Impact of Body Mass Index on Activities of Daily Living in Inpatients with Acute Heart Failure.

OBJECTIVES: To investigate the impact of body mass index on activities of daily living in inpatients with acute heart failure. DESIGN: A retrospective cohort study. SETTING: A hospital-based database contains Diagnosis Procedure Combination survey data from 100 participating acute-care hospitals. PARTICIPANTS: 11,301 inpatients aged 20 year or older who were admitted to the participating hospitals with a diagnosis of acute heart failure. MEASUREMENTS: The Barthel Index score at discharge and hospital death. RESULTS: The number of patients with a body mass index of <18.5 kg/m2 (underweight), 18.5-22.9 kg/m2 (low-normal weight), 23.0-24.9 kg/m2 (high-normal weight), 25.0-29.9 kg/m2 (overweight), and ≥30.0 kg/m2 (obesity) were 1689 (15%), 4715 (42%), 1809 (16%), 2306 (20%), and 782 (7%), respectively. Median Barthel Index scores at admission and discharge were 65 and 100, respectively. Hospital death occurred in 101 (0.9%) patients. Lower body mass index was associated with lower Barthel Index score at discharge and higher mortality. Multivariable analysis adjusted for body mass index, age, sex, New York Heart Association classification, Barthel Index score at admission, the updated Charlson Comorbidity Index, length of hospital stay, number of drugs administered, and rehabilitation during hospitalization revealed that body mass index was independently associated with Barthel Index score at discharge (beta: 0.354; 95% confidence interval: 0.248-0.461) and hospital death (odds ratio: 0.926, 95% confidence interval: 0.877-0.978). CONCLUSION: Overweight and obese inpatients showed greater independence in activities of daily living at discharge and lower rates of mortality, indicating the obesity paradox. A combination of rehabilitation and improved nutrition seems to be important in underweight patients with acute heart failure.

Malignant transformation of pleomorphic xanthoastrocytoma.

A 31-year-old woman presented with a pleomorphic xantho-astrocytoma (PXA) manifesting as epilepsy. The tumour was partially resected. Histological examination revealed cellular pleomorphism and cytoplasmic vacuolation consistent with PXA, but no mitoses, necrosis, or endothelial proliferation. Follow-up neuro-imaging showed the residual tumour had grown rapidly with dissemination in the spinal cord. The recurrent lesion was totally resected and was shown to be glioblastoma. The patient has survived without signs of recurrence for 36 months after adjuvant radiochemotherapy. The biological behaviour of PXA cannot be predicted based on the histological features and careful follow up is essential.

Neuromagnetic separation of secondarily bilateral synchronized spike foci: report of three cases.

To demonstrate the high spatiotemporal resolution of magnetoencephalography (MEG), we report three cases with focal epilepsy that exhibited bilateral synchronized spikes on simultaneous scalp EEG and MEG recording. Constant time lags (19.4 +/- 3.0 ms and 20.0 +/- 5.5) between the leading and the following contralateral spikes were noted on MEG and the current dipole sources were localized in the bilateral homotopic regions symmetrically in Cases 1 and 3. In Case 2, MEG indicated leading spikes in the left frontal region, with a time lag of 42.3 +/- 8.4 ms to reach the contralateral frontal and bilateral temporal regions as well. Chronic subdural EEG recording in Cases 1 and 2 confirmed that the leading spike focus in MEG was close to the seizure onset zone in cortical EEG. Spatio-temporal analysis of MEG spikes may be useful to identify the primary epileptic region in patients with synchronized bilateral epileptiform discharges.

Mesial temporal lobe epilepsy with lateral temporal lobe abnormalities in magnetoencephalography and glucose metabolism.

Magnetoencephalography (MEG) and positron emission tomography (PET) revealed abnormal findings in the lateral temporal lobe of a 22 year old female with mesial temporal lobe epilepsy. Electroencephalography identified the epileptogenic focus in the left mesial temporal lobe and standard anterior temporal lobectomy resulted in a good surgical outcome. These discrepancies can be explained by the presence of anatomical and functional pathways between the mesial and lateral temporal structures, or pathophysiological abnormalities in both the mesial and lateral temporal lobes. Careful evaluation is necessary for analysis of MEG and PET findings in patients with temporal lobe epilepsy.

Severe bradycardia during epilepsy surgery.

Several kinds of arrhythmia are known to occur during epileptic seizure, and bradycardia has been reported in patients with temporal lobe epilepsy. The authors review the anesthesia records of patients with intractable epilepsy. Forty-two consecutive patients with intractable epilepsy who underwent epilepsy surgery were examined. Anterior temporal lobectomy was performed on 29 patients, frontal lobectomy on 2 patients, and a subdural electrode was set on 11 patients. Anesthesia was induced with propofol, fentanyl, and vecuronium and maintained with sevoflurane-fentanyl, propofol-fentanyl, or fentanyl-droperidol. Severe bradycardia (13-39 beats/min) was seen in six patients. All six patients recovered within 1 minute of interrupting the surgical procedure and administering intravenous atropine, and the surgeries were completed with no complications. The authors believe the six events were sinus bradycardias. They all occurred during amygdalo-hippocampectomy in cases of temporal lobectomy. This type of hemodynamic change was not seen in any of the patients undergoing temporal lobectomy without hippocampectomy, in patients undergoing frontal lobectomy, or when setting subdural electrodes. Experimentally, it has been shown that stimulation of the limbic system, such as the hippocampus, amygdala, and insular cortex, induces bradycardia and hypotension resulting from increased parasympathetic flow via the vagus nerve. Severe bradycardia may thus occur during surgery for temporal lobe epilepsy, and hemodynamic changes should be watched carefully during amygdalo-hippocampectomy.

