Treatment of Brain Arteriovenous Malformations.

Brain arteriovenous malformations (AVMs) are a rare entity of vascular anomalies, characteristic of anatomical shunting where arterial blood directly flows into the venous circulation. The main aim of the active treatment policy of brain AVMs is the prevention of haemorrhage. There are well-established treatment strategies that continually improve in their safety and efficacy, primarily due to the advances in imaging modalities, targeted and novel techniques, the development of alternative treatment approaches, and even better experience with the disease itself. There are interesting imaging novelties that may be prospectively applicable in the decision-making and planning of the most effective treatment approach for individual patients with intracranial AVM. Surgery is often considered the first-line treatment; however, each patient should be evaluated individually, and the risks of the active treatment policy should not overcome the benefits of the spontaneous natural history of the disease. All treatment modalities, i.e., surgery, radiosurgery, endovascular embolization, and observation, are justified but need to be meticulously selected for each individual patient in order to deliver the best treatment outcome. This chapter deals with historical and currently applied dogmas, followed by introductions of advances in each available treatment modality of AVM management.

Comparison of decline in different cognitive domain in patients with normal pressure hydrocephalus.

We sought to describe the cognitive profile of patients with Idiopathic Normal Pressure Hydrocephalus (iNPH) using a comprehensive neuropsychological battery. Based on age and education correlated norms, we aimed to compare performance in each measured cognitive domain: executive functions (EFs), verbal memory (VM), non-verbal memory (nVM), visuoconstructional abilities (VA) and attention/psychomotor speed (A/PS). Patients diagnosed with iNPH underwent comprehensive neuropsychological evaluation before shunting. Their performance was compared to the age and education correlated norms. Correlation of different cognitive domains in iNPH profile was performed. A total of 53 iNPH patients (73.21 ± 5.48 years) were included in the study. All of the measured cognitive domains were significantly damaged. The most affected domains were EFs and VM (p<0.001 and p<0.001, respectively). A/PS domain was affected milder than EFs and VM (p<0.001). The least affected domains were nVM (p<0.001) and VA (p<0.001). Patients with iNPH are affected in all cognitive domains and the cognitive decline is uneven across these domains. The impairment of memory was shown to depend on the presented material. VM was shown to be much more severely affected than nVM and along with VM, EFs were shown to be the most affected. A/PS speed was shown to be less affected than VM and EFs and the least affected domains were nVM and VA.

Evaluation of the growth rates and related prognostic factors in radiation-induced meningiomas.

PURPOSE: Literature dedicated to growth patterns and growth rate influencing factors of radiation-induced meningiomas (RIMs) is limited. To deliver new insights into the topic, a volumetric growth analysis of RIMs was performed. METHODS: This single-center, retrospective cohort study included patients diagnosed with intracranial meningioma who received radiation treatment at least > 5 years before the RIM diagnosis. Volumetric analysis of individual RIMs was performed using 3D volumetry at the time of RIM diagnosis and during follow-up. RIM growth was determined by calculating absolute (AGR), and relative (RGR) growth rates. Prognostic factors associated with RIM growth were evaluated. RESULTS: A total of 26 patients with 33 meningiomas were enrolled in the study and radiologically/clinically followed up during a median duration of 5.6 years (IQR 3.9-8.8 years). Median AGR was 0.19 cm3 per year and the median RGR was 34.5% per year. Surgically managed RIMs were more likely fast-growing compared to observed ones based on the AGR (p < 0.002). The recurrence rate after total resection was 14.3%. Younger age at RIM diagnosis was associated with higher tumor growth (RGR ≥ 30%, p = 0.040). A significant correlation was found between the length of latency period and the RGR (p = 0.005). CONCLUSION: To diagnose RIM as early as possible comprehensive MRI surveillance is required. Younger patients with shorter latency periods may profit from shortened MRI intervals, with further management being dependent on the growth rate and eventual symptomatology.

