Cerebral artery overexpression of the NMUR1 gene is associated with moyamoya disease: a weighted gene co-expression network analysis.

INTRODUCTION: This study aimed to elucidate mechanisms underlying moyamoya disease (MMD) pathogenesis and to identify potential novel biomarkers. We utilized gene coexpression networks to identify hub genes associated with the disease. METHODS: Twenty-one middle cerebral artery (MCA) samples from MMD patients and 11 MCA control samples were obtained from the Gene Expression Omnibus (GEO) dataset, GSE189993. To discover functional pathways and potential biomarkers, weighted gene coexpression network analysis (WGCNA) was employed. The hub genes identified were re-assessed through differential gene expression analysis (DGEA) via DESeq2 for further reliability verification. An additional 4 samples from the superficial temporal arteries (STA) from MMD patients were obtained from GSE141025 and a subgroup analysis stratified by arterial type (MCA vs. STA) DGEA was performed to assess if the hub genes associated with MMD are expressed significantly greater on the affected arteries compared to healthy ones in MMD. RESULTS: WGCNA revealed a predominant module encompassing 139 hub genes, predominantly associated with the neuroactive ligand-receptor interaction (NLRI) pathway. Of those, 17 genes were validated as significantly differentially expressed. Neuromedin U receptor 1 (NMUR1) and thyrotropin-releasing hormone (TRH) were 2 out of the 17 hub genes involved in the NLRI pathway (log fold change [logFC]: 1.150, p = 0.00028; logFC: 1.146, p = 0.00115, respectively). MMD-only subgroup analysis stratified by location showed that NMUR1 is significantly overexpressed in the MCA compared to the STA (logFC: 1.962; p = 0.00053) which further suggests its possible localized involvement in the progressive stenosis seen in the cerebral arteries in MMD. CONCLUSION: This is the first study to have performed WGCNA on samples directly affected by MMD. NMUR1 expression is well known to induce localized arterial smooth muscle constriction and recently, type 2 inflammation which can predispose to arterial stenosis potentially advancing the symptoms and progression of MMD. Further validation and functional studies are necessary to understand the precise role of NMUR1 upregulation in MMD and its potential implications.

Improving time for administration of second-line antiseizure medications for children with generalized convulsive status epilepticus using quality improvement methodology.

OBJECTIVE: Status epilepticus is a life-threatening neurological emergency. However, delay in median time to administration of second-line antiseizure medication exists. The aim of this quality improvement initiative was to decrease the average delay before fosphenytoin is administered for pediatric patients with generalized convulsive status epilepticus from 30 min (baseline data collected in 2013) to 15 min (50% reduction) by December 2015 and sustain this for 1 year. METHODS: Our team conducted an analysis of baseline data for patients with continuous generalized convulsive status epilepticus who received fosphenytoin after receiving first-line benzodiazepine treatment. Using quality improvement methodology, areas for improvement were identified and specific interventions developed and implemented. A timeline of 15 min to initiate fosphenytoin administration after failure of first-line treatment was considered reasonable and achievable as a project aim. RESULTS: A total of 199 patients were included in the dataset for the project. The database included patients aged 1 month and older. Ninety-eight percent of patients were between 1 month and 19 years of age. The gender distribution was even, with 54% of patients being White or Caucasian, 30% African American or Black, and 16% classified as "other." From January 2014 through December 2019, the average time before initiating fosphenytoin administration after failure of benzodiazepine therapy, for patients with generalized convulsive status epilepticus, decreased from 30 min (SD = 45.7) to 11.4 min (SD = 8.2, p = .043), thus reducing time to administration by 62%. SIGNIFICANCE: Quality improvement methodology can be successfully applied to decrease administration time between first- and second-line antiseizure medications for status epilepticus.

YouTube as a source of information for narcolepsy: A content-quality and optimization analysis.

