Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage)

OBJECTIVES: To review clinical and radiological findings in patients with Duret hemorrhages and to discuss the pathophysiology and differential diagnosis of these lesions. PATIENTS AND METHODS: We reviewed the case records of four patients with Duret hemorrhages who had been admitted to the neurological intensive care unit with supratentorial mass lesions. RESULTS: Descending transtentorial and subfalcine herniations were present in all cases. Three patients were admitted with acute subdural hematoma and one with intraparenchymal hemorrhage. Computed tomography revealed the presence of blood in the mesencephalon and upper pons. Three patients died; one survived with severe disabilities. DISCUSSION: Duret hemorrhages are typically located in the ventral and paramedian aspects of the upper brainstem (mesencephalon and pons). The pathophysiology of Duret hemorrhage remains under debate: arterial origin (stretching and laceration of pontine perforating branches of the basilar artery), versus venous origin (thrombosis and venous infarction). Multifactorial causation seems likely. CONCLUSION: Duret hemorrhages are delayed, secondary brainstem hemorrhages. They occur in craniocerebral trauma victims with rapidly evolving descending transtentorial herniation. Diagnosis is made on computed tomography of the brain. In most cases the outcome is fatal. On the basis of our observations we believe that arterial hypertension and advanced age are risk factors for the development of Duret hemorrhage.     

Clinical diagnosis of diabetic polyneuropathy with the diabetic neuropathy symptom and diabetic neuropathy examination scores

OBJECTIVE: To evaluate the discriminative power of the Diabetic Neuropathy Symptom (DNS) and Diabetic Neuropathy Examination (DNE) scores for diagnosing diabetic polyneuropathy (PNP), as well as their relation with cardiovascular autonomic function testing (cAFT) and electro-diagnostic studies (EDS). RESEARCH DESIGN AND METHODS: Three groups (matched for age and sex) were selected: 24 diabetic patients with neuropathic foot ulcers (DU), 24 diabetic patients without clinical neuropathy or ulcers (DC), and 21 control subjects without diabetes (C). In all participants, the DNS and DNE scores were assessed and cAFT (heart rate variability [HRV], baroreflex sensitivity [BRS]), and EDS were performed (Nerve Conduction Sum [NCS] score; muscle fiber conduction velocity: fastest/slowest ratio [F/S ratio]). RESULTS: Both the DNS and the DNE scores discriminated between the DU and DC groups significantly (P < 0.001). The DNE score even discriminated between DC and C (P < 0.05). Spearman's correlation coefficients between both DNS and DNE scores and cAFT (HRV -0.42 and -0.44; BRS -0.30 and -0.29, respectively) and EDS (NCS 0.51 and 0.62; F/S ratio 0.44 and 0.62, respectively) were high. Odds ratios were calculated for both DNS and DNE scores with cAFT (HRV 4.4 and 5.7; BRS 20.7 and 14.2, respectively) and EDS (NCS 5.6 and 16.8; F/S ratio 7.2 and 18.8, respectively). CONCLUSIONS: The DNS and DNE scores are able to discriminate between patients with and without PNP and are strongly related to cAFT and EDS. This further confirms the strength of the DNS and DNE scores in diagnosing diabetic PNP in daily clinical practice.     

Characteristics and outcome among 14,933 adult cases of in-hospital cardiac arrest: A nationwide study with the emphasis on gender and age

Aim

To investigate characteristics and outcome among patients suffering in-hospital cardiac arrest (IHCA) with the emphasis on gender and age.

Radiological and clinical outcome of selective thoracic fusion for patients with Lenke 1C and 2C adolescent idiopathic scoliosis with a minimum follow-up of 2 years

Background Context

In Lenke 1C and 2C curves, the choice between selective thoracic fusion (STF) versus non-selective thoracic fusion as the optimal surgical treatment is controversial.

Regulated delivery of glial cell line-derived neurotrophic factor into rat striatum, using a tetracycline-dependent lentiviral vector

