Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature

Background

The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature.

Methods

A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001–2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed.

Results

There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0 mm. Favorable outcome (mRS 0–2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85).

Conclusions

Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.     

History of depressive and/or anxiety disorders as a predictor of treatment response: A post hoc analysis of a 12-week, randomized, double-blind, placebo-controlled trial of paroxetine controlled release in patients with fibromyalgia

Background

Despite of a high comorbidity of depressive and/or anxiety disorders with fibromyalgia, information on the clinical implications of this comorbidity is limited but antidepressants are commonly prescribed to treat fibromyalgia in clinical practice. We investigated whether a history of depressive and/or anxiety disorders was associated with response to paroxetine controlled release (CR) in the treatment of fibromyalgia.

Methods

One hundred sixteen (116) fibromyalgia subjects were randomized to receive paroxetine CR or placebo for 12 weeks. The primary outcome was treatment response defined as ≥ 25% reduction in the Fibromyalgia Impact Questionnaire (FIQ) score. In multivariate logistic regression, we determined if a history of depression and/or anxiety disorders was an independent predictor of response to paroxetine CR.

Results

In logistic regression, the history of depression and/or anxiety did not predict treatment response as measured by ≥ 25% reduction in Fibromyalgia Impact Questionnaire (FIQ) score (OR = 0.66, 95% CI = .29–1.49, Wald = 0.97, p = 0.32), while the drug status (paroxetine CR) was significantly associated with treatment response (OR = 2.57, CI = 1.2–5.61, Wald = 5.5, p = 0.02).

Conclusion

A significant proportion of patients with fibromyalgia had a history of anxiety and or depressive disorders. However response to treatment of fibromyalgia symptoms with paroxetine CR was not associated with a history of depressive and/or anxiety disorders. Our findings need to be confirmed in more adequately-powered and well-designed subsequent studies.     

Outcome prediction by amplitude-integrated EEG in adults with hypoxic ischemic encephalopathy

Introduction

Amplitude-integrated electroencephalography (aEEG) had been widely used in predicting outcome in infants with hypoxic ischemic encephalopathy (HIE). We aimed to evaluate the use of aEEG as a quantitative predictor of outcome in adult patients with HIE.

Methods

aEEG and Glasgow coma scale (GCS) were recorded for patients with HIE within 72 h of onset. aEEG traces were categorized as Grade I (normal amplitude): upper margin of aEEG activity >10 μV, lower margin >5 μV; Grade II (moderately abnormal amplitude): upper margin of aEEG activity >10 μV, lower margin ≤5 μV, or with suppressed amplitude, upper margin ≤10 μV, lower margin >5 μV; Grade III (mild abnormality): either upper margin <10 μV, lower margin <5 μV. GCS was graded as I (9–14), grade II (4–8), or grade III (3). Cerebral performance category scores (CPCs) were determined 1 and 3 month after clinical evolution. CPC 1,2 were defined as favorable outcome; CPC 3,4,5 were considered as poor outcome.

Results

30 cases met inclusion criteria. Both the aEEG grade and GCS scores correlated significantly with short-term outcome, and cases with a worse aEEG grade were more likely to have an unfavorable short-term outcome. Since the number of patients is really too small for long-term outcome analysis, we did not perform the analysis of aEEG, GCS and longer-term outcome. There was significant difference of clinical findings among aEEG classifications, while no statistical difference was found of causes of HIE.

Conclusions

aEEG is a reliable predictor of short-term outcome in HIE, and aEEG results within 72 h after onset were associated with neurodevelopmental outcome at 1 mo following clinical evolution.     

Systemic arterial inflammation, measured with 18FDG-PET, is common amongst subjects with both recent and prior cerebrovascular disease

Objective

To compare systemic arterial inflammation in subjects with recent ischaemic stroke or TIA and controls with prior cerebrovascular disease.

Methods

Systemic arterial inflammation was prospectively measured by ¹⁸F-fluorodeoxygluose positron emission tomography in 11 cases with recent ischaemic stroke or TIA, and 11 sex matched controls with prior cerebrovascular disease.

