Functional MRI study of language organization in left-handed and right-handed trilingual subjects.

Functional MRI (fMRI) is gaining importance in the preoperative assessment of language. Selecting the appropriate language to test by fMRI in trilingual patients is intricate. Our objective is to compare fMRI maps for all three languages in left- and right-handed trilingual subjects. 15 right- and 15 left-handed trilingual volunteers were included in the study. We performed fMRI for each volunteer with a visual responsive naming paradigm that was repeated three times, once in each language. The activated areas and the laterality indices were calculated and correlation with the age of acquisition and proficiency of each language was determined. Strong statistical correlation was found between the Laterality Index (LI) of the three languages, in both the right and left-handed groups. Discordant lateralization of language was only observed in four left-handed subjects who demonstrated bilateral and left-lateralization. In right-handed subjects, the activation maps for the first and the second acquired language were similar. The largest activation was seen with the last acquired language. Irrespective of language proficiency and age of acquisition, the language lateralization might change for left-handed subjects. In right-handed subjects, there is no change and the last acquired language results in the largest activation. fMRI performed for a single language can accurately determine language lateralization in right-handed subjects, whereas in left-handed subjects, it is mandatory to test all languages.

Impact of epilepsy training on school teachers and counselors: An intervention study in Lebanon.

This study aimed to evaluate the immediate impact of an epilepsy training through the administration of a questionnaire (in Arabic) before and immediately after the intervention in Lebanese public and private schools. This project is part of an awareness campaign applied to 3 groups of teachers and counselors and consisted of a pretest, a unified conference and a posttest. The statistical analysis used the McNemar and Stuart Maxwell tests (statistical significance level of 0.05). 73 participants completed the questionnaires. The majority were female (68.5%), aged less than 39 years (57%) and familiar with epilepsy. A positive impact of the training was found regarding the effect of epilepsy on schooling, seizures manifestations, psychological effects, seizure first aid and the possibility of curing epilepsy with surgery. Most of our participants recognized that children with epilepsy have a comparable IQ to others. They did not exhibit a discriminatory attitude against people with epilepsy in terms of the direct attitude towards them, employment or marriage. This is one of few studies done worldwide demonstrating an immediate positive effect of epilepsy training among school teachers. Future research should be undertaken to develop robust training models to destigmatize epilepsy.

How do Lebanese patients perceive the ideal doctor based on the CanMEDS competency framework?

BACKGROUND: During their training, Lebanese medical students develop a high medical expertise but are not focusing on other competencies such as communication, collaboration, erudition, professionalism, leadership and health promotion. There is also insufficient data about patients' preference for these skills. This study describes the different weights patients attribute to these physician's competencies. METHODS: This is a cross-sectional study based on a questionnaire distributed to 133 Lebanese patients. It included 15 questions assessing how patients prioritize the physician's competencies, with open-ended questions asking them to define "the good doctor". Krippendorff's alpha coefficient was used to analyze the reliability of the competencies' classification. RESULTS: One hundred twenty five patients completed the questionnaire in this cross-sectional study. Their mean age was 48 ± 16.76 years. When classifying competencies, 73.6% opted for medical expertise as first choice and 48% put communication as second. Based on the Krippendorff's coefficient, we identified a moderate agreement for the seven choices (alpha = 0.44). In open-ended questions, patients defined the good doctor in 325 answers: 64.3% mentioned medical expertise, 34.1% high ethics and 26.2% communication. CONCLUSIONS: This patient-centered study concurs well with the worldwide practice that puts medical expertise at the center of medical education. However Lebanese patients don't perceive equally other competencies and favor professionalism and communication that should be integrated in priority in students' curricula.

Atypical Presentation of Parietal Convexity Dural-Based Cavernous Hemangioma: A Case Report and Review of Literature.

BACKGROUND: Dural presentation of a cavernous hemangioma is a rare occurrence. Classically an intraparenchymal lesion with varying symptomatology including mostly headaches, seizures, and neurologic deficits depending on its location, a few cases have been reported along the convexity of the brain, even less eroding the calvaria, with none occasioning abnormal movements as the initial presentation. CASE DESCRIPTION: This is a case of a 67-year-old male who presented to the clinic for atypical progressive choreiform movements of the right side of his body and a soft subgaleal mass. Radiographic imaging showed a parietal tumor with intradural and extradural invasion mimicking a meningioma, which does not provide, given its location, a clear explanation of the symptoms. A craniotomy was performed on 29 January, 2018, during which the tumor was resected along with the invaded dura mater and calvaria. CONCLUSIONS: A pathology report was positive for cavernous hemangioma, an unexpected diagnosis based on the tumor's characteristics. After surgery, the patient recovered completely without residual symptoms, suggesting a compressive mass effect causing the atypical movement disorders.

