Virchow-Robin spaces in idiopathic normal pressure hydrocephalus: a surrogate imaging marker for coexisting microvascular disease?

BACKGROUND: Virchow-Robin spaces (VRSs) surround perforating cerebral arteries and are reported to be found with increasing frequency with advancing age. In addition, some studies indicate an association between VRSs and vascular dementias. The present study examined the incidence of VRSs in patients with idiopathic normal pressure hydrocephalus (INPH) and considered their use as a potential surrogate imaging marker of coexisting microvascular disease in patients with this condition. METHODS: The MRI incidence of VRS in the centrum semiovale (CS), basal ganglia (BG), mesencephalon (MES), and the subinsular (SI) region was measured in 12 patients with INPH and in 12 control subjects, using the scoring system proposed by Patankar et al. (Am J Neuroradiology 26:1512, 2005). Historical control data were also used for further comparison. RESULTS: All 12 INPH patients had clearly visible VRSs, distributed in the CS (all 12), basal ganglia (11/12), SI region (9/12), and MES region (6/12). The mean Patankar scores of the INPH group were BG 2.25, CS 1.66, SI 0.91, and ME 0.5. The respective scores for our control group were 1.41, 1.5, 1.16, and 0.16, and for historical controls were 1.46, 0.51, 0.96, and 0.51. There were, however, no statistically significant differences between the INPH patients and either of the control groups. No correlation was found between age and the overall incidence of VRS. CONCLUSION: This preliminary study suggests that there may be a higher incidence of VRSs in patients with INPH, when compared with normal patients of similar age, but our small numbers prevent us from demonstrating statistical significance, and larger studies are clearly required.

General anaesthesia for deep brain stimulator electrode insertion in Parkinson's disease.

BACKGROUND: This paper compares the use of general and local anaesthetic in patients having deep brain stimulator (DBS) surgery. It is a retrospective case note study of 46 patients treated consecutively with subthalamic nucleus stimulation for Parkinson's disease as practise changed in a Neurosurgical unit. METHODS: The first 20 patients (LA group) had permanent electrodes placed under local anaesthesia. The remaining 26 patients (GA group) had the entire procedure under general anaesthesia. The groups were similar for age, sex, duration of Parkinson's disease and preoperative levodopa requirement. RESULTS: The clinical results were similar in that within each group, the reduction in levodopa was not only clinically but also statistically significant (p < 0.001 for both, paired t test): for the LA group, the 6-month requirement was 39.4% (29.5-52.6%) of the preoperative requirement and for the GA group, the 6-month requirement was 32.3% (25.2-41.5%) of the preoperative requirement. The reduction in levodopa was maintained at 1 year. Of note, duration of surgery and length of stay were reduced. The mean duration of surgery was 8.2 h (7.8-8.6) for the LA group and 7.5 h (7.2-7.8) for the GA group (p = 0.003). The geometric mean of length of hospital stay was 5.4 days(4.6-6.3) for the LA group and 3.8 days (3.4-4.4) for the GA group (p = 0.001) There was no difference in electrophysiological recording. CONCLUSION: This study describes benefits in the GA group for the entire procedure of STN DBS. In these samples, there was no difference in the adverse effects seen in patients undergoing deep brain stimulator insertion with general anaesthetic compared with local anaesthetic. The use of general anaesthetic did not detract from the known benefits of surgery.

Surgical treatment of post-traumatic syringomyelia.

STUDY DESIGN: A retrospective study. OBJECTIVES: To review the outcome of 40 patients with post-traumatic syringomyelia treated with laminectomy and reconstitution of the spinal subarachnoid channels. SETTING: Birmingham, United Kingdom. METHOD: A retrospective study of patients undergoing surgery between 1996 and 2007 was carried out. All 40 patients underwent a laminectomy with the creation of a cerebrospinal fluid (CSF) conduit. RESULTS: A total of 18 (1 in 2) patients had long-term stabilization of symptoms after laminectomy and creation of a CSF conduit alone. Later, 17 patients underwent supplementary procedures. Overall, surgical treatment resulted in 27(2 in 3) patients with continued stabilization of symptoms and 13 (1 in 3) experiencing worsening of symptoms in the long term (mean follow-up was 64 months). Radiological review at 6 months revealed a reduction in the size of the syrinx in 21 out of 33 (2 in 3) patients. CONCLUSIONS: Laminectomy for syringomyelia, with reconstruction of the spinal CSF channels alone, resulted in a reduction of syrinx size by 6 months, with half of all patients experiencing stabilization of symptoms in the long term. When additional techniques are taken into account, two in three of patients achieved long-term stabilization of symptoms.

Apical polarity of N-CAM and EMMPRIN in retinal pigment epithelium resulting from suppression of basolateral signal recognition.

