Characterization of Meningitis and Meningoencephalitis in the Israeli Defense Forces From 2004 to 2015: A Population-Based Study.

Background: Meningitis and meningoencephalitis (MME) are potential medical emergencies. Mandatory reporting of all MME cases in the Israel Defense Force (IDF) allows accurate characterization of MME incidence and course. In the present study, we described the epidemiology of MME in soldiers. Methods: Medical charts of 860,000 combat and non-combat soldiers serving during the years 2004-2015, accounting for 2,256,060 patient years, were retrospectively evaluated. The diagnosis of MME was based on signs of meningeal irritation and a count of > 5 white blood cells (WBC) in the cerebrospinal fluid (CSF). Data on the diagnosis of bacterial or aseptic MME, significant sequelae, and associated mortality were collected. Results: Approximately 273 cases of MME were diagnosed. Overall, MME incidence was 12.1/100,000 patient-years. Bacterial and viral pathogens were identified in 31/273 (11.4%) and 52/273 (19%) cases, respectively. Combat soldiers had higher incidence of bacterial meningitis [14/40 (35%) vs. 31/212 (14.6%); p = 0.002] and meningoencephalitis [13/40 (32.5%) vs. 33/212 (15.6%); p = 0.023] compared to non-combat soldiers. Their clinical presentation was more severe, including confusion [10/40 (25%) vs. 22/212 (10.4%); p = 0.018], focal neurological deficits [12/40 (30%) vs. 11/212 (5.2%); p < 0.0001], and status epilepticus [3/40 (7.5%) vs. 0/212 (0.0%); p < 0.01]. Mortality among combat soldiers was higher [5/40 (15%) vs. 1/212 (0.5%); p < 0.001]. N. meningitidis was the most frequently isolated bacteria, despite universal preventative vaccination. Conclusion: The incidence of bacterial MME in the IDF is higher than in the civilian population. Combat soldiers present with higher incidence of meningoencephalitis and bacterial meningitis.

Superficial Temporal Artery-Middle Cerebral Artery Microvascular Bypass: Its Role in Treatment of Patients with Moyamoya Disease, Cerebral Aneurysms, and Vascular Occlusive Disease.

BACKGROUND: Superficial temporal artery-middle cerebral artery microvascular bypass (STA-MCA MVB) is an important strategy for the management of selected patients OBJECTIVES: To present our 19-year experience with STA-MCA MVB METHODS: Data for consecutive patients who underwent STA-MCA MVB from 2000­2019 due to moyamoya/moyamoya-like disease, complex intracranial aneurysms, or intractable brain ischemia due to internal carotid artery or MCA occlusive disease with repeated ischemic events were retrospectively analyzed under a waiver of informed consent. Key surgical steps and the important role of neuroendovascular interventions are presented. Surgical results and late outcomes were analyzed RESULTS: The study included 32 patients (17 women [53%], 15 men [47%]), mean age 42.94 years (range 16­66). The patients underwent 37 STA-MCA MVB procedures during the study period: 22 with moyamoya/moyamoya-like disease (69%) underwent 27 surgeries (five bilateral); 7 patients with complex aneurysms (22%) and 3 patients with vascular occlusive disease (9%) underwent unilateral bypass. Five of seven aneurysms were treated with coiling or flow-diverter stent implant prior to bypass surgery; two were clipped during the bypass procedure. There were no surgical complications, no perioperative mortality, and no death from complications related to neurovascular disease at late follow-up. Transient neurological deficits following 7/37 surgeries (19%) resolved with no permanent neurologic sequelae. Transient ischemic attacks occurred only in the immediate postoperative period in four patients (11%) CONCLUSIONS: In specific cases, STA-MCA MVB is a feasible and clinically effective procedure. It is important to preserve this technique in the surgical armamentarium

Prevalence of polyps ≥6 mm on follow-up CT colonography in a cohort with no significant colon polyps at baseline.