Results

Hot spots (both carotid and non-carotid) of localised ¹⁸FDG uptake were found in more than half of all patients with either recent (n = 6) or prior (n = 8) cerebrovascular disease. There was no significant difference in the total number of hotspots, or hotspots at specific sites, in cases compared with controls. Mean standard uptake values (SUV) were similar in the carotid arteries and aorta of cases and controls, and showed a trend toward higher values in the femoral arteries of the controls (median 1.8; IQR 1.6–2.2) compared to cases (median 1.5; IQR 1.4–1.7).

Conclusion

Arterial inflammation was common, and appeared similar, in patients with recent stroke/TIA, and controls with stroke/TIA more than two years previously.     

Prediction of infarct growth and neurologic deterioration in patients with positive perfusion-diffusion mismatch

Background

To assess the value of baseline clinical severity and perfusion–diffusion mismatch as predictors for further infarct growth and clinical outcome.

Methods

Patients with acute ischemic stroke and initial perfusion–diffusion mismatch within 72 h were enrolled. Baseline perfusion defects on time-to-peak (TTP) and cerebral blood volume (CBV) maps were measured. Infarct volume and stroke severity were assessed by diffusion-weighted image (DWI) and NIHSS, and were repeatedly assessed 7 days later. The predictive value of baseline NIHSS and perfusion defects on further infarct growth and neurologic deterioration was determined.

Results

Fifty-two patients (mean age 68.3 ± 12.8 years, 42% women) were enrolled. CBV defects were significantly associated with infarct growth (CBV, p = 0.02). Initial stroke severity, but not TTP and CBV mismatch (p = 0.65 and 0.76, respectively), significantly inversely correlated with neurologic deterioration (p = 0.001).

Conclusions

In patients with mismatch, those with severe symptoms initially are more likely to have infarct growth, while those with minor symptoms tend to suffer from larger extent of neurologic deterioration within 1 week. CBV is associated with further infarct growth but not clinical deterioration.     

Non-conventional risk factors were associated with infarct patterns in ischemic stroke

Objective

Diffusion-weighted imaging (DWI) infarct patterns can play a useful role in the management of ischemic stroke patients, particularly in identifying index stroke mechanisms. Novel vascular risk factors like high sensitivity C-reactive protein (hs-CRP) and the metabolic syndrome have recently been shown to be of prognostic importance following ischemic stroke. We aimed to determine the relationship between these novel factors and infarct patterns noted on DWI.

Methods

A total of 886 patients with acute cerebral infarcts within the MCA territory were prospectively studied. Using the DWI data the patients were divided into four groups: cortical, small (<1 cm) superficial, border-zone, and deep infarcts patterns. The independent associations of various infarct DWI patterns vs. hs-CRP and presence of the metabolic syndrome were evaluated after adjusting for the confounders.

Results

hs-CRP was highest among patients with cortical infarcts, while the metabolic syndrome was most frequent in patients with border-zone infarcts. Compared to the lowest quartile of hs-CRP level, those in the highest quartile were more likely to have the cortical pattern (OR, 3.55; 95% CI, 1.92–6.56; P < 0.001), and less likely to have the deep infarct pattern (OR, 0.49; 95% CI, 0.29–0.81; P = 0.006) in logistic regression analyses. There was an independent association between presence of the metabolic syndrome and the border-zone pattern (OR, 1.75; 95% CI, 1.12–2.73; P = 0.013).

Conclusions

hs-CRP levels and metabolic derangements are independently associated with infarct pattern in acute ischemic stroke, and may be the potential targets for lessening the clinical impact of certain infarct patterns.     

Correlation of Changes in Leukocytes Levels 24 Hours after Intravenous Thrombolysis With Prognosis in Patients With Acute Ischemic Stroke

Objective

Leukocytes play a crucial role in inflammation and immune response. This study aims to demonstrate the value of changes in leukocytes levels 24 hours after intravenous thrombolysis to predict prognosis in acute ischemic stroke (AIS).

Does the Magnitude of the Electrocardiogram QT Interval Dispersion Predict Stroke Outcome?

