MoCA-assessed cognitive function and excellent outcome after aneurysmal subarachnoid hemorrhage at 1 year.

BACKGROUND AND PURPOSE: After aneurysmal subarachnoid hemorrhage (aSAH), cognitive impairment, even mild and relatively isolated, can be devastating, especially in working-age persons. The Montreal Cognitive Assessment (MoCA) is accepted as a valid screening tool for mild cognitive impairment due to cerebral ischaemia. Whether MoCA is independently associated with excellent outcome [a score of 0 on the modified Rankin Scale (mRS) or 18/18 on the Lawton Instrumental Activities of Daily Living (IADL) scale] 1 year after aSAH was assessed. METHODS: Hong Kong Chinese aSAH patients were assessed prospectively by means of the MoCA, Mini-Mental State Examination (MMSE), mRS and IADL scale at 1 year. This multicenter prospective observational study is registered at ClinicalTrials.gov of the US National Institutes of Health (NCT01038193). RESULTS: In all, 194 patients completed the assessments at 1 year. After adjustment for age, both excellent IADL and mRS outcomes were associated with MoCA (OR 1.2, 95% CI 1.1-1.3, P < 0.001, and OR 1.1, 95% CI 1.0-1.2, P = 0.001, respectively). CONCLUSIONS: MoCA-assessed cognitive function is an important determinant for excellent outcomes after aSAH.

Rivastigmine for cognitive impairment after spontaneous subarachnoid haemorrhage: a pilot study.

BACKGROUND AND OBJECTIVE: Rivastigmine has been shown to be effective for patients with mild-to-moderate Alzheimer's disease. Its effect on cognitive impairment after aneurysmal subarachnoid haemorrhage has not been previously studied. The aim of the study is to evaluate the efficacy and safety of rivastigmine 3 mg/day over 12 weeks in patients with aneurysmal subarachnoid haemorrhage and persistent cognitive impairment. METHODS: Twenty Chinese patients with spontaneous subarachnoid haemorrhage at least 9 months after the initial ictus, and with persistent cognitive impairment, were recruited. The primary outcome measure was Cognitive Subscale of Alzheimer Disease Assessment Scale (ADAS-cog) for global function; the secondary outcome measures were the Frontal Assessment Battery (FAB) for frontal lobe function and the Rivermead Behavioural Memory Test (RBMT) for prospective memory. Baseline cholinergic dysfunction (with pupillometry) was assessed for relationship with treatment efficacy. RESULTS: Sixteen of 20 (80%) patients completed the 12-week course of rivastigmine 1.5 mg twice daily. In comparison with the baseline assessment, ADAS-cog showed significant improvement after treatment (mean difference 6.5, 95% CI 3.5-9.5, P < 0.001); FAB and RBMT also showed significant improvement. Baseline cholinergic dysfunction (with pupillometry) was not correlated with improvement in ADAS-cog, FAB or RBMT. CONCLUSION: The use of rivastigmine was safe in patients with spontaneous subarachnoid haemorrhage and persistent cognitive impairment. A prospective double-blind placebo-controlled trial is required to establish the efficacy of rivastigmine for patients with spontaneous subarachnoid hemorrhage and persistent cognitive impairment and whether it can be translated to improvement in instrumental activity of daily living and quality of life.

Chronic hydrocephalus that requires shunting in aneurysmal subarachnoid haemorrhage [a-SAH]: its impact on clinical outcome.

BACKGROUND: Chronic hydrocephalus is a common occurrence following aneurismal subarachnoid haemorrhage [a-SAH] but its impact on neurological outcome has not been re reviewed systematically. PATIENTS AND METHODS: One hundred and eleven patients were recruited from a prospectively collected a-SAH registry over a 3-year period between 2002 and 2004. Their 6-month extended Glasgow Outcome Scale [GOSE] scores were correlated with routine clinical data and the need for CSF shunting [chronic hydrocephalus that required shunting, CHS]. RESULTS: Thirty patients with CHS were identified and they were associated with an initial poor WFNS grading [median 4 versus 2, p = 0.028]. Among patients with poor WFNS grading, CHS was associated with a better GOSE [median 4 versus 2, p = 0.041] and among patients with good WFNS grading, CHS paradoxically was associated with a poor GOSE [median 3.5 versus 7, p = 0.016]. CONCLUSION: The relationships between CHS and GOSE in a-SAH were complex. Their true clinical significance requires a more in-depth prospective study.

