Anatomy of the occipital lobe using lateral and posterior approaches: a neuroanatomical study with a neurosurgical perspective on intraoperative brain mapping.

BACKGROUND: A major concern of occipital lobe surgery is the risk of visual field deficits. Extending anatomical occipital lobectomy to the functional requires awake conditions because the anterior resection border comprises language-, motor- and visuospatial function-related areas within the temporal and parietal lobes. This study investigated the lateral and posterior perspectives of the occipital lobe anatomy when approaching intraaxial occipital lobe lesions. MATERIALS AND METHODS: Ten adult cadaveric cerebral hemispheres were dissected after being prepared following the concept described by Klingler for the first time. RESULTS: The occipital lobe was located posteriorly to the parietotemporal line. Within the occipital lobe, the occipital horn of the lateral ventricle represented the only anatomical landmark. Laterally, optic radiation was identified as a part of the sagittal stratum. None of the intraoperatively identifiable tracts was found medial to the occipital horn. Language- and motor-related areas were identified anteriorly and should be actively identified when lobectomy based on function is planned. Subcortically, from a posterior perspective, the anterolateral border constituted the arcuate fascicle/superior longitudinal fascicle complex and was anteromedial to the thalamocortical tract. Remaining posterior to the line connecting the preoccipital notch with the superior Rolandic point avoided the cortical and white matter tracts related to language, motor and visuospatial function. CONCLUSIONS: Knowledge of occipital lobe anatomy and surrounding structures is essential to preoperatively assess the risk of the procedure and proper consultation of a patient in terms of the extent of resection, primarily concerning visual field deficits.

The challenge of comparing digitally captured signatures registered with different software and hardware.

Along with the growing popularity of electronic documents authorised with digitally captured signatures, such evidence has appeared in the work of forensic practitioners. Many different vendors offer signature pads with varying specifications. It is therefore expected that forensic handwriting experts will be called upon to compare questioned and known samples captured with completely or partially different hardware and software combinations. Such cases may be challenging as numerical handwriting data produced by various equipment may differ not only in the type of information captured and its quality, but also in its structure and coding. In this research, numerical data of handwriting - i.e. spatial coordinates, force, and time values - were acquired with 26 different combinations of hardware and software to study characteristics of their coding. The analysis of samples revealed that scaling of numerical data is not only hardware but also software dependent. Therefore, their compliance with the ISO/IEC 19794-7 standard is recommended to improve the data interoperability. This standard emphasizes the importance of supplementing numerical signature data with scaling ratios of the used signing solution. The paper also includes descriptions of several phenomena observed in the acquired data to highlight possible pitfalls in performing inter-solution comparisons in casework.

Features of digitally captured signatures vs. pen and paper signatures: Similar or completely different?

The question of whether digitally captured signatures and conventional signatures executed with a pen on paper differ in their characteristics is of practical relevance for forensic handwriting examiners. Due to gaps in the current literature, the present research is dedicated to this issue. Eighty persons signed in three conditions: a) with a stylus on a pad, b) with an inking pen on a sticky note attached to a signature pad allowing to obtain a digital and an analogue version on paper of one and the same writing simultaneously, and c) with a pen on paper. The first step was to investigate to what extent the character shape and number of pen lifts differ between the digital and analogue representation of one and the same signature. This revealed minor differences which are due to technical characteristics of the devices used. The observed distortions are of minor practical relevance according to ratings by eight participating forensic handwriting examiners. Subsequently, signature characteristics were compared between the three different writing conditions in a casework-oriented way. Statistical multi-level models indicate significant differences between the three signature types, but minor effect sizes in most of the examined characteristics. From the point of view of the participating handwriting examiners, these factors do not fundamentally restrict the comparability between digitally captured and conventional signatures in practice. However, caution should be exercised when generalising the results, as several factors, such as the usage of different signature pads as well as signatures made with the finger instead of a stylus, could result in more important differences compared to pen and paper signatures.

Subsyndromal delirium is associated with poor functional outcome after ischaemic stroke.

