Hemorrhage due to a pseudoaneurysm on a dural-pial anastomosis after decompression for Chiari malformation type I: case report.

While intracranial aneurysms rarely develop after neurosurgical procedures, delayed pseudoaneurysm formation after foramen magnum decompression (FMD) has never been reported. A 52-year-old woman presented with an atypical subarachnoid hemorrhage in the posterior fossa 12 years after a FMD for symptomatic Chiari malformation type I was performed. A pseudoaneurysm on a dural-pial anastomosis was identified as the bleeding source and successfully occluded by endovascular means with full clinical recovery of the patient. Injury to the distal posterior inferior cerebellar artery related to surgery and postoperative infection likely caused formation of a dural-pial anastomosis. Additionally, hemodynamic stress or dissection may have contributed to delayed pseudoaneurysm formation and rupture.

[Treatment of metastatic spinal cord compression].

Metastatic spinal cord compression is an oncologic emergency, and the most frequent initial symptom is radicular backpain. Urgent diagnostics with acute MRI and early treatment is essential to prevent permanent neurologic damage. Treatment is mainly palliative. For patients who have a good prognosis, the treatment of choice is decompressive surgery followed by radiotherapy, but only few patients are candidates to surgery due to significant comorbidities and poor performance status. Optimal therapy is required to maintain high quality of life at an acceptable risk, as argued in this review.

Delayed Iatrogenic Intracranial Hypotension After Thoracotomy.

We report a case of intracranial hypotension (IH) after thoracotomy. A 56-year-old woman presented 10 days after a left upper lobectomy with severe headache due to pneumocephalus and pneumorrhachis, which resolved on conservative treatment. Two months later, the patient was readmitted in an unconscious state with characteristics of IH and "sagging brain." Subsequent magnetic resonance imaging revealed a fistula at the level of the left Th5 pedicle. The patient underwent operation with closure of the fistula and recovered without complications. The presence of pneumocephalus and pneumorrhachis after thoracotomy should raise the suspicion of a persistent subarachnoid-pleural fistula to prevent IH and "sagging brain."

Long-term functional outcome after decompressive suboccipital craniectomy for space-occupying cerebellar infarction.

OBJECTIVES: Suboccipital decompressive craniectomy (SDC) is considered the best treatment option in patients with space-occupying cerebellar infarction and clinical signs of deterioration. The primary purpose of this study was to evaluate long-term functional outcome in patients one year after SDC for space-occupying cerebellar infarction, and secondly, to determine factors associated with outcome. PATIENTS AND METHODS: All patients treated with SDC due to space-occupying cerebellar infarction between January 2009 and October 2015 were included in the study. Data was retrospectively collected from patient records, CT/MRI scans and surgical protocols. Long-term functional outcome was determined by the modified Rankin Scale (mRS) and mRS ≥ 4 was defined as unfavorable outcome. RESULTS: Twenty-two patients (16 male, 6 female) were included in the study. Median age was 53 years. Nine patients were treated with external ventricular drainage as an initial treatment attempt prior to SDC. Median time from symptom onset (stroke ictus) to initiation of the SDC surgery was 48 h (IQR 28-99 hours) and median GCS before SDC was 8 (IQR 5-10). At follow up, median mRS was 3 (IQR 2-6). Outcome was favorable (mRS 0-3) in 12 patients and unfavorable in 10 (3 with major disability, 7 dead). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome. CONCLUSIONS: In this small study, functional long-term outcome in patients with space-occupying cerebellar infarction treated by SDC was acceptable and comparable to previously published results (favorable outcome in 54% of patients). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome.

Feasibility of Telemetric Intracranial Pressure Monitoring in the Neuro Intensive Care Unit.

Intracranial pressure (ICP) monitoring is crucial in the management of acute neurosurgical conditions such as traumatic brain injury (TBI). However, pathological ICP may persist beyond the admission to the neuro intensive care unit (NICU). We investigated the feasibility of telemetric ICP monitoring in the NICU, as this technology provides the possibility of long-term ICP assessment beyond NICU discharge. In this prospective investigation, we implanted telemetric ICP sensors (Raumedic Neurovent-P-tel) instead of conventional, cabled ICP sensors in patients undergoing decompressive craniectomy. We recorded ICP curves, duration of ICP monitoring, signal quality, and complications. Seventeen patients were included (median age 55 years) and diagnoses were: severe TBI (8), malignant middle cerebral artery infarction (8), and spontaneous intracerebral hemorrhage (1). In total, 3015 h of ICP monitoring were performed, and the median duration of ICP monitoring was 188 h (interquartile range [IQR] 54-259). The ICP signal was lost 613 times (displacement of the reader unit on the skin) for a median of 1.5 min, corresponding to 0.8% of the total monitoring period. When the signal was lost, it could always be restored by realignment of the reader unit on the skin above the telemetric sensor. Sixteen of 17 patients survived the NICU admission, and ICP gradually decreased from 10.7 mm Hg (IQR 7.5-13.6) during the first postoperative day to 6.3 mm Hg (IQR 4.0-8.3) after 1 week in the NICU. All 17 implanted telemetric sensors functioned throughout the NICU admission, and no wound infections were observed. Therefore, telemetric ICP monitoring in an acute neurosurgical setting is feasible. Signal quality and stability are sufficient for clinical decision making based on mean ICP. The low sampling frequency (5 Hz) does not permit analysis of intracranial pulse wave morphology, but resolution is sufficient for calculation of derived indices such as the pressure reactivity index (PRx).