A rare anatomic variant of a solitary internal carotid artery associated with moyamoya phenomenon of the middle cerebral artery.

A case of a congenital solitary internal carotid artery with complicated anastomosis is presented. This rare anomaly was an incidental finding at cerebral angiography in a patient with a poor-grade subarachnoid hemorrhage and a ruptured anterior communicating artery aneurysm.

Surgical treatment of a neonate with refractory seizures secondary to congenital giant cell astrocytoma: case report and literature review.

Congenital brain tumours are rare. They account for 0.5% to 1.9% of intracranial tumours in childhood and have an incidence of 0.34 per million live births. Most congenital brain tumours are neuro-ectodermal tumours and medulloblastomas; giant cell astrocytoma and other tuberous sclerosis-related tumours are rare. We report on a neonate who developed seizures that were refractory to medical treatment. Imaging studies revealed a right frontal calcified tumour. Surgical resection was performed successfully and pathology revealed the tumour to be a giant cell astrocytoma. The child was seizure-free afterwards.

Intravenous C-Arm Conebeam CT Angiography following Long-Term Flow-Diverter Implantation: Technologic Evaluation and Preliminary Results.

BACKGROUND AND PURPOSE: A noninvasive investigation with high spatial resolution and without metal artifacts is necessary for long-term imaging follow-up after flow-diverter implantation. We aimed to evaluate the diagnostic value of conebeam CT angiography with intravenous contrast enhancement in the assessment of vascular status following implantation of the Pipeline Embolization Device and to analyze the preliminary results of vascular status following long-term Pipeline Embolization Device implantation. MATERIALS AND METHODS: This was an ongoing prospective study of consecutive patients with intracranial aneurysms treated with the Pipeline Embolization Device. Patients with a modified Rankin Scale score of 4-5 were excluded. The median and interquartile range of the time interval of Pipeline Embolization Device implantation to conebeam CT angiography with intravenous contrast enhancement were 56.6 and 42.9-62.4 months, respectively. Conebeam CT angiography with intravenous contrast enhancement was performed with the patient fully conscious, by using a C-arm CT with a flat panel detector. RESULTS: There were 34 patients and 34 vascular segments. In all 34 cases, contrast effect and image quality were good and not substantially different from those of intra-arterial conebeam CTA. Metal artifacts occurred in all 14 cases with coil masses; the Pipeline Embolization Device was obscured in 3 cases. In all 34 cases, there was no residual aneurysm, no vascular occlusion, 1 vascular stenosis (50%), good Pipeline Embolization Device apposition to the vessel, and no Pipeline Embolization Device-induced calcification. All 28 Pipeline Embolization Device-covered side branches were patent. CONCLUSIONS: Conebeam CT angiography with intravenous contrast enhancement is potentially promising and useful for effective evaluation of the vascular status following intracranial flow diverters. The Pipeline Embolization Device for intracranial aneurysms is probably safe and promising for long-term placement, with favorable morphologic outcome and without delayed complications.

Beneficial effect of cerebrolysin on moderate and severe head injury patients: result of a cohort study.

Cerebrolysin is used as a neurotrophic agent for the treatment of ischemic stroke and Alzheimer's Disease. Exploratory studies in patients with post-acute traumatic brain injury have shown that this treatment might help improve recovery. Aim of this study was to investigate whether addition of Cerebrolysin to the initial treatment regimen of moderate and severe head injury patients would improve their outcome. At 6 months, 67% of the patients (Cerebrolysin group) attained good outcome (GOS 3-5). The study group was compared with the historical cohort of patients from the hospital trauma data bank, with age, sex and admitting GCS matching. More patients tended to a good outcome in the Cerebrolysin group (P = 0.065). No significant side-effect requiring cessation of Cerebrolysin was noted. It can be concluded that the use of Cerebrolysin as part of the initial management of moderate and severe head injury is safe and well tolerated. The results suggest that Cerebrolysin is beneficial in regard to the outcome in these patients, especially in elderly patients.

The correlation of midline shifts of human brain with large brain haematoma using a finite element approach.

OBJECTIVES: We report on using a computational (finite element) model to simulate a human skull-brain structure to quantify the distortion of brain. METHODS: We simulated various effects of brain haematoma causing the distortion of brain. Midline shifts of the human brain in relation to size and location of haematoma were compared with the theoretical prediction. RESULTS: Prediction of midline shifts in lobar space-occupying lesions was more accurate that in deep-seated ones (such as thalamic lesions). DISCUSSION: More accurate boundary conditions of space-occupying lesions and better knowledge of physical materials properties of brain tissues can improve predictions of brain deformation using mathematical models.