YouTube is the world's most popular video-sharing site that in recent years has become an important platform for patients in finding educational information about their disease. The purpose of this study was to assess the quality and reliability of narcolepsy-related YouTube videos. We searched the key terms "Narcolepsy", "Narcolepsy-cataplexy," "Narcolepsy excessive daytime sleepiness" and "Narcolepsy excessive drowsiness" on YouTube. 80 videos were analyzed as they meet the inclusion criteria. Quantitative and qualitative metrics were recorded and the videos were scored using the DISCERN instrument by two independent raters. Our findings show that the majority of videos contained clear information (84%), symptoms (78%) and patient experience (69%). Most videos were published by an educational channel not representing a hospital or clinic (41%) or by a patient suffering from the disease (25%). Videos containing animations had a statistically significant correlation between average daily views (p = .0004) and the video power index (p = .0048), suggesting that this feature increased the popularity among viewers. The mean DISCERN score was 27 ± 8, indicating that the quality of narcolepsy related-videos is poor. Therefore, patients that use YouTube as an educational tool are currently not attaining a comprehensive understanding of the disease. For this reason, we have indicated the top 5 videos that physicians can recommend to their patients. Our paper highlights the gaps of knowledge concerning narcolepsy information on YouTube. Therefore, this information can be used to create better educational content in the future.

YouTube as a source of patient information for Coronavirus Disease (COVID-19): A content-quality and audience engagement analysis.

YouTube is the second most popular website in the world and is increasingly being used as a platform for disseminating health information. Our aim was to evaluate the content-quality and audience engagement of YouTube videos pertaining to the SARS (severe acute respiratory syndrome)-CoV-2 virus which causes the Coronavirus Disease 2019 (COVID-19), during the early phase of the pandemic. We chose the first 30 videos for seven different search phrases: "2019 nCoV," "SARS CoV-2," "COVID-19 virus," "coronavirus treatment," "coronavirus explained," "what is the coronavirus" and "coronavirus information." Video contents were evaluated by two independent medical students with more than 5 years of experience using the DISCERN instrument. Qualitative data, quantitative data and upload source for each video was noted for a quality and audience engagement analysis. Out of the total 210 videos, 137 met our inclusion criteria and were evaluated. The mean DISCERN score was 31.33 out of 75 possible points, which indicates that the quality of YouTube videos on COVID-19 is currently poor. There was excellent reliability between the two raters (intraclass correlation coefficient = 0.96). 55% of the videos discussed prevention, 49% discussed symptoms and 46% discussed the spread of the virus. Most of the videos were uploaded by news channels (50%) and education channels (40%). The quality of YouTube videos on SARS-CoV-2 and COVID-19 is poor, however, we have listed the top-quality videos in our article as they may be effective tools for patient education during the pandemic.

Prognostic potential of CK-19 managing disseminated oral squamous cell carcinomas in Pakistan: A descriptive cross-sectional study.

A cross-sectional study was conducted to assess the adoptability of CK-19 as a routine diagnostic assay and potential prognostic marker following disseminated oral squamous cell carcinoma in Pakistani population. The current descriptive study was conducted at Isra Dental College Hospital, Isra University, Hyderabad, Pakistan. Suspected patients of oral squamous cell carcinomas (OSCC), who visited the Isra Dental College Hospital's outpatient department from January 2014 up to January 2015 with four year follow up (from January 2015 up to December 2019), were included after ethical approval of the Institutional board. SPSS version 21.0 was used for data analysis. Sixty cases of oral squamous cell carcinoma (OSCC) were selected for CK-19 quantification by using PCR before and after incisional biopsy. Of the 60 included subjects, fifty-two (87 %) were male, whereas only 8 were female. The mean age of females was 43.2±21.5years and the mean age of males was 36.14±14.1years. Of the 12 CK-19 positive cases, only seven cases of OSCCs were found positive following four year follow up duration. Our study shows that CK-19 has a positive (20%) prognostic potential for diagnosing disseminated carcinomas (p=0.0001). Before adopting CK-19 as a routine laboratory assay for diagnosing disseminated carcinomas, proper research is required to fulfil existing knowledge gap and standardising clinical and histopathological criteria for disseminating OSCCs in parallel to CK-19 concentration.

YouTube as a source of patient information on brain aneurysms: a content-quality and audience engagement analysis.

