Characterizing the need for tracheostomy placement and decannulation after cervical spinal cord injury

Purpose

There have been few reports on the risk factors for tracheostomy and the possibility of patients for decannulation. The purpose of this study was to identify factors necessitating tracheostomy after cervical spinal cord injury (SCI) and detect features predictive of successful decannulation in tracheostomy patients.

Methods

One hundred and sixty four patients with cervical fracture/dislocation were retrospectively reviewed. The patients comprised 142 men and 22 women with a mean age of 44.9 years. The clinical records were reviewed for patients’ demographic data, smoking history, level of cervical spine injury, injury patterns, neurological status, evidence of direct thoracic trauma and head injury, tracheostomy placement, and decannulation. Risk factors necessitating tracheostomy and factors predicting decannulation were statistically analysed.

Results

Twenty-five patients (15.2 %) required tracheostomy. Twenty-one patients were successfully decannulated. Smoking history (relative risk [RR], 3.05; p = 0.03) and complete SCI irrespective of injury level (C1–4 complete SCI: RR, 67.55; p < 0.001, C5–7 complete SCI: RR, 57.88; p < 0.001) were significant risk factors necessitating tracheostomy. C1–4 complete SCI was more frequent among those who could not be decannulated. However, even in patients with high cervical complete SCI at the time of injury, patients regaining sufficient movement to shrug their shoulders within 3 weeks after injury could later be decannulated.

Conclusions

The risk factors for tracheostomy after complete SCI were a history of smoking and complete paralysis irrespective of the level of injury. High cervical level complete SCI was found to be a risk factor for the failure of decannulation in patients without shoulder shrug within 3 weeks after injury.     

Application of 4D-CTA using 320-row area detector computed tomography on spinal arteriovenous fistulae: initial experience

Time-resolved computed tomography angiography (4D-CTA) using a 320-row area detector CT scanner has recently been applied in the evaluation of cranial vascular disorders. However, application of 4D-CTA to spinal vascular disorder evaluation has never before been described. The authors herein report their initial experience of 4D-CTA in the evaluation of spinal arteriovenous fistulas (AVFs) and compare this novel modality with other imaging modalities. Four consecutive patients with spinal AVF underwent time-resolved contrast-enhanced magnetic resonance angiography (trMRA), 4D-CTA, and selective catheter angiography (CA). In 4D-CTA, volume data was transformed into 3D volume-rendered images and maximum intensity projection. These images were also evaluated by time-resolved serial phases. Then, images of each modality were compared, focusing on the detection of perimedullary draining veins and the prediction of AVF location and drainage flow direction. All modalities successfully detected perimedullary draining veins in all cases. Location of the AVF was detected in all cases by CA. trMRA and 4D-CTA detected the AVF in three out of the four cases. With regard to flow direction, while 4D-CTA successfully depicted ascending or descending drainage flow in the spinal canal, CA failed to detect the flow direction in one case while trMRA failed in two cases. In the case with epidural AVF, 4D-CTA was the only technique to detect the flow direction of perimedullary drainage. Although this is only an initial experience of the application of 4D-CTA to spinal vascular diseases, 4D-CTA was capable of detecting the dynamic vascular flow of spinal AVFs. The authors believe that 4D-CTA can be a useful option in the evaluation of spinal AVFs.     

<Emphasis Type="Italic">KRAS</Emphasis> and <Emphasis Type="Italic">BRAF</Emphasis> Mutations in 203 Esophageal Squamous Cell Carcinomas: Pyrosequencing Technology and Literature Review

Background

Epidermal growth factor receptor (EGFR) signaling is one of the most promising targets for molecular-targeted therapies in esophageal squamous cell carcinoma (ESCC). Thus, the molecular diagnosis of KRAS and BRAF mutations is clinically important in therapeutic decision making. However, the frequency of KRAS and BRAF mutations in ESCCs remains inconclusive because of the limited sample sizes of previous studies (all N ≤ 80). Pyrosequencing is a nonelectrophoretic nucleotide extension sequencing technology that can be used for mutation testing.

Methods

The frequency of KRAS and BRAF mutations was examined using a nonbiased database of 203 resected ESCCs and a high-throughput pyrosequencing assay.

Results

The validity of the KRAS pyrosequencing method was initially demonstrated by detection of all 4 types of KRAS mutations [c.35G>T (codon 12 GGT>GTT), c.35G>A (codon 12 GGT>GAT), c.34G>T (codon 12 GGT>TGT), c.38G>A mutation (codon 13 GGC>GAC)], which had been previously diagnosed using Scorpion-ARMS technology, in 9 colon cancer tissues (9 of 9; 100 %). Similar results were demonstrated for BRAF mutational status in 3 colon cancer cell lines (HCT116, Colo201, and HT29), which were validated by Sanger dideoxy sequencing. Subsequently, the KRAS mutation was found to be extremely rare (1 of 203; 0.5 %), and the BRAF mutation was absent (0 of 203; 0 %), in the dataset of 203 ESCCs.

Conclusions

These results suggest that KRAS and BRAF mutations play a limited role in the development of ESCC and that mutation analysis is not useful as a screening test for sensitivity to anti-EGFR therapy in ESCC.

