Topical anesthetic EMLA for postoperative wound pain in stereotactic gamma knife radiosurgery: a perspective, randomized, placebo-controlled study.

BACKGROUND: Patients who undergo stereotactic gamma knife radiosurgery (GKRS) need a rigid frame fixation for the stereotactic procedures. Many patients suffered from postoperative wound pain after frame removal. The present study investigated whether an additional application of a topical anesthetic prior to frame removal could reduce this discomfort. PATIENTS AND METHODS: 60 patients who underwent GKRS were enrolled in this study. Of these 60 patients, 30 were treated with a topical application of EMLA, a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine; the remaining 30 were treated with a placebo. The nurses explained the definition of the visual analogue scale (VAS, scored from 0 to 10), and the patients evaluated their pain at 7 time points during the GKRS procedure by using the VAS. After each of these evaluations, the patients' vital signs (blood pressure, heart rate, and respiratory rate) were measured. RESULTS: There was no significant difference in the patients' age, gender, duration of frame fixation, and types of the lesions between the EMLA and placebo groups. The EMLA group reported significantly lower pain scores 20 and 60 min after frame removal than the placebo group (p=0.001 and p<0.001, respectively). Additionally, patients in the placebo group had significantly higher blood pressure readings compared with baseline data, during and after frame removal, thus indicating that postoperative wound pain caused them more discomfort after frame removal. CONCLUSION: EMLA when applied 60 min before frame removal has an anesthetic effect of reducing the postoperative wound pain in patients who undergo GKRS.

Traumatic brain injury causes frontotemporal dementia and TDP-43 proteolysis.

Traumatic brain injury (TBI) is a major risk factor for dementia. Recently, TBI has also been suggested as a risk factor for frontotemporal dementia (FTD), and plasma immunoreactivity to the TAR-DNA binding protein 43 (TDP-43) has been observed in both patients with acute TBI and long-term survivors of this condition. We used a population-based study to estimate and compare the risk of FTD in individuals with and without TBI. Furthermore, we used a rat model of TBI to show that increased TDP-43 proteolysis following TBI produces FTD-like impairments, including abnormal limb-clasping, and impaired performances in the Morris water maze. We recruited 24,585 patients who received ambulatory or hospital care for TBI and 122,925 patients without TBI for this study. Each individual was investigated for 4years to evaluate FTD development, and data were analyzed by Cox proportional hazard regression. In the TBI rat model, behavior and TDP-43 inclusions were assessed following intracranial administration of a caspase-3 inhibitor or vehicle. FTD was more likely to occur in the TBI group than in the group without TBI (adjusted hazard ratio, 4.43; 95% confidence interval, 3.85-5.10; P<0.001). Rats developed behavioral impairments similar to those in patients with FTD after TBI. Further, the behavioral impairments were likely associated with TDP-43 short fragment mislocalization and accumulation. Our findings suggest that in humans, TBI is associated with a greater occurrence of FTD. Moreover, clinical FTD manifestations may be associated with TDP-43 proteolysis, since impaired behaviors in TBI rats were reminiscent of those in humans with FTD.

Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage.

BACKGROUND AND PURPOSE: The purpose of the present study was to analyze the outcome and outcome predictors of caudate hemorrhage and role of external ventricular drainage in acute hydrocephalus. METHODS: Clinical data from 36 consecutive patients with hypertensive caudate hemorrhage was used in the present study. Age, gender, volume of parenchymal hematoma, hematoma in the internal capsule, initial Glasgow Coma Scale (GCS), hydrocephalus, severity of intraventricular hemorrhage, and hemorrhagic dilatation of the fourth ventricle were analyzed for effect on outcome. Effect of external ventricle drainage for hydrocephalus was evaluated by comparing preoperative and postoperative GCS scores. RESULTS: By univariate analyses, poor outcome was associated with a poor initial GCS score (P=0.016), hydrocephalus (P<0.001), intraventricular hemorrhage severity (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). By multivariate analysis, stepwise logistic regression revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001). Postoperative 48-hour GCS score was better than the preoperative score by use of paired-sample t test (P<0.001). CONCLUSIONS: Hydrocephalus is the most important predictor of poor outcome. External ventricular drainage response for hydrocephalus was good in the present study, whereas an early decision should be made regarding preoperative neurological condition.

Bacterial brain abscess: microbiological features, epidemiological trends and therapeutic outcomes.

BACKGROUND: Despite the advent of modern neurosurgical techniques, new antibiotics, and powerful imaging technologies, brain abscess remains a potentially fatal central nervous system infection. AIM: To determine the epidemiological trends, prognostic factors, and outcomes of bacterial brain abscess, to improve the therapeutic strategy for this disease. DESIGN: Retrospective hospital-based epidemiology study. METHODS: Over a period of 15 years (1986-2000), 123 patients were retrospectively identified as having brain abscesses at Kaohsiung Chang Gung Memorial Hospital. To compare changes over time, the appearance of disease among our patients was divided into two time periods: 1986-1993 and 1994-2000. RESULTS: The prevalence rate of brain abscesses caused by Gram-negative organisms significantly increased in the second study period. Viridans streptococci and Klebsiella pneumoniae were the two prevalent pathogens associated with haematogenous spread. Metastatic septic abscess, a devastating complication of K. pneumoniae septicaemia, frequently occurs in diabetic patients, with a high mortality rate. Viridans streptococci were the most prevalent pathogens from infection in paranasal sinusitis, but no fatality occurred. In recent years, head trauma and/or post-neurosurgical states have become important predisposing factors, and nosocomial infections also play an important role. DISCUSSION: Despite the availability of new antibiotics and the development of better neurosurgical techniques, therapeutic outcomes of brain abscess showed no significant change when comparing the two study periods, and only the presence of septic shock influenced outcome.