INTRODUCTION: The internet allows patients to access a vast amount of health information. We aimed to evaluate the credibility of YouTube videos that members of the public are accessing on brain aneurysms, and to evaluate what characteristics drive audience engagement. MATERIAL AND METHODS: The first 50 videos for each of the following search terms were taken for analysis: 'brain aneurysm', 'cerebral aneurysm' and 'intracranial aneurysm'. The quality of each video was evaluated by two neurosurgeons and two medical students independently using the Journal of the American Medical Association (JAMA) and the DISCERN instruments. Qualitative and quantitative video data was analysed for quality and audience engagement. Inter-rater agreement was ascertained. RESULTS: Out of a total of 150 videos, 70 met the inclusion criteria. The mean total DISCERN score was 36.5 ± 8.4 (out of 75 points), indicating that the videos were of poor quality. The mean JAMA score was 2.7 ± 0.7 (out of 4 points). Inter-rater agreement between the four raters was excellent (intraclass correlation coefficient 0.90 for DISCERN and 0.93 for JAMA). Most videos were uploaded by hospitals (50%) or educational health channels (30%). Videos had a higher number of average daily views when they included animation (P = 0.0093) and diagrams (P = 0.0422). CONCLUSIONS: YouTube is a poor source of patient information on brain aneurysms. Our quality and audience engagement analysis may help content creators (i.e. hospital staff and physicians) to create more holistic, educational and engaging medical videos concerning brain aneurysms. Physicians could usefully refer their patients to the highest quality videos that we have found.

Can sectioning the posterior communicating artery be predicted with computed tomography angiography in the microsurgical clipping of basilar apex aneurysms?

BACKGROUND: Microsurgical clipping is a viable option for managing high-riding basilar apex aneurysms (BAXs) using a transsylvian approach. Cutting the posterior communicating artery (PCoA) at the perforator-free zone provides sufficient exposure of BAX, although it is not always safe. The aim was to qualitatively predict sectioning of the interfering PCoA by using preoperative computed tomographic angiography (CTA). METHODS: A virtual trajectory from the lesser sphenoid wing to the neck of the aneurysm was simulated on CTA in 19 consecutive patients operated on BAX aneurysms from 2013 to 2018. The angles on CTA resembled the typical view through the extended pterional craniotomy. Next, the ipsilateral PCoA was tracked from the internal carotid to its end at the posterior cerebral artery in the trajectory. RESULTS: The opticocarotid and carotid-oculomotor window served as the corridors for entering the interpeduncular fossa in 16 patients (84.2%) and in 3 patients (15.8%), respectively. The PCoA was intentionally cut during nine surgeries and preserved in 10 of them. The PCoA was cut more often when positioned toward the cranial base and more medially in the corridor; both the Kernel density analysis and the data points representing the position of the PCoA supported this finding (p < 0.01). The CTA-based position of either ends of the PCoA in the trajectory did not differ between cut and not-cut groups (p = 0.19-0.96). Aneurysm projection, rupture, size, PCoA diameter, length, and other distances on CTA were not related to the sectioning of PCoA (p > 0.05). CONCLUSIONS: The probability of PCoA sectioning is higher when the PCoA is positioned medially and closer to the cranial base. If the anatomical course of the PCoA is recognized beforehand, it can contraindicate surgery. Preoperative CTA-based planning facilitates the surgery of BAX aneurysms. Therefore, CTA can make microsurgical clipping planning more predictable for the neurosurgeon and safer for the patient.

Does Spinal Cord Stimulation Due to Failed Back Surgery Syndrome Lead to Permanent Occupational Disability?

OBJECTIVE: Spinal cord stimulation (SCS) is a recommended treatment method for patients afflicted by failed back surgery syndrome (FBSS). Although SCS is shown to be clinically effective, not many patients return to work (RTW). The aim of this study is to assess the RTW rate of these patients. MATERIALS AND METHODS: We prospectively evaluated 102 patients with FBSS, managed by low frequency SCS at a single institution in Poland. RTW rate was the main endpoint in the study. Additionally, we browsed the first 300 records in Google and extracted the suggested RTW time post-SCS implantation. RESULTS: Mean follow-up was 8.5 years. 79.4% of patients were actively working at the baseline. Fifteen patients were sick leave benefit claimants (15/81; 18.5%) and six were permanently disabled (6/81; 7.4%). In the follow-up, 40 did not change their work status. Only 2 of 21 patients resumed work and the total RTW rate was 9.5%. On the other hand, 38 of 81 patients (46.9%), who actively worked before SCS, gained disability status. Out of entire group, 20.6% (21 of 102) were not working at the baseline and 55.9% (57 of 102) were not working in the follow-up. Neither factor influenced RTW rate. In the second stage of the study, internet data search yielded a mean RTW time of 6.1 weeks. CONCLUSIONS: Unlike the well-analyzed effectiveness of SCS, RTW remains an underutilized outcome measure. The RTW rate in our series was the second lowest in the reviewed literature. We demonstrated that half of the patients with an implanted SCS either did not resume their work or left their job.