AIM: Assess the prevalence of neoplasia ≥6 mm at repeat CT colonoscopy (CTC) in individuals with no significant lesions at baseline. METHODS: Individuals aged ≥18 years, with/without CRC risk factors, with no polyps ≥6 mm on baseline CTC (negative baseline) who underwent repeat CTC in a large HMO from 2001 to 2011 were retrospectively identified. Studies were reviewed by board-certified radiologists with experience interpreting CTC. Demographic details, CRC risk factors, and the number, size, and location of incident lesions were noted. Findings were classified using the C-RADS scale. Lesion prevalence at CTC-2 was determined, and study interval and risk characteristics of patients with- and without findings were compared. RESULTS: Our study included 636 individuals (369 men [58.0%]; mean age 59.9 years) with negative baseline CTC who underwent repeat CTC after a mean 4.6 year interval (SD 1.6 years). At baseline, 469/636 (73.7%) were at average risk for CRC; 418 remained at average risk for CTC-2 with 51 (8.0%) developing new risk factors in the interval between studies. At CTC-2, 47 participants (7.4%) presented 52 significant neoplasia: 35 polyps 6-9 mm, 14 polyps ≥10 mm, and 3 masses in 3/636 participants (0.47%). 2/3 masses, 6/14 polyps ≥10 mm (42.9%), and 12/25 polyps 6-9 mm (48.0%) were in individuals with risk factors for CRC. Histopathology was available for 12/52 lesions (23.1%): 8 tubular adenomas, 2 villous adenomas, 1 hamartomatous polyp, 1 case of normal tissue. CONCLUSION: A mean 4.6 years after negative-baseline CTC, neoplasia ≥6 mm were seen in 7.4% of participants, including masses in 0.47%, supporting recommendations for a 5-year study interval.

Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression.

BACKGROUND AND CONTEXT: Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management. PURPOSE: Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC. STUDY DESIGN/SETTING: Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015. PATIENT SAMPLE: Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression. OUTCOME MEASURES: Duration of ambulation and survival. METHODS: Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis. RESULTS: Forty patients were included (21 male, 54%; mean age 74 years, range 65-87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0-1662) and 525 days (range 11-1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65-69, 70-79, or 80-89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0-11. CONCLUSIONS: Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery.

Spinal epidural abscess with a rapid course in young healthy infantry recruits with multiple skin lacerations.

In recent years, there has been high prevalence of Staphylococcus aureus (S. aureus) infection among soldiers in the Israeli military, with devastating sequelae in several cases. Emergency department physicians have developed a high level of suspicion for spinal epidural abscess (SEA) in patients presenting known risk factors; however, SEA is a particularly elusive diagnosis in young healthy adults with no history of drug abuse. We review three cases of SEA secondary to methicillin-sensitive S. aureus (MSSA) infection in young healthy soldiers without known risk factors. We retrospectively reviewed clinical files of soldiers treated at our Medical Center from 2004-2015 to identify patients diagnosed with SEA. Those aged less than 30years with no history of intravenous drug use, spine surgery or spine trauma were included in the study. Three young army recruits met the inclusion criteria. These young men developed SEA through extension of MSSA infection to proximal skin and soft tissue from impetigo secondary to skin scratches sustained during "basic" training. All presented with mild nuchal rigidity and severe persistent unremitting lancinating radicular pain. Although healthy at baseline, they had a severe, rapidly progressive course. Following urgent surgery, two patients recovered after rehabilitation; one remained with paraparesis at late follow-up. Neurological deficits and systemic evidence of S. aureus infection progressed rapidly in these young healthy SEA patients with no history of drug abuse, emphasizing the critical role of timely MRI, diagnosis, and surgery.

Comparison of outcomes following complex posterior fossa surgery performed in the sitting versus lateral position.

The sitting position during surgery is thought to provide important advantages, yet it remains controversial. We compared surgical and neurological outcomes for patients operated on in the sitting versus lateral position. Technically difficult procedures performed from the years 2001-2008 for complex lesions in the posterior fossa (vestibular schwannomas, other cerebellopontine angle tumors, foramen magnum meningiomas, brainstem cavernomas, pineal region tumors) were included. Outcomes in the two surgical positions were compared for all 243 patients (93 sitting, 38.3%; 150 lateral, 61.7%) and for 130/243 patients with vestibular schwannomas (50 sitting, 38.5%; 80 lateral, 61.5%). Sitting and lateral patient subgroups were clinically comparable. There were no surgical mortalities. The extent of removal and surgical and neurological outcomes were comparable. We found no advantage in surgical or neurological outcomes for use of the sitting or lateral surgical positions in technically difficult posterior fossa procedures. In vestibular schwannoma surgeries facial nerve preservation (House-Brackmann score 1-2) was related to extent of resection but not to surgical position. The choice of operative position should be based on lesion characteristics and the patient's preoperative medical status as well as the experience and preferences of the surgeons performing the procedure.

