Delirium in neurosurgery: a systematic review and meta-analysis.

Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.

Need analysis for a new high acuity medical psychiatry unit: which patients are considered for admission?

BACKGROUND: The study aims were: to estimate the proportion of patients with an indication for admission to a new high acuity Medical Psychiatric Unit (MPU), to explore the reasons for MPU-admission according to different health disciplines, and to check for differences in patient characteristics. The results of this study are to be utilized in the proposed establishment of a high-acuity MPU in a University Medical Center. Such a unit currently does not exist at Erasmus MC. METHODS: Hospital in-patients were included if they received psychiatric consultation from the Psychiatric Consultative Service (PCS). As part of the study protocol, psychiatrists, other medical specialists, and nurses determined the need for admission to the proposed MPU. Patient groups were compared with respect to diagnoses, socio-demographic characteristics and patient routing. RESULTS: One hundred and fifty-one patients were included, 43% had an indication for MPU-admission, for the other patients PCS involvement was sufficient. There was agreement on suicide attempts as a reason for MPU-admission. For psychiatrists, the need for further diagnostic evaluation was a common reason for MPU admission, while other medical specialists more often emphasized the need for safety measures. Patients with an unplanned hospital admission had a higher chance of MPU eligibility (OR = 2.72, 95% CI 1.10-6.70). The main psychiatric diagnoses of MPU-eligible patients were organic disorders (including delirium), mood disorders, and disorders related to substance abuse. The most common diagnoses found were similar to those in previous research on MPU populations. CONCLUSION: Different medical disciplines have different views on the advantages of MPUs, while all see the need for such facilities. The proposed MPU should be able to accommodate patients directly from the Emergency Unit, and the MPU should provide specialized diagnostic care in an extra safe environment.

Functional connectivity and microstructural white matter changes in phenocopy frontotemporal dementia.

OBJECTIVES: Phenocopy frontotemporal dementia (phFTD) is a rare and poorly understood clinical syndrome. PhFTD shows core behavioural variant FTD (bvFTD) symptoms without associated cognitive deficits and brain abnormalities on conventional MRI and without progression. In contrast to phFTD, functional connectivity and white matter (WM) microstructural abnormalities have been observed in bvFTD. We hypothesise that phFTD belongs to the same disease spectrum as bvFTD and investigated whether functional connectivity and microstructural WM changes similar to bvFTD are present in phFTD. METHODS: Seven phFTD patients without progression or alternative psychiatric diagnosis, 12 bvFTD patients and 17 controls underwent resting state functional MRI (rs-fMRI) and diffusion tensor imaging (DTI). Default mode network (DMN) connectivity and WM measures were compared between groups. RESULTS: PhFTD showed subtly increased DMN connectivity and subtle microstructural changes in frontal WM tracts. BvFTD showed abnormalities in similar regions as phFTD, but had lower increased DMN connectivity and more extensive microstructural WM changes. CONCLUSIONS: Our findings can be interpreted as neuropathological changes in phFTD and are in support of the hypothesis that phFTD and bvFTD may belong to the same disease spectrum. Advanced MRI techniques, objectively identifying brain abnormalities, would therefore be potentially suited to improve the diagnosis of phFTD. KEY POINTS: • PhFTD shows brain abnormalities that are similar to bvFTD. • PhFTD shows increased functional connectivity in the parietal default mode network. • PhFTD shows microstructural white matter abnormalities in the frontal lobe. • We hypothesise phFTD and bvFTD may belong to the same disease spectrum.

Organization of inferior olivary projections to the flocculus and ventral paraflocculus of the rat cerebellum.

The climbing fiber projection to the rat flocculus and adjacent ventral paraflocculus was investigated by using Phaseolus vulgaris-leucoagglutinin as an anterograde and horseradish peroxidase as a retrograde tracer. Large injections of horseradish peroxidase in the flocculus and ventral paraflocculus indicated that the climbing fibers to this region are derived exclusively from any of the following contralateral olivary regions: the dorsal cap of Kooy, the ventrolateral outgrowth, the caudal half of the ventral leaf of the principal olive near its lateral bend, and the rostral pole of the medial accessory olive. Subsequent anterograde and retrograde studies with small injections demonstrated that the latter area projects to the C2 zone, which runs caudally in the ventral paraflocculus and enters the caudal most aspect of the flocculus. The ventral leaf of the principal olive is connected to a D zone in the cerebellar hemisphere and paraflocculus, which, upon entering the ventral paraflocculus, divides into a caudal and rostral strip, termed FD and FD', respectively. The dorsal cap and the ventrolateral outgrowth each project to two distinct zones in the flocculus and part of the ventral paraflocculus. Two floccular zones, which are continuous with the parafloccular FD and FD' zones, receive their climbing fibers from the ventrolateral outgrowth. Two other zones, (FE and FE') receive their climbing fibers from the dorsal cap. The FE' zone is found at the rostral pole of the flocculus and is followed caudalwards by the FD', FE, FD, and C2 zones, respectively. The rostromedial part of the dorsal cap is connected to the continuation of the FE zone into the ventral paraflocculus. The observation that the dorsal cap and the ventrolateral outgrowth are both connected to a set of two alternating zones of floccular/ventral parafloccular Purkinje cells is in agreement with recent studies in the rabbit, and suggests that these zones reflect functionally distinct and discrete units related to specific aspects of visuomotor control.