Background

QT dispersion, maximal interlead difference in QT interval on 12-lead electrocardiogram (ECG), measures cardiac repolarization abnormalities. Data are conflicting whether QT dispersion predicts adverse outcome in acute ischemic stroke (AIS) patients. Our objective is to determine if QT dispersion predicts: (1) short-term clinical outcome in AIS, and (2) stroke location (insular versus noninsular cortex).

Modified Lund concept versus cerebral perfusion pressure-targeted therapy: a randomised controlled study in patients with secondary brain ischaemia

Purpose

Secondary brain ischaemia (SBI) usually develops after aneurysmal subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI). Current approaches to managing these conditions are based either on intracranial pressure-targeted therapy (ICP-targeted) with cerebral microdialysis (CM) monitoring according to the modified Lund concept or cerebral perfusion pressure-targeted therapy (CPP-targeted). We present a prospective, randomised controlled study comparing relative effectiveness of the two management strategies.

Methods

Sixty comatose operated patients with SBI following aneurysmal SAH and severe TBI were randomised into ICP-targeted therapy with CM monitoring and CPP-targeted therapy groups. Mortality rates in both groups were calculated and tissue biochemical signs of cerebral ischaemia were analysed using CM. Measured CM data were related to outcome (Glasgow Outcome Scale [GOS] score 1, 2 and 3 for poor outcome or GOS score 4 and 5 for good outcome).

Results

Patients treated with ICP-targeted therapy with CM monitoring had significantly lower mortality rate as compared with those treated with CPP-targeted therapy (P = 0.03). Patients monitored with CM who had poor outcome had lower mean values of glucose and higher mean values of glycerol and lactate/pyruvate ratio as compared with those who had good outcome (glucose: P = 0.003; glycerol: P = 0.02; lactate/pyruvate ratio: P = 0.01). There was no difference in the mortality outcome between aneurysmal SAH and severe TBI in the two groups (P = 0.28 for ICP-targeted therapy with CM monitoring, P = 0.36 for CPP-targeted therapy). Also, there were no differences in the CM values between patients with aneurysmal SAH and severe TBI who underwent ICP-targeted therapy (glucose: P = 0.23; glycerol: P = 0.41; lactate/pyruvate ratio: P = 0.40).

Conclusion

The modified Lund concept, directed at bedside real-time monitoring of brain biochemistry by CM showed better results compared to CPP-targeted therapy in the treatment of comatose patients sustaining SBI after aneurysmal SAH and severe TBI.     

Comparison of two methods for the detection of oligoclonal bands in a large number of clinically isolated syndrome and multiple sclerosis patients

Objective

A novel oligoclonal band (OB) assay which consists of isoelectric focusing (IEF) and IgG immunodetection by alkaline phosphatase-labeled anti IgG antibody was reported to be very sensitive. It also accurately predicted conversion to MS in patients with CIS. The aim of our study was to compare sensitivity of a novel and the standard procedure with peroxidase immunodetection in a large number of CIS and MS patients.

Methods

OB were determined in serum and CSF samples in 161 patients (104 females), 47 with CIS and 114 with MS with median age 38 years (range 19–68) using both methods.

Results

Eighty-three percent of patients had CSF OB with the standard and 89% with the novel method. Median number of OB was 5 (range 0–17) with the peroxidase and 8 (range 0–18) with the alkaline phosphatase method; p = 0.001. Twenty-one percent of patients had ≥10 OB with the standard and 37% with the novel method of the detection; p = 0.021. Subjective impression of band clarity showed that 20% of patients had sharper and stronger bands when the peroxidase and 65% when the alkaline phosphatase method was used; p < 0.0001.

Conclusion

The alkaline phosphatase method is more sensitive than the peroxidase method and at the same time cheaper, easy to perform and less time consuming.     

Topography of maturational changes in EEG burst spectral power of the preterm infant with a normal follow-up at 2years of age

Objective

To quantify the electroencephalography (EEG) burst frequency spectrum of preterm infants by automated analysis and to describe the topography of maturational change in spectral parameters.

