The Osteoporotic Condition as a Predictive Factor for Hemorrhagic Transformation in Acute Cardioembolic Stroke.

OBJECTIVE: Hemorrhagic transformation (HT) can be occurred after acute cerebral infarction. HT can worse symptoms in severe cases and adversely affect long-term prognosis. As bone and vascular smooth muscle are composed of type 1 collagen, we aimed to identify a potential relationship between bone mineral density (BMD) and HT after acute cardioembolic stroke. METHODS: As an indicator of BMD, we used mean frontal skull Hounsfield unit (HU) values on brain computed tomography (CT). Multivariative hazard ratios were calculated using Cox regression analysis to identify whether the osteoporotic condition was an independent predictor of HT after acute cardioembolic stroke. RESULTS: This 11-year analysis enrolled 506 patients who diagnosed as acute cardioembolic infarction. The first tertile of skull HU value was an independent predictor of HT development compared to the third tertile (hazard ratio, 2.12; 95% confidence interval, 1.13-3.98; p=0.020). We observed no interactions between age and skull HU with respect to HT statistically. CONCLUSION: The results of this study revealed an association between osteoporotic conditions and HT development after acute cardioembolic stroke. A convenient method to measure the cancellous bone HU value of the frontal skull using brain CT images may be useful for predicting HT in patients with acute cerebral infarction.

Effect of Possible Osteoporosis on Parenchymal-Type Hemorrhagic Transformation in Patients with Cardioembolic Stroke.

BACKGROUND: hemorrhagic transformation (HT) is a frequent complication of ischemic stroke, and parenchymal hematoma (PH)-type HT has been shown to correlate with symptomatic deterioration. Because both bone and vascular smooth muscle cells are composed of type 1 collagen, we hypothesized that the integrity of blood vessels around the infarction area might be more damaged in osteoporotic conditions after a cardioembolic stroke. METHODS: we measured frontal skull Hounsfield unit (HU) values on brain CT images from cardioembolic stroke patients. We conducted a receiver operating characteristic curve analysis in a large sample registry to identify the optimal HU threshold for predicting osteopenia and osteoporosis. Hazard ratios were estimated using a Cox regression analysis to identify whether osteoporotic conditions were an independent predictor of PH-type HT in patients with cardioembolic stroke. RESULTS: altogether, 600 consecutive patients (>18 years old) with cardioembolic stroke were enrolled over a 12-year period at our hospital. The infarction volume and hypothetical osteoporosis were independent predictive factors for PH-type HT development in patients with cardioembolic stroke. In the male group, hypothetical osteoporosis was an independent predictor for PH-type HT development after cardioembolic stroke (hazard ratio, 4.12; 95% confidence interval, 1.40-12.10; p = 0.010). CONCLUSIONS: our study suggests an association between possible osteoporosis and the development of PH-type HT in patients with cardioembolic stroke. Our findings could help to predict PH-type HT by providing a convenient method for measuring the HU value using brain CT images.

Radiologic Factors Predicting Deterioration of Mental Status in Patients with Acute Traumatic Subdural Hematoma.

OBJECTIVE: To evaluate whether subdural hematoma (SDH) volume and other radiologic factors predict deterioration of mental status in patients with acute traumatic SDH. METHODS: SDH volumes were measured with a semiautomated tool. The area under the receiver operating characteristic curve was used to determine optimal cutoff values for mental deterioration, including the variables midline shift, SDH volume, hematoma thickness, and Sylvian fissure ratio. Multivariate logistic regression was used to calculate the odds ratio for mental deterioration based on several predictive factors. RESULTS: We enrolled 103 consecutive patients admitted to our hospital with acute traumatic SDH over an 8-year period. We observed an increase in SDH volume of approximately 7.2 mL as SDH thickness increased by 1 mm. A steeper slope for midline shift was observed in patients with SDH volumes of approximately 75 mL in the younger age group compared with patients in the older age group. When comparing cutoff values used to predict poor mental status at time of admission between the 2 age groups, we observed smaller midline shifts in the older patients. CONCLUSIONS: Among younger patients, an overall tendency for more rapid midline shift progression was observed in patients with relatively low SDH volumes compared with older patients. Older patients seem to tolerate larger hematoma volumes owing to brain atrophy compared with younger patients. When there is a midline shift, older patients seem to be more vulnerable to mental deterioration than younger patients.

Correlation of survivin and B-cell lymphoma 2 expression with pathological malignancy and anti-apoptotic properties of glial cell tumors.