Spontaneous spinal epidural hematoma: the importance of preoperative neurological status and rapid intervention.

We describe the presentation, management, and outcome of spontaneous spinal epidural hematoma (SSEH) in two tertiary academic centers. We retrospectively reviewed clinical and imaging files in patients diagnosed with SSEH from 2002-2011. Neurologic status was assessed using the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A total of 17 patients (10 females; mean age 54 years, range 10-89) were included. Among patients presenting with AIS A, 5/8 showed no improvement and 3/8 reached AIS C. Among those presenting with AIS C, 5/6 reached AIS E and 1/6 reached AIS D. Of those presenting with AIS D, 3/3 reached AIS E. Mean time-to-surgery (TTS) was 28 hours (range 3-96). TTS surgery in two patients remaining at AIS A was ⩽ 12 hours; in 4/8 patients recovering to AIS E it was > 12 hours, including three patients operated on after > 24 hours. In patients remaining at AIS A, a mean of 4.4 levels were treated compared with means of 3.7 and 3.5 in those with AIS C and E, respectively, at late follow-up. In this series, preoperative neurological status had greater impact on late outcome than time from symptom onset to surgery in patients with SSEH.

Efficacy and safety of vertebral stenting for painful vertebral compression fractures in patients with metastatic disease.

BACKGROUND AND PURPOSE: Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures. MATERIALS AND METHODS: Patients >18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5-L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1-3 months after stenting. RESULTS: Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8.0 (range 8-10), falling to 2.0 immediately postop (range 1-6, P  =  0.000) and 0 at all subsequent follow-up (P ≤ 0.012). Mean preoperative vertical height loss was 25.8% (range 0-84.0%) versus a postoperative mean of 18.0% (range 0-66.0%, P  =  0.000). Median pre- and postoperative kyphotic angle improved from 8.3° (range 0.2°-54.0°) to 7.1° (range 0.2°-25.0°, P  =  0.000). Wilcoxon signed rank test or student's t-test was used for comparisons. CONCLUSIONS: Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.

Timing of stereotactic radiosurgery and surgery and wound healing in patients with spinal tumors: a systematic review and expert opinions.

BACKGROUND AND PURPOSE: Stereotactic radiosurgery (SRS) and surgery may be used in combination to manage cord compression due to spinal tumors. Procedure sequence and interval affect wound healing. We aimed to review the evidence on effects of timing and sequence of surgery and SRS on wound healing and bone fusion in patients with spine tumors. MATERIALS AND METHODS: We performed a comprehensive literature search (Medline, Embase, Google Scholar, Cochrane Database of Systematic Reviews) to identify relevant studies published in 2000-2011. Additional reports were identified in reference lists from relevant papers. Case reports and series discussing patients aged ≧18 with primary or metastatic tumors to the spine who underwent surgical excision with/without instrumentation and SRS before or after surgery were included. The apparent relationship of procedure sequence and interval on wound healing and bone fusion was assessed. RESULTS: Evidence on outcomes following treatment with SRS and surgery was provided in 31 studies; neither wound healing nor bone fusion were endpoints in any study. Wound healing complications were discussed in six studies (20%) including 88 patients treated with both modalities. Animal studies and limited evidence in humans suggest that at least 1 week is indicated between SRS and surgery or surgery and SRS. CONCLUSIONS: Evidence to guide decisions regarding the sequence and timing of surgery and SRS with respect to wound healing is limited. Consistent reporting of wound healing complications will improve ability to develop guidelines for optimal treatment of spinal tumors.

Are they too old? Surgical treatment for metastatic epidural spinal cord compression in patients aged 65 years and older.