Methods

Eighteen preterm infants <32 weeks gestation and normal neurological follow-up at 2 years underwent weekly 4-h EEG recordings (10–20 system). The recordings (n = 77) represent a large variability in postmenstrual age (PMA, 28–36 weeks). We applied an automated burst detection algorithm and performed spectral analysis. The frequency spectrum was divided into δ1 (0.5–1 Hz), δ2 (1–4 Hz), θ (4–8 Hz), α (8–13 Hz) and β (13–30 Hz) bands. Spectral parameters were evaluated as a function of PMA by regression analysis. Results were interpolated and topographically visualised.

Results

The majority of spectral parameters show significant change with PMA. Highest correlation is found for δ and θ band. Absolute band powers decrease with increasing PMA, while relative α and β powers increase. Maturational change is largest in frontal and temporal region.

Conclusions

Topographic distribution of maturational changes in spectral parameters corresponds with studies showing ongoing gyration and postnatal white matter maturation in frontal and temporal lobes.

Significance

Computer analysis of EEG may allow objective and reproducible analysis for long-term prognosis and/or stratification of clinical treatment.     

Decreased resting energy expenditure in patients with Duchenne muscular dystrophy

Background

Skeletal muscle metabolism is a major determinant of resting energy expenditure (REE). Although the severe muscle loss that characterizes Duchenne muscular dystrophy (DMD) may alter REE, this has not been extensively investigated.

Methods

We studied REE in 77 patients with DMD ranging in age from 10 to 37 years using a portable indirect calorimeter, together with several clinical parameters (age, height, body weight (BW), body mass index (BMI), vital capacity (VC), creatine kinase, creatinine, albumin, cholinesterase, prealbumin), and assessed their influence on REE. In addition, in 12 patients maintaining a stable body weight, the ratio of energy intake to REE was calculated and defined as an alternative index for the physical activity level (aPAL).

Results

REE (kcal/day, mean ± SD) in DMD patients was 1123 (10–11 years), 1186 ± 188 (12–14 years), 1146 ± 214 (15–17 years), 1006 ± 136 (18–29 years) and 1023 ± 97 (?30 years), each of these values being significantly lower than the corresponding control (p < 0.0001). VC (p < 0.001) was the parameter most strongly associated with REE, followed by BMI (p < 0.01) and BW (p < 0.05). The calculated aPAL values were 1.61 (10–11 years), 1.19 (12–14 years), 1.16 (15–17 years), and 1.57 (18–29 years).

Conclusion

The REE in DMD patients was significantly lower than the normal value in every age group, and strongly associated with VC. Both the low REE and PAL values during the early teens, resulting in a low energy requirement, might be related to the obesity that frequently occurs in this age group. In contrast, the high PAL value in the late stage of the disease, possibly due to the presence of respiratory failure, may lead to a high energy requirement, and thus become one of the risk factors for development of malnutrition.     

Postsurgical infection after myelomeningocele repair: a multivariate analysis of 60 consecutive cases

Objective

We investigate the demographic, clinical and surgical variables associated with wound and ventriculoperitoneal (VP) shunt infections in a well-defined group of patients submitted to neurosurgical myelomeningocele repair.

Methods

We analyzed the data of sixty consecutive patients with a myelomeningocele diagnosis submitted to neurosurgical repair between January 2002 and December 2005. Multiple logistic regression analysis identified clinical, demographic and neurosurgical variables that were independently associated with the occurrence of wound and VP shunt infections.

Results

Seven patients (11.7%) developed wound infections after myelomeningocele repair and two (3.3%) presented with sepsis unrelated to the neurosurgical procedures. Forty-six patients (76.7%) received a VP shunt and nine of them (19.6%) had VP shunt infection. There was a non-significant trend (p = 0.09) for a higher association between thoracic than lumbar or sacral topography and the occurrence of any type of infection. Among patients who underwent VP shunt placement, there was a non-significant trend for a higher association between VP shunt infection and thoracic topography compared to lumbar or sacral regions (adjusted OR 4.3; CI 95% 0.7–24.7; p = 0.10). Evans’ index scores higher than 70 were ten times more associated with VP shunt infection (adjusted OR 10.5; CI 95% 1.6–67.4; p = 0.01) than lower scores.

