Traumatic middle meningeal artery aneurysm: a case report.

INTRODUCTION: Traumatic intracranial aneurysms are rare, making up about 1% of all intracranial aneurysms. They can happen due to direct injury or blunt force, with the middle cerebral artery being the most frequent site. The middle meningeal artery (MMA) is the main artery that supplies the cranial dura mater, and, because of its location, is susceptible to damage after trauma. This article reported an unusual case of giant post-traumatic MMA pseudoaneurysm. CASE: A 45 year-old man was referred to our department with a history of craniectomy. He complained of non-specific headache, but neurological examination was normal. A follow-up brain CT scan identified a right temporal fossa hyperdense mass. Digital subtraction angiography diagnosed a traumatic MMA aneurysm. The patient was treated with preoperative aneurysm embolization and surgical resection. DISCUSSION: Traumatic MMA aneurysm is a rare presentation after head trauma. It can manifest as epidural hematoma, subdural hematoma or intraparenchymal hematoma, and sometimes resembles the present case, which was discovered incidentally. CONCLUSION: Pseudoaneurysm is a rare complication of MMA trauma, with late presentation. It should be considered in patients with history of traumatic brain injury and temporal fossa extra-axial mass lesion with vascular characteristics.

Patient with a history of Glanzmann thrombasthenia presented with chronic subdural hematoma: a case report study.

Glanzmann thrombasthenia (GT) is a rare platelet disorder characterized by qualitative/quantitative deficiencies of the platelets' fibrinogen receptor, glycoprotein (GP) IIb/IIIa complex, resulting in impaired platelet aggregation and increased bleeding time. Most cases are hereditary with an autosomal recessive pattern of inheritance, but acquired GT also occurs. We report the surgical management of symptomatic chronic subdural hematoma (CSDH), a rare condition in young individuals, in a 37-year-old man who had GT and a history of mild head trauma approximately one month before admission. Despite hematologic consultation, normal bleeding time and clotting time, and platelet transfusion before surgery, massive hemorrhage during surgery, epidural hematoma, and anisocoria in the ICU occurred that led to craniectomy. This report highlights that CSDH management in patients with GT requires close monitoring of these patients as well as collaboration between neurosurgeons, intensive care physicians, hematologists, and anesthesiologists.

Functional Outcome and Mortality Predictors in Patients with Cerebral Ischemic Infarction After Decompressive Craniectomy: Cross-Sectional Study.

OBJECTIVE: Surgeons commonly perform Decompressive craniectomy (DC) to manage patients with cerebral ischemic infarction. However, there are conflicting data on the long-term functional outcomes following DC. Therefore, this study aims to determine the functional outcome of patients with cerebral ischemic infarction after DC. METHODS: This prospective and retrospective cross-sectional study included 148 patients with cerebral ischemic infarction who underwent DC at Ghaem Hospital, Mashhad, Iran, from March 2011 to March 2021. The Modified Rankin Scale (mRS) assesses disability in these patients and determines the recovery and degree of long-term functional outcomes. Demographic and clinical data were extracted and recorded in a researcher-made questionnaire. RESULTS: In summary, the follow-up revealed a survival rate of 39.2% among patients with ischemic stroke. The comparison of the mean infarct volume in patients with various mRS scores showed that the mean infarct volume was significantly higher in patients with unfavorable functional outcomes, based on mRS scores at discharge (P = 0.05), 3 months mRS (P < 0.01), and mRS score at final follow-up (P = 0.01). Final mortality was higher in patients with higher mRS scores at discharge, after 3 months, and final follow-up (P < 0.01). Older age and infarction volume can predict mRS and mortality in patients with ischemic stroke (P < 0.01). CONCLUSIONS: The present study showed that mortality and mRS scores at various times are associated with infarction volume and older age in patients with ischemic stroke.

Effects of Intraventricular Vancomycin Administration on the Prevention of Ventricular Shunt Infection.