Apoptosis, whose mechanism remains unclear, is regulated by multiple factors. B-cell lymphoma 2 (Bcl-2) is a well-known anti-apoptotic mediator. Survivin is also a recently recognized novel family inhibitor of apoptosis protein, which inhibits apoptosis via a pathway distinct from Bcl-2 family members. Survivin and Bcl-2 are expressed in various types of human cancer. In the present study, survivin and Bcl-2 expression were characterized in glial cell tumors, and the correlation with pathological malignancy and anti-apoptotic properties were investigated. Fifty-eight patients who had undergone surgical resection for glial cell tumors were evaluated. The pathological types of glial cell tumors were categorized according to the World Health Organization classification. Survivin and Bcl-2 expression levels were investigated by western blot analysis, and apoptosis was detected by DNA fragmentation analysis. The anti-apoptotic rate of glial cell tumors was calculated in tumor samples according to the expression of survivin and Bcl-2 or co-expression. Survivin was characterized in 60.3%, and Bcl-2 was expressed in 43.1% of glioma samples. Co-expression of survivin and Bcl-2 was observed in 25.9% of the tumor specimens. Survivin expression in astrocytic tumors was identified to be significantly associated with the pathological grade (P<0.05); however, Bcl-2 was not (P>0.05). Anti-apoptotic rate of glial cell tumors were detected in 91.4, 92.0 and 100% of patients exhibiting survivin, Bcl-2 or co-expression, respectively. However, the difference in anti-apoptotic frequency between the three groups was not identified to be statistically significant (P>0.05). The present study suggests that survivin expression is correlated with pathological grades of gliomas. In addition, the expression of survivin or Bcl-2 exerts potent anti-apoptotic properties in gliomas. Thus, survivin or Bcl-2 may serve as potential targets for inducing the apoptosis of gliomas.

Increased Short-Term Mortality in Patients with Spontaneous Intracerebral Hemorrhage and its Association with Admission Glucose Levels and Leukocytosis.

OBJECTIVE: Spontaneous intracerebral hemorrhage (ICH) can be a devastating event. An increased glucose level in patients with ICH is known to be related to poor outcomes, including acute leukocytosis, which is a well-established response to ICH. The purpose of this study was to evaluate the association between admission laboratory factors and 3-month mortality in patients with spontaneous supratentorial ICH. METHODS: We performed a Kaplan-Meier analysis to evaluate the risk factors for 3-month mortality in patients with ICH. We used univariate and multivariate Cox regression analyses to calculate hazard ratios with 95% confidence intervals for short-term mortality based on clinical and laboratory factors. The area under the receiver operating characteristic curve was used to determine the laboratory risk factors that predicted mortality. RESULTS: In total, 538 patients from our hospital admitted with primary spontaneous supratentorial ICH over an 8-year period were enrolled in this study. Higher leukocyte counts (hazard ratio, 1.019; 95% confidence interval, 1.012-1.027; P < 0.001) and glucose levels on admission were associated with higher 3-month mortality. The receiver operating characteristic curve analysis showed that the areas under the curve of ICH volume, glucose, and leukocyte counts were 0.696 (cutoff value, 41.63), 0.687 (cutoff value, 134), and 0.642 (cutoff value, 9.4), respectively. CONCLUSIONS: Higher admission white blood cell counts and glucose levels were associated with higher 3-month mortality in patients with spontaneous ICH. These data show that an altered glucose metabolism and inflammatory state after ICH may be related to early deterioration after an ICH.

Concurrent Ruptured Pseudoaneurysm of the Internal Carotid Artery and Cerebral Infarction as an Initial Manifestation of Polycythemia Vera.

The most common neurologic manifestations of polycythemia vera (PV) are cerebral infarction and transient ischemic attacks, while cerebral hemorrhage or intracranial dissection has been rarely associated with PV. Here we report the first case of a 59-year-old patient with intracranial supraclinoid internal carotid artery (ICA) dissection causing cerebral infarction and concomitant subarachnoid hemorrhage due to pseudoaneurysm rupture as clinical onset of PV. This case report discusses the possible mechanism and treatment of this extremely rare condition.

Unilateral C1 Lateral Mass and C2 Pedicle Screw Fixation for Atlantoaxial Instability in Rheumatoid Arthritis Patients: Comparison with the Bilateral Method.