[Acute surgical treatment of malignant stroke].

Malignant stroke is an intracranial herniation syndrome caused by cerebral oedema after a large hemispheric or cerebellar stroke. Malignant middle cerebral artery infarction is a devastating disease with a mortality around 80% despite intensive medical treatment. Decompressive craniectomy reduces mortality and improves functional outcome - especially in younger patients (age ≤ 60 years). Decompression of the posterior fossa is a life-saving procedure in patients with malignant cerebellar infarctions and often leads to good neurological outcome.

Neuronal precursor cell proliferation in the hippocampus after transient cerebral ischemia: a comparative study of two rat strains using stereological tools.

BACKGROUND: We are currently investigating microglial activation and neuronal precursor cell (NPC) proliferation after transient middle cerebral artery occlusion (tMCAo) in rats. This study aimed: (1) to investigate differences in hippocampal NPC proliferation in outbred male spontaneously hypertensive rats (SHRs) and Sprague-Dawley rats (SDs) one week after tMCAo; (2) to present the practical use of the optical fractionator and 2D nucleator in stereological brain tissue analyses; and (3) to report our experiences with an intraluminal tMCAo model where the occluding filament is advanced 22 mm beyond the carotid bifurcation and the common carotid artery is clamped during tMCAo. METHODS: Twenty-three SDs and twenty SHRs were randomized into four groups subjected to 90 minutes tMCAo or sham. BrdU (50 mg/kg) was administered intraperitoneally twice daily on Day 4 to 7 after surgery. On Day 8 all animals were euthanized. NeuN-stained tissue sections were used for brain and infarct volume estimation with the 2D nucleator and Cavalieri principle. Brains were studied for the presence of activated microglia (ED-1) and hippocampal BrdU incorporation using the optical fractionator. RESULTS: We found no significant difference or increase in post-ischemic NPC proliferation between the two strains. However, the response to remote ischemia may differ between SDs and SHRs. In three animals increased post-stroke NPC proliferation was associated with hippocampal ischemic injury. The mean infarct volume was 89.2 +/- 76.1 mm3 in SHRs and 16.9 +/- 22.7 mm3 in SDs (p < 0.005). Eight out of eleven SHRs had ischemic neocortical damage in contrast to only one out of 12 SDs. We observed involvement of the anterior choroidal and hypothalamic arteries in several animals from both strains and the anterior cerebral artery in two SHRs. CONCLUSIONS: We found no evidence of an early hippocampal NPC proliferation one week after tMCAo in both strains. Infarction within the anterior choroidal artery could induce hippocampal ischemia and increase NPC proliferation profoundly. NPC proliferation was not aggravated by the presence of activated microglia. Intraluminal tMCAo in SHRs gave a more reliable infarct with neocortical involvement, but affected territories supplied by the anterior cerebral, anterior choroidal and hypothalamic arteries.

Neuroglobin in the rat brain (II): co-localisation with neurotransmitters.

In an accompanying article, we found that neuroglobin (Ngb) was expressed in a few well-defined nuclei in the rat brain. Here, we show by use of immunohistochemistry and in situ hybridisation (ISH) that Ngb co-localise with several specific neurotransmitters. Ngb co-localise consistently with tyrosine hydroxylase (TH) in the noradrenergic/adrenergic A1/C1 and A2/C2; the noradrenergic A5, A6 and A7. Ngb were not observed to co-localise TH in the dopaminergic A8-A16 cell populations. Ngb were only seen to co-localise with choline acetyltransferase (ChAT) in the laterodorsal tegmental nucleus (LDTg) and in the pontine tegmental nucleus (PPTg). Many Ngb-ir neurones co-localised with neuronal nitric oxide synthase (nNOS) in the LDTg, whereas fewer Ngb-ir neurones co-localise nNOS in the anterior basomedial (BMA) and the posterodorsal medial (MePD) amygdaloid nucleus, in the medial preoptic area (MPA) and in part of the lateral hypothalamus (LH). Ngb-ir neurones co-localise heme oxygenase 1 (HO-1) in the LDTg and locus coeruleus. Ngb-ir neurones co-localise hypocretin-1 (Hcrt1) in the perifornical (PeF) and perifornical lateral hypothalamus (PeFLH). Within the LH, Ngb-ir neurones co-localised melanin concentration hormone (MCH). A few Ngb-ir perikarya in the paraventricular hypothalamic nucleus (PVN) co-localised arginine vasopressin (aVP). Ngb were not observed to co-localise with serotonin, vasointestinal peptide (VIP), or cocaine amphetamine-regulated transcript (CART) at any places. In the present study, we found no evidence that one or more particular neurotransmitters are coupled 100% to Ngb or that Ngb is coupled 100% to a specific neurotransmitter. Based on these findings, we suggest that Ngb could be involved in some sort of regulation of the sleep-wake cycle. Secondly, that Ngb in some neurones is involved in regulation of gaseous neurotransmission, and that this in any given case only involves a subset of neurones. To us this indicates that the cellular and physiological function of Ngb in different subsets of neurones might not be identical, or that all neurones containing Ngb has one thing in common that we at presently not are aware of.

