Delayed revascularization in acute ischemic stroke patients.

Stroke shares a significant burden of global mortality and disability. A significant decline in the quality of life is attributed to the so-called post-stroke cognitive impairment including mild to severe cognitive alterations, dementia, and functional disability. Currently, only two clinical interventions including pharmacological and mechanical thrombolysis are advised for successful revascularization of the occluded vessel. However, their therapeutic effect is limited to the acute phase of stroke onset only. This often results in the exclusion of a significant number of patients who are unable to reach within the therapeutic window. Advances in neuroimaging technologies have allowed better assessment of salvageable penumbra and occluded vessel status. Improvement in diagnostic tools and the advent of intravascular interventional devices such as stent retrievers have expanded the potential revascularization window. Clinical studies have demonstrated positive outcomes of delayed revascularization beyond the recommended therapeutic window. This review will discuss the current understanding of ischemic stroke, the latest revascularization doctrine, and evidence from clinical studies regarding effective delayed revascularization in ischemic stroke.

Diagnostic and Neurological Overview of Brain Tuberculomas: A Review of Literature.

Tuberculosis is a disease caused by a bacteria named Mycobacterium tuberculosis (M. tb). It is estimated by World Health Organization (WHO) that nearly a quarter of the world's population is infected. Tuberculoma of the brain is one of the most severe extrapulmonary forms that affects patients younger than 40 years of age. Brain parenchymal tuberculoma develops in nearly one of 300 non-treated cases of pulmonary tuberculosis cases. In endemic regions, tuberculomas account for as many as 50% of all intracranial masses. Tuberculoma results in a hematogenous spread of M. tb from an extracranial source. Tuberculomas can mimic a variety of diseases and can present themselves in a subacute or chronic course, from asymptomatic to severe intracranial hypertension. Diagnosis is based on computed tomography (CT) scan and magnetic resonance imaging (MRI) studies with a similar ring-enhancing lesion. Treatment is primarily medical, and the duration for brain tuberculoma can vary from six to 36 months. In certain cases, surgery is recommended.

Epilepsy and Deep Brain Stimulation of Anterior Thalamic Nucleus.

Presently, at least 60 million people are suffering from epilepsy worldwide. Although multiple pharmacological options for treatment exist, about 30% to 40% of these patients are estimated to have drug-resistant epilepsy (DRE), which is associated with severe disability and morbidity. The surgical treatment options are restricted to either open surgical procedures or laser ablations. When a resective option is not favorable, then neuromodulation options such as vagal nerve stimulation and deep brain stimulation are considered. A relatively recent and more commonly used clinical application is the deep brain stimulation (DBS) of the anterior thalamic nucleus, FDA approval for which was obtained in 2018. Furthermore, new technological advances in DBS technology are expected to positively impact the treatment options of these patients.

Current Surgical Options for Moyamoya Disease.

Moyamoya disease (MMD) is a cerebrovascular disease of unknown etiology characterized by stenotic and occlusive arterial changes of the anterior circulation, with subsequent proliferative development of arterial collateralization. In spite of there being limited understanding of the clear etiology of MMD, surgical revascularization for MMD is considered the standard treatment to prevent further stroke. While the use of surgical revascularization to prevent future hemorrhagic stroke in MMD is still controversial, it is considered effective in the case of ischemic stroke. This article presents a review of the current surgical management of MMD based on an analysis of the most recent data from peer-reviewed articles and opinion based on personal experience with surgical revascularization in the treatment of MMD.

Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers.

BACKGROUND: The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA. METHODS: After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique. RESULTS: In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively. CONCLUSIONS: This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.

Acute-phase inflammatory response in idiopathic sudden deafness: pathogenic implications.