Effect of nitrous oxide on spike activity during epilepsy surgery.

There are controversies over the effect of nitrous oxide on the electrocorticograms in patients with epilepsy. To clarify the effect of nitrous oxide on electrocorticograms, spike activities were compared with and without nitrous oxide under neuroleptoanesthesia in 10 patients with intractable epilepsy during surgery. Spikes decreased with nitrous oxide significantly (P<0.01) and disappeared in 3 cases. We conclude that discontinuation of nitrous oxide should be taken into consideration during electrocorticographic monitoring in epilepsy surgery.

[Diffusion-weighted magnetic resonance imaging (MRI) in acute brain stem infarction].

Diffusion-weighted magnetic resonance imaging (DWI) provides one of the earliest demonstrations of ischemic lesions. However, some lesions may be missed in the acute stage due to technical limitation of DWI. We therefore conducted the study to clarify the sensitivity of DWI to acute brain stem infarctions. Twenty-eight patients with the final diagnosis of brain stem infarction(midbrain 2, pons 9, medulla oblongata 17) who had been examined by DWI within 24 hours of onset were retrospectively analyzed for how sensitively the initial DWI demonstrated the final ischemic lesion. Only obvious(distinguishable with DWI alone without referring clinical symptoms and other informations) hyperintensity on DWI was regarded to show an ischemic lesion. Sixteen(57.1%) out of 28 patients had brain stem infarctions demonstrated by initial DWI. In the remaining 12 cases, no obvious ischemic lesion was evident on initial DWI. Subsequent MRI studies obtained 127 hours, on average after the onset showed infarction in the medulla oblongata in 11 cases and in the pons in one case. Negative findings of DWI in the acute stage does not exclude possibility of the brain stem infarction, in particulary medulla oblongata infarction.

Remote discharges in the posterior language area during basal temporal stimulation.

A 23-year-old woman with refractory complex partial seizures underwent implantation of subdural grid electrodes over the left hemisphere to map epileptic foci and language function. Aphasic symptoms occurred during stimulation of the basal temporal area, which were always associated with intrastimulus remote discharges (ISRDs) in the classical posterior language area. No sequential language deficits occurred after anterior temporal lobectomy including the basal temporal area. These results suggest a close functional relationship between the basal temporal area and posterior language area in patients with temporal lobe epilepsy. ISRDs may explain the paradoxical observation that resection of the basal temporal language area results in no language deficits.

Surgical treatment of pineal region tumours through the occipital transtentorial approach: evaluation of the effectiveness of intra-operative micro-endoscopy combined with neuronavigation.

OBJECT: To determine the efficacy and accuracy of surgically-assisted systems including endoscopy combined with neuronavigation in the treatment of pineal region tumours through the occipital transtentorial approach, an evaluation of thirty-one patients undergoing surgery was performed over a 10-year period. METHOD: The study was performed in 2 parts. The surgical approach to the pineal region was the same in the two parts, but in part 2 a smaller craniotomy window was used. Part 1 (from March 1989 to March 1997) included 15 patients who underwent surgical removal of pineal region tumours without using assisted systems; four out of the fifteen patients had surgery-related complications, including seizure and hemianopsia. Part 2 (from April 1997 to February 1999) included 16 patients who underwent surgical treatment by the same surgical team and with assisted systems; all 16 patients had excellent outcomes, with no complications. CONCLUSIONS: Although this study was the first specifically to examine the efficacy of endoscopy combined with neuronavigation in the treatment of pineal region tumours, our findings suggest that these systems are very useful, safe, and accurate in evaluating the primary tumour and surrounding anatomy as well as in determining operative strategy, such as the location and size of the scalp incision, craniotomy, and the extent of surgical removal. Therefore, we conclude that the addition of endoscopy combined with neuronavigation to standard surgical procedures can improve the outcome of surgical treatment of pineal region tumours.

[Pathological features of dysembryoplastic neuroepithelial tumor (DNT): study of five surgical cases with intractable epilepsies].