Atlantal stenosis: a rare cause of quadriparesis in a child. Case report.

The authors report the case of a 3-year-old boy who suffered from quadriparesis and respiratory distress after failing to execute a somersault properly. Neuroimaging revealed spinal cord contusion with marked spinal canal stenosis at the level of the atlas. No subtle instability, occult fracture, or other congenital abnormalities were confirmed. Spinal cord contusion with marked canal stenosis is rare, and only several adult cases have been reported. Severe stenosis at the level of the atlas may predispose individuals to severe spinal cord contusion, as occurred in our patient after sustaining trivial trauma.

Changes of bilateral palmar skin temperature in transthoracic endoscopic T-2 sympathectomy.

OBJECT: Transthoracic endoscopic T-2 sympathectomy is currently the treatment of choice for palmar hyperhidrosis (PH). Intraoperative monitoring of palmar skin temperature (PST) is often used to assess the adequacy of sympathetic ablation. The aim of this study was to investigate the time course of PST changes during the operation and to determine factors involved in the sympathetic modulation of the palmar skin blood flow. METHODS: Eighty-one patients with PH underwent bilateral transthoracic endoscopic sympathectomy of T-2 in which continuous intraoperative PST monitoring was used. Palmar skin temperature data, recorded every 30 seconds throughout the operation, were plotted against time, and a graph of two PST curves was obtained in each case. A multiphasic curve pattern of great similarity was observed in nearly 70% of cases. Specific PST readings at different operative stages were collected and averaged for all cases. The trend of PST changes in response to different procedures during the operation was analyzed. It was found that unilateral procedures caused simultaneous bilateral PST alterations. In almost all cases, bilateral PST was dramatically lowered when unilateral skin incision and intercostal muscle dissection were performed. The temperature remained low until the T-2 sympathectomy was finished on one side. In addition, unilateral T-2 sympathectomy induced synchronous elevation of bilateral PST. However, the ipsilateral response was significantly stronger than that on the contralateral side. CONCLUSIONS: Although intraoperative monitoring of PST is a reliable guide for surgeons performing endoscopic transthoracic sympathectomy, it is important to realize that PST fluctuates at different stages during the operation and that surgical procedures themselves can significantly influence PST readings. The PST data recorded at specific time points, therefore, can be misleading in terms of accuracy and the completeness of ablation of the target sympathetic ganglia, especially when the sympathetic trunk or ganglia are anatomically aberrant.

The prognosis of hearing impairment complicating HIV-negative cryptococcal meningitis.

Eight patients who had sensorineural hearing loss (SNHL) associated with cryptococcal meningitis were studied. After a minimum 3-year follow-up, one had died. Among the seven survivors, three had improved, two stabilized, and two progressed. Predictive factors included visual disturbance, meningeal enhancements on MRI, and a CSF cryptococcal antigen titer of >1:1,024. SNHL accounted for 30.8% (8/26) of cryptococcal meningitis patients in our study.

Early prediction of aphasia outcome in left basal ganglia hemorrhage.

OBJECTIVES: The independent predictors of aphasia outcome for patients with left basal ganglia hemorrhage were evaluated. PATIENTS AND METHODS: We included 140 patients of 1,036 patients with spontaneous intracerebral hemorrhage admitted to our hospital from January 1993 through December 1997. Aphasia was assessed using the aphasia scale of the Scandinavian stroke scale. Univariate and step-wise logistic regression analyses were performed to assess the relationships between the initial aphasia score, age, gender, blood volume, locations of hematoma and aphasia outcome. RESULTS: Step-wise logistic regression analysis revealed that the following two factors were independently associated with the final aphasia outcome: initial aphasia score (P < 0.0001) and location of hematoma involving the posterior limb of the internal capsule (P = 0.004). CONCLUSIONS: A particularly high likelihood of poor aphasia outcomes of patients with left basal ganglia hemorrhage are predicted in those who have poor initial aphasia score and whose brain computed tomography shows the hematoma involves the posterior limb of the internal capsule.

Klebsiella brain abscess in adults.

BACKGROUND: We analyzed the clinical manifestations and therapeutic outcomes of Klebsiella brain abscesses. PATIENTS AND METHODS: The clinical data of 15 patients with Klebsiella brain abscesses, retrospectively collected over a 14-year period, were studied. RESULTS: The 15 patients included 13 cases of Klebsiella pneumoniae infection and two cases of Klebsiella oxytoca. All but one case were community-acquired infections. Locations of all of these abscesses were supratentorial. 12 cases involved a single abscess, and three involved multiple abscesses. Gas formation was also found in two cases (13%). Common predisposing factors included metastatic spread, chronic otitis media and neurosurgical procedures. Among these 15 patients, 11 were treated surgically and four received antibiotics alone. In total, 11 patients survived and four died, with an overall mortality rate of 26.7%. CONCLUSION: The clinical presentations and therapeutic outcomes varied according to the different Klebsiella species. While debilitating diseases were common in K. pneumoniae infections, they were not common in K. oxytoca infection. And while metastatic septic abscess is a well-known, devastating complication of K. pneumoniae septicemia, usually seen as a brain abscess with a gas-forming appearance, all of these K. oxytoca infections had both otogenic infections and more favorable outcomes.