High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option.

BACKGROUND: A systematic review of the evidence pertaining to methylprednisolone infusion following acute spinal cord injury was conducted in order to address the persistent confusion about the utility of this treatment. METHODS: A committee of neurosurgical and orthopedic spine specialists, emergency physicians and physiatrists engaged in active clinical practice conducted an electronic database search for articles about acute spinal cord injuries and steroids, from January 1, 1966 to April 2001, that was supplemented by a manual search of reference lists, requests for unpublished additional information, translations of foreign language references and study protocols from the author of a Cochrane systematic review and Pharmacia Inc. The evidence was graded and recommendations were developed by consensus. RESULTS: One hundred and fifty-seven citations that specifically addressed spinal cord injuries and methylprednisolone were retrieved and 64 reviewed. Recommendations were based on one Cochrane systematic review, six Level I clinical studies and seven Level II clinical studies that addressed changes in neurological function and complications following methylprednisolone therapy. CONCLUSIONS: There is insufficient evidence to support the use of high-dose methylprednisolone within eight hours following an acute closed spinal cord injury as a treatment standard or as a guideline for treatment. Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body weight over fifteen minutes within eight hours of closed spinal cord injury, followed 45 minutes later by an infusion of 5.4 mg per kilogram of body weight per hour for 23 hours, is only a treatment option for which there is weak clinical evidence (Level I- to II-1). There is insufficient evidence to support extending methylprednisolone infusion beyond 23 hours if chosen as a treatment option.

The Trail Making Test: a study in focal lesion patients.

The relationship of the Trail Making Test (TMT) to the frontal lobes was tested by comparing patients with damage to the frontal and nonfrontal regions to control participants. Although the analysis of time measurements, both raw and transformed, showed notable slowing of frontal groups, error analysis proved to be a more useful method of categorizing performance. Analysis of errors on Part B indicated that all patients who made more than 1 error had frontal lesions. Dividing the frontal damaged patients into subgroups on the basis of the number of errors yielded specificity of brain-behavior relations within the frontal lobes. Patients with damage in dorsolateral frontal areas were most impaired. Those with inferior medial damage to the frontal lobes were not significantly affected in TMT Part B performance.

Wisconsin Card Sorting Test performance in patients with focal frontal and posterior brain damage: effects of lesion location and test structure on separable cognitive processes.

Forty-six patients with single focal lesions (35 frontal, 11 nonfrontal) were administered the Wisconsin Card Sorting Test (WCST) under three conditions of test administration. The three conditions varied in the amount of external support provided via specificity of instructions. The WCST, while a multifactorial test, is specifically sensitive to the effects of frontal lobe damage if deficits in language comprehension and visual-spatial search are controlled. There is also specificity of functioning within the frontal lobes: patients with inferior medial frontal lesions, unilateral or bilateral, were not impaired on the standard measures although they had increased loss of set when informed of the sorting categories. Verbal instructions may provide a probe to improve diagnosis and prognosis, assessment of the potential efficacy of treatment, and the time frame of plasticity of specific cognitive operations.

The effects of focal anterior and posterior brain lesions on verbal fluency.

Seventy-four patients with focal brain lesions were compared to a neurologically normal control group on tasks of letter-based and category-based list generation. When patients were divided only by right frontal, left frontal, or nonfrontal lesion sites, the pattern of fluency impairments confirmed prior claims. When more precise lesion sites within the frontal lobes were compared between groups classified based on their fluency performance, much more specific brain-behavior relations were uncovered. Damage to the right dorsolateral cortical or connecting striatal regions, the right posterior area, or the medial inferior frontal lobe of either hemisphere did not significantly affect letter-based fluency performance. Superior medial frontal damage, right or left, resulted in moderate impairment. Patients with left dorsolateral and/or striatal lesions were most impaired. Left parietal damage led to performance relatively equivalent to the superior medial and left dorsolateral groups. The same lesion sites produced impairments in category based fluency, but so did lesions of right dorsolateral and inferior medial regions. Task analysis and correlations with other measures revealed that different cognitive processes related to different brain regions underlie performance on verbal fluency tests.

Dissection of the intracranial vertebral artery.

