Brainstem ptosis (midbrain ptosis) associated with mesencephalic hemorrhage

We reported a patient with a brainstem ptosis (midbrain ptosis) associated with mesencephalic hemorrhage. A 57-year-old woman had the sudden onset of bilateral blepharoptosis and diplopia. On admission, computed tomography of the brain and magnetic resonance imaging disclosed a small hematoma in the left tegmentum of midbrain. She had no past history of hypertension of head trauma. Cerebral angiography gave no additional informations. The lesion involving the central caudal subnucleus of IIIrd nerve nucleus may be responsible for the bilateral ptosis, since this finding is consistent with current models of oculomotor organization in monkeys (Warwick 1953).     

Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy

PURPOSE: To identify surgeon characteristics associated with mortality or morbidity, following carotid endarterectomy (CEA). METHODS: Data on all inpatient discharges from the 284 nonfederal Pennsylvania hospitals were obtained from the Pennsylvania Health Care Cost Containment Council for the period from 1994 to 1995. Physician data were obtained from the Physicians List of the American Medical Association, including name, gender, specialty, year of birth, board certified, and year of licensure. Cases were selected if any of six procedures codes were ICD-9-CM rubric 38.12, indicating CEA. RESULTS: Among the 12,725 cases studied, in-hospital mortality was 0.7%, nonfatal morbidity was 3.0%, and the total bad outcome rate was 3.7%. Surgeons who performed 1 to 2 CEAs over 2 years had the highest mortality (2.0%) and total bad outcome (9.2%) rates. For surgeons performing three or more cases in 2 years, increased volume was not associated with better outcomes. A greater number of years since the surgeon was licensed was associated with greater mortality (p = 0.001), but not with morbidity or bad outcome rates. In regression analyses that adjusted for patient risk, both years since licensure and specialty predicted surgical mortality rate, but only volume predicted surgical bad outcome rate. CONCLUSIONS: More years since licensure and very low patient volume are associated with worse patient outcomes following CEA.     

Outcome after prolonged convulsive seizures in 186 children: low morbidity, no mortality

Prolonged convulsive seizures are a common neurological emergency and a potential cause of neuronal damage and functional sequelae. We explored the role of seizure duration and various background factors for neurological sequelae in children with prolonged convulsive seizures. The population-base of this study was all children (age < 16 years) who had been admitted to the Tampere University Hospital, Finland between 1993 and 1999 with convulsive seizures lasting more than 5 minutes. Patients were followed up individually (mean length of follow-up 2 years 1 month, range 0 to 7 years 8 months). All available data on the prolonged seizure episodes and clinical follow-up were analyzed retrospectively by a detailed review of all medical charts and records. In 186 children (94 males, 92 females; mean age 4 years 5 months, SD 3 years 10 months, range 1 month to 15 years 4 months) there were 279 separate convulsive seizure episodes lasting over 5 minutes, yielding an annual incidence of 47.5 out of every 100000 episodes. Seizure aetiology was idiopathic in 26.2% of episodes, febrile in 41.9%, remote symptomatic in 28%, and acute symptomatic in 3.9% of episodes. Mean duration of all seizure episodes was 42.5 minutes (SD 46.1 minutes) and was significantly correlated with the aetiology: shortest in the febrile group (mean 35.4 minutes) and longest in the acute symptomatic group (mean 88.6 minutes; p < 0.001). There was no mortality related directly to these acute seizure episodes. The most common sequela was an onset of epilepsy in 40 children (22%). Permanent neurological sequelae were noted in only four patients (2.2%; mean seizure duration 16 minutes) and non-permanent sequelae in six patients (3.2%; mean seizure duration 38 minutes). Neurological sequelae of prolonged convulsive seizures in children are rare and are related to aetiological factors rather than the duration of a single seizure. The role of acute seizures in the evolution of epilepsy in children remains obscure.     

Mental health symptoms associated with morbidity, not mortality, in an elderly community sample

Purpose  

Six previous reviews have found a relationship between depression and mortality. However, many past studies have failed to adequately control for the role of physical health. A proposed mechanism of the depression–mortality relationship suggests that physical health may mediate the relationship. The present study used new methods to examine relationships between mental health symptoms and mortality in an elderly community cohort while accounting for potential mediation of these relationships by physical health.     

