Recent concepts in the pathophysiology and treatment of pseudotumor cerebri

Management of refractory cases of pseudotumor cerebri [PTC] could be difficult with risk of permanent visual affection. Various pathogenic mechanisms have been considered to explain this disease, but none appears satisfactory on its own. The role of venous disease in the etiology of PTC has been revisited as several groups using invasive monitoring, have documented high pressure in the venous sinuses in typical cases. We included 20 patients with symptoms and signs confirming PTC according to the Dandy diagnostic criteria. All underwent complete general and neurological assessment with measurement of body mass index [BMI] and lumbar puncture. Ophthalmologic assessment included visual acuity measurement, fundus examination and automated perimetry study. Laboratory investigations included routine laboratory, erythrocyte sedimentation rate, hormonal profile, collagen profile and procoagulant profile. Radiological assessment included CT scan brain +/- MRI brain without contrast, MRV of the intracranial venous system. All underwent digital subtraction cerebral Angiography [DSA] [venous phase] to confirm the validity of filing gaps seen at the level of MRV whether they are true stenosis or not. Menstrual irregularity was documented in 2 patients [10%]. Sixteen patients [80%] were considered to be overweight or obese. MRV brain showed that 14 patients [70%] showed filling gaps suggestive of sinus stenosis. On the other hand, digital subtraction cerebral angiography [venous phase] gave different data as it showed that only 5 patients [25%] had stenosis in their dural sinuses. MRV was found to be a good screening tool since it had 100% sensitivity and negative predictive value. Therefore, if MRV is normal no further investigations are needed. However, since it has a moderate specificity [62%] with a positive predictive value [PPV] of only 35%, then lesions detected should be confirmed with digital subtraction cerebral angiography [venous phase] particularly those involving the transverse and sigmoid sinus. In our study most of the cases having venous sinus stenosis occurred among patients with age of onset between 22-30 y old [p < 0.05] and among those with BMI > 30 [p < 0.05]. Furthermore, significant association was found between visual symptoms and stenosis since 80% of cases with stenosis had diplopia, TVO's, grade 3 papilledema and in grade 3 field defect [p < 0.05]. By logistic regression model, diplopia and TVO's were considered as independent predictors of occurrence of stenosis among the studied cases. Studying the intracranial venous system in patients with PTC is an important step as it may help in understanding the pathophysiology of the disease, in expecting the response to medical and surgical treatment. In addition, detection of venous sinus stenosis opens the way to a novel therapeutic option for refractory patients ie venous sinus stenting

Cognitive dysfunction in patients with chronic hepatitis C: a psychometric and magnetic resonance spectroscopic study

Patients with chronic hepatitis C virus [HCV] infection frequently describe neuropsychological symptoms and there is a growing body of literature on cerebral dysfunction occurring at an early stage of chronic HCV infection. The aim of the present study was to elucidate whether patients' subjective impression of cognitive impairment was accompanied by objective evidence of cerebral dysfunction. 12 Patients with chronic hepatitis C virus infection with compensated liver function were recruited from Ain-Shams university hospitals. Another 8 healthy controls matched for age and sex were recruited from available hospital staff or patients relatives. Patients with potential risk factors for cognitive impairment were excluded. All patients and controls underwent clinical assessment, laboratory test, abdominal ultrasound, neuropsychological assessment, digital electroencephalography [DEEG], brain MRI and MR spectroscopy [MRS]. DEEG of all 12 patients revealed normal background with well formed alpha waves with no focal or generalized slowing and no epileptic activity. Psychometric assessment revealed that attention and sustained attention was affected in 6 patients [50%], short term memory was affected in 4 patients [33.5%], psychomotor speed and learning ability was affected in 4 patients [33.5%] and immediate verbal and visual memories were affected in 6 patients [50%]. Depression was absent in all patients. The MRI brain of all patients revealed no abnormalities. On intermediate echo sequence of MRS, the HCV group showed significant decrease in N-acetylaspartate/creatine ratios [NAA/Cr ratio] in frontal white matter [P < 0.05]. Mild, statistically non significant, elevation of choline/creatine ratios predominantly in basal ganglionic [BG] region was noted on both short and intermediate echo sequences. On short echo sequence of MRS, the HCV group showed a mild, statistically non significant, increase in myoinositol/creatine in frontal white matter region as compared to controls. Thus, there is a suggested reduction of normal neurons and accentuation of gliosis in frontal white matter together with membrane degradation in BG in patients with hepatitis C virus infection. Agreement between psychometry and MRS revealed a significant agreement between decreased NAA/Cr and impaired attention and sustained attention, immediate verbal memory and immediate visual memory [P < 0.05]. HCV infection itself is associated with changes in the brain, even in the absence of hyperammonemia. Specifically, HCV-infected individuals may have deficits in cognitive functions such as attention, working memory, and speed of information processing. They also have abnormalities on magnetic resonance spectroscopy [MRS] that favor the organic explanation of the patients' mental symptoms

Gradient-echo MRI assessment of microbleed in ischemic stroke patients

Cerebral microbleeds are considered evidence of [microangiopathy], thus, they are commonly found in patients with severe leukoaraiosis and lacunar infarction. The aim of the present study was to evaluate the possible risk factors or [determinants] of microbleeds in patients with ischemia stroke, especially highlighting the association of the presence of microbleeds with small vessel vasculopathy [leukoaraiosis and lacunar infarcts]. The study included 52 patients with ischemic stroke, divided into 3 groups according to MRI findings: Group [A] patients with microbleeds +/- leukoaraiosis, Group [B] patients with leukoaraiosis without microbleeds and Group [C] patients with neither leukoaraiosis nor microbleeds [considered as a control group]. Assessment was done through clinical examination, laboratory investigations, carotid duplex, MRA and MRI brain with gradient-echo T2-weighted technique. Among the patients with microbleeds, the commonest site of microbleeds was in the deep grey nuclei followed by the hemispheric subcortical region then the brain stem while the cerebellum was involved in only 4 patients. Both groups [A] and [B] differed significantly from group [C] as they were older, hypertension was more commonly encountered and was poorly controlled. Stroke recurrence was more common among groups [A] and [B]. Furthermore, group [A] differed from group [C] in having longer duration of hypertension and more history of previous antiplatelet therapy. Group [A] differed from group [B] only concerning control of hypertension [larger number of poorly controlled patients] and number of lacunar infarcts [larger number of lacunar infarcts]. Cerebral microbleeds are commonly associated with lacunar infarctions and leukoaraiosis. Lack of proper control of hypertension [not just its mere presence or its duration] is an important determinant factor for both microbleeds and lacunar infarction, which might be complicated in the future by intra-cerebral hemorrhage

Saccular intracranial aneurysm coiling: experience in department of neurology, Ain-Shams University

Subarachnoid hemorrhage is a devastating type of stroke associated with 45% case fatality and 30% long-term dependency in survivors. Ruptured aneurysms should be treated early [within 24 to 72 hours] because the risk of subsequent rupture is high. Options for treatment include surgical clipping and endovascular coilings which is less invasive. Endovascular coiling has been proven to be effective and safer than clipping in most ruptured and unruptured intracranial aneurysms. We performed endovascular coiling for ruptured saccular aneurysm [presenting with acute subarachnoid hemorrhage, Hunt and Hess grade I-IV] and for asymptomatic aneurysms [>/= 7 mm in the anterior circulation or