BACKGROUND AND PURPOSE: Subsyndromal delirium (SSD) refers to patients with delirious symptoms who do not meet the criteria for delirium. The aim was to determine the prognostic significance of SSD in stroke patients. METHODS: In all, 564 patients with ischaemic stroke (median age 71 years, 50.5% female) were included. The Confusion Assessment Method was used to assess symptoms of delirium and the Diagnostic and Statistical Manual of Mental Disorders, 5th edn, criteria were used to diagnose delirium. SSD was defined as one or more core features of delirium without fulfilling diagnostic criteria. Functional outcome was assessed using the modified Rankin Scale at 3 and 12 months after stroke. RESULTS: Delirium was diagnosed in 23.4% of patients and SSD in 10.3% of patients. SSD was associated with increased risk of poor functional outcome. The adjusted odds ratios (ORs) for unfavourable outcome at 3 and 12 months were 2.88 [95% confidence interval (CI) 1.43-5.79, P < 0.01] and 2.93 (95% CI 1.39-6.22, P < 0.01), respectively. In multivariate analysis, delirium was an independent predictor of poor functional outcome at 3 months (OR 6.41, 95% CI 3.36-12.21, P < 0.01) and 12 months (OR 6.11, 95% CI 3.05-12.27, P < 0.01) after stroke. Delirium was also independently associated with increased risk of death within 3 months (hazard ratio 3.68, 95% CI 1.69-8.02, P < 0.01) and 12 months (hazard ratio 3.76, 95% CI 2.05-6.90, P < 0.01). SSD was not associated with increased risk of death. CONCLUSIONS: In SSD patients the risk of poor functional outcome after stroke is increased and intermediate between patients with and patients without delirium.

The supreme turbinate and the drainage of the posterior ethmoids: a computed tomographic study.

BACKGROUND: It is generally acknowledged that the posterior ethmoidal cells drain under the superior nasal turbinate (SorNT) or, rarely, under the supreme nasal turbinate (SmeNT), and the sphenoid ostium (SO) opens to the sphenoethmoidal recess. However, detailed relations between these structures are variable, complex and still not clear. There is no reliable data on the prevalence of SmeNT and drainage of the posterior ethmoidal cells under this structure. The aim of this study was to re-evaluate the anatomy of the aforementioned region. MATERIALS AND METHODS: Multiplanar and three-dimensional reconstruction analysis of 100 thin slice paranasal sinus computed tomography scans. RESULTS: SmeNT was identified in 77 subjects (136 sides). It formed the ostium to the posterior ethmoidal cell adjacent to the skull base or orbit in 58 subjects (91 sides). This cell drained independently from the remaining posterior ethmoidal cells. The sphenoethmoidal (Onodi) cell drained to supreme meatus in 41 subjects (54 sides), and to superior meatus in 37 subjects (49 sides). SO was always located medial to the posteroinferior attachment of SmeNT, or SorNT (in absence of SmeNT). CONCLUSIONS: Patients with divergent drainage of the posterior ethmoids (with posterior ethmoidal cell draining to the supreme meatus) may require more extensive surgery to avoid persistence or recurrence of inflammatory disease. SmeNT is more common than thought, but due to its posterior and superior location to SorNT, it is rarely seen intraoperatively. If SmeNT is present, SO is always located medial to its posteroinferior attachment. (Folia Morphol 2018; 77, 1: 110-115).

Surgical management of posterior petrous meningiomas.

BACKGROUND AND PURPOSE: The aim of the study is to present our experience in the surgical treatment of posterior petrous meningiomas in regard to clinical presentation, surgical anatomy, complications and long-term functional postoperative results. MATERIAL AND METHODS: A series of 48 consecutive patients operated on for posterior petrous meningiomas at the authors' institution between 2002 and 2011 is reported. The main symptom on first admission was hypoacusis, impairment of the fifth cranial nerve and cerebellar ataxia. The tumour was found to be attached to the premeatal dura in 46%, the inframeatal dura in 29% and the postmeatal dura in 25% of cases. Tumour resection was categorized as grade I in 16 patients, grade II in 29 patients, grade III in 1 patient and grade IV in 2 patients, according to the Simpson classification system. The petrosal approach and retrosigmoid approach were suitable for posterior petrous meningiomas. RESULTS: Postoperative facial nerve dysfunction appeared in 8 and further deteriorated in 2 patients. Hearing function deteriorated after surgery in 8 and improved in 2 cases. Perioperative death occurred in two patients. Tumour recurrence was observed in two patients, and both underwent a second operation and postoperative stereotactic radiotherapy. CONCLUSIONS: Surgical treatment of posterior petrous meningiomas has become increasingly safe but these tumours still remain a surgical challenge because of the relatively high incidence of permanent complications associated with their removal. The site of displacement of the cranial nerves depending on the dural origin of the tumour has the most influence on the related difficulties in its removal.