Current management in the treatment of intramedullary ependymomas in children.

PURPOSE: Current management of pediatric intramedullary ependymoma is extrapolated from adult series since large studies in children are unavailable. This has led us to share our experience with this rare tumor and compare it to the literature and to review and highlight important aspects of current management and point out inconsistencies. METHODS: This is a retrospective analysis of patients with intramedullary ependymoma managed at our institution between 2004 and 2021. RESULTS: During the study period, 5 patients were treated for intramedullary ependymoma. Cases of myxopapillary ependymoma were excluded. The mean age of our cohort was 11.2 years. We identified 4 cases of grade II ependymoma and 1 case of grade III ependymoma. Gross tumor removal (GTR) was achieved in two patients (40%) of patients. One patient was treated with radiotherapy for recurrence and two patients received chemotherapy. There were no cases of recurrence among patients treated with GTR, but in all patients treated with STR. Eighty percent of patients either improved or stayed stable neurologically. During follow-up (mean 73 months), 2 patients died of disease. CONCLUSION: GTR and tumor grade remain the key prognostic factor of long-term tumor-free survival. Many questions prevail regarding outcomes, correct use of adjuvant therapy, and prognostic factors.

Application of diffusion tensor imaging of the facial nerve in preoperative planning for large vestibular schwannoma: a systematic review.

The accurate identification and preservation of the facial nerve (FN) during vestibular schwannoma (VS) surgery is crucial for maintaining facial function. Investigating the application of diffusion tensor imaging (DTI) in preoperative planning for large VS surgery is provided. PubMed, Cochrane Library, Science Direct, ISI Web of Science, Embase, and additional sources were searched to identify cohort studies about the preoperative DTI usage for the FN tracking before large VS (≥ 2.5 cm) surgery published between 1990 and 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed; the Newcastle-Ottawa Scale was used to assess the risk of bias and to evaluate limitations based on selection/outcome biases. A total of 8 publications yielding 149 VS (mean size 3.66 ± 0.81 cm) were included. Surgical concordance with preoperative DTI FN tracking was 91.67% (range 85-100%). Overall DTI reliability was 88.89% (range 81.81-95.83%). Larger tumor size predicted either DTI inaccurate finding or complete DTI failure (p = 0.001). VS size above > 3.5 cm was associated with a higher risk of DTI failure (p = 0.022), with a higher risk of inaccurate DTI finding preoperatively (p = 0.033), and with a higher House-Brackman score postoperatively (p = 0.007). Application of DTI in larger VS surgery is a valuable FN identification along with electrophysiological monitoring and neuronavigation, therefore also in its preservation and in lowering risk of complications. DTI represents a valuable adjunct to electrophysiological monitoring and neuronavigation in FN identification, applicable not only for smaller, but also larger VS.

Diffusion tensor imaging helps identify shunt-responsive normal pressure hydrocephalus patients among probable iNPH cohort.

The aim of this study was to investigate whether white matter changes as measured by diffusion tensor imaging (DTI) can help differentiate shunt-responsive idiopathic normal pressure hydrocephalus (iNPH) patients from patients with other causes of gait disturbances and/or cognitive decline with ventriculomegaly whose clinical symptoms do not improve significantly after cerebrospinal fluid derivation (non-iNPH). Between 2017 and 2022, 85 patients with probable iNPH underwent prospective preoperative magnetic resonance imaging (MRI) and comprehensive clinical workup. Patients with clinical symptoms of iNPH, positive result on lumbar infusion test, and gait improvement after 120-h lumbar drainage were diagnosed with iNPH and underwent shunt-placement surgery. Fractional anisotropy (FA) and mean diffusivity (MD) values for individual regions of interest were extracted from preoperative MRI, using the TBSS pipeline of FSL toolkit. These FA and MD values were then compared to results of clinical workup and established diagnosis of iNPH. An identical MRI protocol was performed on 13 age- and sex-matched healthy volunteers. Statistically significant differences in FA values of several white matter structures were found not only between iNPH patients and healthy controls but also between iNPH and non-iNPH patients. ROI that showed best diagnostic ability when differentiating iNPH among probable iNPH cohort was uncinate fasciculus, with AUC of 0.74 (p < 0.001). DTI methods of white matter analysis using standardised methods of ROI extraction can help in differentiation of iNPH patients not only from healthy patients but also from patients with other causes of gait disturbances with cognitive decline and ventriculomegaly.