Parecoxib is neuroprotective in spontaneously hypertensive rats after transient middle cerebral artery occlusion: a divided treatment response?

BACKGROUND: Anti-inflammatory treatment affects ischemic damage and neurogenesis in rodent models of cerebral ischemia. We investigated the potential benefit of COX-2 inhibition with parecoxib in spontaneously hypertensive rats (SHRs) subjected to transient middle cerebral artery occlusion (tMCAo). METHODS: Sixty-four male SHRs were randomized to 90 min of intraluminal tMCAo or sham surgery. Parecoxib (10 mg/kg) or isotonic saline was administered intraperitoneally (IP) during the procedure, and twice daily thereafter. Nineteen animals were euthanized after 24 hours, and each hemisphere was examined for mRNA expression of pro-inflammatory cytokines and COX enzymes by quantitative RT-PCR. Twenty-three tMCAo animals were studied with diffusion and T2 weighted MRI within the first 24 hours, and ten of the SHRs underwent follow-up MRI six days later. Thirty-three SHRs were given 5-bromo-2'-deoxy-uridine (BrdU) twice daily on Day 4 to 7 after tMCAo. Animals were euthanized on Day 8 and the brains were studied with free-floating immunohistochemistry for activated microglia (ED-1), hippocampal granule cell BrdU incorporation, and neuronal nuclei (NeuN). Infarct volume estimation was done using the 2D nucleator and Cavalieri principle on NeuN-stained coronal brain sections. The total number of BrdU+ cells in the dentate gyrus (DG) of the hippocampus was estimated using the optical fractionator. RESULTS: We found a significant reduction in infarct volume in parecoxib treated animals one week after tMCAo (p < 0.03). Cortical ADC values in the parecoxib group were markedly less increased on Day 8 (p < 0.01). Interestingly, the parecoxib treated rats were segregated into two subgroups, suggesting a responder vs. non-responder phenomenon. We found indications of mRNA up-regulation of IL-1beta, IL-6, TNF-alpha and COX-2, whereas COX-1 remained unaffected. Hippocampal granule cell BrdU incorporation was not affected by parecoxib treatment. Presence of ED-1+ activated microglia in the hippocampus was related to an increase in BrdU uptake in the DG. CONCLUSION: IP parecoxib administration during tMCAo was neuroprotective, as evidenced by a large reduction in mean infarct volume and a lower cortical ADC increment. Increased pro-inflammatory cytokine mRNA levels and hippocampal granule cell BrdU incorporation remained unaffected.

Does neuroglobin protect neurons from ischemic insult? A quantitative investigation of neuroglobin expression following transient MCAo in spontaneously hypertensive rats.

Neuroglobin (NGB) is a recently characterized heme globin expressed primarily in retinal nerve cells and at very low levels in endocrine-active regions of vertebrate brains. When artificially over-expressed, NGB reduces the infarct size observed after transient Middle Cerebral Artery occlusion (tMCAo) in rats. This study addresses the post-ischemic NGB expression in vivo. Ten Spontaneously Hypertensive Rats (SHRs) were randomized to tMCAo (n = 6) or sham (n = 4), and euthanized 24 h later. NGB mRNA expression was determined by means of quantitative Reverse Transcription Polymerase Reaction (qRT-PCR). Thirteen animals subjected to either 90 min tMCAo (n = 7) or sham (n = 6) surgery, were euthanized 1 week after surgery. Post-ischemic expression of NGB and the neuronal marker NeuN was studied using free-floating immunohistochemistry. Design-based stereological quantification of NGB- and NeuN-positive cells in the striatum was performed using the optical fractionator. Significantly less NGB mRNA was expressed in the ischemic hemispheres of tMCAo animals after 24 h (P < or = 0.002). At the protein level, we found a significantly lower number of NGB- and NeuN-positive striatal neurons in tMCAo rats (P < or = 0.004). NGB expression was mainly confined to the hypothalamus and amygdala. Less than one out of every two thousand neurons expressed NGB in the striatum. In the ischemic territory we did not observe selective sparing of NGB expressing neurons. No significant change in the NGB/NeuN ratio was observed. Our data indicate that endogenous expressed NGB does not provide protection against ischemic injury induced by tMCAo in SHRs.