Electrophysiological correlates of attentional processes in patients with liver cirrhosis without minimal or clinically-overt hepatic encephalopathy.

Liver cirrhosis is often accompanied by a spectrum of cognitive deficits, labelled hepatic encephalopathy (HE). The precise specification of cognitive impairment associated with HE has not been yet elucidated. The aim of this study was an attempt to examine cortical function in cirrhotic patients using EEG event-related potentials during a demanding task involving selective attention. We compared group of 30 patients with liver cirrhosis without minimal or overt HE with education-, age- and sex-matched 29 non-cirrhotic controls. Both groups performed an attentional blink (AB) task, which requires detecting and identifying two target characters in a longer series of rapidly and sequentially presented characters. EEG signals from 32 electrodes were measured and then analyzed in the paradigm of event-related potentials (ERP). Though the groups did not differ in the detection rate of the target stimuli, ERP waveforms revealed two group differences of component amplitudes. The first difference was related to the waveform amplitude within the 200-400 ms after first target in the right frontal region (frontocentral N2 component). Moreover, in patient group this amplitude positively correlated with the blood plasma level of alkaline phosphatase and gamma-glutamyl transpeptidase. The second amplitude difference was observed in the midline parieto-occipital regions within the 400-600 ms after the first target (P3b component). The AB task and ERP analysis allowed to find differences in cortical functioning in cirrhotic patients even without overt cognitive deficits. Our finding demonstrates that liver dysfunction can influence cortical processing associated with detecting and categorizing stimulus change.

Cognitive evoked response potentials in patients with liver cirrhosis without diagnosis of minimal or overt hepatic encephalopathy. A pilot study.

Liver cirrhosis is often accompanied by cognitive deficits called minimal hepatic encephalopathy (MHE) when it is observed to a moderate extent. In the present study, brain activity and cognitive functioning were examined in patients with liver cirrhosis without MHE or overt clinical hepatic encephalopathy. A battery of neuropsychological tests and event related potentials (ERPs) were used. Moreover, an additional n-back task was administered with two difficulty levels (1- and 2-back). This task was designed to engage cognitive processes of storage and manipulation of information in working memory. The participants have to decide whether the letter shown was the same as a target (congruence condition). No significant differences were found in the performance of either the neuropsychological tests or the n-back task. However, the expected effects of decreased performance as well as a decrease in P3 amplitude with difficulty level were identified. The interaction of group x congruence condition was also observed in the P2 component time window. These results may indicate group differences manifesting in early stages of information processing in working memory. It confirms that the patients whose neuropsychological performance is within the normal range can still reveal subtle changes in CNS functioning visible in ERP research. The study confirms the usability of the ERP method in diagnosis of neurocognitive functions in patients with liver cirrhosis, which seems to be more sensitive than neuropsychological tests.

Interleukin 6-174G>C polymorphism and risk of aneurysmal subarachnoid hemorrhage: case-control study and meta-analysis.