The acute-phase inflammatory response in the peripheral bloodstream can be an expression of transient cerebral ischaemia in idiopathic sudden deafness. For this, a neurological and otorhinolaryngological examination of each patient, performing tests on audiometry, and tympanometry, haemogram, and cranial magnetic resonance were performed. The acute-phase inflammatory response manifests as an increased neutrophil/lymphocyte ratio that is detected 48-72 hours after the appearance of sudden deafness. This study shows that there is an acute-phase response in the peripheral bloodstream with an increased neutrophil/lymphocyte ratio as an expression of an inflammatory process that can be caused by transient cerebral ischaemia in sudden deafness. In addition, the increased neutrophil/lymphocyte ratio can rule out a viral origin of sudden deafness, since a viral infection lowers the neutrophil count and increases the lymphocyte count, thus reducing the neutrophil/lymphocyte ratio. These findings aid in understanding the pathogenic mechanisms involved in sudden deafness and offer better treatment to the patient.

Terapia sonora en sordera súbita / Sound therapy in sudden deafness

Introducción y objetivos: La hipoacusia neurosensorial súbita idiopática es un trastorno auditivo de causa desconocida. El índice de recuperación espontánea puede variar, según la literatura, en un rango del 50-75% de los pacientes. Experimentos científicos mediante terapia sonora en animales hipoacúsicos avalan el presente estudio en pacientes con sordera súbita tratados con sonidos. Pacientes y métodos: Estudio sin aleatorización de una serie retrospectiva de casos. Durante el período 2003-2009, pacientes con hipoacusia neurosensorial súbita idiopática fueron tratados con corticosteroides, piracetam y antioxidantes, en presencia y ausencia de terapia sonora de música y palabra. Resultados: Cuando se comparan los resultados de los pacientes tratados con medicación(n = 65) y los tratados con medicación más terapia sonora (n = 67), se observa que los segundos tienen mayor recuperación. En este grupo, 25 (37%) se recuperaron completamente, 28 (42%) tuvieron buena recuperación, 11 (16%) ligera recuperación y 3 (5%) pobre recuperación o ninguna recuperación. Conclusión: El 54% de los pacientes del grupo con medicación ha recuperado más de la mitad de la audición perdida y el 79% del grupo que recibió medicación y terapia sonora. La recuperación auditiva no sufrió alteraciones, al menos, en los siguientes 12 meses del tratamiento(AU)

Introduction and goals: Idiopathic sudden sensorineural hearing loss is a hearing disorder of unknown cause. The spontaneous recovery rate ranges from 50 to 75% of the patients. Scientific experiments on animals support the present study in patients with sudden deafness treated with sounds. Patients and methods: During the period 2003-2009, patients with idiopathic sudden sensorineural hearing loss were administered steroids, piracetam and antioxidants, together with the addition of sounds by means of music and words. Results: Comparing the results of patients treated with medication (n = 65) and those treated with medication and sounds (n = 67), it was observed that patients treated with medication and sounds had higher recovery. Within the group of patients treated with medication and sounds,25 (37%) experienced complete recovery, 28 (42%) good recovery, 11 (16%) slight recovery and3 (5%) poor or no recovery .Conclusion: The patients who recovered more than half of their audition accounted for 54% in the group treated with medication and for 79% in the group of patients receiving medication and sounds. Auditory recuperation showed no alterations, at least up to 12 months after therapy(AU)

Medición de acúfenos con audiómetro convencional versus audiómetro de alta frecuencia / Tinnitus measurement with conventional audiometer versus high-frequency audiometer