Bupivacaine Field Block With Clonidine for Postoperative Pain Control in Posterior Spine Approaches: A Randomized Double-Blind Trial.

BACKGROUND: The synergistic effect of clonidine with bupivacaine, well established in peripheral nerve blocks, remains controversial in local field block for postoperative analgesia. OBJECTIVE: To investigate the potential analgesic benefit of adding clonidine to bupivacaine during preincisional field block in posterior approaches for spine surgeries. METHODS: Two hundred twenty-five patients were enrolled in this study and underwent lumbar spinal fusion (n = 80), lumbar laminectomy (n = 25), lumbar microdiscectomy (n = 94), or cervical laminectomy (n = 26). In each surgical subgroup, patients were randomly assigned in a double-blinded fashion to receive either 20 mL of 0.25% bupivacaine alone (control group, n = 109) or with 150 µg clonidine (clonidine group, n = 116) in the form of a preincisional field block. Outcome parameters included area under the curve of pain from postoperative day D0 to D8 and rescue morphine consumption from D0 to D3. RESULTS: The area under the curve was reduced in the clonidine group, particularly in the microdiscectomy subgroup, and without reaching statistical significance in the cervical laminectomy subgroup. Total rescue morphine consumption was reduced in the clonidine group, particularly at D1-D2, a benefit that was exclusive to the lumbar stenosis and lumbar fusion subgroups. Field block with clonidine, surgical subgroup, and the presence of preoperative spinal pain were factors independently influencing postoperative wound pain in multivariate analysis. CONCLUSION: The addition of clonidine to local preincisional field block with bupivacaine resulted in better and prolonged postoperative analgesia in posterior lumbar spine surgeries, an effect that was more pronounced in patients with no preoperative spinal pain.

Customized Polymethylmethacrylate Cranioplasty Implants Using 3-Dimensional Printed Polylactic Acid Molds: Technical Note with 2 Illustrative Cases.

OBJECTIVES: Prefabricated customized cranioplasty implants are anatomically more accurate than manually shaped acrylic implants but remain costly. The authors describe a new cost-effective technique of producing customized polymethylmethacrylate (PMMA) cranioplasty implants with the use of prefabricated 3-dimensional (3D) printed molds. METHODS: The first patient had a left frontal cranial defect after a craniotomy for a glial tumor. A 3D image of his skull was obtained from axial 0.6-mm computed tomography (CT) scan images. The image of the implant was generated by a digital subtraction mirror-imaging process using the normal side of his cranium as a model. The second patient had a bifrontal defect after the resection of an infected customized polyetheretherketone implant. A 3D image of the infected implant was directly obtained from an axial 0.6-mm CT scan before discarding it. The images were then used to produce for each patient a mold of the external surface of the cranium using a low-cost polylactic acid 3D printer. Intraoperatively, each mold was put in a sterile bag and then used to cast a customized PMMA implant subsequently trimmed before fixation. RESULTS: Both patients had excellent cosmetic results and underwent postoperative CT scans that showed excellent restoration of the symmetrical contours of the cranium. No neurologic or infectious complications occurred over a 6-month follow-up for either patient. CONCLUSIONS: Making customized PMMA cranioplasty implants via 3D printed polylactic acid molds is a cost-effective technique for delayed reconstruction of various cranial defects.

Radiofrequency ablation of spinal osteoid osteoma: a prospective study.