     

Kawasaki disease: basic and pathological findings

Kawasaki disease (KD) is considered to be a kind of systemic vasculitis syndrome. It most frequently affects infants and young children and primarily invades medium-sized muscular arteries, including the coronary arteries. The etiology of KD is unknown, but epidemiological data suggest involvement of infectious agents, such as bacteria and viruses, in the onset of KD. In addition, host genetics underlie the disease’s pathogenesis. Histologically, coronary arteritis begins 6–8 days after KD onset, and inflammation of all layers of the artery rapidly ensues. The inflammation spreads completely around the artery, resulting in severe damage to structural components. Then, the artery begins to dilate. KD arteritis is characterized by inflammation consisting of marked accumulation of monocytes/macrophages. Aberrant activation of monocytes/macrophages is thought to be involved in the formation of vascular lesions. Inflammatory-cell infiltration persists until about the 25th day of the disease, after which the inflammatory cells gradually decrease in number. Lesions in all arteries are relatively synchronous, as they evolve from acute to chronic injury. If a giant aneurysm remains or vessel recanalization occurs after thrombotic occlusion of an aneurysm, remodeling of the vascular structure, sometimes including even reocclusion, continues even in the remote stage.     

An MR image of spinal cord sarcoidosis

Abstract

We present a case of spinal cord sarcoidosis with a unique magnetic resonance imaging (MRI) finding. MRI of the cervical spine revealed an unusual lesion of low signal intensity on T2-weighted image at the core of the lesion surrounded by high signal intensity. Tl-weighted gadolinium enhanced image showed a high signal at the core lesion. Low signal intensity on T2-weighted image in the case was suggested to be due to hemosiderin deposition. Steroid therapy dramatically improved clinical symptoms with a marked reduction of peripheral T2 high intensity area and the core lesion size detected by gadolinium enhancement. [Neurol Res 1999; 21: 755-757]     

Surgical treatment of arteriovenous malformations in the lateral ventricle

Ten patients with arteriovenous malformation (AVM) predominantly involving the lateral ventricle were operated upon. All the AVM's were not large, less than 2 cm in diameter. Four AVM's were located in the head of the caudate nucleus; 3 were resected through frontal trans-cortical (transventricular) approach and 1 was excised through anterior transcallosal approach. Two of the former and the latter gave excellent results. Two AVM's located in the temporal horn and trigon in the dominant hemisphere were excised by middle temporal gyrus approach with excellent results. Four AVM's on the dorsal aspect of the thalamus were removed through posterior transcallosal approach with excellent results in 2 and good ones in 1. The brain incision should be as small as possible to enter the lateral ventricle. Position of the patients is also very important. Exposure to excise the AVM's predominantly located in the lateral ventricle is briefly discussed.     

Cognitive behavioural therapy with behavioural analysis for pharmacological treatment-resistant chronic insomnia

This study aimed to determine whether (1) cognitive behavioural therapy with behavioural analysis for insomnia (CBTi-BA) is more effective for insomnia and co-morbid depressive symptoms than treatment as usual (TAU) and (2) whether CBTi-BA promotes earlier reduction of the daily dose of hypnotic medication in chronic insomnia resistant to pharmacological treatment. A total of 63 patients with chronic insomnia aged 20–77 years who already received hypnotic medication regularly were assigned to two interventions: combined therapy or TAU alone. The subjects provided demographic information and completed self-rating scales for insomnia and depressive symptoms. After treatment, the combined therapy group showed significant decreases in the symptoms of both insomnia and depression and significant reductions in the daily dose of hypnotic medication compared with the group receiving TAU alone. In the combined therapy group, 71% of the participants reported a reduction in insomnia to normal levels and 79% succeeded in decreasing the daily dose of hypnotics to 50% or less of the baseline dose. These results revealed that CBTi-BA can reduce insomnia and depressive symptoms as well as the daily dose of hypnotic medication in patients with chronic insomnia resistant to pharmacological treatment.     

Analysis of ischemic cerebral lesions using 3.0-T diffusion-weighted imaging and magnetic resonance angiography after revascularization surgery for ischemic disease

Background

Cerebral revascularization surgery (CRS) is increasingly recognized as an important component in the treatment of complex cerebral vascular disease and tumors. CRS requires that the incidence of perioperative neurological complications should be minimized, because CRS for ischemic disease is often not the goal of treatment, but rather a prophylactic surgery. CRS carries the risk of focal postoperative neurological deficits. Little has been established concerning mechanisms of post-CRS ischemia. We used 3.0-T diffusion-weighted magnetic resonance imaging (DWI) and magnetic resonance angiography (MRA) to analyze the incidence and mechanism of ischemic lesions.

Methods

We studied the anterior circulation territory after 20 CRS procedures involving 33 vascular anastomosis procedures (13 double anastomoses and 7 single anastomoses) in 12 men and 8 women between June 2007 and October 2011. The operations included single or double superficial temporal artery–middle cerebral artery (STA–MCA) anastomosis to treat internal carotid artery/MCA occlusions or severe MCA stenosis. A combined STA–MCA anastomosis and indirect bypass were performed for moyamoya disease. Postoperative DWI and MRA were obtained in all patients between 24 and 96 h after surgery to detect thromboembolism, hypoperfusion, or procedural ischemic complications and vasospasms of the donor STA.

Results

Follow-up DWI and MRA were carried out 1.8 ± 0.6 days after CRS (range, 1–4 days). Temporary occlusion time for anastomoses averaged 18.9 min (range, 16–32 min). Asymptomatic new hyperintensities occurred in the ipsilateral hemisphere of 2 patients on postoperative DWI (10% patients/6.0% anastomoses), and 1 moyamoya patient (5.0% patients/3.0% anastomoses) developed a symptomatic hyperintensity in the ipsilateral occipital lobe in response to the operation. Two abnormal small (<5 mm) cortical DWI lesions were caused by sacrifices of a small branch of the recipient MCA.

Conclusion

This study is the first postoperative 3.0-T DWI study of CRS and related clinical events. The incidence of symptomatic postoperative DWI abnormalities was restricted to 1 moyamoya patient representing 5.0% of total patients and 3.0% anastomoses. Although some postoperative DWI abnormalities occurred, CRS was found to be safe with a low risk of symptomatic ischemia.