OBJECTIVES: We aimed to assess the efficacy of surgical decompression of metastatic epidural spinal cord compression (MESCC) in patients ≧65 years and review our multidisciplinary surgical decision-making process. METHODS: We identified all patients operated for MESCC from August 2008 to June 2012. Patients ≧65 years, with a single area of cord compression, back/radicular pain, neurological signs of cord compression, surgery within 48 hours after onset of MESCC-related paraplegia, and follow-up for ≧1 year or until death were included. Files were reviewed retrospectively. The requirement for informed consent was waived. Neurological status was assessed with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Duration of ambulation and survival were assessed with Kaplan-Meier and Cox regression analysis. RESULTS: Twenty-one patients met inclusion criteria (11 women/10 men; mean age 73 years, range 65-87). All presented with debilitating back/neck pain. Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%). Motor symptoms had been present for a mean of 3·8 days (range 1-14). All patients regained ambulation. Overall, mean survival was 320 days (range 19-798) and mean ambulation was 302 days (range 18-747). On 31 March 2013, 7 patients (33%) were alive and ambulatory at a mean of 459 days (range 302-747); 14 patients had died (67%) at a mean of 251 days (range 19-798), with a mean ambulation of 223 days (range 18-730). DISCUSSION: With careful patient selection, surgery may achieve long duration of ambulation in patients ≧65 years with MESCC.

Parasellar meningiomas in pregnancy: surgical results and visual outcomes.

BACKGROUND: Rapid visual deterioration may occur as the result of the quick growth of parasellar meningiomas in the high-hormone/increased fluid retention milieu of pregnancy; however, surgery before delivery entails increased maternal-fetal risk. We present our experience in the management of parasellar meningiomas that compress the optic apparatus during pregnancy, with a focus on decisions regarding the timing of surgery. METHODS: Serial visual examinations and other clinical data for 11 women presenting from 2002 to 2012 with visual deterioration during pregnancy or delivery as the result of parasellar meningiomas involving the optic apparatus were reviewed. Indications for surgery during pregnancy included severely compromised vision, rapid visual deterioration, and early-to-midstage pregnancy with the potential for significant tumor growth and visual decrease before delivery. All patients underwent surgery with the use of skull base techniques via pterional craniotomy. An advanced extradural-intradural (i.e., Dolenc) approach, with modifications, was used in seven. RESULTS: All women achieved a Glasgow Outcome Score of 5 at discharge with no new neurologic deficits; all children are developing normally at a mean 4.5 years of age (range, 1-9.5 years). Surgery during pregnancy was recommended for six women: four operated at gestational weeks 20-23 had excellent postoperative visual recovery; two who delayed surgery until after delivery have permanent unilateral blindness. Among five others operated after delivery, four had good visual recovery and one has pronounced but correctable deficits. Three of five women diagnosed at gestational weeks 32-35 experienced spontaneous visual improvement after delivery, before surgery. CONCLUSIONS: We recommend that surgery be offered to patients during pregnancy when a delay may result in severe permanent visual impairment.

Cost-effectiveness of baseline low-dose computed tomography screening for lung cancer: the Israeli experience.

OBJECTIVE: Reduced mortality with low-dose computed tomography (LDCT) lung cancer screening was demonstrated in a large randomized controlled study of high-risk individuals. Cost-effectiveness must be assessed before routine LDCT screening is considered. We aimed to evaluate the cost-effectiveness of LDCT lung cancer screening in Israel. METHODS: A decision analytic framework was used to evaluate the decision to screen or not screen from the health system perspective. The screening arm included 842 moderate-to-heavy smokers aged 45 years or older, screened at Hadassah-Hebrew University Medical Center from 1998 to 2004. In the usual-care arm, stage distribution and stage-specific life expectancy were obtained from the Israel National Cancer Registry data for 1994 to 2006. Lifetime stage-specific costs were estimated from medical records of patients diagnosed and treated at Hadassah Medical Center in the period 2003 to 2004. The analysis considered possible biases-lead time, overdiagnosis, and self-selection. Cost per quality-adjusted-life-year (QALY) gained by screening was estimated. RESULTS: Base-case incremental cost per QALY gained was $1464 (2011 prices). Extensive sensitivity analysis affirmed the low cost per QALY gained. The cost per QALY gained is lower than $10,000 with probability 0.937 and is lower than $20,000 with probability 0.978. CONCLUSIONS: Our analysis suggests that baseline LDCT lung cancer screening in Israel presents a good value for the money and should be considered for inclusion in the National List of Health Services financed publicly.