OBJECTIVE: Bilateral C1 lateral mass and C2 pedicle screw fixation (C1LM-C2P) is an ideal technique for correcting atlantoaxial instability (AAI). However, the inevitable situation of vertebral artery injury or unfavorable bone structure may necessitate the use of unilateral C1LM-C2P. This study compares the fusion rates of the C1 lateral mass and C2 pedicle screw in the unilateral and bilateral methods. METHODS: Over five years, C1LM-C2P was performed in 25 patients with AAI in our institute. Preoperative studies including cervical X-ray, three-dimensional computed tomography (CT), CT angiogram, and magnetic resonance imaging were performed. To evaluate bony fusion, measurements of the atlanto-dental interval (ADI) and CT scans were performed in the preoperative period, immediate postoperative period, and postoperatively at 1, 3, 6, and 12 months. RESULTS: Unilateral C1LM-C2P was performed in 11 patients (44%). The need to perform unilateral C1LM-C2P was due to anomalous course of the vertebral artery in eight patients (73%) and severe degenerative arthritis in three patients (27%). The mean ADI in the bilateral group was 2.09 mm in the immediate postoperative period and 1.75 mm in 12-months postoperatively. The mean ADI in the unilateral group was 1.82 mm in the immediate postoperative period and 1.91 mm in 12-months postoperatively. Comparison of ADI measurements showed no significant differences in either group (p=0.893), and the fusion rate was 100% in both groups. CONCLUSION: Although bilateral C1LM-C2P is effective for AAI from a biomechanical perspective, unilateral screw fixation is a useful alternative in patients with anatomical variations.

Prognostic role of copeptin after stroke: A systematic review and meta-analysis of observational studies.

Copeptin, the C-terminal part of provasopressin, has emerged as a novel prognostic marker after hemorrhagic or ischemic stroke. The aim of this study was to quantitatively assess the prognostic significance of plasma copeptin level on functional outcome and mortality in patients with acute stroke using a meta-analysis of the available evidence. Thirteen relevant studies from 2,746 patients were finally included in our study. An elevated plasma copeptin level was associated with an increased risk of unfavorable outcome and mortality after stroke (OR 1.77; 95% CI, 1.44-2.19 and OR 3.90; 95% CI 3.07-4.95, respectively). The result of the pooled measure on standardized mean difference (SMD) was that plasma copeptin levels were found to be significantly higher in patients who died compared to survivors (SMD 1.70; 95% CI, 1.36-2.03). A stratified analysis by study region showed significant differences in SMD of copeptin, and the heterogeneity among studies was significantly decreased. However, the positive association of copeptin with poor prognosis after stroke was consistent in each stratified analysis. The present meta-analysis suggests that early measurement of plasma copeptin could provide better prognostic information about functional outcome and mortality in patients with acute stroke.

The safety and efficacy of cadaveric allografts and titanium cage as a fusion substitutes in pyogenic osteomyelitis.

OBJECTIVE: The safety and efficacy of various fusion substitutes in pyogenic osteomyelitis has not been investigated. We evaluated and compared the cadaveric allograft and titanium cages used to reconstruct, maintain alignment and achieve fusion in the management of pyogenic spinal infection. METHODS: There were 33 patients with pyogenic osteomyelitis underwent fusion in this study. Fifteen of the 33 patients were operated on by fusion with allografts (cadaveric patella bones) and 18 of those were operated with titanium mesh cages filled with autologous cancellous iliac bone. After the affected disc and vertebral body resection with pus drainage, cadaveric allograft or titanium cages were inserted into the resected space. Posterior transpedicular screw fixation and rod compression in resected space, where cadaveric allograft or titanium cages were inserted, was performed to prevent the malposition in all patients except in 1 case. Recurrent infection was identified by serial erythrocyte sedimentation rate and cross reactive protein follow-up. Osseous union and recurred infection available at a minimum of 2 years following operation was identified. The amount of kyphosis correction and the subsidence were measured radiographically. RESULTS: Spinal fusion was achieved in 29 of 33 patients. In the cadaveric allograft group, 93.3% of patient (14 of 15) showed the osseous union while 83.3% of patient (15 of 18) in the titanium cage group showed union. Subsidence was noted in 12 of the patients. Twelve patients (36.3%) showed unsettling amounts of subsidence postoperatively whereas 46.6% of patients in the cadaveric allograft group and 37.7% of patients in the titanium cage group showed similar subsidence, respectively. There were statistical difference in the fusion rate (p=0.397) and subsidence rate (p=0.276) between the two groups. There was significant statistical difference in the postoperative improvement of segmental kyphosis between the two groups (p=0.022), that is the improvement in sagittal alignment was greater in the titanium cage group than in the cadaveric allograft group. There was no case of recurred infection. CONCLUSION: The cadaveric allograft and titanium cages are effective and safe in restoring and maintaining sagittal plane alignment without increased incidence in infection recurrence in pyogenic osteomyelitis. The postoperative improvement of segmental kyphosis was better in the cage group.