Predicting one year clinical outcome in traumatic brain injury (TBI) at the beginning of rehabilitation.

Predicting long-term clinical outcome for patients with traumatic brain injury (TBI) at the beginning of rehabilitation provides essential information for counseling of the family and priority-setting for the limited resources in intensive rehabilitation. The objective of this study is to work out the probability of the one-year outcome at the beginning of rehabilitation. Sixty-eight patients with moderate-to-severe TBI and known one-year outcome were employed for outcome prediction using the logistic regression model. A large number of prospectively collected data at admission (age, Glasgow Coma Scale [GCS] Score, papillary response), during intensive care unit (ICU) management (duration of coma, intracranial pressure [ICP] and its progress) and at the beginning of rehabilitation (baseline Functional Independence Measure [FIM], Neuro-behavioral Cognitive Status Examination [NCSE] and Functional Movement Assessment [FMA]) were available for preliminary screening by univariate analysis. Six prognostic factors (age, GCS, duration of coma, baseline FIM, NCSC and FMA) were utilized for the final logistic regression model. Age, GCS and baseline FIM at the beginning of rehabilitation have been found to be independent predictors for one-year outcome. The accuracy of prediction for a good Glasgow Outcome Score is 68% and an outcome for disability (either moderate or severe) is 83%. Validation of this model using a new set of data is required.

Intravenous magnesium sulfate to improve outcome after aneurysmal subarachnoid hemorrhage: interim report from a pilot study.

OBJECTIVES: Magnesium sulfate (MgSO4) may be useful in preventing neurological injury after subarachnoid haemorrhage (SAH). In this randomized, double-blind study we evaluated the safety and efficacy of MgSO4 infusion to improve clinical outcome after aneurysmal SAH. METHODS: With ethics committee approval and informed consents, 45 patients with SAH were randomly allocated to receive either MgSO4 80 mmol/day or saline infusion for 14 days. All patients also received intravenous nimodipine. Episodes of vasospasm were treated with hypertensive, hypervolemic therapy. Neurological status was assessed 3 months after haemorrhage using Barthel index and Glasgow outcome scale (GOS). Incidences of cardiac and pulmonary complications were also recorded. Data were compared between groups using Mann-Whitney or Fisher exact tests as appropriate. P < 0.05 was considered significant. RESULTS: Patient characteristics, severity of SAH and surgical treatment did not differ between groups. Although the number of episodes was not reduced, MgSO4 shortened the duration of vasospasm. Patients receiving MgSO4 tended to have fewer neurological deficits, better functional recovery and an improved score in GOS. However, none of these outcome variables reached statistical significance. The incidence of cardiac and pulmonary complications in the MgSO4 group (43%) was also similar to that in the saline group (59%), P = 0.14. CONCLUSIONS: MgSO4 infusion after aneurysmal SAH is well tolerated and may be useful in producing better outcome. A larger study is required to confirm the neuroprotective effect of MgSO4.

Cervical meningocele with tethered cervical cord in a Chinese infant.

Cervical meningocele and myelomeningocele are rare spinal dysraphic lesions. Unlike lumbosacral dysraphic lesions, there is often no neurological deficit in infants with cervical lesions, thus the subtle features of cervical cord tethering may be overlooked on imaging. We report a case of cervical meningocele in an 8-month-old girl. The tethering band, confirmed intra-operatively, was not evident on imaging. Untethering of the cord was performed together with resection of the sac and repair of the dura. Tethered cord should be suspected in the presence of cervical meningocele and intact neurology. It should be carefully looked for using high-resolution magnetic resonance imaging or computed tomography. Treatment aims to prevent future neurological deterioration, and should include careful intradural exploration with untethering of the cord.

Intravascular lymphomatosis.

Intravascular lymphomatosis (IVL) is a rare angiotrophic large cell lymphoma producing vascular occlusion of arterioles, capillaries, and venules. Antigenic phenotyping shows that these lymphomas are mostly of B cell type, and less commonly T cell or Ki-1 lymphomas. The central nervous system and skin are the two most commonly affected organs; patients usually present with progressive encephalopathy with mental status changes and focal neurological deficits and skin petechia, purpura, plaques, and discolouration. Other involved organs include adrenal glands, lungs, heart, spleen, liver, pancreas, genital tract, and kidneys. Bone marrow, blood, cerebrospinal fluid, and lymph nodes are typically spared. Fever of unknown origin is another common presentation. Only one case of IVL presenting with disseminated intravascular coagulation and anasarca (generalised oedema) has been reported in the literature. This report describes a postmortem case of a patient with IVL who initially presented with disseminated intravascular coagulation complicated by intracerebral haemorrhage.