YouTube as a source of patient information for stroke: A content-quality and an audience engagement analysis.

BACKGROUND: Stroke is the second leading cause of death worldwide following ischemic heart disease, and the fifth in the United States. The video-sharing database, YouTube, is the second most popular visited website with more than 2 billion users, thus it's increasingly being used as a medium for delivering health information. AIM: We aimed to evaluate the quality, reliability and audience engagement of stroke-related YouTube videos. METHODS: In October 2019 we conducted a search on YouTube using 5 keywords: stroke, brain attack, hemorrhagic stroke, ischemic stroke and transient ischemic attack. We selected the first 30 videos from each search query for further analysis. The validated DISCERN instrument was used (a score of 0-5 per question) to assess the videos by four independent raters. We then recorded qualitative data and quantitative data for each video. RESULTS: After sorting through 150 stroke videos, a total of 101 unique YouTube videos met our inclusion criteria. We found that the mean overall quality of YouTube videos according to DISCERN is of fair quality. Most videos (65.3%) were uploaded by hospitals, mentioned the symptoms of stroke (66.3%), had a doctor speaking (60.4%) and contained diagrams (20.8%). CONCLUSION: YouTube is a useful source of gathering information about treatment choices for patients and their families as the quality of YouTube videos is fair. The audience engagement suggestions in our paper may help content creators improve the appeal of YouTube videos.

Extent of anterior clinoidectomy for clipping of carotid-ophthalmic aneurysms predicted on three-dimensional computerised tomography angiography.

AIM OF STUDY: We aimed to verify the value of computerised tomography angiography (CTA) on predicting the extent of anterior clinoidectomy that is optimal for particular carotid-ophthalmic aneurysms (COAs). CLINICAL RATIONALE FOR STUDY: The anterior clinoid process (ACP) often impedes the complex microsurgery of COA. Complete removal of the ACP ensures safe clipping; however, it also may increase the risk of severe complications. The probability of performing a successful partial anterior clinoidectomy could be evaluated by preoperative CTA. MATERIALS AND METHODS: 28 patients with either a ruptured (n=4) or unruptured COA were included in this prospective, single-centre, observational study. One aneurysm was giant, two were large, and the rest were smaller. Successful aneurysm clipping was the aim in all cases. The anterior clinoidectomy was preoperatively planned on multiplanar three-dimensional reconstructions of CTA images (3D-CTA) which resembled the typical view of a frontotemporal craniotomy. Finally, the predicted clinoidectomy was compared to the extent of the actual clinoidectomy. RESULTS: 21 aneurysms (75%) projected superolateral or superior. The ACP was completely and selectively resected in 25% (7 of 28) and 67.9% of patients (19 of 28) respectively. Optic nerve (ON) unroofing was always performed in the case of total anterior clinoidectomy, but accompanied only 8 of 19 selective clinoidectomies (p = 0.03). The extent of the actual clinoidectomy was predicted by the 3D-CTA-based preoperative planning in 17 of 27 cases (63.0%). Particularly, prediction of the osteotomy was correct in 85.7% of complete, 62.5% of selective lateral, and 57.1% of medial clinoidectomy. None of the radiological and clinical factors determined the correlation between the planned and the actual extent of ACP removal. There was one incomplete occlusion among 23 obtained follow-up CTAs. CONCLUSIONS: The predictive value of 3D-CTA on the extent of anterior clinoidectomy still remains unsatisfactory; it is limited by the individual variability of COA and its surrounding structures. CLINICAL IMPLICATIONS: Currently, the role of 3D-CTA planning is restricted to educational purposes only.