We describe four patients and review prior reports to clarify the clinical, radiographic, and pathologic findings of intracranial vertebral artery (VA) dissection. A 43-year-old man and a 33-year-old woman had chronic bilateral VA dissecting aneurysms. The man had multiple episodes of subarachnoid hemorrhage (SAH) and necropsy showed multiple dissections and defects in the internal elastica. The woman had many brainstem TIAs and strokes during 3 years. Two other patients had SAH and unilateral dissections. Intracranial VA dissection causes four overlapping syndromes: (1) brainstem infarcts are usually due to subintimal dissection extending into the basilar artery, affect younger patients, and often are single fatal events; (2) SAH is due to subadventitial or transmural dissection; (3) aneurysms cause mass effect on the brainstem and lower cranial nerves; and (4) chronic dissections due to connective tissue defects cause extensive bilateral aneurysms and repeated TIAs, small strokes, and SAH.

Immunocytochemical analysis of intermediate filaments in human ependymal tumors.

The peroxidase anti-peroxidase technique was used for localization of glial fibrillary acidic protein (GFAP) and vimentin (VM) in 19 ependymal tumors in order to determine if a unique pattern of intermediate filament (IF) expression could be demonstrated. Cytokeratin (CK) immunoreactivity was examined in a subgroup of 7 tumors with papillary pattern. Nineteen non-ependymal neuroectodermal tumors were used as controls. Ependymomas, subependymomas and astrocytomas were positive for both IF. Oligodendrogliomas, oligodendroglial portions of mixed gliomas and the majority of medulloblastomas were negative for GFAP and VM. Areas of poor differentiation in all tumors demonstrated little expression of any IF. A composite ependymoma/choroid plexus papilloma showed the presence of GFAP, VM and CK in the papillomatous portion only. Four papillary ependymomas were negative for CK. This study emphasizes the parallel distribution of GFAP and VM in well differentiated ependymomas and other glial tumors and casts doubt upon the concept of VM as a marker for de-differentiation in neuroectodermal neoplasia.

Gangliocytoma of the cerebellum: ultrastructure and immunohistochemistry.

A 31-year-old man presenting with a cerebellopontine angle syndrome underwent subtotal resection of a gangliocytoma of the left middle cerebellar peduncle. The tumor was positive for 68-kD neurofilament protein and vasoactive intestinal peptide. No glial cells were identified on immunohistochemical or ultrastructural examination. Electron microscopic study of neoplastic ganglionic cells revealed the presence of dense core vesicles, synaptic junctions, Hirano bodies, and marked dystrophic changes in the neuritic processes. The nosology of this lesion is discussed. Similarities between the morphological changes shown by mature neoplastic ganglion cells and comparable structural alterations seen in the physiological senescence of nonneoplastic neurons are stressed.

Intravascular papillary endothelial hyperplasia in an intracranial cavernous hemangioma.

A novel presentation of intravascular papillary endothelial hyperplasia within a cerebral cavernous angioma in an adult is described. The pathogenesis of the lesion and its histological differentiation from malignant angiosarcoma are stressed.

Vomiting in children following head injury.

The criteria for hospital admission of children who have suffered a minor head injury are highly subjective. Often the presence of post-traumatic emesis becomes an influential factor, but the mechanisms that trigger emesis following minor head injuries are not known. From a prospective study of 96 consecutive children with their first mild head injury (GCS 13-15) and a retrospective study of 29 consecutive more seriously injured children (GCS 8-12), we conclude that post-traumatic emesis is more common: (1) following minor head injuries than following more severe head injuries (P less than 0.05); (2) in children over 2 years old; (P less than 0.001); (3) in children injured within an hour of a meal or snack (p less than 0.001). The presence of a skull fracture or the site of the impact does not influence the incidence or duration of post-traumatic emesis. Retching and vomiting generally subside within 3 h in children injured within an hour of a meal or snack. When vomiting appears in children injured more than an hour after a meal or a snack, it may be quite protracted (mean = 7.5 h). Children over 2 years of age with post-traumatic emesis who are neurologically stable following a mild head injury that occurred within an hour of a meal or snack can be expected to improve quickly. Their counterparts injured more than an hour after a meal or snack are likely to remain distressed much longer and are best admitted to hospital.