OBJECTIVE Surgery has been considered the standard treatment for spinal osteoid osteomas that are refractory to analgesic agents. Radiofrequency ablation (RFA) is a less invasive technique with established efficiency for the treatment of peripheral osteoid osteomas. The main objectives of this study are to evaluate the safety of RFA based on the results of a previous experimental study in rats conducted in the authors' laboratory and to identify its short- and long-term efficiency in the treatment of spinal osteoid osteomas. METHODS Between March 2009 and July 2016, 8 consecutive patients with spinal osteoid osteomas were enrolled in the study and underwent 9 CT-guided RFA procedures. All patients presented with spinal pain (median preoperative visual analog scale [VAS] score 7.55, range 6-8.8) predominantly during the night, and they all had normal neurological examination results before the procedure. Pain (according to the VAS score) and neurological status were reassessed immediately before discharge, with further follow-up at 1, 6, and 12 months after the procedure. At the final follow-up, VAS score, neurological examination, patient satisfaction, and a radiological control (CT scan) were documented (median 48 months, range 12-84 months). VAS scores before and after the procedure were compared during the 3 days before surgery (D0), on the day of the surgery, Day 1 (D1), and at the final follow-up. RESULTS No neurological deficit was documented following the procedure or at the final follow-up. A statistically significant reduction in the VAS score was observed on Day 1 (mean 2.56 ± 0.68, p = 0.005) compared with D0. At the final follow-up, all patients reported a VAS score of 0 and a satisfaction rate of 100%. Only 1 patient had recurrent symptoms (pain, VAS score 8.1) 6 months after the initial RFA. A second procedure was performed, and the patient was subsequently symptom free at the final follow-up. CT scanning performed in all patients (12-84 months post-RFA) showed residual sclerosis in 4 patients and complete resolution of the radiological lesion in the remaining 4 patients. CONCLUSIONS CT-guided RFA appears to be a safe and effective method for the management of spinal osteoid osteoma and can be safely performed for lesions close to the dura or exiting nerve root based on the motor response threshold testing performed during the procedure. It should be considered the treatment of choice for spinal osteoid osteomas refractory to conservative treatment, thus avoiding more aggressive spinal approaches with subsequent potential morbidity.

Antithrombotic Medication Use and Misuse Among Patients with Intracranial Hemorrhage: A 16-Year, Lebanese, Single-Center Experience.

OBJECTIVE/BACKGROUND: The use of antithrombotic medication (ATM) frequently is reported in patients with intracranial hemorrhage (ICH) and is associated with increased mortality. Unfortunately, ATMs sometimes are prescribed and/or used inappropriately. We sought to determine the rate of ATM misprescription/misuse among patients with ICH in a single-center retrospective study. METHODS: All patients admitted with ATM-related ICH in 1998-2014 were included. Charts were reviewed and demographic, clinical, and radiologic variables were recorded. The type of ATM, dose, and duration of treatment were analyzed critically. The adequacy of ATM prescription/use was assessed in light of the recommendations and guidelines of the American Heart Association, American Stroke Association, and French National Authority for Health, in effect at the time of admission. RESULTS: A total of 106 patients with mean age 68 years were identified. Aspirin (53.8%) was the most commonly used drug, followed by oral anticoagulants (31.1%) and clopidogrel (22.6%). In only 80 patients (75.5%), the use of ATM was in line with contemporary guidelines. In the remaining 26 (24.5%), the use of ATMs was inappropriate, including bad drug combination, wrong dose, poor indication, wrong drug class, and/or incorrect treatment duration. CONCLUSIONS: In this Lebanese cohort of patients with ICH, the 24.5% rate of ATM misprescription and/or misuse is highly alarming and the origin of this problem is likely multifactorial. Immediate measures should be undertaken, and efforts should be focused on regaining tight control of ATM prescription and fulfillment, ensuring good patient education, and offering more vigilant oversight on physician licensure.

Aneurysmal Bone Cyst of the Cervical Spine in Children: A Review and a Focus on Available Treatment Options.

OBJECTIVE: To present a series of pediatric cervical spine (CS) aneurysmal bone cysts (ABC), to review the literature, and to propose a treatment algorithm. MATERIAL: We present a series of 4 cases of ABC and review the literature using PubMed, EMBASE, and Google scholar. RESULTS: Only 51 cases are documented. The mean age at diagnosis is 11.5 years, and there is a small female predominance (F:M ratio=1.6). Most of ABC occurs in the upper CS (41%), are located in the posterior component (75%), and extends in 40% of the vertebral body. A single treatment modality was used in 56.9%, whereas combination of surgery with other treatment modalities was used in the rest. Of the total number of cases, 56.8% were managed with marginal resection, and instrumentation was used in 80%. Mean follow-up was 72.5 months, with the majority of patients disease free. Pain is the most common symptom present at the latest follow-up. CONCLUSIONS: ABC of the spine is a pediatric tumor occurring rarely in the CS. Treatment options vary from simple curettage to total resection with or without instrumentation. Recurrence after surgery is highest after curettage alone. The main indications for surgery are rapid progression, despite intracystic injection, and/or the presence of neurological signs or symptoms.

Solitary fibrous tumor of the lumbar spine: the great mimicker-report of the fifth case.

Solitary fibrous tumor (SFT) is a rare neoplasm occurring in the central nervous system. It rarely occurs in the spine. This paper reports the fifth case of SFT in a 34-year-old female and focusses on differential diagnosis and importance of surgical treatment.