Long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study

BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) represents the severest form of stroke, yet examinations of long-term prognosis and associated health care use are rare. This study assessed survival, morbidity and cost of hospital care over 11 years following a first-ever ICH in the UK. METHODS: We used a population-based retrospective inception cohort design using data from the Hospital Record Linkage System in Scotland. Long-term survival, morbidity and treatment provided in hospitals were evaluated in all patients with a first diagnosis of ICH in 1995. A cohort of ischemic stroke (IS) patients was also examined for comparison. RESULTS: A total of 705 patients with ICH and 8,893 with IS were identified. The mean age was 65 years (SD = 17.2) for ICH and 73 years (SD = 11.8) for IS at stroke onset. The acute in-hospital mortality was 45.7 and 30.1% for ICH and IS, 51.2 and 39.9% at 1 year, while 76.0 and 80.4% were dead 11 years later. The cumulative risk of nonfatal or fatal ICH was 8.0, 12.7 and 13.7% at 1, 5 and 10 years, and 7.0, 11.1 and 12.9% for IS in the ICH cohort. The mean cost of initial hospital care was GBP 10,332 (SD = 19,919) for ICH and GBP 9,937 (SD = 15,777) for IS. The mean total costs over 11 years were GBP 18,629 (SD = 29,943) for ICH and GBP 21,505 (SD = 27,190) for IS. CONCLUSION: Following a first ICH, individuals have a poorer short-term prognosis than individuals with IS, yet both ICH and IS imply significant follow-up care.     

Immediate morbidity and mortality associated with transcallosal resection of tumors of the third ventricle

Resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach represents a surgical challenge. It carries a risk of postoperative complications, due to the role of surrounding structures in control of eloquent functions. We reviewed the immediate morbidity and mortality associated with this approach. Between June 1993 and July 2007, 38 patients underwent resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach at The University of Texas M. D. Anderson Cancer Center. Their 30-day postoperative morbidity and mortality rates were retrospectively analyzed relative to clinical variables possibly affecting these rates. Complications were categorized as neurological, regional, and systemic and were subclassified as major or minor. The overall complication rate was 50%. Major complications occurred in 37% of patients; 34% suffered neurological complications (16% being major complications). Surgical mortality was 8%. Univariate analysis demonstrated that tumor hemorrhage (p = 0.04), preoperative Karnofsky Performance Scale (KPS) score (p = 0.04), tumor status (recurrent versus [vs.] new or residual; p = 0.01), and cauterization of any of the bridging veins (p = 0.04) were associated with the incidence of postoperative complications. Multivariate analysis showed that increased age at surgery (p = 0.04), tumor status (p = 0.03), preoperative KPS score (p = 0.02), and the extent of tumor resection (p = 0.05) correlated significantly with the incidence of postoperative complications. Resection of tumors of the third ventricle via the interhemispheric transcallosal approach is associated with significant postoperative morbidity. Preserving the venous structures is of paramount importance in minimizing major neurological complications. Our results have practical risk-predictive value and can serve as the foundation for subsequent outcome studies.     

Complement Factor H Y402H polymorphism is associated with an increased risk of mortality after intracerebral hemorrhage

Intracerebral hemorrhage (ICH) accounts for 10% to 15% of all strokes and is a major cause of morbidity and mortality. Despite advances in management, numerous clinical trials have failed to demonstrate significant benefit of medical and surgical interventions, underscoring the need for the identification of novel therapeutic targets based on improved understanding of ICH pathophysiology and optimal risk stratification based on reliable and effective prognosticators. The alternative complement cascade has been implicated as an important contributor to neurological injury after ICH. Therefore, common, functionally relevant genetic variants in the key components of this pathway have been associated with greater inflammation post-ictus, further cerebral damage, and ultimately, a worse outcome. We investigated the affects of single-nucleotide polymorphisms (SNP) on mortality in complement component 3 C3 (rs2230199), complement component 5 C5 (rs17611), and Complement Factor H (CFH; rs1061170) genes, which are associated with the onset and progression of several neurological diseases, in a prospective cohort of patients with spontaneous ICH. From February 2009 through May 2010, adult patients with spontaneous ICH were admitted to the Columbia University Neurological Intensive Care Unit and enrolled in the Intracerebral Hemorrhage Outcomes Project. Demographic, clinical, radiographic, and treatment data were prospectively collected. Buccal swabs were obtained, and isolated cells were sequenced for the aforementioned SNP. A total of 103 patients were admitted with ICH, and of these, 82 consented for genetic testing and were included in the analysis. The median age was 61 years and 39% were females. The median Glasgow Coma Scale score on admission was 11.5. The CFH SNP was significantly associated with both discharge (p = 0.01) and 6-month mortality (p = 0.02), while no such association was observed for C3 (p = 0.545 and p = 0.830) or C5 (p = 0.983 and p = 0.536) SNP. Additionally, after controlling for pertinent variables identified in the univariate analysis, the CFH genotype independently predicted mortality at discharge (p = 0.019, odds ratio [OR] 7.62, 95% confidence interval [CI] 1.40–41.6) and at 6 months (p = 0.041, OR 1.822, 95% CI 1.025–3.239). The CFH genotype was also independently predictive of survival duration (p = 0.041, OR 1.822, 95% CI 1.025–3.239). We concluded that CFH Y402H polymorphism independently predicts mortality at discharge and 6-months and survival duration after spontaneous ICH.     