OBJECTIVES: Vascular inflammation contributes to the pathogenesis of aneurysmal subarachnoid hemorrhage (aSAH). Interleukin 6 (IL6) is a proinflammatory cytokine involved in many vascular pathologies. Two studies analyzing an association of the functional IL6 gene -174G>C promoter polymorphism with aSAH provided inconsistent results. The aim of this study was to investigate whether this IL6 polymorphism is associated with aSAH in a Polish population. MATERIAL AND METHODS: We genotyped 276 aSAH patients and 581 unrelated control subjects. All were of Caucasian origin. In addition, a meta-analysis combining results of the current and previously published studies was conducted. RESULTS: The distribution of IL6 genotypes and alleles did not differ significantly between aSAH (GG - 29.7%, GC - 50.0%, CC - 20.2%, G - 54.7%) and control subjects (GG - 32.0%, GC - 47.3%, CC - 20.7%, G - 44.3%). In the meta-analysis, the IL6-174G>C polymorphism was not associated with aSAH risk either. CONCLUSIONS: We failed to find an association between the IL6 -174G>C polymorphism and aSAH in analyzed European populations.

Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques.

BACKGROUND: Recent studies have questioned the ability of the transtibial technique to place the anterior cruciate ligament graft within the footprint of the anterior cruciate ligament on the femur. There are limited data directly comparing the abilities of transtibial and tibial tunnel-independent techniques to place the graft anatomically at the femoral attachment site of the anterior cruciate ligament in patients. HYPOTHESIS: Because placement with the tibial tunnel-independent technique is unconstrained by the tibial tunnel, it would allow for more anatomic tunnel placement compared with the transtibial technique. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: High-resolution, multiplanar magnetic resonance imaging and advanced 3-dimensional modeling techniques were used to measure in vivo femoral tunnel placement in 8 patients with the transtibial technique and 8 patients with a tibial tunnel-independent technique. Femoral tunnel placement in 3 dimensions was measured relative to the center of the native anterior cruciate ligament attachment on the intact contralateral knee. RESULTS: The tibial tunnel-independent technique placed the graft closer to the center of the native anterior cruciate ligament attachment compared with the transtibial technique. The transtibial technique placed the tunnel center an average of 9 mm from the center of the anterior cruciate ligament attachment, compared with 3 mm for the tibial tunnel-independent technique. The transtibial technique resulted in a more anterior and superior placement of the tunnel compared with the tibial tunnel- independent technique. CONCLUSION: The tibial tunnel-independent technique allowed for more anatomic femoral tunnel placement compared with the transtibial technique.

Association between hyperglycemia, heart failure and mortality in stroke patients.

BACKGROUND: Acute hyperglycemia predicts increased mortality after stroke. The aim of our study was to determine if acute stroke patients with hyperglycemia suffer from increased rate of in-hospital adverse events which could influence survival such as pneumonia, heart failure and myocardial infarction. METHODS: In a retrospective study with prospective follow-up, 689 patients with first-ever ischaemic stroke and high frequency of cardiovascular diseases were eligible. Follow-up period was 1-7 years (14 308 person-months). RESULTS: The frequency of in-hospital heart failure and nosocomial pneumonia was the highest in patients without pre-hospital diagnosis of diabetes mellitus and with fasting glucose >or=7 mmol/l (50% and 20.2%, respectively) and the lowest in patients without pre-hospital diagnosis of diabetes and fasting glucose

Glucagon-induced vasospasm of hepatic artery branches during visceral angiography.

Glucagon is often used in radiology to decrease bowel motility for enhanced imaging, including visceral digital subtraction angiography. We present a case in which branch hepatic artery vasospasm followed the intravenous administration of glucagon during visceral angiography.

Hypoalbuminemia in acute ischemic stroke patients: frequency and correlates.

OBJECTIVE: Hypoalbuminemia in acute stroke patients is associated with increased mortality and morbidity. The aim of our study was to determine the frequency and correlates of hypoalbuminemia in unselected cohort of patients with acute cerebral infarction. DESIGN: Prospective study. SETTING: University hospital. SUBJECTS: Seven hundred and five consecutive ischemic stroke patients. METHODS: Albumin and other serum protein fractions were measured within 36 h after stroke using electrophoresis. RESULTS: Hypoalbuminemia defined as serum albumin level <35 g/l was found in 45.5% of patients. Serum albumin level correlates significantly with age (r=-0.13, P<0.01), Scandinavian Stroke Scale score (r=0.14, P<0.01), body temperature on admission (r=0.14, P<0.01), leukocyte count (r=-0.17, P<0.01), fasting glucose (r=-0.16, P<0.01), total cholesterol (r=0.14, P<0.01), alpha1-globulin (r=-0.48, P<0.01), alpha2-globulin (r=-0.49, P<0.01), beta-globulin (r=-0.26, P<0.01) and gamma-globulin (r=-0.35, P<0.01). CONCLUSIONS: Hypoalbuminemia is a frequent finding in acute stroke patients and it is associated with more severe stroke and pro-inflammatory pattern of serum protein electrophoresis.

ACE I/D polymorphism in different etiologies of ischemic stroke.

OBJECTIVES: Data concerning an association between angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and ischemic stroke (IS) remain inconsistent. Results of some studies suggest that DD genotype may be a risk factor for small vessel disease (SVD) stroke. Here, we investigated whether this polymorphism is associated with IS of different etiologies in a Polish population. SUBJECTS AND METHODS: Ischemic stroke etiology was established according to the TOAST criteria. We studied 92 stroke patients with large vessel disease and their 184 matched controls; 96 stroke patients with SVD and 192 controls; 180 patients with cardioembolic stroke (CE) and 180 controls. ACE I/D polymorphism was determined using the polymerase chain reaction method. RESULTS: The distribution of ACE genotypes and alleles was essentially the same in all analyzed IS subtypes and their matched controls. CONCLUSIONS: We failed to find an association between ACE polymorphism and etiological subtypes of IS in a Polish population.

Paraoxonase gene polymorphisms and sporadic ALS.

BACKGROUND: The human paraoxonase (PON) gene family consists of three members, PON1, PON2, and PON3, located adjacent to each other on chromosome 7. PON catalytic activity may be influenced by frequent amino acid variants. Chronic exposure to certain chemicals or to environmental factors causing enhanced lipid peroxidation metabolized by paraoxonases may be a risk factor for sporadic ALS (sALS). OBJECTIVE: The aim of this study was to examine the association between PON1 Q192R, PON1 L55M, and PON2 C311S functional polymorphisms and the risk of sALS in a Polish population. METHODS: The authors included 185 patients with a definite or probable diagnosis of sALS (El Escorial Criteria) and 437 healthy controls of similar age and gender. The paraoxonase polymorphisms were studied by PCR and restriction enzyme digestion. RESULTS: Using logistic regression analyses, the C allele of the C311S polymorphism was associated with sALS in dominant and additive models, whereas the R allele of the Q192R polymorphism was associated with sALS in recessive, additive, and dominant models. The authors compared the distribution of haplotypes between cases and controls. The R-C haplotype was overrepresented among cases (odds ratio 3.44, 95% CI: 1.55 to 7.62, p = 0.002). CONCLUSIONS: Frequent amino acid variants in the paraoxonase 1 and paraoxonase 2 genes are associated with sporadic ALS in a Polish population.

Serum albumin level and nosocomial pneumonia in stroke patients.

Hypoalbuminemia is associated with increased risk of infections. The aim of this study was to determine if serum albumin level is an independent predictor of nosocomial pneumonia in stroke patients. Data of 705 consecutive ischemic stroke patients admitted within 24 h after stroke onset were analyzed retrospectively. Serum albumin level was measured within 36 h after stroke onset. Nosocomial pneumonia was found in 10.5% of stroke patients. Patients with pneumonia had significantly lower serum albumin level than those without pneumonia (31.9 +/- 7.5 g/l vs. 35.5 +/- 6.9 g/l) and serum albumin level was associated with risk of pneumonia on multivariate analysis (OR: 0.95, 95% CI: 0.91-0.98). Our results show that serum albumin level is an independent predictor of nosocomial pneumonia in stroke patients.

DD genotype of ACE gene is a risk factor for intracerebral hemorrhage.

Genetic factors may play a role in susceptibility to stroke. The angiotensin converting enzyme (ACE) gene is a candidate gene for two phenotypically different types of stroke affecting small perforating arteries: spontaneous intracerebral hemorrhage (SIH) and ischemic stroke due to small vessel disease (SVD). The authors report evidence that ACE gene DD homozygosity of the I/D polymorphism in intron 16 is an independent risk factor for SIH, and not for SVD stroke, in a Polish population.