INTRODUCTION AND OBJECTIVES: Shunt infection causes death in many patients diagnosed with hydrocephalus and increases the duration of hospitalization and treatment costs. A high percentage of children are forced to undergo re-surgery due to shunt dysfunction or infection. The present study aimed to investigate the role of intraventricular (IVT) vancomycin in the prevention of ventricular shunt infection in children with hydrocephalus who were referred to Akbar Hospital in Mashhad, Iran, between the years 2017 and 2021. MATERIALS AND METHODS: The present descriptive cross-sectional study was conducted on 192 children with hydrocephalus who underwent shunt surgery at Akbar Hospital in Mashhad, Iran, between the years 2017 and 2021. Patients were divided into two groups of intervention (n=69) and control (n=123). The patients in the intervention group received 30 mg of IVT vancomycin during shunt surgery. The rate of shunt obstruction and infection were then compared between the two study groups. RESULTS: The two study groups were matched in terms of demographic and clinical information except for gender (P=0.02). Moreover, no significant difference was reported between the two groups in terms of intelligence development (χ2=0.51; P=0.47), verbal development (χ2=0.1; P=0.75), and movement development (χ2=1.05; P=0.3). The frequency of shunt infection and shunt obstruction was estimated at 8.8% and 18.2%, respectively. The shunt infection rate was lower in the vancomycin IVT group than in the control group (χ2=4.07; P=0.04), while no difference was observed between the two groups in terms of shunt obstruction (χ2=3.66; P=0.056). The comparison of the two study groups indicated no significant difference between them in terms of mortality (χ2=0.004; P=0.95). CONCLUSION: It seems that IVT vancomycin should be recommended for inclusion in hydrocephalus surgery protocol to reduce postoperative shunt infection. It is recommended that shunt protocols be adopted in future multicenter prospective randomized controlled trials on the reduction of ventriculoperitoneal shunt infections to further evaluate the efficacy of IVT antibiotics.

Glycoprotein IIb/IIIa inhibitors in the treatment of thromboembolic events related to endovascular treatment of cerebral aneurysms-systematic review and meta-analysis.

BACKGROUND AND AIMS: Thromboembolism complication is considered the most common complication associated with the treatment of endovascular. This systematic review and meta-analysis aimed to assess the studies investigating the effect of glycoprotein IIb/IIIa inhibitor agents on thromboembolic complications during endovascular aneurysm coiling. MATERIALS AND METHODS: This systematic review investigated the outcome of the use of three glycoprotein IIb/IIIa inhibitor agents (ie abciximab, tirofiban, and eptifibatide) on the thromboembolic complications during endovascular aneurysm coiling. The electronic databases of PubMed, Web of Science, Scopus, and Medline were searched up to 25 June 2021, using the keywords "Abciximab," "Tirofiban," and "Eptifibatide" incombination with "Thromboembolism Complication," "Aneurysms," and "Endovascular Aneurysm Coiling." RESULTS: A total of 21 articles were found to be eligible and included in this review. The rates of complete and partial recanalization were estimated to be 56% and 92% in patients who underwent abciximab and tirofiban therapy, respectively. Rupture aneurysms were found in the majority of patients. In general, the mortality rate of the patients treated for thromboembolic complications during endovascular treatment of cerebral aneurysms with glycoprotein IIb/IIIa inhibitors was found to be 4.8% (CI 95%:0.027-0.067; p < .005). The average remission rate in studies investigating thromboembolism was 91% (CI 95%:0.88-0.95, I2 : 65.65/p < .001). CONCLUSION: Based on the obtained results, a higher mean rate of complete recanalization by eptifibatide was found in studies in which abciximab or tirofiban were used, compared to other mentioned agents. Moreover, the amount of hemorrhage was reported to be less after using tirofiban rather than abciximab.

Maternal and zygotic activin signaling promotes adequate pattern and differentiation of mesoderm through regulation of pluripotency genes during zebrafish development.

