Perioperative outcomes and complications associated with allogeneic duraplasty for the management of Chiari malformations Type I in 48 pediatric patients.

OBJECT: The authors debate the optimal management for Chiari malformation Type I (CM-I) while sharing their experience with posterior fossa decompression and duraplasty (PFDD). METHODS: The charts of 48 consecutive pediatric patients surgically treated for CM-I were retrospectively reviewed. RESULTS: Patients ranged in age from 2 to 17 years with an average age of 9.8 years. The most common presentations were headache, affecting 34 patients (71%), and pain (neck, back, or extremities), affecting 21 patients (44%). Twenty-seven patients (56%) had a syrinx. All 48 patients underwent PFDD utilizing acellular tissue matrix. The average hospital stay overall was 3.56 days, whereas the average stay for patients with (29 [60%] of 48) or without (19 [40%] of 48) scoliosis and/or syringomyelia was 3.72 and 3.32 days, respectively. The odds of a patient having a hospital stay of 4 or more days was nearly 3 times greater in patients with scoliosis and/or syringomyelia as compared with patients without either condition (OR 2.73, 95% CI 0.74-10.11, p = 0.1330). The average hospital stay for patients 0-8 years of age was 3.29 days; and for those 9-17 years of age, 3.78 days. The odds of a patient having a hospital stay of 4 or more days was nearly 4 times greater in 9- to 17-year-olds as compared with 0- to 8-year-olds (OR 3.73, 95% CI 1.03-13.52, p = 0.0455). Forty patients (89%) experienced early improvement in their signs and symptoms following PFDD. There were 2 revision PFDDs (4%). CONCLUSIONS: Posterior fossa decompression and duraplasty is a safe and effective surgical option in the management of pediatric CM-I.

A functional magnetic resonance imaging study of factors influencing motor function after surgery for gliomas in the rolandic region.

BACKGROUND: Pre- and postoperative fMRI was performed in patients with rolandic gliomas to evaluate factors influencing motor function after surgery. METHODS: The study population consisted of 9 right-handed patients (mean age, 43.3 years; range, 25-67, 2 female/7 male) affected by high-grade gliomas growing within or adjacent to the rolandic cortex. Patients had a diverse onset and evolution of their disease. All patients underwent morphological imaging and fMRI on a 3-T scanner before and after surgery. Postprocessed imaging data were analyzed off-line using SPM. RESULTS: Patterns of activation in real-time maps and SPM were similar when coregistered head motion artifacts did not exceed more than 50% voxel size of the echo-planar imaging sequence. Movements of the hand opposite the affected hemisphere showed activation of the cMI in all patients. Coactivation of the iMI occurred in 5 patients. The cMII was activated in 4 patients, all with excellent postoperative motor function. The iMII and SMA were activated in patients with a good functional outcome. When the unaffected hand was tested, this activation pattern was similar. Postoperative fMRIs were comparable with the preoperative scans. CONCLUSIONS: Postoperative evaluation is feasible and may add confirmatory information to preoperative findings in selected patients. Bilateral activation of primary and secondary motor areas may be the correlate for compensatory recruitment of additional functional areas and a predictor for better functional outcome.

The relationship of cognitive retraining to neurological patients' driving status: the role of process variables and compensation training.

PRIMARY OBJECTIVE: To explore the relationship of cognitive retraining performance to discharge driving status. METHODS AND PROCEDURES: One hundred and three brain-injured patients from a holistic milieu-oriented work/school re-entry programme. EXPERIMENTAL INTERVENTIONS: Initial, last, mean, and best cognitive retraining scores; Behavioural Checklist ratings; Working Alliance (WA) scores. MAIN OUTCOMES AND RESULTS: At the time of discharge, 50.5% of the sample were cleared to drive. Better performance on a cognitive retraining task addressing information processing and motor speed, focused attention, visual scanning and memory was associated with clearance to drive. Patients' behavioural approach to cognitive retraining tasks (use of compensations, organizational and procedural skills) and higher mean and discharge WA scores with staff were associated with driving clearance. Higher mean WA scores were also related to an enhanced behavioural approach to cognitive retraining tasks, including timeliness to sessions, compensation use, better communication pragmatics, decreased distractibility and the ability to apply the 'big picture' benefits of cognitive retraining to the 'real world'. CONCLUSIONS: Cognitive retraining exercises that incorporate skill remediation, 'process' variables and metacognitive skills, as well as a better WA with patients, positively related to clearance to drive at the time of discharge from a holistic milieu-oriented programme.