Conclusion

The thoracic topography of myelomeningocele has a trend for a higher association with infection in general and VP shunt infection. Evans’ index scores higher than 70 were independently associated with VP shunt infection.     

Effect of concentration and mode of intrathecal baclofen administration on soleus H-reflex in patients with muscle hypertonia

Objectives

Assess spinal reflex excitability after increasing intrathecal baclofen (ITB) flow by manipulation of drug concentration and mode of administration.

Methods

The effect of concentration was assessed by comparing changes in H-reflex (H/M ratio) 1–6 h after a 50 μg ITB bolus at 50 μg/ml concentration administered manually via lumbar puncture (LP, duration 1–2 min, n = 27) to a 50 μg bolus at 500 μg/ml concentration programmed through the pump and delivered via intrathecal catheter (IC, duration 10 min) above simple continuous dose (25–100 μg/day, n = 16). The effect of mode of administration was assessed by comparing peak changes in H/M ratio after 50 μg IC bolus above simple continuous dose (complex continuous mode, n = 27) to simple continuous mode only (n = 22) at equivalent daily doses (75–150 μg/day).

Results

H/M decrease was faster and overall greater after LP than IC bolus (mean 1-h 77% vs. 63%, p = 0.012; 1–6 h 91% vs. 82%, p < 0.001, respectively). H/M ratio also decreased significantly more with complex (91%) than simple continuous mode of administration (78%, p = 0.025).

Conclusions

Lower ITB concentration and complex continuous mode of administration lead to greater decrease in H/M ratio.

Significance

Decreased spinal reflex excitability after adjustment of drug and pump parameters to increase ITB flow may result in better clinical response.     

Clinical outcome of concomitant chemoradiotherapy followed by adjuvant temozolomide therapy for glioblastaomas: Single-center experience

Introduction

The use of radiotherapy plus temozolomide administered concomitantly with and after radiotherapy for glioblastoma was recently shown to improve median and 2-year survival in a large international multicenter study. To compare this result in routine clinical practice, an audit of the management and outcome of patients with glioblastoma at our institute was performed.

Methods

A total of 79 patients with pathologically confirmed glioblastoma were treated with radiotherapy (daily fractions of 2 Gy for a total of 60 Gy) combined with temozolomide at a dose of 75 mg/m² per day, followed by 6 cycles of adjuvant temozolomide (150–200 mg/m², 5 consecutive days per month). The primary end point was overall survival (OS). Secondary endpoints included progression-free survival (PFS) and toxicity. We evaluated the clinical outcome of concomitant chemoradiotherapy for newly diagnosed glioblastomas at a single institute in Korea.

Results

The median age was 52 years (15–76 years), 47 patients were male and 32 patients were female. 92.4% of the patients had undergone debulking surgery. The median overall survival (OS) was 18.3 months (95% CI, 16.3–20.1 months), and the time to progression was 6.7 months (95% CI, 5.2–8.3 months). The 1-year and 2-year survival rates were 70.1% and 37.1%, respectively. In the retrospective analysis, the patients with a post-operative KPS over 80 showed more prolonged survival than those who had a KPS less 80 (23.1 months vs. 13.4 months; p < 0.001). Age and extent of surgery did not emerge as significant factors. Twenty-four patients (30%) were treated with low-dose continuous temozolomide therapy after the tumor had recurred. Hematologic toxicity was the main adverse effect, occurring in seven patients (8.8%). Patients with lymphopenia were not reported.

Conclusions

This study is the largest study of radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma in Korean patients, who share a common genetic feature. The median and 2-year survival outcomes in this study are comparable to the previous reports. However, for the recurrent glioblastomas refractory to temozolomide, further clinical trials using other agents should be studied continuously in the future.     

Anti-aquaporin-4 antibody in Chinese patients with central nervous system inflammatory demyelinating disorders

Objective

To determine seroprevalence of aquaporin-4 (AQP4) antibody in Chinese patients with central nervous system (CNS) inflammatory demyelinating disorders.