Introducción y objetivos: Las determinaciones de las características psicoacústicas del acúfeno (frecuencia e intensidad) son válidas para el diagnóstico, tratamiento, seguimiento y fines de investigación. El objetivo de este estudio es conocer si se encuentran diferencias entre las determinaciones de la frecuencia e intensidad del acúfeno con metodología convencional o metodología de alta frecuencia. Métodos: Se utiliza audiómetro convencional (rango de frecuencias: 125-12.000Hz) y audiómetro de alta frecuencia (rango de frecuencias: 125-18.000Hz) para medir la frecuencia e intensidad de los acúfenos en 47 pacientes con acúfenos continuos en forma de pitidos. Resultados: Se han encontrado diferencias estadísticamente significativas entre las determinaciones de la frecuencia del acúfeno efectuadas con audiómetro convencional y audiómetro de alta frecuencia, así como correlación entre los acúfenos de alta frecuencia y las molestias manifestadas por los pacientes. Conclusiones: 1) La frecuencia del acúfeno determinada con audiómetro de alta frecuencia es mayor que la frecuencia determinada con audiómetro convencional; 2) cuanto mayor es la frecuencia del acúfeno, más molestias manifiesta el paciente; y 3) no hay relación entre la intensidad y la molestia producida por el acúfeno(AU)

Introduction and objectives: Determinations of the psychoacoustic characteristics of tinnitus (frequency and intensity) are valid for diagnosis, treatment, monitoring and research purposes. The aim of this work is to compare the frequency of the tinnitus measured with a standard audiometer and a high frequency audiometer. Methods: We used a conventional audiometer (frequency range: 125-12 000Hz) and a high-frequency audiometer (frequency range: 125-18 000Hz) to measure the frequency and intensity of tinnitus in 47 patients with tinnitus as a continuous ringing. Results: We found statistically-significant differences between the determination of the frequency of tinnitus made with conventional and high-frequency audiometers, as well as a correlation between high-frequency tinnitus and distress expressed by patients. Conclusions: 1) The frequency of tinnitus determined by high-frequency audiometer is greater than the frequency determined by conventional audiometer; 2) the higher the frequency of tinnitus, the more discomfort the patient manifests; and 3) there is no relationship between the intensity and discomfort caused by tinnitus(AU)

Otology versus Otosociology.

Otology concerns the biological study of ear alterations and diseases, solely. So, the diagnosis of audiovestibular diseases tends to be idiopathic or is based on theoretical concepts such as idiopathic sudden deafness, Ménière disease, benign paroxysmal positional vertigo, tinnitus, hyperacusis, or idiopathic facial paralysis. The treatment for these pathologies is symptomatic. Otosociology takes the aetiology and pathogenesis of the ear and situates them within the social and cultural environment of the patient. Then, audiovestibular disease is based on evidence, and the treatment options seek to solve the causes and consequences produced. Otosociology should be considered as a new discipline. Otosociology came into being since otology does not provide definitive solutions for the audiovestibular alterations produced from the point of view of the ear, whereas otosociology finds these solutions within the social/cultural environment of the patient. Where otology emphasises the diseases of the ear, otosociology deals with social manifestations. Where otology deals with idiopathic diseases, otosociology deals with causes and pathogeny produced by interactions in the social and cultural surroundings of the patient. Where otology offers symptomatic treatment, otosociology offers treatment of causes and consequences. Otosociology can fill significant voids in audiovestibular processes from the perspective of the patient's social environment.

[Tinnitus measurement with conventional audiometer versus high-frequency audiometer]. / Medición de acúfenos con audiómetro convencional versus audiómetro de alta frecuencia.

INTRODUCTION AND OBJECTIVES: Determinations of the psychoacoustic characteristics of tinnitus (frequency and intensity) are valid for diagnosis, treatment, monitoring and research purposes. The aim of this work is to compare the frequency of the tinnitus measured with a standard audiometer and a high frequency audiometer. METHODS: We used a conventional audiometer (frequency range: 125-12,000 Hz) and a high-frequency audiometer (frequency range: 125-18,000 Hz) to measure the frequency and intensity of tinnitus in 47 patients with tinnitus as a continuous ringing. RESULTS: We found statistically-significant differences between the determination of the frequency of tinnitus made with conventional and high-frequency audiometers, as well as a correlation between high-frequency tinnitus and distress expressed by patients. CONCLUSIONS: 1) The frequency of tinnitus determined by high-frequency audiometer is greater than the frequency determined by conventional audiometer; 2) the higher the frequency of tinnitus, the more discomfort the patient manifests; and 3) there is no relationship between the intensity and discomfort caused by tinnitus.