[Prospective study of microdiskectomy for lumbar disc herniation: evolution of pain, quality of life and satisfaction of Lebanese patients at short and long-term follow-up]. / Etude prospective á court et long terme de la microdiscectomie lombaire. Evaluation de la douleur, qualité de vie et satisfaction des patients libanais.

BACKGROUND AND PURPOSE: Lumbar disc herniation frequently affects young patients and is responsible for high rate of worker's compensation claims. The aim of this study is to evaluate at short and long-term the results of microdiscectomy in terms of pain control, quality of life and patient's satisfaction. METHODS: In this prospective study, 28 patients were enrolled and operated on by microdiscectomy for lumbar disc herniation. Three questionnaires were administered preoperatively. They evaluated the pain, the quality of life and the expectation of the patients. Four questionnaires were administered at six months and two years postoperatively evaluating pain, quality of life, results and satisfactions. RESULTS: A 62.3% and 53.2% improvement of low back pain at 6 months and 2 years respectively, and a 91.7% and 88.4% improvement of radicular pain were reported. A 73.2% and 79.8% improvement in quality of life was recorded respectively. Patient's expectation was evaluated at 3.85 and results estimated 3.24. Patient's satisfaction was 93.3% and 88.3% respectively. It was positively correlated to radicular pain, and inversely correlated to patient's expectations. CONCLUSION: Microdiscectomy for lumbar disc herniation offers a marked improvement in back and radicular pain. Quality of life is much improved. Although satisfaction is high, it is somewhat decreased for patients with high expectations.

Brain abscesses in HIV-positive patients due to Pneumocystis jiroveci.

Cerebral toxoplasmosis is common in AIDS patients; however, pneumocystosis of the brain is rarely documented. We report a patient with AIDS hospitalized for brain abscesses. Stereotactic brain biopsy with immunofluorescence staining was positive for Pneumocystis jiroveci. The patient received high doses of cotrimoxazole and had a favorable clinical course.

Lumbar microdiscectomy: a clinicoradiological analysis of outcome.

BACKGROUND: The long-term outcome after lumbar microdiscectomy (LMD) may be affected by low back pain (LBP) and segmental instability, the determinants of which remain unclear. We sought to analyze the interaction between clinical, functional, and radiological variables and their impact on patient outcome. METHODS: All patients who underwent LMD in 2004-2005 were invited to participate in this retrospective cohort study. Patients were re-evaluated clinically and radiologically after a three to five year follow-up. RESULTS: Forty-one of 97 eligible patients were enrolled. Twelve patients (29.3%) reported moderate-to-severe sciatica, 12 (29.3%) had moderate LBP, and 13 (31.7%) exhibited clinical evidence of segmental instability. Thirty-eight patients (92.7%) had minimal disability and 3 (7.3%) had moderate disability. Twenty-three patients (56.1%) were fully satisfied, while 18 (43.9%) had only partial satisfaction, having expected a better outcome. Thirty-three patients (80.5%) returned to full-time work. Median disc space collapse (DSC) was 20% (range 5-66%) and L4-L5 was particularly affected. Prevalence of Modic changes increased from 46.3% to 78% with type 2 predominance. Multivariate logistic regression analysis identified the following negative prognostic factors: female sex, young age, lack of regular exercise, and chronic preoperative LBP. There was no correlation between the course of Modic changes, DSC, and patient outcome. CONCLUSION: Although many patients may be symptomatic following LMD, significant disability and dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome.

What happens to Modic changes following lumbar discectomy? Analysis of a cohort of 41 patients with a 3- to 5-year follow-up period.

OBJECT: The natural history of Modic changes (MCs) in the lumbar spine is often marked by conversion from one type to another, but their course following lumbar discectomy remains unknown. The authors sought to study the impact of surgery on the natural history of these lesions. METHODS: Forty-one patients treated with lumbar microdiscectomy between 2004 and 2005 were enrolled in this study and underwent clinical evaluation and repeat MR imaging after a median follow-up of 41 months (range 32-59 months). Preoperative and follow-up MR images were reviewed and the type, location, and extent of MCs at the operated level were recorded and compared. RESULTS: The study population consisted of 27 men and 14 women with a mean age of 54 years (range 24-78 years). During the follow-up period, the prevalence of MCs increased from 46.3% to 78%, and 26 patients (63.4%) had Type 2 lesions at the operated level. Of the 22 patients without MCs, 4 (18.2%) converted to Type 1 and 9 (40.9%) to Type 2. Of the 5 Type 1 lesions, 3 (60%) converted to Type 2, and 2 (40%) remained Type 1 but increased in size. In contrast, none of the 14 Type 2 changes converted to another type, although 10 (71.4%) increased in extent. There were no reverse conversions to Type 0. CONCLUSIONS: Following lumbar discectomy, most patients develop Type 2 changes at the operated level, possibly as a result of accelerated degeneration in the operated disc. Neither the preoperative presence of MCs nor their postoperative course appears to affect the clinical outcome.