In this study, a tetracycline-regulated lentiviral vector system, based on the tetracycline-dependent transactivator rtTA2(S)-M2, was developed for controlled expression of glial cell line-derived neurotrophic factor (GDNF) in the rat brain. Expression of the marker gene green fluorescent protein (GFP) and GDNF was tightly regulated in a dose-dependent manner in neural cell lines in vitro. Injection of high-titer lentiviral vectors into the rat striatum resulted in a 7-fold induction of GDNF tissue levels (1060 pg/mg tissue), when doxycycline (a tetracycline analog) was added to the drinking water. However, low levels of GDNF (150 pg/mg tissue) were also detected in animals that did not receive doxycycline, indicating a significant background leakage from the vector system in vivo. The level of basal expression was markedly reduced when a 10-fold lower dose of the tetracycline-regulated GDNF vector was injected into the striatum (3-11 pg/mg tissue), and doxycycline-induced GDNF tissue levels obtained in these animals were about 190 pg/mg tissue. Doxycycline-induced expression of GDNF resulted in a significant downregulation of the tyrosine hydroxylase (TH) protein in the intact striatum. Removal of doxycycline from the drinking water rapidly (within 3 days) turned off transgenic GDNF mRNA expression and GDNF protein levels in the tissue were completely reduced by 2 weeks, demonstrating the dynamics of the system in vivo. Accordingly, TH protein expression returned to normal by 2-8 weeks after removal of doxycycline, indicating that GDNF-induced downregulation of TH is a reversible event.     

Towards quantitative analysis of coronary CTA

The current high spatial and temporal resolution, multi-slice imaging capability, and ECG-gated reconstruction of multi-slice computed tomography (MSCT) allows the non-invasive 3D imaging of opacified coronary arteries. MSCT coronary angiography studies are currently carried out by the visual inspection of the degree of stenosis and it has been shown that the assessment with sensitivities and specificities of 90% and higher can be achieved. To increase the reproducibility of the analysis, we present a method that performs the quantitative analysis of coronary artery diseases with limited user interaction: only the positioning of one or two seed points is required. The method allows the segmentation of the entire left or right coronary tree by the positioning of a single seed point, and an extensive evaluation of a particular vessel segment by placing a proximal and distal seed point. The presented method consists of: (1) the segmentation of the coronary vessels, (2) the extraction of the vessel centerline, (3) the reformatting of the image volume, (4) a combination of longitudinal and transversal contour detection, and (5) the quantification of vessel morphological parameters. The method is illustrated in this paper by the segmentation of the left and right coronary trees and by the analysis of a coronary artery segment. The sensitivity of the positioning of the seed points is studied by varying the position of the proximal and distal seed points with a standard deviation of 6 and 8 mm (along the vessels course) respectively. It is shown that only close to the individual seed points the vessel centerlines deviate and that for more than 80% of the centerlines the paths coincide. Since the quantification depends on the determination of the centerline, no user variability is expected as long as the seed points are positioned reasonably far away from the vessel lesion. The major bottleneck of MSCT imaging of the coronary arteries is the potential lack of image quality due to limitations in the spatial and temporal resolution, irregular or high heart beat, respiratory effects, and variations of the distribution of the contrast agent: the number of rejected vessel segments in diagnostic studies is currently still too high for implementation in routine clinical practice. Also for the automated quantitative analysis of the coronary arteries high image quality is required. However, based upon the trend in technological development of MSCT scanners, there is no doubt that the quantitative analysis of MSCT coronary angiography will benefit from these technological advances in the near future.     

Perceptions of balance and falls following a supervised training intervention – a qualitative study of people with Parkinson’s disease

Purpose: To explore perceptions of balance and falls among people with mild to moderate Parkinson’s disease 3???12?months following participation in supervised balance training.

Materials and methods: This qualitative study used in-depth individual interviews for data collection among 13 people with Parkinson’s disease. Interviews were systematically analyzed using qualitative content analysis with an inductive approach.

Results: Three main themes arose: Falls – avoided and intended highlights the wide spectrum of fall perceptions, ranging from worse-case scenario to undramatized events; Balance identity incorporates how gradual deterioration in balance served as a reminder of disease progression and how identifying themselves as “aware not afraid” helped certain participants to maintain balance confidence despite everyday activity restriction; Training as treatment recounts how participants used exercise as disease self-management with the aim to maintain independence in daily life. Interpretation of the underlying patterns of these main themes resulted in the overarching theme Training as treatment when battling problems with balance and falls.

Conclusions: Whereas certain participants expressed a fear of falling which they managed by activity restriction, others described being confident in their balance despite avoidance of balance-challenging activities. Training was used as treatment to self-manage disease-related balance impairments in order to maintain independence in daily life.

• Implication for Rehabilitation

• People with Parkinson’s disease require early advice about the positive effects of physical activity as well as strategies for self-management in order to ease the psychological and physical burden of progressive balance impairment.

• Fear of falling should be investigated alongside activity avoidance in this group in order to provide a more accurate insight into the scope of psychological concerns regarding balance and falls in everyday life.

• Certain people with Parkinson’s disease define their balance according to activities they continue to participate in, while others who express fear-related activity avoidance require help to adapt balance-challenging activities in order to maintain balance confidence and avoid physical inactivity.