[Sound therapy in sudden deafness]. / Terapia sonora en sordera súbita.

INTRODUCTION AND GOALS: Idiopathic sudden sensorineural hearing loss is a hearing disorder of unknown cause. The spontaneous recovery rate ranges from 50 to 75% of the patients. Scientific experiments on animals support the present study in patients with sudden deafness treated with sounds. PATIENTS AND METHODS: During the period 2003-2009, patients with idiopathic sudden sensorineural hearing loss were administered steroids, piracetam and antioxidants, together with the addition of sounds by means of music and words. RESULTS: Comparing the results of patients treated with medication (n=65) and those treated with medication and sounds (n=67), it was observed that patients treated with medication and sounds had higher recovery. Within the group of patients treated with medication and sounds, 25 (37%) experienced complete recovery, 28 (42%) good recovery, 11 (16%) slight recovery and 3 (5%) poor or no recovery. CONCLUSION: The patients who recovered more than half of their audition accounted for 54% in the group treated with medication and for 79% in the group of patients receiving medication and sounds. Auditory recuperation showed no alterations, at least up to 12 months after therapy.

[Open-field treatment of hyperacusis]. / Tratamiento de la hiperacusia en campo abierto.

OBJECTIVE: Prospective study of the effectiveness of treatment in patients with hyperacusis by means of an open-field technique of acoustic treatment with nature sounds. MATERIAL AND METHODS: 34 patients were referred to a tinnitus and hyperacusis clinic at a private Otorhinolaryngology Department. Clinical and exploratory ENT studies were performed. Open-field nature sounds were applied by means of a compact disk for half an hour each day during a period of several weeks. RESULTS: By the end of treatment, the 34 patients studied had reached normal discomfort thresholds in a maximum of 9 weeks. CONCLUSIONS: The progressive open-field application of nature sounds has been effective in eliminating hyperacusis in a short space of time.

Tratamiento de la hiperacusia en campo abierto / Open-field treatment of hyperacusis

Objetivo. Estudio prospectivo de la eficacia del tratamiento de pacientes con hiperacusia mediante técnica de tratamiento acústico con sonidos de la naturaleza en campo abierto. Material y métodos. Acudieron 34 pacientes a consulta de acufenos e hiperacusia de una unidad de otorrinolaringología de una clínica privada. Se realizó estudio otorrinolaringológico clínico y exploratorio. Se aplican sonidos de la naturaleza mediante un disco compacto en campo abierto, media hora al día y durante varias semanas de duración. Resultados. Al finalizar el tratamiento, los 34 pacientes estudiados consiguieron unos umbrales de malestar normales en un plazo máximo de 9 semanas. Conclusiones. La aplicación progresiva de sonidos de la naturaleza en campo abierto ha sido efectiva a corto plazo para eliminar la hiperacusia

Objective. Prospective study of the effectiveness of treatment in patients with hyperacusis by means of an open-field technique of acoustic treatment with nature sounds. Material and methods. 34 patients were referred to a tinnitus and hyperacusis clinic at a private Otorhinolaryngology Department. Clinical and exploratory ENT studies were performed. Open-field nature sounds were applied by means of a compact disk for half an hour each day during a period of several weeks. Results. By the end of treatment, the 34 patients studied had reached normal discomfort thresholds in a maximum of 9 weeks. Conclusions. The progressive open-field application of nature sounds has been effective in eliminating hyperacusis in a short space of time

Sulpiride and melatonin decrease tinnitus perception modulating the auditolimbic dopaminergic pathway.