[Brain tumors and epilepsy: postoperative evaluation of surgical procedures]. / Evolution postopératoire de l'epilepsie chez les patients opérés de tumeurs cérébrales.

OBJECTIVES: To study the efficacy of surgery on the postoperative control of epilepsy in patients operated for brain tumors. METHODS: Forty patients operated for supratentoriel cerebral tumors with epilepsy, at Hotel-Dieu de France (HDF) hospital center, between 1983 and 2005, were included in this study. Clinical, paraclinical and surgical information were collected. The extent of the tumor resection was based on the postoperative MRI results. RESULTS: The mean duration of the follow-up was 52 +/- 6 months (from 6 months to 10 years). 62.5% of our patients have had acute seizures (< 1 year) and 37% had experienced chronic seizures (> or = 1 year). The histopathologic exam revealed 2 DNET, 3 pilocytic astrocytomas, 2 diffuse astrocytomas, 6 A oligodendrogliomas, 7 B oligodendrogliomas, 7 anaplastic astrocytomas and glioblastomas and 13 meningiomas. Twenty-two patients had a complete resection, whereas the postoperative MRI of 18 patients have shown a tumoral remnant. After one year of follow-up, a complete remission was noted in 57.5% of the patients (Engel I). The prognostic factors of good outcome were: low-grade glial tumors (I +/- II), meningiomas, and complete tumor resection. CONCLUSION: The efficacy of surgery for epilepsy associated to cerebral tumors, established by the majority of articles, matched the results obtained for the patients operated at HDF, with complete seizures control in 57.5% of patients. This control depended essentially on the extent of tumor resection and on tumor's nature.

Endoscopic third ventriculostomy: the Lebanese experience.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has gained wide popularity as a first-line treatment for obstructive hydrocephalus (OHC). We have been performing ETV since 1998. We report our experience with this technique in the management of OHC. METHODS: Between 1998 and 2007, we performed 49 ETV procedures in 46 patients suffering from OHC. Medical records were retrospectively reviewed. Success was defined as shunt-free survival. RESULTS: There were 29 males and 17 females with a mean age of 23 years (6 months-65 years). Aqueductal stenosis and tectal tumor were the most common etiologies (63%). Seven patients (15.6%) had early ETV failure. Of 38 patients with initial success and available follow-up, shunt independence was achieved in 29 patients (76.3%) after a mean follow-up of 37 months. Kaplan-Meier analysis yielded a 70% 5-year shunt-free survival rate. On multivariate analysis, no variables could predict early or late ETV failure. Transient complications occurred in 6 patients (13%), but there were no ETV-related deaths or permanent morbidity. CONCLUSION: ETV is a safe and effective treatment for OHC, resulting in a high rate of long-term shunt independence with a low risk of complications. ETV should be considered the treatment of choice for patients with OHC and its development as a substitute to shunt placement should be encouraged in neurosurgically developing countries.

Multifocal meningeal melanocytoma: a new pathological entity or the result of leptomeningeal seeding?

Meningeal melanocytoma is a rare benign CNS tumor derived from the leptomeningeal melanocytes. Although unusual, malignant transformation with leptomeningeal seeding into the brain or spinal cord may occur years after the initial diagnosis. The authors report a unique case of multifocal benign meningeal melanocytoma involving both cerebellopontine angles and the thoracic spinal cord, with associated diffuse leptomeningeal hyperpigmentation. They review the literature relevant to this topic and discuss the radiological and pathological features of this disease as well as its treatment options.

Impact of the lunar cycle on the incidence of intracranial aneurysm rupture: myth or reality?

OBJECTIVE: To analyze the impact of the lunar cycle and season on the incidence of aneurysmal subarachnoid hemorrhage (SAH). PATIENTS AND METHODS: The medical records of 111 patients who were admitted over a 5-year period to our department because of aneurysmal SAH were retrospectively reviewed. The date of aneurysm rupture was matched with the corresponding season and moon phase. RESULTS: An incidence peak for aneurysm rupture (28 patients) was seen during the phase of new moon, which was statistically significant (p < 0.001). In contrast, no seasonal variation in the incidence of SAH was observed. CONCLUSION: The lunar cycle seems to affect the incidence of intracranial aneurysm rupture, with the new moon being associated with an increased risk of aneurysmal SAH.