Cardiac and cerebrovascular morbidity and mortality associated with antipsychotic medications in elderly psychiatric inpatients.

OBJECTIVE: To evaluate the rate of adverse medical outcomes for elderly exposed to antipsychotic treatment. METHODS: This was a retrospective evaluation of psychiatric inpatients records. Age, gender, diagnosis, treatment with antipsychotics, and duration of treatment were analyzed. An acute cardiac or cerebrovascular event necessitating transfer to a general hospital or resulting in death was the outcome measure. RESULTS: During 15 years (1990 to 2005), 3,111 elderly were hospitalized. Their mean age was 73.5 +/- 6.1 years, 1,220 were male (39%), and 1,891 were female (61%). Most patients (2,583 [83%]) were exposed to antipsychotics, of which 1,402 (54%) were exposed to second-generation antipsychotics (SGAs). Antipsychotic-treated patients did not have a higher rate of adverse medical outcomes compared with patients who had not received antipsychotics. No significant differences were noted between patients exposed to typical antipsychotics or SGAs. CONCLUSION: Treatment of elderly psychiatric inpatients with antipsychotics did not increase their risk of adverse medical outcomes. Thus, regulating the use of conventional antipsychotics or SGAs for all elderly patients in all indications may be premature.     

Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke

BACKGROUND AND OBJECTIVES: Prior ischemic stroke is a risk factor for intracerebral hemorrhage (ICH) in patients taking warfarin, but the mechanism is not known. This study investigates radiographic and clinical characteristics of patients with warfarin-related ICH following ischemic stroke. METHODS: In this case-control study, the authors selected all patients with warfarin-related ICH and previous symptomatic ischemic stroke from a prospective cohort of consecutive patients with ICH. Control subjects were similarly aged patients with history of symptomatic stroke randomly chosen from an anticoagulant therapy unit. The 26 eligible ICH cases and 56 controls were compared for vascular risk factors, stroke characteristics, and extent of leukoaraiosis (graded in anterior and posterior brain regions on a validated scale of 0 to 4). RESULTS: The presence and severity of leukoaraiosis on CT scan correlated strongly with the occurrence of ICH. Leukoaraiosis was seen in 24 of 26 cases (92%) compared with 27 of 56 controls (48%), yielding an odds ratio of 12.9 (95% CI 2.8 to 59.8). Other clinical factors associated with ICH included an international normalized ratio >3.0, history of multiple previous strokes, and the presence of carotid artery stenosis. The relationship between leukoaraiosis and ICH persisted in multivariable analyses controlling for these risk factors as well as hypertension and diabetes mellitus. CONCLUSIONS: Leukoaraiosis is an independent risk factor for warfarin-related ICH in survivors of ischemic stroke, including those in the commonly employed range of anticoagulation.     

Hyperglycemia is not associated with mortality in bacterial meningitis

An association between hyperglycemia and mortality from cerebral ischemia has been reported in both animals and man. Recently, a similar observation has been made in animals with bacterial meningitis. The present study of 83 patients with bacterial meningitis showed no association between initial serum glucose concentration and subsequent mortality. Therefore, no therapeutic recommendations regarding optimal blood glucose levels in patients with meningitis can be made at this time.