Superficial siderosis of the central nervous system due to chronic hemorrhage from a giant invasive prolactinoma.

Superficial siderosis of the central nervous system (CNS) is a rare disorder caused by deposition of hemosiderin in neuronal tissue in the subpial layer of the CNS due to slow subarachnoid or intraventricular hemorrhage. The most common neurologic manifestations include progressive gait ataxia, sensorineural hearing loss, and corticospinal tract signs. We present a case of superficial siderosis in a 43-year-old man who presented to the Emergency Department with sudden onset bilateral visual deterioration and a loss of consciousness. A hemorrhagic giant prolactinoma was diagnosed based on brain CT scan, T1-weighted MRI, and an endocrine blood examination. Susceptibility-weighted non-contrast MRI showed pathognomonic signs of superficial siderosis in the form of a hypointensity rim surrounding the brainstem, cerebellar fissures, and cranial nerves VII and VIII. This report demonstrates that superficial siderosis can be caused by pituitary apoplexy.

Clinical relevance of negative initial angiogram in spontaneous subarachnoid hemorrhage.

BACKGROUND: We aimed to compare the presentation, management, and clinical course in patients with perimesencephalic and nonperimesencephalic (aneurysmal) bleeding patterns on noncontrast CT, but negative initial 4-vessel digital subtraction angiography (DSA). METHODS: We retrospectively reviewed clinical and imaging data for 280 patients presenting with spontaneous SAH admitted between 2005 and 2011. We identified 56 patients (20%) with SAH diagnosed on high resolution head CT performed within 48 hours of admission, and negative initial DSA, and divided them into perimesencephalic and non-perimesencephalic groups based on hemorrhage patterns. Patients with traumatic subarachnoid bleeding and those with initial positive DSA were excluded from this analysis. RESULTS: Perimesencephalic SAH was seen in 25 patients (45%); non-perimesencephalic bleeding patterns were seen in 31 (55%). All patients with perimesencephalic SAH presented with Hunt and Hess (HH) I, versus 45% HH I and 55% HH II-IV in those with non-perimecenphalic SAH. All patients with perimesencephalic SAH achieved modified Rankin score (mRS) 0 at discharge and 6-month follow-up, compared with 45% mRS 0 at discharge and 68% at 6-month follow-up in non-perimesencephalic SAH. Patients with perimesencephalic SAH presented a uniformly uncomplicated clinical course. Among non-perimesencephalic SAH patients there were 19 neurological/neurosurgical and 10 medical complications, two small aneurysms diagnosed at follow-up DSA, and one death. CONCLUSIONS: In this series, perimesencephalic SAH was associated with good clinical grades, consistently negative initial and follow-up angiograms, and an excellent prognosis. In contrast, non-perimesencephalic SAH was associated with a worse clinical presentation, higher complication rates, higher rates of true aneurysm detection on follow-up angiogram, and a poorer outcome.

Blind spots at oncological CT: lessons learned from PET/CT.

Improved accuracy in oncological computed tomography (CT) could lead to a decrease in morbidity and improved survival for oncology patients. Visualization of metabolic activity using the glucose analogue [(18)F]fluorodeoxyglucose (FDG) in combination with the high anatomic resolution of CT in an integrated positron emission tomography (PET)/CT examination has the highest sensitivity and specificity for the detection of primary and metastatic lesions. However, PET/CT costs are high and patient access is limited; thus CT remains the primary imaging modality in oncology patients. We have noted that subtle lesions are more easily detected on CT by radiologists with PET/CT experience. We aimed to provide a brief review of the literature with comparisons of multi-detector computed tomography (MDCT) and PET/CT in primary and metastatic disease with an emphasis on findings that may be overlooked on MDCT in cancer of the breast, lung, colon, and ovaries, and in melanoma, as well as thrombosis in oncology patients. We further reviewed our experience for illustrative comparisons of PET/CT and MDCT studies. Experience in interpreting conventional CT scans alongside PET/CT can help the reader develop an appreciation for the subtle appearance of some lesions on CT that might otherwise be missed. This could improve detection rates, reduce errors, and improve patient management.