Retinal pigment epithelial (RPE) cells apically polarize proteins that are basolateral in other epithelia. This reversal may be generated by the association of RPE with photoreceptors and the interphotoreceptor matrix, postnatal expansion of the RPE apical surface, and/or changes in RPE sorting machinery. We compared two proteins exhibiting reversed, apical polarities in RPE cells, neural cell adhesion molecule (N-CAM; 140-kD isoform) and extracellular matrix metalloproteinase inducer (EMMPRIN), with the cognate apical marker, p75-neurotrophin receptor (p75-NTR). N-CAM and p75-NTR were apically localized from birth to adulthood, contrasting with a basolateral to apical switch of EMMPRIN in developing postnatal rat RPE. Morphometric analysis demonstrated that this switch cannot be attributed to expansion of the apical surface of maturing RPE because the basolateral membrane expanded proportionally, maintaining a 3:1 apical/basolateral ratio. Kinetic analysis of polarized surface delivery in MDCK and RPE-J cells showed that EMMPRIN has a basolateral signal in its cytoplasmic tail recognized by both cell lines. In contrast, the basolateral signal of N-CAM is recognized by MDCK cells but not RPE-J cells. Deletion of N-CAM's basolateral signal did not prevent its apical localization in vivo. The data demonstrate that the apical polarity of EMMPRIN and N-CAM in mature RPE results from suppressed decoding of specific basolateral signals resulting in randomized delivery to the cell surface.

Pattern, management and outcome of cervical spine injuries associated with head injuries in paediatric patients.

INTRODUCTION: This study examines the management and outcome of cervical spine injuries in children with head injuries, to assess the need for surgical treatment. MATERIAL AND METHODS: We performed a retrospective analysis (1995-2005) of 445 children admitted intubated and ventilated to the intensive care unit with head injuries. OUTCOME MEASURES: Frankel grade for spinal injuries and Glasgow Outcome Scale (GOS) for head injuries. RESULTS: Cervical spine injuries were detected in 11 patients (incidence 2.5%, mean age: 6.3 years, range: 21 months-15 years). The injuries were: C1/2 distraction: 2; C1/2 subluxation: 2; odontoid peg fracture with C1/2 dislocation and cord transection: 1; disruption of posterior longitudinal ligament at C2: 1; odontoid peg fracture with C2/3 distraction: 1; C2/3 subluxation: 1; C3 lamina fracture: 1; C3/4 facet fracture: 1; C6/7 fracture dislocation with cord transection: 1. One patient was managed operatively, ten patients nonoperatively, two with halo vests and eight with hard collars. There were three deaths (mortality 27%) associated with severe head injuries. At 6 months follow-up, two patients remained quadriplegic (Frankel Grade A), one of them ventilator dependent, one had residual motor function but of no practical use (Frankel Grade C), five had good spinal outcome (Frankel Grade E). Seven patients had good head injury outcomes (GOS 5), one remained disabled (GOS 3). CONCLUSION: Most children with cervical injury can be managed nonoperatively with good outcomes. Surgical management may be necessary in severe unstable injuries.

Human hepatitis B virus and hepatocellular carcinoma. II. Experimental induction of hepatocellular carcinoma in tree shrews exposed to hepatitis B virus and aflatoxin B1.

On the basis of the successful establishment of an animal model in tree shrews experimentally infected with human hepatitis B virus (HBV), a study on the hepatocarcinogenic effects of HBV and/or aflatoxin B1 (AFB1) was conducted. The results showed that the incidence of hepatocellular carcinoma (HCC) was significantly higher in the animals both infected with HBV and exposed to AFB1 (52.94%) than in those solely infected with HBV (11.11%) or exposed to AFB1 (12.50%). No HCC of precancerous lesions were found in the controls that were neither HBV-infected nor AFB-1 exposed. Precancerous lesions, including liver cell dysplasia and enzyme-altered hyperplastic hepatocyte foci, were observed before the occurrence of HCC, and the frequency of their appearance correlated well with the incidence of HCC. HBV DNA and the protein it encodes were detected in the cancer cells and/or the surrounding hepatocytes. Integration of HBV DNA into the host liver genome was found during hepatocarcinogenesis among the animals infected by HBV. These results suggest that exposure to HBV and AFB1 may play a synergistic role in the development of HCC, and support the viewpoint of an aetiological relationship between HBV and HCC.

Human hepatitis B virus and hepatocellular carcinoma. I. Experimental infection of tree shrews with hepatitis B virus.