Predictors of postoperative complications and functional outcomes in pediatric patients with surgically treated fourth ventricle tumors.

BACKGROUND: Tumors of the fourth ventricle are frequently treated pathologies in pediatric neurosurgery. Data regarding predictors for permanent neurological deficits, long-term functional outcomes, cerebellar mutism (CM), the extent of resection (EOR), and oncological outcomes are scarce. We attempt to contribute to this topic with an analysis of our institutional cohort. METHODS: A retrospective single-center study of patients aged ≤ 19 years who underwent primary surgical resection of a fourth ventricular tumor over a 15-year period (2006-2021). Predictors analyzed included age, gender, surgical approach, anatomical pattern, tumor grade, EOR, tumor volume, and others as appropriate. RESULTS: One hundred six patients were included (64 males, mean age 7.3 years). The rate of permanent neurological deficit was 24.2%; lateral tumor extension (p = 0.036) and tumor volume greater than 38 cm3 (p = 0.020) were significant predictors. The presence of a deficit was the only significant predictor of reduced (less than 90) Lansky score (p = 0.005). CM occurred in 20.8% of patients and was influenced by medulloblastoma histology (p = 0.011), lateral tumor extension (p = 0.017), and male gender (p = 0.021). No significant difference between the transvermian and telovelar approach in the development of CM was detected (p = 0.478). No significant predictor was found for the EOR. EOR was not found to be a significant predictor of overall survival for both low-grade and high-grade tumors; however, gross total resection (GTR) was protective against tumor recurrence compared to near-total or subtotal resection (p < 0.001). In addition, survival was found to be better in older patients (≥ 7.0 years, p = 0.019). CONCLUSION: The overall rate of postoperative complications remains high due to the eloquent localization. Older patients (> 7 years) have been found to have better outcomes and prognosis. Achieving GTR whenever feasible and safe has been shown to be critical for tumor recurrence. CM was more common in patients with medulloblastoma and in patients with tumors extending through the foramen of Luschka. The telovelar approach uses a safe and anatomically sparing corridor; however, it has not been associated with a lower incidence of CM and neurological sequelae in our series, showing that each case should be assessed on an individual basis.

Epidural spinal cord stimulation can facilitate ejaculatory response in spinal cord injury individuals: a report of two cases.

BACKGROUND: The recovery of autonomic functions and the ability to reproduce in particular is of the highest priority to individuals with spinal cord injury (SCI). The potential of epidural spinal cord stimulation (ESCS) for promoting recovery of sensorimotor functions in the chronic phase of SCI has long been studied. In recent years, several studies have emerged confirming the positive effect of ESCS also on the cardiovascular system and neurogenic bladder and bowel. However, the potential of ESCS in restoring sexual function, especially ejaculation, has not yet been addressed. CASE REPORT: Two cases of people with chronic sensorimotor complete SCI in the 4th thoracic spinal segment are presented. Both men were also diagnosed with severe erectile dysfunction and anejaculation. Thanks to ESCS, Participant 1 successfully restored the ejaculatory reflex using PVS in his home environment. His outcome was subsequently verified under clinical conditions. During ESCS, Participant 1 was also able to achieve ejaculation by masturbation; moreover, he conceived a child naturally without the need for IVF. In Participant 2, we then demonstrated the same effect of ESCS on the restoration of the ejaculatory reflex when targeting the stimulation to the same spinal segment. CONCLUSION: This is the first report on the potential of ESCS for restoring the ability to ejaculate in individuals with complete SCI. Confirmation of these results could significantly reduce the need for assisted reproduction and improve the quality of life of men after SCI in the future.