To investigate the role of maternal Activin-like factors in the preservation of stemness and mesendoderm induction, their effects were promoted and inhibited using synthetic human Activin A or SB-505124 treatments, respectively, before the maternal to zygotic transition (MZT). To study the role of zygotic Activin-like factors, SB-505124 treatment was also used after the MZT. Promoting the signaling intensity of maternal Activin-like factors led to premature differentiation, loss of stemness, and no mesendoderm malformation, while its alleviation delayed the differentiation and caused various malformations. Inhibition of the zygotic Activin-like factors was associated with suppressing the ndr1, ndr2, oct4 (pou5f3), mycb and notail transcription as well as differentiation retardation at the oblong stage, and a broad spectrum of anomalies in a dose-dependent manner. Together, promoting the signal intensity of maternal Activin-like factors drove development along with mesendodermal differentiation, while suppression of the maternal or zygotic ones maintained the pluripotent state and delayed differentiation.

The effect of Activin pathway modulation on the expression of both pluripotency and differentiation markers during early zebrafish development compared with other vertebrates.

Activin-like factors control many developmental processes, including pluripotency maintenance and differentiation. Although Activin-like factors' action in mesendoderm induction has been demonstrated in zebrafish, their involvement in preserving the stemness remains unknown. To investigate the role of maternal Activin-like factors, their effects were promoted or blocked using synthetic human Activin A or SB-431542 treatments respectively until the maternal to zygotic transition. To study the role of zygotic Activin-like factors, SB-431542 treatment was also applied after the maternal to zygotic transition. The effect of the pharmacological modulations of the Activin/Smad pathway was then studied on the mRNA expressions of the ndr1, ndr2, tbxta (no tail/ntl) as the differentiation index, mych, nanog, and oct4 (pou5f3) as the pluripotency markers of the zebrafish embryonic cells as well as sox17 as a definitive endoderm marker. Expression of the target genes was measured at the 16-cell, 256-cell, 1K-cell, oblong, dome, and shield stages using the real-time quantitative polymerase chain reaction (RT-qPCR). Activation of the maternal Activin signaling pathway led to an increase in zygotic expression of the tbxta, particularly marked at the oblong stage. In other words, promotion of the maternal Activin/Smad pathway induced differentiation by advancing the major peaks of ndr1 and nanog, thereby eliciting tbxta expression. Whereas suppression of the maternal or zygotic Activin/Smad pathway sustained the pluripotency by preventing the major peaks of ndr1 and nanog as well as tbxta encoding.

A Study on the Psychometric Properties of Revised-nonverbal Pain Scale and Original-nonverbal Pain Scale in Iranian Nonverbal-ventilated Patients.

BACKGROUND AND AIMS: The nonverbal pain scale is one of the instruments which study pain in nonverbal-ventilated patients with regard to the changes of behavioral and physiological indices. The purpose of the study is to survey the psychometric properties of revised-nonverbal pain scale (R-NVPS) and original-nonverbal pain scale (O-NVPS) in ventilated patients hospitalized in critical care units. MATERIALS AND METHODS: Four nurses studied pain in sixty patients hospitalized in trauma, medical, neurology, and surgical critical care units using R-NVPS and O-NVPS at six times (before, during, and after nociceptive and nonnociceptive procedures). The test was repeated in 37 patients after 8-12 h. RESULTS: Cronbach's alpha coefficient for R-NVPS and O-NVPS was 0.8 and 0.76, respectively. The inter-rater correlation coefficient during different times was r = 0.89-0.96 for R-NVPS and r = 0.80-0.87 for O-NVPS. Test-retest correlation coefficient for R-NVPS and O-NVPS was r = 0.55-0.86 and r = 0.51-0.75, respectively. The meaningful difference in pain score between nociceptive and nonnociceptive procedures (P < 0.001) and a higher pain score in patients who confirmed pain (P < 0.001) showed a discriminant and criterion validity for both scales of NVPS, respectively. CONCLUSIONS: R-NVPS and O-NVPS can both be used as valid and reliable scales in studying pain in ventilated patient. However, in comparing the items, "respiration" (R-NVPS) had a higher sensitivity than "physiology II" (O-NVPS) in assessing pain.

Effects of pulsatile perfusion during cardiopulmonary bypass on biochemical markers and kidney function in patients undergoing cardiac surgeries.