A family experiential model of recovery after brain injury.

The Family Experiential Model (FEM) described in this article is a therapeutic "navigation tool" for families traversing the recovery process with their loved one after brain injury. Its conception furnishes a personal voice and the pragmatic "stoplight model" depicts how the family's myriad of powerful emotions affects the chosen path in the rehabilitation and recovery process. As an example of mentalizing, the FEM is a healing tool that instills mutual insight and empathy among the family, psychotherapist, and patient. The application of the FEM to individual and group treatment in a holistic treatment milieu is also described.

The fate of medical knowledge and the neurosciences during the time of Genghis Khan and the Mongolian Empire.

In 25 years, the Mongolian army of Genghis Khan conquered more of the known world than the Roman Empire accomplished in 400 years of conquest. The recent revised view is that Genghis Khan and his descendants brought about "pax Mongolica" by securing trade routes across Eurasia. After the initial shock of destruction by an unknown barbaric tribe, almost every country conquered by the Mongols was transformed by a rise in cultural communication, expanded trade, and advances in civilization. Medicine, including techniques related to surgery and neurological surgery, became one of the many areas of life and culture that the Mongolian Empire influenced.

The relationship of cognitive retraining to neurological patients' work and school status.

PRIMARY OBJECTIVE: To explore the relationship of cognitive retraining performance to discharge productivity status. METHODS AND PROCEDURES: One hundred and one brain-injured patients from a holistic milieu-oriented work/school re-entry programme. EXPERIMENTAL INTERVENTIONS: Initial, last, mean and best cognitive retraining scores; cognitive retraining behavioural checklist ratings; and working alliance scores. MAIN OUTCOMES AND RESULTS: Most (82.2%) of the sample returned to paid work or school. Better performance on two cognitive retraining tasks addressing information processing speed, visual scanning, visuospatial skills and memory were associated with return to the same level of work/school with and without modifications. Selected process variables related to the patients' behavioural approach to cognitive retraining tasks (e.g. their use of compensations, organizational and abstraction skills, procedural skills and unassisted task recall) were associated with better work/school outcomes. Patients' positive working alliance ratings related to their behavioural approach to cognitive retraining tasks. This highlights the importance of combining interventions targeting both the therapeutic interactive process and skill remediation to maximize work/school reintegration. CONCLUSIONS: Cognitive Retraining exercises that incorporate both process variables and metacognitive skills, as well as a better working alliance with patients, positively related to return to work and school at the time of discharge from a holistic milieu-oriented programme.

Rudolf Ludwig Karl Virchow: pathologist, physician, anthropologist, and politician. Implications of his work for the understanding of cerebrovascular pathology and stroke.

The history of apoplexy and descriptions of stroke symptoms date back to ancient times. It was not until the mid-nineteenth century, however, that the contributions of Rudolf Ludwig Karl Virchow, including his descriptions of the phenomena he called "embolism" and "thrombosis" as well as the origins of ischemia, changed the understanding of stroke. He suggested three main factors that conduce to venous thrombosis, which are now known as the Virchow triad. He also showed that portions of what he called a "thrombus" could detach and form an "embolus." Thus, Virchow coined these terms to describe the pathogenesis of the disorder. It was also not until 1863 that Virchow recognized and differentiated almost all of the common types of intracranial malformations: telangiectatic venous malformations, arterial malformations, arteriovenous malformations, cystic angiomas (possibly what are now called hemangioblastomas), and transitional types of these lesions. This article is a review of the contributions of Rudolf Virchow to the current understanding of cerebrovascular pathology, and a summary of the life of this extraordinary personality in his many roles as physician, pathologist, anthropologist, ethnologist, and politician.