The dysembryoplastic neuroepithelial tumor (DNT), characterized by its favorable prognosis, must be precisely differentiated from other gliomas to prevent overtreatment by radio/chemotherapy. We studied, here, pathological features of five surgical cases of DNT with intractable epilepsies. There were two males and three females with a median age of 20.4 years (range 12-41). We evaluated lesional topography, gross appearances and microscopic findings including immunohistochemical data. One tumor was located in the temporal lobe, another two in the parietal lobe, another in the occipital lobe, and the other one in the occipito-parietal junction. The lesions were predominantly intracortical in all cases. Macroscopically, two tumors were grayish-soft, another two were yellowish-elastic, and the other one was resected as soft-mucinous fragments. Microscopically, the main glial components were oligodendrocyte-like cells (OLCs) in all cases, except for one case in which atypical glial cells were also prominent. Histopathological characteristics of the DNTs included the specific glioneuronal elements (the mixture of OLCs and neurons) in four cases, alveolar pattern (all cases), microcystic degeneration (all cases), multinodular architecture (four cases), and adjacent cortical dysplasia (all cases). Immunohistochemically, Ki-67 labelling indices ranged from 0 to 0.8%. OLCs were positive for glial fibrillary acidic protein in two cases, for S-100 protein in all cases, for synaptophysin in two cases, and for class III beta tubulin in all cases. Pathological features of our cases were characterized by its heterogeneous histological appearances and divergent cellular differentiation.

Anterior sacral meningocele completely occupied by an epidermoid tumor.

A 2-year-old girl presented with an anterior sacral meningocele completely occupied by an epidermoid tumor. Preoperative magnetic resonance imaging had shown the meningocele with contents of the same intensity as cerebrospinal fluid. Surgery via a posterior sacral approach disclosed the tumor beneath an unexpected membrane inside the meningocele. Additionally, the presence of pus inside epidermoid tumor suggested that possible episodes of asymptomatic meningitis or other infection might have occurred before treatment, these being the major complication in anterior sacral meningocele. Therefore, we recommend that surgical treatment should be performed at the earliest possible stage in childhood, once the diagnosis is established, and dural plasty carried out to prevent infectious complications.

Glucose metabolism in the human cerebellum: an analysis of crossed cerebellar diaschisis in children with unilateral cerebral injury.

Using high-resolution positron emission tomography (PET), we have recently described the normal pattern of glucose utilization in 11 anatomical regions of the human cerebellum. In the present study, we evaluated the phenomenon of crossed cerebellar diaschisis in 40 patients (mostly children) with unilateral cerebral injury sustained at various periods of brain development. Diaschisis refers to a functional impairment at a remote site following injury to an anatomically connected area of brain and, presumably due to a loss of afferent input to the remote site. Of the 40 patients, 11 had sustained their cerebral injury prenatally, 7 in the perinatal period (+/- 24 hours of birth), and 22 postnatally (1 day to 15 years). Crossed cerebellar hypometabolism was seen in 22 patients; symmetric cerebellar metabolism was found in 16 subjects. The presence of crossed cerebellar hypometabolism was typically associated (75% of cases) with a postnatal injury, while symmetric cerebellar metabolism was seen only in patients with injury occurring prior to 4 weeks of age (13 of the 16 had prenatal or perinatal insults). A third pattern of cerebellar metabolism, consisting of paradoxical crossed cerebellar hypermetabolism, was seen in two patients; both had sustained their cerebral injury at 4 months of age. These findings suggest the presence of considerable plasticity, which is dependent on age at injury, in the cerebrocerebellar pathway of developing brain.

Glucose metabolism in the human cerebellum: anatomical-functional correlations.

Functional maturation of human cerebellar structures was previously difficult to evaluate with positron emission tomography (PET) because of scanner resolution. Only vermis and cerebellar hemispheres could be reliably identified with 2-deoxy-2[18F]fluoro-D-glucose (FDG) PET. In the present study, we have used a new high resolution PET system, the Siemens EXACT-HR, to study, in depth, the patterns of glucose metabolism in various cerebellar structures. Due to the orientation of the cerebellar fissures which are important landmarks, the largest number of regions could be identified when the cerebellar regions were displayed on coronal planes. The high resolution PET images, together with magnetic resonance imaging (MRI) data and standard atlases, now allow identification of the following cerebellar structures: anterior vermis, posterior vermis, dentate nucleus, anterior lobe, posterior quadrangular lobule, superior semilunar lobule, inferior semilunar, gracile, and biventer lobules, tonsil, and cerebellar white matter. These cerebellar regions are displayed in an atlas format together with magnetic resonance images to allow easy identification. The present study is a prerequisite for detailed PET analyses of cerebellar metabolism in children with diseases of the cerebellum.

[A case of tectal glioma].

A case of tectal glioma with mild choked disc is reported. An 11-year-old boy was admitted to our hospital because of visual disturbance and choked disc. Neurologically, the patient had nothing but choked disc. Magnetic resonance imaging (1.5T) was performed. Relative T1 weighted image showed a lesion of low signal intensity, and T2 weighted image showed high intensity, about 1.0 x 1.0 cm in size, at the pineal region. The sagittal view showed a mass at the tectum, and stenosis of the aqueduct. It was diagnosed as tectal glioma. Left occipital craniotomy was performed and the tumor was removed subtotally. Histological examination demonstrated a fibrillary astrocytoma. Radiochemotherapy was performed postoperatively. Tectal glioma is very rare. The differential diagnosis from germ cell tumor or pineal cyst is essential for treatment. The authors performed an operation in order to remove the tumor and determine the course of treatment.