Acute pancreatitis - predicting the severity of the disease.

RATIONALE: Acute pancreatitis (AP) is a serious acute abdominal disease. AP is often referred to as an unpredictable illness, which can take a mild to severe (fatal) course. AIMS OF THE STUDY: 1) To identify clinical parameters that are significantly related to the clinical course of acute pancreatitis. 2) To compile a scoring system enabling the severity of AP to be predicted when the patient is first admitted to hospital. METHODS: Analysis of available publications and clinical guidance, and retrospective analysis of data on patients hospitalised with AP at our clinic enable us to identify clinical details and laboratory results recorded at the time of patients' admission to hospital that are related to the subsequent severity of the disease. For the purposes of statistical analysis, the sample of patients was divided into two groups: group A (mild AP, without local or organ complications), group B (moderately severe and severe AP with local and/or organ complications). PATIENT GROUPS AND RESULTS: In total, between 01.01.2013 and 30.06.2022, 312 patients with acute pancreatitis were allocated to the retrospective-prospective study sample. 74 % (231/312) of these patients were allocated to group A and 26 % (81/312) were allocated to group B. Univariate analysis of the data collected on the patient sample identified 5 parameters that are statistically significantly associated with the severity of the clinical course of the disease. Presence of SIRS on admission (A vs B, Odds ratio 10.787, 95% CI 5.09-22.85, p < 0.0001), diabetes mellitus type 2 in case history (A vs B, Odds ratio 7.703, 95% CI 3.04-19.51, p 2 mmol/l (A vs B, Odds ratio 3.293, 95% CI 1.59-6.82, p = 0.0013).In order to develop a scoring system, each of these parameters was allocated a points value based on its Odds ratio (OR): presence of SIRS 3 points, hypocalcaemia 3 points, diabetes mellitus type 2 in case history 2 points, urea concentration > 8 mmol/l 1 point and lactate concentration > 2 mmol/l 1 point. The authors refer to their scoring system as The Acute Pancreatitis Admission Score (APAS). The accuracy of APAS was modelled for various cut off values. Across the whole sample, we ascertained that an APAS ≥ 4 points predicts moderately severe or severe AP with a sensitivity of 81 % (95% CI: 71 - 89 %) and specificity of 87 % (95 CI: 81 - 91 %). The positive predictive value (PPV) of APAS ≥ 4 is 0.68, while its negative predictive value (NPV) is 0.93 and accuracy 0.85 (95% CI 0.81 - 0.89). CONCLUSION: In this study we identify significant simple clinical and laboratory parameters that are commonly tested as part of an initial examination when admitting a patient with AP to hospital. Having identified these parameters we are able to establish a simple scoring system that is able to predict the severity of the course of AP at the moment of hospitalisation (Tab. 5, Fig. 2, Ref. 27).

Incidence of surgical site infections after cervical spine surgery: results of a single-center cohort study adhering to multimodal preventive wound control protocol.

PURPOSE: The incidence of surgical site infections is considered a relevant indicator of perioperative and postoperative care quality. The aim of this study is to analyze and evaluate SSIs after elective cervical spine surgery under the guidance of our preventive multimodal wound protocol. METHODS: A monocentric observational cohort study analyzed 797 patients who underwent cervical spine surgery from 2005 to 2010 (mean age 51.58 ± 11.74 year, male 56.09%, mean BMI 26.87 ± 4.41, ASA score 1-2 in 81.68% of patients), fulfilling the entry criteria: (1) cervical spine surgery performed by neurosurgeons (degenerative disease 85.19%, trauma 11.04%, tumor 3.76%), (2) elective surgery, (3) postoperative care in our neurointensive care unit. Our preventive wound control protocol management focused mainly on antibiotic prophylaxis, wound hygiene regime, and drainage equipment. All wound complications and surgical site infections were monitored up for 1 year after surgery. RESULTS: We had only 2 (0.25%) patients with SSI after cervical spine surgery-one organ/space infection (osteomyelitis, primary due to liquorrhea) after anterior surgical approach, and one deep surgical site infection (due to dehiscence) after posterior approach. We had 17 (2.13%) patients with some wound complications (secretion 7, dehiscence 4, hematoma 1, edema 3, and liquorrhea 2) that were not classified as SSI according to the CDC guidelines. CONCLUSION: Concerning our study population of patients undergoing elective cervical surgery, with ASA scores 1-2 in 81.68% of our patients, the incidence of SSI was 0.14% after anterior surgical approach, 1.4% after posterior surgical approach, and 0.25% altogether in the referred cohort.