Reliability of diffusion tensor tractography of facial nerve in cerebello-pontine angle tumours.

AIM OF THE STUDY: This study aimed to verify the accuracy of preoperative visualisation of the facial nerve (FN) by magnetic resonance-based (MR) diffusion tensor imaging-fibre tracking (DTI-FT) with neuronavigation system integration in patients with cerebello-pontine angle (CPA) tumours. CLINICAL RATIONALE FOR THE STUDY: Complete excision with preservation of the FN remains the critical goal of today's vestibular schwannoma (VS) surgery. DTI-FT of the FN with neuronavigation is yet to be fully evaluated, and could make surgery safer. MATERIALS AND METHODS: This was a prospective cohort study in which 38 consecutive patients with a CPA tumour (32 VSs, five meningiomas and one epidermoid cyst) were operated on via the retrosigmoid route from 2013 to 2019. The course of the FN was simulated before surgery using StealthViz and the images were transferred to the Medtronic S7 neuronavigation system. The FN location reconstructed by DTI-FT was verified during the surgery. RESULTS: MR acquisition was inappropriate in three patients (7.9%). DTI-FT correctly predicted the course of the FN in 31 of the 38 patients; the discordance rate was 18.4%. The accuracy of DTI-FT was 81.6% (95% CI: 65.67-92.26), sensitivity 88.57% (95% CI: 73.26-96.80) and positive predictive value was 91.18% (95% CI: 90.17-92.09). The reliability of the neuronavigation-integrated visualisation of the FN did not depend on the tumour size (p = 0.85), but the method was more accurate when the nerve was compact in shape (p = 0.03, area under curve (AUC) 0.87, 95% CI: 0.60-1.00) and in females (p = 0.04, AUC 0.78, 95% CI: 0.56-1.00). Following surgery, 86.5% of the patients presented with useful facial function (House-Brackmann grades I-III). Correct simulation of the FN did not prevent postoperative facial palsy (p = 0.35). CONCLUSIONS: The accuracy of DTI-FT of the FN integrated with neuronavigation remains unsatisfactory. This method does not provide any clinical benefit over non-integrated DTI-FT in terms of nerve function preservation. CLINICAL IMPLICATIONS: Due to the low reliability of the predictions, further technical advances in predicting the course of the FN are awaited by clinicians. However, DTI-FT images in the operating theatre would make tumour excision more comfortable for the surgeon.

Neurosurgery residency burnout: what can prevent this?

Burnout is an occupational phenomenon indicating that the work and the workplace are responsible. We here discuss how a supportive resident-mentor relationship, and a positive working environment, could help to prevent resident burnout. A positive resident-mentor relationship can be achieved by understanding the mentor, the mentee, and the generational differences of each individual. A positive working environment depends on a healthy work-life balance and the atmosphere in the department. The benefits of preventing burnout include not only happier physicians but also fewer medical errors and better medical care. The universal reminders and proven suggestions in our paper could help address the burnout problem among working physicians worldwide.

KNOWLEDGE, ATTITUDES AND PRACTICES OF HEPATITIS B AND C AMONG BARBERS OF URBAN AND RURAL AREAS OF RAWALPINDI AND ISLAMABAD.

BACKGROUND: Hepatitis B and Hepatitis C are serious global public health problems with a prevalence of 10-15% with majority of the cases seen in the developing countries including Pakistan. It is a blood borne infection transmitted by infected blood and blood products through transfusions, contaminated needles, vertical transmission, unsafe sex and reuse of razors by barbers. The literature search so far did not reveal any study comparing knowledge, attitude and practices of hepatitis B & C in barbers working in Urban and rural areas. METHODS: A comparative cross sectional survey was carried out among barbers of urban and rural areas of Rawalpindi and Islamabad. A structured close ended questionnaire was filled from total of 202 barbers by non-probability convenience sampling technique. Comparative data analysis was done including variables like age, education, knowledge about hepatitis B & C, mode of transmission, role of the blades and media etc. RESULTS: Knowledge about hepatitis B & C was good in urban areas (92%) as compared to those working in the rural areas (68%). Using new blade for every customer was seen in urban (100%) and rural (93%) area. However barbers knowledge about symptoms of the disease (urban 81% & rural 93%) and vaccination trend of Hepatitis B was low. CONCLUSION: This study showed a marked difference in the knowledge, attitude and practices of the barbers working in the urban and the rural areas. Main focus should be on launching Health education programs and behaviour change communication campaigns for the barbers. Strict regulatory monitoring must be done against unlicensed street barbers.