Tree shrews (Tupaia belangeri chinenesis) can be experimentally infected with human hepatitis B virus (HBV) by inoculation with human serum positive for HBV, the experimental infection rate being 55.21%. Successive infections have been passed through five generations among the tree shrews inoculated with HBV-positive sera from the infected animals, the average infection rate being 94.0%. The experimental infection of tree shrews with HBV may be prevented by immunization with hepatitis B vaccine, the protection rate being 88.89%. Standard serum containing HBV at 10(8) CID (chimpanzee infection dose)/ml, was diluted 10(-6), 10(-7), 10(-8), 10(-9), and 10(-10) and produced infection rates of 80.0%, 88.8%, 66.7%, 55.6% and 42.9% respectively. Thus the CID50 in tree shrews may reach a dilution of 10(-9), which shows that tree shrews are sensitive to HBV infection. These results successfully establish tree shrews as a reliable and useful animal model for research on HBV infection and its relation to hepatocarcinogenesis.

[Mebendazole-medicated-salt in the control of hookworm infection].

From 1984-1987, mass application of mebendazole-medicated salt was studied for the control of hookworm infection in 5 pilot areas (Wuming, Shanlin, Bobai, Guilin and Rongxian Counties) in Guangxi Zhuang Autonomous Region. The dosages of mebendazole (mixed with salt) administered were 15mg, 25mg, 30mg, 40mg, 50mg, 30mg, 70mg, 80mg, 100mg or 200mg per person per day for 15, 20 or 30 days. The results showed that 40mg/day for 15-20 days could result in stool egg negative conversion rates of 92.3 to 94.4%, while 50mg/day for 30 days resulted in 96.9 to 100%. Concurrently, the hookworm infection rate in pilot areas dropped by 57.9-71.7% in a short time; whereas the stool egg negative conversion rate of Ascaris lumbricoides was as high as 99.1% to 100% at the same dosage, when the dosage of 100mg/day for 30 days was given, the egg negative reversion rate for Trichuris trichiura was 97.6%. Promising result was also recorded concerning the tolerance of the medicated salt, as the side effects in the inhabitants were mild. In conclusion, the authors considered that the application of mebendazole-medicated salt was a simple and effective measure in controlling hookworm infection, especially in the light of solving the problem of incomplete mass detection and selected mass treatment. Furthermore, it is much more economic from the cost-effect point of view.

Diastematomyelia in children: treatment outcome and natural history of associated syringomyelia.

OBJECTIVE: To quantify the long-term outcome of children with diastematomyelia and the implication of syringomyelia in the natural history. MATERIALS: Retrospective study of 17 children (nine girls and eight boys) with diastematomyelia operated during 1989-2004. Mean age at diagnosis was 3.4 years (range 5 days-12 years), mean follow-up was 5 years; 14 had excision of spur and cord untethering, 3 had excision of spur alone. RESULTS: The bony spur was in the lumbar region in 12 and thoracic in 5 patients. Syringomyelia was present in eight (47%), associated with bony spur between L1 and 4 (p=0.088), spina bifida occulta in ten (58.8%), and spinal lipoma in one (6%). Preoperative Necker Enfants Malades (NEM) scores were 17 in eight patients, 16 in four, 15 in three, 13 in one, and 12 in one patient. Presenting neurological deficits were motor in eight, sensory deficits in three, and anal incontinence in one patient. There was improvement of NEM scores postoperatively in five patients only, but still with residual deficit. Repeat spur excision and cord untethering was performed in three patients for neurological deterioration 1-4 years after first operation. On postoperative MRI scans syringomyelia remained unchanged in all eight patients. There were one skin infection, one transient motor deterioration, and one patient with sensory deficit after surgery. CONCLUSION: Prophylactic operations were associated with the best clinical outcome. Despite improvement, all patients with established preoperative deficit still had residual neurological deficits at their last follow-up. The associated syringomyelia remained unchanged after surgery, indicating that it does not contribute to the neurological syndrome.

Parafalcine meningioma presenting with facial pain: evidence for cortical theory of pain?

Intracranial tumours causing facial pain are very rare. All previously reported tumours have been located in either the posterior or middle fossa. We present a unique case of a bilateral parasagittal meningioma located in the parietal-occipital cortex presenting with right-sided facial pain.

Ring fracture of the skull base: case report and review of the literature.

Ring fractures of the skull base are rare and have hitherto been regarded as invariably fatal injuries. They are difficult to diagnose, as routine radiographs of the head and spine are usually normal. Increasing use of computerized tomography in the evaluation of head and neck injuries may, however, lead to an increased frequency of diagnosis of this injury. We present a case of such a fracture where the patient survived with a generally good neurological recovery.

Aneurysmal bone cyst of the sphenoid sinus.

Aneurysmal bone cysts of the sphenoid sinus are very rare, with only six cases described in the literature. We present a case of an aneurysmal bone cyst of the sphenoid sinus with associated fibrous dysplasia in which the radiological findings had some features of a mucocoele. We discuss the differences in pathogenesis, clinical presentation and radiological appearances between these two lesions, and propose a simple drainage procedure as an effective modality of treatment.