Overview of cerebral cavernous malformations: comparison of treatment approaches.

OBJECTIVES: The comparison of treatment efficacy for cerebral cavernous malformations (CCMs) has not yet been well researched. DESIGN: PubMed, Cochrane Library, Science Direct, ISI Web of Science, Embase and additional sources were searched to identify cohort studies about the treatment of CCMs published between 1990 and 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed; the Newcastle-Ottawa Scale was used to assess the risk of bias and to evaluate limitations based on selection/outcome biases. The cumulative incidences with 95% CIs were calculated using the random effects model. The models of Poisson distribution were applied to evaluate risk factors of poorer treatment outcome by calculating rate ratios within 100 person-years with 95% CIs. RESULTS: A total of 100 cohorts yielding 8994 patients treated for CCMs within 41 098 person-years of follow-up were analysed. The efficacy of ensuring the prevention of haemorrhage was 97% in surgical, 86% in radiosurgical and 77% in the conservative treatment. The lowest mortality (1%) was after radiosurgery, and the highest persistent morbidity (22%) was in natural history series. Deep-seated and brainstem CCMs were associated with higher bleeding rates. Lobar localisation was a protective factor in all analyses. Patients with history of previous haemorrhage were exposed to higher risk of rebleeding. Male gender was a protective factor associated with lower risk of post-treatment haemorrhage. CONCLUSIONS: Surgical resection of CCM is effective in ensuring the prevention of haemorrhage with acceptable morbidity and mortality, but conservative and radiosurgical management is a justified treatment alternative. Brainstem and deep-seated CCMs are predominantly associated with higher haemorrhage rates.

Repeated Aneurysm Intervention.

Over the past 25 years the endovascular treatment of cerebral aneurysms has gained preference in some countries over the traditional surgical procedures. The review part of the article clearly demonstrates that the clinical results of both modalities are similar and the difference is seen only in technical effectivity. Surgical techniques fail far less frequently than the endovascular ones. Incompletely occluded or growing aneurysms after the endovascular approach expose the patient to the risk of rebleeding with all possible consequences. Markedly repeated procedures are much more common for endovascularly treated aneurysms, again with all the risks.In the authors institution over the past 20 years, a total of 2032 aneurysms were treated. In 1263 endovascularly managed aneurysms the regrowth or inclomplete initial occlusion necessitated 159 repeated propcedures (12.6%). In surgical group the total of 27 aneurysms needed retreatment (3.5%). The difference is statistically significant. In nine patients in endovascular group the rebleeding was the reason for repeated procedures. No rebleeding was seen in the surgical group.This fact, also shown in the review part of the article, is important in patients counseling. Given the similar clinical results of both modalities the patient should be advised on the necessity of repeated follow-ups and of possible technical failure and eventual repeated procedure which is more likely if endovascular procedure is chosen.

Boosting phase-contrast MRI performance in idiopathic normal pressure hydrocephalus diagnostics by means of machine learning approach.