OBJECTIVES: Sulpiride and melatonin decrease dopamine activity. Sulpiride, a D2 antagonist of dopamine receptors, and melatonin, a pineal substance with antidopaminergic action, are administered to tinnitus patients to decrease tinnitus perception. DESIGN: A prospective, randomized, double-blinded, placebo-controlled study was done. SETTING: General otorhinolaryngologic consultation for 2002-2004 in Seville, Spain. METHODS: One hundred twenty patients consulted for subjective tinnitus. They were included randomly in four groups of 30. One group took sulpiride (50 mg/8 h) alone, the second group took melatonin (3 mg/24 h), the third group took the same doses of sulpiride (50 mg/8 h) plus melatonin (3 mg/24 h), and the fourth group took placebo (lactose 50 mg/8 h), all for 1 month. Ninety-nine patients completed the study. MAIN OUTCOME MEASURES: Clinical history, tonal audiometry, tympanometry, and tinnitometry were done at the beginning and end of the study. Subjective grading of tinnitus perception and a visual analogue scale (0-10) were done for evaluation of results. RESULTS: Based on the subjective grading, tinnitus perception diminished by 56% in patients treated with sulpiride, by 40% in patients treated with melatonin, by 81% in patients treated with sulpiride plus melatonin, and by 22% in patients treated with placebo. Based on the visual analogue scale, tinnitus perception diminished from 7.7 to 6.3 in patients treated with sulpiride, to 6.5 in those treated with melatonin, to 4.8 in patients treated with sulpiride plus melatonin, and to 7.0 in those treated with placebo. CONCLUSIONS: Sulpiride and melatonin reduce tinnitus perception, decreasing dopamine activity. The tinnitus auditolimbic dopaminergic pathway has broad therapeutic implications.

Sulpiride plus hydroxyzine decrease tinnitus perception.

OBJECTIVES: The aim of the study is to confirm the effectiveness of sulpiride and hydroxyzine in tinnitus patients. The administration of sulpiride, a D2 antagonist of dopamine receptors, together with hydroxyzine, a subcortical sedative, covers the areas of tinnitus perception. METHODS: A prospective, randomized, single blinded, placebo-control study was done in general otorhinolaryngology consultations for 2002-2004 in Seville and Zaragoza (Spain). One hundred and fifty patients consulted for subjective tinnitus. They were included randomly in three groups of 50. A group took sulpiride (50 mg/8 h) alone, other the same dose of sulpiride plus hydroxyzine (25 mg/12 h), and the third placebo (lactose), for 1 month. One hundred and twenty-two patients completed the study. Clinical history, tonal audiometry, tympanometry, and tinnitometry were done in the beginning and end of the study. Subjective Grading of Tinnitus Perception and visual analogical scale (0-10) were done for result evaluation. RESULTS: Based on the Subjective Grading of Tinnitus Perception, tinnitus perception diminished by 56% in patients treated with sulpiride and by 81% in patients treated with sulpiride plus hydroxyzine. Based on the visual analogical scale, tinnitus perception diminished from 7.8 to 6.3 in the patients treated with sulpiride, and from 7.8 to 5.1 in those treated with sulpiride plus hydroxyzine. CONCLUSIONS: Sulpiride plus hydroxyzine decreases tinnitus perception. Tinnitus auditolimbic dopaminergic pathway opens wide therapeutical implications.

Sequential sound therapy in tinnitus.

Sequential sound therapy, which uses wide-band white noise distinguished by some unique characteristics, is applied in the treatment of tinnitus. The methodology is described, as are the differences from and similarities to tinnitus retraining therapy. We have performed sequential sound therapy in 26 patients from 2002 through part of 2003. Thirty-eight generators of sounds were adapted for use in this therapy and, of these, 34 incorporated an earphone. The results of sequential sound therapy in our 26 patients were compared with the results of tinnitus retraining therapy in 15 patients treated during the years 2000 and 2001. Satisfactory results obtained with sequential sound therapy totaled 100%, whereas only 33% of subjects treated with tinnitus retraining therapy obtained satisfactory results. In 6 patients who received sequential sound therapy, tinnitus disappeared altogether. In addition, no patient receiving sequential sound therapy has left the treatment protocol, whereas 53% of patients receiving tinnitus retraining therapy abandoned the treatment protocol.