Methods

AQP4 antibody was detected by anti-AQP4 antibody assay. We measured seroprevalence in 200 patients with neuromyelitis optica (NMO, n = 44), multiple sclerosis (MS, n = 46), transverse myelitis (TM, n = 44), optic neuritis (ON, n = 13), acute disseminated encephalomyelitis (ADEM, n = 2), and other neurological diseases (OND, n = 51).

Results

AQP4 antibody seropositivity was 88.6% in patients with NMO, 4.3% in patients with MS, 30.8% in patients with ON and 51.7% in patients with LETM (longitudinally extensive TM). No patients with acute partial TM, ADEM, OND were positive for AQP4 antibody. Sensitivity of the test was 88.6% (95% CI 80–95) in patients with NMO. Specificity is 97.9% (95% CI 95.1–100) in 46 MS patients, with 51 OND patients as the control group. If the patients with recurrent ON, LETM were considered high risk for NMO (n = 37) and the remaining patients (n = 119) were considered controls, the sensitivity of this assay would be 48.6% (95% CI 33.4–64.1) and the specificity 97.5% (95% CI 94.7–100).

Conclusion

This study confirms that AQP4 antibody is a sensitive and specific biomarker for discrimination between NMO and other CNS autoimmune diseases.     

Efficacy of temozolomide as adjuvant chemotherapy after postsurgical radiotherapy alone for glioblastomas

Objectives

The aim of this study was to assess the efficacy of adjuvant TMZ chemotherapy for newly diagnosed GBM patients who were treated with surgery followed by radiotherapy alone.

Material and methods

Between January 2003 and April 2005, 59 consecutive GBM patients underwent radiation therapy after surgical resection and subsequently received TMZ chemotherapy. For the comparative analysis, we selected 60 clinically matched GBM patients who underwent radiotherapy followed by nitrosourea-based chemotherapy (NUBC), at the same institution between June 1995 and April 2005. The study cohort was divided into two groups, those with adjuvant TMZ treatment and with NUBC.

Results

59 patients with adjuvant TMZ treatment were assigned to the treatment group and 60 patients with NUBC to the control group. The median overall survival for the treatment group was 18.2 months (95% CI, 11.7–24.7 months), compared with the survival of 14.5 months (95% CI, 11.2–17.7 months) for the control group (p = 0.019). The progression-free survival for the treatment group was 5.6 months (95% CI, 4.4–6.7 months), while the control group showed progression-free survival of 3.3 months (95% CT, 3.2–6.0 months) (p = 0.030). Uni- and multivariate analysis revealed that extent of surgical resection, age ≥55 years and postoperative KPS were significantly associated with survival.

Conclusion

Adjuvant TMZ chemotherapy provided a clinically relevant benefit of survival, as compared with NUBC. Thus, we suggest that adjuvant TMZ chemotherapy may be effective even for patients who did not receive concomitant chemoradiotherapy for GBM.     

Preliminary findings of the effects of autonomic dysfunction on functional outcome after acute ischemic stroke

Background and purpose

Impaired autonomic function is common in the acute poststroke phase but little is known about its effects on functional outcome after acute ischemic stroke. This study sought to investigate the impact of autonomic dysfunction by Ewing's classification on functional outcome 2 months after acute ischemic stroke.

Methods

34 consecutive acute ischemic stroke patients within 7 days after onset were enrolled. On admission, autonomic function was assessed by Ewing's battery tests. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS), autonomy in activities of daily living by the Barthel Index (BI), and global disability by the modified Rankin Scale (mRS). BI and mRS were also evaluated 2 months after ischemic stroke onset.

Results

On admission, eight patients were diagnosed as minor autonomic dysfunction and 26 patients as relatively severe autonomic dysfunction. The prevalence of relatively severe autonomic dysfunction in ischemic stroke patients was 76.5%. There were no significant differences in baseline characteristics between the minor and severe autonomic dysfunction groups. 2 months after stroke onset, the mean BI score of patients with minor autonomic dysfunction and severe autonomic dysfunction increased from 76.3 ± 15.3 on admission to 95.0 ± 7.1, 66.5 ± 15.2 on admission to 74.8 ± 15.9 respectively. The mean BI score after 2-month stroke onset and the change in BI from admission to 2-month outcome (delta BI) in patients with severe autonomic dysfunction were lower than those in patients with minor autonomic dysfunction (all P < 0.05).