OBJECTIVE: Phase-contrast MRI allows detailed measurements of various parameters of CSF motion. This examination is technically demanding and machine dependent. The literature on this topic is ambiguous. Machine learning (ML) approaches have already been successfully utilized in medical research, but none have yet been applied to enhance the results of CSF flowmetry. The aim of this study was to evaluate the possible contribution of ML algorithms in enhancing the utilization and results of MRI flowmetry in idiopathic normal pressure hydrocephalus (iNPH) diagnostics. METHODS: The study cohort consisted of 30 iNPH patients and 15 healthy controls examined on one MRI machine. All major phase-contrast parameters were inspected: peak positive, peak negative, and average velocities; peak amplitude; positive, negative, and average flow rates; and aqueductal area. The authors applied ML algorithms to 85 complex features calculated from a phase-contrast study. RESULTS: The most distinctive parameters with p < 0.005 were the peak negative velocity, peak amplitude, and negative flow. From the ML algorithms, the Adaptive Boosting classifier showed the highest specificity and best discrimination potential overall, with 80.4% ± 2.9% accuracy, 72.0% ± 5.6% sensitivity, 84.7% ± 3.8% specificity, and 0.812 ± 0.047 area under the receiver operating characteristic curve (AUC). The highest sensitivity was 85.7% ± 5.6%, reached by the Gaussian Naive Bayes model, and the best AUC was 0.854 ± 0.028 by the Extra Trees classifier. CONCLUSIONS: Feature extraction algorithms combined with ML approaches simplify the utilization of phase-contrast MRI. The highest-performing ML algorithm was Adaptive Boosting, which showed good calibration and discrimination on the testing data, with 80.4% accuracy, 72.0% sensitivity, 84.7% specificity, and 0.812 AUC. Phase-contrast MRI boosted by the ML approach can help to determine shunt-responsive iNPH patients.

Cerebral venous sinus thrombosis in infant with COVID-19.

We present a rare case of cerebral venous sinus thrombosis in a COVID-19-positive, 2-month-old infant, to this day the youngest described patient with this rare combination of findings. He was hospitalized with focal seizures. The first brain imaging showed subdural hematoma and focal ischemic changes. The subdural hematoma was successfully evacuated. The control imaging, done due to lethargy, showed an extensive cerebral venous sinus thrombosis. The thrombosis was managed with low molecular weight heparin leading to clinical and radiological improvement. With this case report, we would like to add to the information pool of COVID-19 neurological manifestations in children, particularly those younger than 1 year.

Diagnostic accuracy of DSA in carotid artery stenosis: a comparison between stenosis measured on carotid endarterectomy specimens and DSA in 644 cases.

BACKGROUND AND PURPOSE: DSA (digital subtraction angiography) is the gold standard for measuring carotid artery stenosis (CS). Yet, the correlation between DSA and stenosis is not well documented. MATERIAL AND METHODS: We compared CS as measured by DSA to carotid artery specimens obtained from carotid endarterectomy surgery. Patients were divided into three groups according to NASCET criteria (North American Symptomatic Carotid Endarterectomy Trial): stenosis of 30-49% (mild), stenosis of 50-69% (moderate), and stenosis of 70-99% (severe). RESULTS: This prospective cohort study involved 644 patients. The mean stenosis in the mild stenosis group (n = 128 patients) was 54% ECST (European Carotid Surgery Trial), 40% NASCET, and 72% ESs (endarterectomy specimens). The mean absolute difference between ECST and NASCET was 14%. The mean stenosis in the moderate stenosis group (n = 347 patients) was 66% ECST, 60% NASCET, and 77% ES. The mean absolute difference between ECST and NASCET was 6%. The mean stenosis in the severe group (n = 169 patients) was 80% ECST, 76% NASCET, and 79% ES. No significant correlation coefficients were found between DSA and ES methods. In the mild group, the CC was 0.16 (ESCT) and 0.13 (NASCET); in the moderate group, the CC was 0.05 (ESCT) and 0.01 (NASCET); and in the severe group, the CC was 0.23 (ESCT) and 0.10 (NASCET). For all groups combined, CC was 0.22 for the ECST and 0.20 for the NASCET method. CONCLUSION: The relationship between DSA and ES methods to measure CS is almost random. This lack of a relationship between the DSA and ES techniques questions the validity of current DSA-based guidelines.