Boosting Confidence: Enhancing Spinal Cord Stimulator Needle and Lead Placement Through Simulation Training.

Background This pilot study aims to examine the effectiveness of a spinal cord stimulator (SCS) simulator training system in improving the confidence of pain fellows in SCS placement. Methodology Five Ukrainian physicians (neurologists, neurosurgeons, and an anesthesiologist) completed a 10-item survey regarding their confidence in various aspects of SCS placement and their opinions on how effective SCS models were for educational purposes. After placing SCS leads using the SCS simulator, the physicians took the same survey again. The Mann-Whitney U test was used to determine if there was a significant difference in total scores pre and post-simulator training. The software PAST (PAleontological STatistics) was used for statistical analysis. Results Overall, five participants had a 38% statistically significant increase in survey scores before and after the intervention (mean: 4.2 vs. 6.2, p = 0.0055). With regards to each item of the survey, participants had a significantly increased confidence in driving leads (2.6 vs. 5.2, p = 0.008) and in overall technical skills for the SCS procedure after the training (2.8 vs. 5.2, p = 0.0188). Although the other eight survey items were not statistically significant (p > 0.05), participants had a 28% increase in confidence when inserting epidural needles, a 20% increase in interpreting simulated X-rays, a 32% increase in navigating challenging anatomical variations, a 12% increase in identifying key anatomical landmarks, a 20% increase in ensuring the correct placement of the lead, or a 53% increase in preparedness for performing an SCS procedure in a real clinical setting. The participant's perspective on how valuable the stimulator training was for enhancing procedural skills increased by 38% and how well the simulator replicated real-life SCS procedure increased by 52%, although both were statistically insignificant (p > 0.05). Conclusions This pilot study shows that the utilization of simulated neuromodulation training is a viable means of augmenting neuromodulation education by increasing physician's confidence in aspects of the SCS placement procedure. The extent to which simulator training improves procedural skills in a real-life SCS placement needs to be investigated further.

Evaluation of PHASES Score for Predicting Rupture of Intracranial Aneurysms: Significance of Aneurysm Size.

BACKGROUND: Recent data have identified that certain risk factors for rupture differ between small and larger intracranial aneurysms (IAs). Such differing risk factors make up 5 out of the 6 predictor variables used in the PHASES score, which raises the question on whether IA size has a significant effect on the score's performance. METHODS: Patients who were diagnosed with an IA incidentally or due to a subarachnoid hemorrhage between 2015 and 2023 were selected for potential inclusion. The median IA size of the cohort was chosen as the cutoff point to categorize small and large (6 mm). The PHASES score was calculated for all patients, and a receiver operating characteristic curve analysis was performed to evaluate the classification accuracy of PHASES in predicting rupture for small and large IAs. RESULTS: A total of 677 IAs were included. Among the IAs, 400 (58.9%) presented as UIAs and 279 (41.0%) as subarachnoid hemorrhage. The average PHASES score was 2.9 and 6.5 for small (n = 322) and large (n = 355) IAs, respectively. The PHASES score performed significantly lower for predicting rupture in smaller IAs (area under the curve: 0.634) compared with the larger (area under the curve: 0.741) (P = 0.00083). CONCLUSIONS: PHASES was shown to underperform on small IAs. The decision to treat small unruptured IAs remains highly controversial, and the development of a new score to estimate the annual rupture rate while accounting for IA morphology is of great need. Our findings can help encourage future researchers to develop such a score.

Aggressive behavior and prognosis in patients with mild cognitive impairment.