Conclusions

Autonomic dysfunction occurs in acute stroke patients. Relatively severe autonomic dysfunction is related to an unfavorable functional outcome in patients with acute ischemic stroke.     

Anhedonia in Japanese patients with Parkinson's disease: analysis using the Snaith-Hamilton Pleasure Scale

Background

Anhedonia, a lowered ability to experience physical or social pleasure, has recently been recognized as a non-motor symptom of Parkinson's disease.

Objective

To identify the frequency of anhedonia and the factors influencing hedonic tone in Japanese patients with Parkinson's disease.

Patients and methods

We recruited 86 consecutive outpatients with a clinical diagnosis of PD attending two Japanese hospitals (one university hospital and one community hospital) in February 2010. We used the self-rating Snaith–Hamilton Pleasure Scale (SHAPS) translated into Japanese language from the original English version to assess and quantify hedonic tone as a subjectively experienced phenomenon. We studied the association of anhedonia with the variables age, age at onset, gender, disease duration, disease severity and antiparkinsonian drugs.

Results

Thirty-nine patients (45%) were male and 47 (55%) were female. Mean age was 72.01 ± 9.07 (49–89) years, with mean age at onset of 64.93 ± 11.42 (31–88) years. Mean disease duration was 7.20 ± 5.54 (1–23) years. The mean Hoehn and Yahr scale was 2.76 ± 0.78. The mean SHAPS score of the total sample was 1.19 ± 1.86. The SHAPS score of 14 patients (16.3%) was 3 or more, indicating anhedonia. The mean SHAPS score was lower in patients taking pramipexole (0.58 ± 0.97) than in patients not taking pramipexole (1.57 ± 2.16). Multiple linear regression analysis identified pramipexole as a significant negative influencing factor on the SHAPS score, while disease severity and entacapone treatment were identified as positive influencing factors. The age, onset age, gender, disease duration, and use of pergolide, amantadine, zonisamide, selegiline, anticholinergic agents and droxidopa did not significantly affect the SHAPS score.

Conclusion

Anhedonia is not rare non-motor symptom in Japanese patients with Parkinson's disease. This study suggests an anti-anhedonic property of pramipexole.     

The incidence of pulmonary embolism (PE) after spinal fusions

Background

Pulmonary embolism (PE) is a rare but serious event that may occur after spinal surgery.

Objective

To correlate PE incidence after spinal arthrodesis with surgical approach, region of spine operated, and primary spinal pathology. To identify PE incidence trends in this population.

Methods

The Nationwide Inpatient Sample was queried using ICD-9 codes (81.01–81.08) for spinal fusion procedures over a 21-year period (1988–2008). Other data points included PE occurrence, surgical approach, spinal region, surgical indication, and mortality. Multivariate and relational analyses were performed.

Results

4,505,556 patients were identified and 9530 had PE (incidence = 0.2%). PE patients had higher odds of combined A/P surgical approaches than posterior approaches (OR = 1.97; 95% CI = 1.66–2.33), and PE incidence was higher in thoracic versus cervical or lumbar fusions (OR = 2.54; 95% CI = 2.14–3.02). PE was more likely with vertebral fracture (OR = 1.85; 95% CI = 1.53–2.23) and SCI with vertebral fracture (OR = 4.59; 95% CI = 3.72–5.70) than without trauma. Between 1988 and 2008, the PE incidence remained stable for patients with intervertebral disk degeneration and scoliosis, but increased for patients with vertebral fracture, and SCI with vertebral fracture. There was greater inpatient mortality with occurrence of a PE (OR = 12.92; 95% CI = 10.55–14.41).

Conclusion

Although the incidence of PE in spinal arthrodesis patients is only 0.2%, there is a higher incidence after combined A/P approaches, thoracic procedures, and trauma surgical procedures. Despite the overall PE incidence remaining stable since 1988, incidence steadily increased among trauma patients. Further research is needed to explain these trends, given the context of changing patient populations and improving surgical techniques and prophylaxis measures. Greater caution and prophylaxis among trauma patients may be warranted.