Survival and functional outcomes in paediatric thalamic and thalamopeduncular low grade gliomas.

BACKGROUND: Childhood thalamopeduncular gliomas arise at the interface of the thalamus and cerebral peduncle. The optimal treatment is total resection but not at the cost of neurological function. We present long-term clinical and oncological outcomes of maximal safe resection. METHODS: Retrospective review of prospectively collected data: demography, symptomatology, imaging, extent of resection, surgical complications, histology, functional and oncological outcome. RESULTS: During 16-year period (2005-2020), 21 patients were treated at our institution. These were 13 girls and 8 boys (mean age 7.6 years). Presentation included progressive hemiparesis in 9 patients, raised intracranial pressure in 9 patients and cerebellar symptomatology in 3 patients. The tumour was confined to the thalamus in 6 cases. Extent of resection was judged on postoperative imaging as total (6), near-total (6) and less extensive (9). Surgical complications included progression of baseline neurological status in 6 patients, and 5 of these gradually improved to preoperative status. All tumours were classified as low-grade gliomas. Disease progression was observed in 9 patients (median progression-free survival 7.3 years). At last follow-up (median 6.1 years), all patients were alive, median Lansky score of 90. Seven patients were without evidence of disease, 6 had stable disease, 7 stable following progression and 1 had progressive disease managed expectantly. CONCLUSION: Paediatric patients with low-grade thalamopeduncular gliomas have excellent long-term functional and oncological outcomes when gross total resection is not achievable. Surgery should aim at total resection; however, neurological function should not be endangered due to excellent chance for long-term survival.

Structural volumetry in NPH diagnostics and treatment-future or dead end?

To assess automated volumetric analysis as a potential presurgical diagnostic tool or as a method to potentially shed light on normal pressure hydrocephalus (NPH) pathophysiology. MRI imaging according to our protocol was performed in 29 NPH patients, 45 non-NPH (but suspected) patients and 15 controls. Twenty patients underwent a second MRI 3 months after ventriculoperitoneal (VP) shunt surgery. All structures relevant to NPH diagnosis were automatically segmented using commercial software. The results were subsequently tested using ANOVA analysis. Significant differences in the volumes of the corpus callosum, left hippocampus, internal globus pallidus, grey and white matter and ventricular volumes were observed between NPH group and healthy controls. However, the differences between NPH and non-NPH groups were non-significant. Three months after, VP shunt insertion decreased ventricular volume was the only clearly significant result (p value 0.0001). Even though a detailed volumetric study shows several significant differences, volumetric analysis as a standalone method does not provide a simple diagnostic biomarker, nor does it shed a light on an unknown NPH aetiology.

Normal pressure hydrocephalus-an overview of pathophysiological mechanisms and diagnostic procedures.

Normal pressure hydrocephalus (NPH) is an important differential diagnosis of neurodegenerative diseases. The prevalence of dementia is increasing in line with the worldwide increase in life expectancy. NPH can be divided into idiopathic (iNPH) and secondary (sNPH) which is important in terms of clinical symptoms, future progress, and the outcome of possible treatment. The full clinical triad is not prevalent in all of the cases and the pathophysiology of iNPH remains unclear. Diagnosis is based on the evaluation of clinical symptoms (Hakim's triad) combined with an MRI assessment, evaluation of CSF dynamic parameters by different methods such as a tap test, lumbar infusion test (LIT), and external lumbar drainage (ELD). Despite the development of diagnostic techniques and strategies in management, NPH remains to be a challenge for the specialists despite more than 50 years of research. However, results of this research have brought new opportunities in the diagnosis, therapy, and quality of life as well as survival time of NPH patients with improved symptoms. The aim of this article is to present the pathophysiological hypotheses of NPH and an overview of the diagnostic techniques used for the evaluation of NPH patients.