Vertebral augmentation in the treatment of vertebral compression fractures: review and new insights from recent studies.

Vertebral compression fractures (VCF) due to osteoporotic degeneration and metastatic disease represent an increasingly significant public health problem. Percutaneous vertebroplasty (VP) began as a simple, low-cost procedure that aimed to provide pain relief for patients with VCF. Balloon kyphoplasty (KP) was introduced later, and was presented not only as a "pain killer," but also as a deformity correction procedure. The preponderance of evidence has shown that vertebral augmentation provides significant and sustained clinical benefit for patients with VCF. The debate raised by studies published in the New England Journal of Medicine comparing VP with a sham procedure highlights the importance of very careful patient selection for vertebral augmentation procedures, since osteoporotic VCF is usually a self-limiting condition. However, vertebral augmentation may be beneficial in patients with comorbidities that make prolonged bed rest dangerous, in patients with fractures that fail to heal, and in patients with painful VCF due to metastatic disease. Patient selection should be based on a combination of clinical and radiological indications. We review recent studies in the extensive literature on vertebral augmentation, with the goal of clarifying some of the controversy surrounding these procedures.

Statement of Ethics in Neurosurgery of the World Federation of Neurosurgical Societies.

This Statement of Ethics in Neurosurgery was developed by the Committee for Ethics and Medico-Legal Affairs of the World Federation of Neurosurgical Societies to help neurosurgeons resolve problems in the treatment of individual patients and meet obligations to the larger society. This document is intended as a framework rather than a set of rules. It cannot cover every situation and should be used with flexibility. However, it is our intent that the fundamental principles enunciated here should serve as a guide in the day-to-day practice of neurosurgery.

State-of-the-art reperfusion strategies for acute ischemic stroke.

Timely recanalization of the occluded artery is the only effective treatment for acute ischemic stroke. Intravenous tissue plasminogen activator (i.v. tPA), administered within 3 hours of symptom onset, is the only United States Food and Drug Administration-approved treatment. This short window often precludes effective intervention, and i.v. tPA often fails to recanalize major and mid-sized arteries. Intra-arterial thrombolysis has been used for decades, but its safety and effectiveness in cerebrovascular occlusions is also limited. Recently, new mechanical neuroendovascular devices have shown high recanalization rates with acceptable safety in early studies. Multi-modal reperfusion therapy (MMRT)--including intra-arterial infusion of thrombolytics and/or antiplatelet agents, mechanical clot disruption and retrieval, and balloon angioplasty with stent placement--is the prevailing concept for the management of major acute stroke. Recent results suggest that MMRT results in higher chances for both recanalization of the occluded artery and reperfusion of the ischemic tissue.

Healthy aging and preclinical dementia: the United States-Israel Longitudinal Database project.

This article proposes the establishment of a United States-Israel Longitudinal Database for Healthy Aging and Preclinical Dementia as a prototype model for the eventual creation of an international database. It is envisioned that such a comprehensive international database, as a shared research resource, will provide the foundation for a systems approach to solve the dual public health problems of: (1) Early detection of individuals at an elevated risk of developing Alzheimer's disease, and (2) Developing interventions to delay onset of, or prevent, chronic brain disorders later in life.

Dual-energy derived virtual nonenhanced computed tomography imaging: current status and applications.

Radiation exposure is a growing concern, and computed tomography is a main contributor to overall radiation dose in American patients. Dual-energy computed tomography, by allowing virtual nonenhanced (VNE) imaging, may obviate the need for image acquisition during a true nonenhanced phase when multiphase studies are needed, thereby reducing radiation exposure. Various groups have reported on the technical feasibility and clinical applicability of VNE imaging in the kidney, liver, lung, brain, and aorta. VNE is consistently reported to be both feasible and clinically relevant, although both hardware and postprocessing capabilities currently pose various specific challenges. We review the current state of VNE imaging and discuss some challenges to its future application.