as the parent vessel at the level of aneurysm with Onyx 18 or 34. Candidates for this treatment were patients with distal aneurysms including mycotic aneurysms, dissecting aneurysms, and pseudoaneurysms in which coiling was considered impossible.

Results

Of the 16 patients, 12 presented with subarachnoid and/or intracerebral hemorrhage. Median aneurysm size was 4.6 mm. Aneurysm locations were as follows: Posterior inferior cerebellar artery (n = 5), distal anterior inferior cerebellar artery (n = 3), distal pericallosal (n = 3), distal anterior cerebral artery (n = 3), lenticulostriate artery (n = 1), and anterior ethmoidal artery (n = 1). There were 4 mycotic aneurysms. Complete aneurysm obliteration was achieved in all 6 patients with available angiographic follow-up. There was only 1 (6.3%) symptomatic complication in the series. There were no instances of reflux or accidental migration of embolic material. Favorable outcomes were noted in 82% of patients at discharge. Two patients with mycotic aneurysms died from cardiac complications of endocarditis. No aneurysm recanalization or rehemorrhage were seen.

Conclusion

Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms.