Comparison of a Non-Opioid Multimodal Analgesia Protocol with Opioid-Based Patient-Controlled Analgesia for Pain Control Following Robot-Assisted Radical Prostatectomy: A Randomized, Non-Inferiority Trial.

Background: Opioid use after surgery is a potential contributor to the opioid epidemic. An adequate pain control method after surgery while minimizing opioid exposure is needed. This study aimed to compare the effect of non-opioid multimodal analgesia (NOMA) protocol with opioid-based patient-controlled analgesia (PCA) for pain relief after robot-assisted radical prostatectomy (RARP). Methods: This prospective randomized, open, non-inferiority trial included 80 patients scheduled for RARP. The NOMA group received pregabalin, paracetamol, bilateral quadratus lumborum block, and pudendal nerve block. PCA group received PCA. Pain scores, postoperative nausea and vomiting, opioid requirements, and quality of recovery were recorded 48 hours after surgery. Results: We found no significant differences in pain scores. The mean difference in pain score during rest at 24 h was 0.5 (95% CI -0.5 to 2.0). This result demonstrated the non-inferiority of NOMA protocol to PCA at our non-inferiority margin (-1). In addition, 23 patients in the NOMA group did not receive any opioid agonist for 48 h after surgery. Recovery of bowel function was also faster in the NOMA group than in the PCA group (25.0 hours vs 33.4 hours, p = 0.01). Limitations: We did not evaluate whether our NOMA protocol could decrease the incidence of new continuous opioid use after surgery. Conclusion: NOMA protocol successfully controlled postoperative pain and was non-inferior to morphine-based PCA regarding patient-reported pain intensity. It also promoted recovery of bowel function and decreased postoperative nausea and vomiting.

Arterial Stiffness in Subacute Stroke: Changing Pattern and Relationship with Functional Recovery.

BACKGROUND: To examine changing patterns in arterial stiffness and functional outcome in patients with subacute stroke, and to determine which parameter shows a strong correlation with the reversal of arterial stiffness, during a 3-month period of comprehensive rehabilitation therapy. METHODS: This descriptive, observational cohort study enrolled 60 patients (43 male and 17 female; average age, 62.7 years), and all received conventional rehabilitation therapy, during a 3-month period. Brachial-ankle pulse wave velocity (baPWV) was measured as an index of arterial stiffness. Functional assessments included the 6-minute walk test (6MWT), Fugl-Meyer Assessment of hemiparetic upper and lower limbs, the functional ambulatory category, the Berg balance scale, the Korean Mini-Mental Status Examination, and the Korean-Modified Barthel Index. All measurements were conducted at baseline and 1 and 3 months after stroke onset. RESULTS: Rehabilitation therapy resulted in a statistically significant improvement in baPWV since 3 months post stroke. Another functional outcome measure showed statistically significant improvements since 1 month after rehabilitation. Multivariable linear regression analysis revealed that a change in baPWV was significantly correlated with changes in the 6MWT. CONCLUSIONS: Three months of comprehensive rehabilitation therapy led to statistically significant improvements in arterial stiffness and functional outcomes during the subacute phase of stroke. Thus, the comprehensive rehabilitation focused on improving gait endurance would be warranted in subacute stroke patients.

Porphyromonas gingivalis causing brain abscess in patient with recurrent periodontitis.

We report an extremely rare case of Porphyromonas gingivalis causing brain abscess in a patient with recurrent periodontitis. The patient presented with right-sided homonymous hemianopsia and right hemiparesis. Emergent surgical drainage was performed and antibiotics were administered. P. gingivalis was identified from the anaerobic culture of the abscess. The clinical course of the patient improved with full recovery of the neurologic deficit.

Intracranial Vasospasm without Intracranial Hemorrhage due to Acute Spontaneous Spinal Subdural Hematoma.

Spontaneous spinal subdural hematoma (SDH) is very rare. Furthermore, intracranial vasospasm (ICVS) associated with spinal hemorrhage has been very rarely reported. We present an ICVS case without intracranial hemorrhage following SDH. A 41-year-old woman was admitted to our hospital with a complaint of severe headache. Multiple intracranial vasospasms were noted on a brain CT angiogram and transfemoral cerebral angiography. However, intracranial hemorrhage was not revealed by brain MRI or CT. On day 3 after admission, weakness of both legs and urinary incontinence developed. Spine MRI showed C7~T6 spinal cord compression due to hyperacute stage of SDH. After hematoma evacuation, her symptoms gradually improved. We suggest that spinal cord evaluation should be considered in patients with headache who have ICVS, although intracranial hemorrhage would not be visible in brain images.

Non-traumatic spinal epidural haematoma after breath-hold diving.

We report a case of non-traumatic spinal epidural haematoma in a female vocational diver after breath-hold diving. Sudden and repetitive atmospheric changes along diving may cause venous engorgement of the valveless spinal epidural veins. We suggest that repetitive barotrauma was the cause of the spinal epidural haematoma in this patient.

Six nails in the head: multiple pneumatic nail gun head injury.

A 62-year-old man was admitted to our hospital after attempting to commit suicide with a pneumatic nail gun. Six nails were launched. Because the nail head acted as a brake, the launched nail could make a hole in the skull but could not entirely pass it.

Caesalpinia sappan L. ameliorates hypercholesterolemia in C57BL/6 mice and suppresses inflammatory responses in human umbilical vein endothelial cells (HUVECs) by antioxidant mechanism.

Oxidative stress and inflammatory mediators were measured in the plasma and livers of C57BL/6 mice fed a high-cholesterol diet for 14 weeks and in cultured human umbilical vein endothelial cells (HUVECs). Some of the mice fed with the atherogenic diet received drinking water supplemented with 0.01 g of a 70% ethanol extract of Caesalpinia sappan L. (CSLE) per 20 g of body weight. Numerous parameters were determined: concentrations of total, high-, and low-density cholesterol; atherogenic index; plasma trolox equivalent antioxidant capacity (TEAC); levels of hepatic thiobarbituric acid reactive substances (TBARS) and protein carbonyls; and the activities of hepatic antioxidant enzymes, including Cu·Zn-SOD, Mn-SOD, glutathione peroxidase, glutathione reductase, and catalase. HUVECs were stimulated with tumor necrosis factor α (TNFα) and the expression of intracellular reactive oxygen species (ROS), lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), adhesion molecules, inhibitory κBα (IκBα), and nuclear factor κB (NFκB) were measured. Compared to mice fed a hypercholesterolemic diet alone, mice fed a hypercholesterolemic diet supplemented with CSLE exhibited decreased total plasma cholesterol and increased high-density lipoprotein cholesterol, and thus a lower atherogenic index. Furthermore, plasma TEAC and levels of hepatic TBARS and protein carbonyls were significantly decreased in CSLE-supplemented mice (P < 0.05), whereas all hepatic antioxidative indicators were significantly elevated (P < 0.05). In HUVECs stimulated with TNFα, CSLE significantly decreased the expression of intracellular ROS, LOX-1, and adhesion molecules; the degradation of IκBα; and the nuclear translocation of NFκB; in contrast, CSLE induced the expression of Nrf2 and HO-1 (P < 0.05 for all results).

The early detection of recurrence of malignant peripheral nerve sheath tumor by frequent magnetic resonance imaging.

Surgery has a key role in the treatment of malignant peripheral nerve sheath tumors (MPNSTs), but the resectability of paraspinal MPNSTs is only 20%. Therefore, spinal MPNSTs show frequent recurrence and poor prognosis. Local recurrence is much more common than metastasis for MPNSTs, and surgery still has a key role in the treatment of local recurrence. Therefore, it is important that recurrence must be detected before resectability is lost. However, no evidence-based follow-up protocol has been established for MPNST. The authors performed gross total resection in a 34-year-old woman presented with thoracic MPNST. Adjuvant radiotherapy and chemotherapy were not administered since these adjuvant therapies generally do not improve survival in MPNST and may cause additional neurovascular damage. Instead, the authors monitored the primary site every 3 months using magnetic resonance imaging to detect local recurrence at the earliest opportunity. The tumor recurred locally on two occasions without overt symptoms at 21 and 24 months postoperatively. These recurrences were treated successfully by gross total removal.

Cerebral aneurysm in the long fenestration at the middle portion of m1 segment.

We report a unique case of bilateral mirror image M1 aneurysms, one of which was an unruptured aneurysm arising from the proximal end of right middle cerebral artery fenestration with long loop and the other ruptured aneurysm from the contralateral side. We clipped ruptured aneurysm first and unruptured one in three months after the first operation. The difficulties of identifying this unusual vascular anomaly and possible problems during the surgery of an aneurysm at the site of fenestration are discussed with a review of the literature.

Imaging of the walls of saccular cerebral aneurysms with double inversion recovery black-blood sequence.

In this study, we evaluated the wall of saccular cerebral aneurysms (SCAs) using two-dimensional double inversion recovery black-blood sequence (BBDI). We examined 14 patients with an unruptured SCA (USCA). The BBDI was peripheral-pulse gated, and was acquired during the mid-diastolic period. We evaluated whether the aneurysmal wall could be visualized with BBDI, and the wall thickness in the neck and dome portion of the aneurysm was measured in cases with acceptable imaging quality. BBDI demonstrated the USCA walls in ten patients. In four patients, the USCA walls were poorly delineated from the adjacent brain parenchyma or cerebrospinal fluid. The mean aneurysm size was 8.0 mm. The mean thickness of the aneurysmal wall in the neck portion was 0.60 +/- 0.13 mm in 10 cases. The mean thickness at the dome portion was 0.46 +/- 0.05 mm in five cases. In this study, BBDI revealed some portion of the USCA wall, despite the limited spatial and contrast resolution for delineation of the entire USCA wall. In our opinion, this technique may be used as an additional imaging tool for the evaluation of the aneurysmal wall.

Reproducible and persistent weakness in adult rats after surgical resection of motor cortex: evaluation with limb placement test.

OBJECT: The purpose of this study was to develop a new rat model for surgical brain injury with motor weakness and to find an adequate behavior test for the application of the model. METHODS: Thirty rats were divided into three groups: craniectomy (n = 10), durotomy (n = 10), and corticectomy (n = 10) groups. The coordinates of the three points from the bregma (coordinate A = +4,+1, B = -2,+1, and C = +4,+6). We evaluated right limb motor performance by the modified limb placement test and the cylinder test. CONCLUSION: Persistent motor weakness was observed for 2 months in the corticectomy group by the limb placement test, whereas the cylinder test could not detect the weakness. We established a reproducible and persistent rat brain injury model and found that the modified limb placement test is sensitive enough to evaluate residual subtle weakness in this model.

Expression of erythropoietin in the spinal cord of lewis rats with experimental autoimmune encephalomyelitis.

BACKGROUND AND PURPOSE: Erythropoietin (Epo), originally recognized for its central role in erythropoiesis, has been shown to improve the outcomes in patients with various neurological disorders. The aim of this study was to elucidate the Epo expression pattern in the spinal cords of Lewis rats with experimental autoimmune encephalomyelitis (EAE) and to assess the systemic effect of Epo during the course of EAE. METHODS: We used an EAE model induced in Lewis rats by immunization with myelin basic protein. Immunized rats were given recombinant human Epo (rhEpo) intraperitoneally at a dose of 5,000 U/kg for 7 consecutive days, either starting on day 3 post-immunization (five rats) or on the day of clinical symptom onset (score >/=1, five rats). After immunization, the rats were observed daily for clinical signs of EAE. Epo expression was investigated by Western blot analysis and immunohistochemistry. RESULTS: Western blot analysis showed that, Epo expression was significantly elevated relative to control in the rat spinal cord during the peak stage of EAE (p<0.05), and then decreased thereafter. Immunohistochemistry demonstrated that Epo was expressed in some neurons and glial cells. Epo immunoreactivity was detected in ED1-positive macrophages and astrocytes in EAE lesions. Furthermore, we found that the intraperitoneal administration of rhEpo reduced both the disease severity and duration of paralysis in EAE rats, and reduced macrophage activity and increased Epo activity. CONCLUSIONS: Based on these findings, we postulate that Epo expression begins to increase at the start of EAE and that rhEpo administration leads to functional recovery from EAE paralysis.

Spinal congenital dermal sinus with dual ostia.

OBJECT: Congenital dermal sinus (CDS) usually develops in the midline of the body as a single tract. To date, only a few patients with multiple CDS tracts and ostia have been reported. The authors analyzed the clinical features of patients with spinal CDS and multiple ostia and proposed a novel hypothesis for the pathogenesis of the atypical CDS. METHODS: Five patients with spinal CDS and multiple ostia were included. The clinical, radiological, and operative features of these patients were reviewed retrospectively. RESULTS: Three patients demonstrated bilateral paramedian ostia at the same or a very similar spinal level. One patient showed a paramedian and a midline ostium. One patient had 2 unilateral paramedian ostia at different spinal levels. The layers of the internal ending of CDS tracts were diverse. Complete removal of the tracts was possible in all patients. Two patients had dermoid tumors. All patients had an associated anomaly, such as a lumbosacral lipoma or the Currarino triad. The authors propose a "zipping error" hypothesis for the formation of dual ostia located at the spinal level of primary neurulation. An associated anomaly such as a lumbosacral lipoma may contribute to the formation of dual ostia. CONCLUSIONS: Unilateral or bilateral dual ostia may be present in patients with CDS, especially when an associated anomaly is present. The atypical CDS may develop from aberrant neural tube closure.

Cerebellar pilocytic astrocytoma presenting with intratumor bleeding, subarachnoid hemorrhage, and subdural hematoma.

INTRODUCTION: Massive intracranial hemorrhage is a very rare initial presentation of cerebellar pilocytic astrocytomas. There are no reports in the medical literature on a cerebellar pilocytic astrocytoma presenting with intratumor bleeding (ITB), subarachnoid hemorrhage (SAH), and subdural hematoma (SDH). CASE REPORT: A 15-month-old boy presented with lethargy and nausea to our hospital. Magnetic resonance imaging showed a mass with ITB at the left cerebellar hemisphere in addition to SDH in the posterior fossa and SAH at the interpeduncular cistern. The patient underwent emergency surgery. On incising the dura, we found SDH, the tumor was visible at the cerebellar cortex, and near total removal followed. Microscopic examination of tissue sections revealed a pilocytic astrocytoma. DISCUSSION: The authors' case is the first report with a presentation including ITB, SAH, and SDH. The presumed mechanism of the SAH and SDH was leaking of the ITB into subarachnoid and subdural spaces.

Optic pathway glioma: outcome and prognostic factors in a surgical series.

OBJECTS: The goals of this study were to evaluate the surgical outcomes of optic pathway glioma (OPG) and to analyze the prognostic factors related to the progression-free survival. MATERIALS AND METHODS: A retrospective review was conducted on 33 patients who underwent surgery for OPG; these included 15 male and 18 female patients with a mean age of 8.3 years. The mean duration of follow-up was 52 months. RESULTS AND CONCLUSIONS: The preservation rate of ipsilateral vision was 25%, while that of contralateral vision was 83% (P<0.001). There was no remarkable endocrine improvement after surgery. The overall and progression-free survival rates at 5 years were 93.6 and 52.4%, respectively. In our study, the predictors for tumor progression were children younger than 5 years of age (p=0.023) and of female gender (p=0.022). Because of the variable course of OPG, treatment policy should be optimized individually according to patient's status.

Cytokinetics of secondary neurulation in chick embryos: Hamburger and Hamilton stages 16-45.

OBJECTIVES: In an attempt to understand the events in the secondary neurulation in embryonic stage, we investigated cytokinetic changes in the tail bud of normal developing chick embryos. MATERIALS AND METHODS: We investigated chick embryos of Hamburger and Hamilton stages 16-45 by staining for proliferating cell nuclear antigen (PCNA) and applying the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) method. RESULTS AND CONCLUSIONS: The cytokinetics of secondary neurulation have several distinctive properties: a general chronological delay compared to primary neurulation; absence of ventrodorsal differences; larger rostrocaudal differences; and degeneration of the distal end of the spinal cord in the later stages of development. These differences in morphogenetic and cytokinetic behavior between primary and secondary neurulation may help to improve our understanding of anomalies originating during secondary neurulation.

Unilateral (probable) moyamoya disease: long-term follow-up of seven cases.

OBJECTS: Some cases of unilateral involvement have angiographic findings on the affected side which resemble those of definite cases of moyamoya disease (MMD). We analyzed these cases to determine whether the entity "unilateral MMD" actually exists and whether unilateral involvement represents only the early phase of the pathologic process found in definitive bilateral disease. METHODS: Between 1988 and 2000, seven cases of unilateral MMD were evaluated. The male-to-female ratio was 2:5, mean age was 5.1 years (7 months to 8 years), and mean follow-up duration was 64.7 months. The presenting symptoms of these cases were similar to those of definite MMD, and no familial occurrence was found. Two of the seven unilateral MMD cases showed progression to bilateral involvement. However, the remaining cases showed no evidence of contralateral progression during the follow-up period. CONCLUSIONS: Most cases of unilateral MMD seem to be an unusual form of stenoocclusive process of the proximal intracranial arteries, distinguishing the condition from definite MMD. Surgical treatment on the symptomatic side and close observation for signs of bilateral involvement are necessary.

Fetal ventriculomegaly: prognosis in cases in which prenatal neurosurgical consultation was sought.

OBJECT: The prognosis of fetal ventriculomegaly (FVM) varies because of the disease's heterogeneity and the diversity of accompanying anomalies. Moreover, the cases that are referred to neurosurgeons may have different clinical features from those typically encountered by obstetricians. The object of this study was to delineate the prognosis of FVM in cases for which neurosurgical consultation was sought. METHODS: Forty-four cases of FVM that were diagnosed before birth and referred to neurosurgeons for prenatal consultation were analyzed retrospectively. Twenty-five of the 44 patients had accompanying anomalies, but in only three (12%) of the cases were they detected prenatally. Postnatal imaging studies revealed that agenesis of the corpus callosum (nine cases) was the most common associated anomaly. Neuronal migration disorders, periventricular leukomalacia, and arachnoid cysts were present in four cases each, and aqueductal stenosis was present in three cases. Thirty-three patients were followed up longer than 11 months; in 15 (45%) delayed cognitive and/or motor development was documented, and all had accompanying anomalies. All 10 of the patients with isolated FVM exhibited normal development during the follow-up period. Eleven (25%) of the 44 patients underwent neurosurgical interventions for ventriculomegaly, which included ventriculoperitoneal shunt placement in seven cases. Four patients (9%) died. CONCLUSIONS: The authors conclude that delayed development and disturbed functional status in patients in whom FVM was diagnosed prenatally are closely related to the presence of certain accompanying anomalies. On postnatal examination, more than half of the patients in whom the diagnosis of FVM was based on ultrasonography findings and whose parents were offered prenatal neurosurgical consultation were found to have additional anomalies that were not detected prenatally. Because of the possibility of additional undiagnosed anomalies, consulting neurosurgeons should be cautious in giving a prognosis in cases of FVM, even when prenatal ultrasonography reveals isolated ventriculomegaly and tests for intrauterine infection and chromosomal abnormality yield negative results.