The use of stereotactic navigation guidance in minimally invasive transnasal nasopharyngectomy: a comparison with the conventional open transfacial approach.

The purpose of this paper is to study the efficacy of applying stereotactic navigation guidance to nasopharyngectomy via a minimally invasive transnasal approach as compared with the conventional open transfacial approaches. The nasopharynx is the centre of the anterior skull base, which is remote from the surface of the facial skeleton. It is well known that there are several surgical approaches for access to resect tumours from the nasopharynx. However, the open techniques have been associated with much morbidity and only provide access to, and identification of, the ipsilateral internal carotid artery that forms the lateral boundary and resection limit of the nasopharynx. The coupling of stereotactic navigation guidance and a minimally invasive transnasal approach for nasopharyngectomy allows the surgeon to identify and protect the internal carotid artery bilaterally at the nasopharynx. This technique reduces operating time and morbidity to a minimum and yet is oncologically sound for resecting nasopharyngeal lesions. We compare 15 patients who underwent the stereotactic navigation guidance approach with 20 patients who received a conventional open transfacial approach.

Lytic skull metastasis secondary to thyroid carcinoma in an adolescent.

We report an unusual case of skull metastasis secondary to thyroid carcinoma in an adolescent girl. The 18-year-old presented with an occipital scalp swelling of 5 years' duration. She reported having thyroid surgery in mainland China 10 years previously. Radiological investigations on presentation demonstrated a lytic hypervascular skull lesion. Preoperative angiography and embolisation was followed by surgical excision. Pathological examination showed the lesion to be a thyroid carcinoma with a predominantly follicular pattern and a completion hemithyroidectomy was subsequently performed. Computed tomography of the thorax showed small micronodules in both lung fields compatible with metastases. The patient was given whole body iodine-131 internal radiation treatment and subsequently commenced thyroid-stimulating hormone-suppressive treatment with thyroxine. The management of thyroid carcinoma and subsequent skull metastasis in children and adolescents is reviewed and controversial points are highlighted.

Triple coaxial catheter technique for transfacial superior ophthalmic vein approach for embolization of dural carotid-cavernous fistula.

We report a triple coaxial catheter technique to facilitate the venous access to the superior ophthalmic vein during transvenous embolization of dural carotid-cavernous fistula (DCCF) via the transfacial venous route. Two patients with transvenous embolization of DCCFs by coils were treated with transfacial superior ophthalmic vein (SOV) approach by the triple coaxial catheter technique. The triple coaxial catheter system consisted of a 6F guiding catheter as the outer catheter and a 4F guiding catheter as the middle catheter and a microcatheter as the inner catheter to help navigation and manipulation. The DCCFs were completely obliterated in both cases. There were no complications associated with the procedure. The ophthalmic symptoms of the patients had totally resolved at two-month follow-up. The triple coaxial catheter technique can be used with the transfacial SOV approach in embolization of DCCF. This technique has two advantages over the double coaxial catheter technique because it offers additional length and support for the distal navigation of microcatheter into the SOV.

Transvenous embolization for dural transverse sinus fistulas with occluded sigmoid sinus.

Dural transverse sinus arteriovenous fistulas with cortical venous drainage were associated with a high hemorrhagic risk. Dural transverse sinus arteriovenous dural fistulas could be treated by embolization (transarterial or transvenous), surgery or a combination of both. Transvenous packing of the diseased sinus was considered to be a less invasive and effective method of treatment. Occluded sigmoid sinus proximally, especially cases with isolated transverse sinus, could make the transvenous approach difficult. Craniotomy for sinus packing or surgical excision remained the treatment of choice when the percutaneous transvenous approach was not feasible. We reviewed the techniques of transvenous embolization described in the literature and illustrated our techniques in two consecutive cases of transvenous embolization of the dural arteriovenous fistulas through the occluded sigmoid sinus. We concluded that transvenous embolization remains a safe and feasible technique other than surgery for patients with transverse sinus dural fistula, achieving a long-term occlusion of the pathology.