For several years there is no conclusive guideline on the effectiveness of pulsatile or non-pulsatile perfusion during cardiopulmonary bypass (CPB) in patients undergoing cardiac surgeries. In this study, we evaluated the effect of pulsatile versus continuous perfusion on the myocardial release of the cardiac biochemical markers including, creatine phosphokinase (CPK), cardiac creatine kinase (CK-MB), and lactate dehydrogenase (LDH), and also kidney function tests including: blood urea nitrogen test (BUN) and creatinine test (Cr) in patients that underwent both pulsatile and non-pulsatile methods before and after heart surgeries. A total of 80 patients were enrolled in this study, 40 patients in each pulsatile and non-pulsatile group. Venous blood samples were drown from each patient in two groups before operation and after operation at, 24, 48, and 72 h and analyzed separately for CPK, its cardiac isoenzyme (CK-MB), LDH, BUN and Cr. There were no significant differences between the two groups with regard to preoperative parameters such as sex, age, and body surface area. Our study shows that the effect of pulsatile perfusion on cardiac and kidney function is better than the non-pulsatile method.

Rupture of a giant cardiac hydatid cyst in the left ventricular free wall: successful surgical management of a rare entity.

Hydatid cyst of heart is a rare but potentially fatal site of pathology, especially left ventricular free wall. We managed a successful surgical treatment on a case of a 24 year old man who had a giant cardiac hydatid cyst (71 x 64 mm) that ruptured left ventricular free wall. The cyst was excised gently and all the cystic materials were removed, the cyst cavity was closed with GORE-TEX soft tissue patch. The patient was discharged on the 9th postoperative day without symptoms. This case is different from other cardiac hydatid cysts that have been reported in literature previously; because this patient was young and had advanced phase of the disease that presented to our clinic lately. Additionally, the cyst had limited both ventricular volumes significantly.

A proposed new method for electroencephalography trace recording in children younger than two years: an observational study.

Epilepsy is a common disorder in pediatric neurology, and electroencephalography (EEG) continues to play an important role in its diagnosis. However, the small size of a child's head and immaturity of the brain make EEG interpretation more difficult in children than in adults. This article presents a new method of EEG recording for children younger than 2 years designed to improve recording accuracy in children with small heads. This novel method of EEG recording, in which an increase in distance between recording electrodes is achieved without decreasing the number of electrodes or channels, compares with the traditional 10-20 system in terms of pathologic waves, artifacts, sleep spindles, and wave frequencies. Increased wave amplitude was noted with the new montages in 90 of 105 (85.7%) individuals. The calculation of wave frequency was easier and more reliable in the new montages in comparison with the prevailing recordings. More numerous sleep spindles were detected in 49 of 105 (47.6%) children. The number of detected pathological waves increased in 49 of 105 (47.6%) children on the new montages versus the 10-20 electrode system. The incidence of artifact waves in the traces was similar between the two methods in 94 (89.5%) patients and diminished in 11 of 105 (10.5%) patients. These preliminary studies suggest that the new recording system might be a suitable substitute for the routine 10-20 system, especially in young infants and neonates. Further evaluation and multicenter clinical trials will contribute to the reliability of this proposed method.

Effect of staged preconditioning on biochemical markers in the patients undergoing coronary artery bypass grafting.

The present study has investigated the effectiveness of staged-preconditioning, in both remote and target organs. After IP the myocardial release of the biochemical markers including, creatine phosphokinase (CPK), cardiac creatine kinase (CK-MB), cardiac troponin T (cTnT) and lactate dehydrogenase (LDH) were evaluated in patients who underwent CABG, with and without staged-preconditioning. Sixty-one patients entered the study; there were 32 patients in the staged-preconditioning group and 29 patients in the control group. All patients underwent on-pump CABG using cardiopulmonary bypass (CPB) techniques. In the staged-preconditioning group, patients underwent two stages of IP on remote (upper limb) and target organs. Each stage of preconditioning was carried out by 3 cycles of ischemia and then reperfusion. Serum levels of biochemical markers were immediately measured postoperatively at 24, 48 and 72 h. Serum CK-MB, CPK and LDH levels were significantly lower in the staged-preconditioning group than in the control group. The CK-MB release in the staged-preconditioning patients reduced by 51% in comparison with controls over 72 h after CABG. These results suggest that myocardial injury was attenuated by the effect of three rounds of both remote and target organ IP.