The diagnosis of mild cognitive impairment (MCI) is associated with an increased risk of developing dementia. When evaluating the further prognosis of MCI, the occurrence of neuropsychiatric symptoms, particularly aggressive and impulsive behavior, may play an important role. Objective: The aim of this study was to evaluate the relationship between aggressive behavior and cognitive dysfunction in patients diagnosed with MCI. Methods: The results are based on a 7-year prospective study. At the time of inclusion in the study, participants, recruited from an outpatient clinic, were assessed with Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). A reassessment was performed after 1 year using the MMSE scale in all patients. The time of next MMSE administration was depended on the clinical condition of patients took place at the end of follow-up, that is, at the time of diagnosis of the dementia or after 7 years from inclusion when the criteria for dementia were not met. Results: Of the 193 patients enrolled in the study, 75 were included in the final analysis. Patients who converted to dementia during the observation period exhibited a greater severity of symptoms in each of the assessed CMAI categories. Moreover, there was a significant correlation between the global result of CMAI and the results of the physical nonaggressive and verbal aggressive subscales with cognitive decline during the first year of observation. Conclusions: Despite several limitations to the study, aggressive and impulsive behaviors seem to be an unfavorable prognostic factor in the course of MCI.

O diagnóstico de comprometimento cognitivo leve (CCL) está associado a um risco aumentado de desenvolver demência. Ao avaliar o prognóstico adicional do CCL, a ocorrência de sintomas neuropsiquiátricos, particularmente o comportamento agressivo e impulsivo, pode desempenhar um papel importante. Objetivo: Avaliar a relação entre comportamento agressivo e disfunção cognitiva em indivíduos com diagnóstico de CCL. Métodos: Nossos resultados são baseados em um estudo prospectivo de sete anos. No momento da inclusão no estudo, os participantes, recrutados em um ambulatório, foram avaliados com o Mini-Exame do Estado Mental (MEEM) e o Inventário de Agitação de Cohen-Mansfield (CMAI). A reavaliação foi realizada após um ano com a escala MEEM em todos os pacientes. O momento da próxima administração do MEEM dependeu da condição clínica dos indivíduos e ocorreu no final do acompanhamento, ou seja, no momento do diagnóstico da demência ou após sete anos da inclusão, quando os critérios para demência não foram atendidos. Resultados: Dos 193 pacientes incluídos no estudo, 75 foram incluídos na análise final. Os indivíduos que converteram para demência durante o período de observação exibiram uma maior gravidade dos sintomas em cada uma das categorias avaliadas pelo CMAI. Além disso, houve uma correlação significativa entre o resultado global do CMAI e os resultados das subescalas de agressão física e verbal com declínio cognitivo durante o primeiro ano de observação. Conclusões: Apesar das várias limitações do estudo, os comportamentos agressivos e impulsivos parecem ser um fator prognóstico desfavorável no curso do CCL.

Risk Factors for Ischemic Stroke After Revascularization Surgery in Patients with Moyamoya Disease: An Age-Stratified Comparative Meta-Analysis.

BACKGROUND: Patients who undergo revascularization surgery for moyamoya disease may develop postoperative ischemic stroke (pIS). Several studies have sought to identify risk factors; however, the findings remain highly inconsistent. METHODS: PubMed, Scopus, and Web of Science were used to extract references. The first phase of screening required the studies to be in English, involve patients surgically treated for moyamoya disease, and report pIS. The second phase required the studies to provide ≥10 patients and include a control group. RESULTS: All 22 studies were rated as high quality. Univariate analysis identified pediatrics <3 years of age as a risk factor for pIS (odds ratio [OR], 7.60; P < 0.0001). Among adult patients only, diabetes (OR, 2.10; P = 0.005), a Suzuki grade greater than 3 (OR, 1.74; P = 0.005), mean intraoperative systolic blood pressure (OR, 1.04; P < 0.0001), mean intraoperative diastolic blood pressure (OR, 1.04; P = 0.002), and revascularization in the left hemisphere (OR, 2.09; P = 0.001) were risk factors. Among both age groups, preoperative ischemic stroke (OR, 2.59; P < 0.00001) was a risk factor for pIS. Additionally, perioperative antiplatelet drug administration was a protective factor for specifically acute postoperative white thrombus among adult patients (OR, 0.35; P = 0.002). CONCLUSIONS: In addition to the methods discussed that can mitigate the risk of pIS, the risk factors identified in our analysis may be of great value among surgeons for identifying high-risk patients in order to apply prophylactic measures, as well as scheduling longer and more frequent follow-up visits.