Surgery of acute occlusion of the extracranial internal carotid artery - a meta-analysis.

Acute occlusion of the extracranial internal carotid artery (eICA) is associated with poor prognosis. Surgical desobliteration has not received adequate attention in recent years. We therefore conducted a literature review and meta-analysis of surgical studies published after 2000 that treated eICA occlusion surgically in an emergency setting. The search identified 10 relevant articles that included a total of 175 patients. The outcomes analysed included rates of recanalization (93 %), early neurological improvement (66 %), modified Rankin Scale 0-2 (62 %), mortality (5 %), early reocclusion (4 %), in-hospital stroke (4 %) and symptomatic intracerebral haemorrhage (4 %). In conclusion, acute surgical desobliteration of eICA occlusion leads to high rates of recanalization and a majority of patients experience early neurological improvement and achieve favourable outcome. Rates of mortality, early reocclusion, in-hospital stroke and sICH are acceptable in the view of unfavourable natural history.

Low incidence of multidrug-resistant bacteria and nosocomial infection due to a preventive multimodal nosocomial infection control: a 10-year single centre prospective cohort study in neurocritical care.

BACKGROUND: Nosocomial infection (NI) control is an important issue in neurocritical care due to secondary brain damage and the increased morbidity and mortality of primary acute neurocritical care patients. The primary aim of this study was to determine incidence of nosocomial infections and multidrug-resistant bacteria and seek predictors of nosocomial infections in a preventive multimodal nosocomial infection protocol in the neurointensive care unit (NICU). The secondary aim focused on their impact on stay, mortality and cost in the NICU. METHODS: A10-year, single-centre prospective observational cohort study was conducted on 3464 acute brain disease patients. There were 198 (5.7%) patients with nosocomial infection (wound 2.1%, respiratory 1.8%, urinary 1.0%, bloodstream 0.7% and other 0.1%); 67 (1.9%) with Extended spectrum beta-lactamase (ESBL); 52 (1.5%) with Methicillin-resistant Staphylococcus aureus (MRSA), nobody with Vancomycin-resistant enterococcus (VRE). The protocol included hygienic, epidemiological status and antibiotic policy. Univariate and multivarite logistic regression analysis was used for identifying predictors of nosocomial infection. RESULTS: From 198 NI patients, 153 had onset of NI during their NICU stay (4.4%; wound 1.0%, respiratory 1.7%, urinary 0.9%, bloodstream 0.6%, other 0.1%); ESBL in 31 (0.9%) patients, MRSA in 30 (0.9%) patients. Antibiotics in prophylaxis was given to 63.0% patients (59.2 % for operations), in therapy to 9.7% patients. Predictors of NI in multivariate logistic regression analysis were airways (OR 2.69, 95% CI 1.81-3.99, p<0.001), urine catheters (OR 2.77, 95% CI 1.00-7.70, p=0.050), NICU stay (OR 1.14, 95% CI 1.12-1.16, p<0.001), transfusions (OR 1.79, 95% CI 1.07-2.97, p=0.025) antibiotic prophylaxis (OR 0.50, 95% CI 0.34-0.74, p<0.001), wound complications (OR 2.30, 95% CI 1.33-3.97, p=0.003). NI patients had longer stay (p<0.001), higher mortality (p<0.001) and higher TISS sums (p<0.001) in the NICU. CONCLUSIONS: The presented preventive multimodal nosocomial infection control management was efficient; it gave low rates of nosocomial infections (4.2%) and multidrug-resistant bacteria (ESBL 0.9%, MRSA 0.9% and no VRE). Strong predictors for onset of nosocomial infection were accesses such as airways and urine catheters, NICU stay, antibiotic prophylaxis, wound complications and transfusion. This study confirmed nosocomial infection is associated with worse outcome, higher cost and longer NICU stay.