Plasma brain natriuretic peptide level on admission predicts long-term outcome in patients with non-traumatic subarachnoid hemorrhage.

INTRODUCTION: Non-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH. METHODS: We studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation. RESULTS: Twenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p < 0.0001), neurological grade (p < 0.0001), elevated BNP level (p < 0.0001), increased plasma norepinephrine levels (p < 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p < 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p < 0.0001). CONCLUSION: Plasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.

Cervical Myelopathy Due to Direct Cord Compression by Posterior Inferior Cerebellar Artery Associated with Aberrant Vertebral Artery.

BACKGROUND: The effectiveness of surgical microvascular decompression (MVD) of the vertebral artery (VA) for treating conditions such as trigeminal neuralgia or hemifacial spasm is well known. However, the use of MVD for a case in which the posterior inferior cerebellar artery (PICA) is directly compressing the high cervical cord has not been reported. CASE DESCRIPTION: A 48-year-old male was diagnosed with a rare case of myelopathy due to the PICA directly compressing the high cervical cord. The patient had a C-2 segmental type of VA that penetrated the intradural space at the C1 level. The VA-PICA portion was located just after where the intradural space was penetrated, and the branching PICA strongly and vertically compressed the high cervical cord. CONCLUSIONS: MVD of the PICA was performed, and the patient experienced rapid improvement of myelopathy. The patient immediately improved postoperative day 1 and was doing well at his 1-year follow-up. This is a rare case of the PICA directly compressing the cervical cord and causing myelopathy. MVD of the PICA resulted in good patient recovery.

Arteriovenous malformation of the vestibulocochlear nerve.

We describe a rare case of an arteriovenous malformation (AVM) embedded in the vestibulocochlear nerve presenting with subarachnoid hemorrhage (SAH) treated by microsurgical elimination of the main feeding artery and partial nidus volume reduction with no permanent deficits. This 70-year-old woman was incidentally diagnosed 4 years previously with two small unruptured tandem aneurysms (ANs) on the right anterior inferior cerebral artery feeding a small right cerebellopontine angle AVM. The patient was followed conservatively until she developed sudden headache, nausea and vomiting and presented to our outpatient clinic after several days. Magnetic resonance imaging demonstrated findings suggestive of early subacute SAH in the quadrigeminal cistern. A microsurgical flow reduction technique via clipping between the two ANs and partial electrocoagulation of the nidus buried within the eighth cranial nerve provided radiographical devascularization of the ANs with residual AVM shunt flow and no major deficits during the 2.5 year follow-up. This is only the second report of an auditory nerve AVM. In the event of recurrence, reoperation or application of alternative therapies may be considered.

Endoscopic third ventriculostomy for hydrocephalus due to unruptured pineal AVM: case report and review of the literature.

INTRODUCTION: Arteriovenous malformations (AVM) are considered to be static congenital lesions; however, a subset may possess dynamic pathophysiological capabilities of growth, regression or other morphological changes with time. We report on an adult patient harboring a pineal AVM who presented with progressive symptoms of obstructive hydrocephalus and was successfully treated by endoscopic third ventriculostomy (ETV). CLINICAL PRESENTATION: This 63-year-old man was incidentally diagnosed 8 years previously with an asymptomatic unruptured pineal AVM and followed conservatively until he developed a progressive impairment in consciousness with gait apraxia and incontinence over a period of 2 months. Magnetic resonance imaging (MRI) revealed obstructive hydrocephalus due to nidal compression at the level of the aqueduct. Treatment by ETV resulted in resolution of neurological deficits and ventriculomegaly without evidence of complications at 18-months follow-up. CONCLUSION: Treatment by ETV in adults with obstructive hydrocephalus due to deep pineal AVMs is a reasonable option in selected cases. A discussion of the pathological mechanisms and therapeutic options for this rare entity is presented.

Relationship between diffusion-tensor fractional anisotropy and long-term outcome in patients with hemiparesis after intracerebral hemorrhage.

We assessed the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and long-term outcome (3-7 months after onset) in patients with hemiparesis after intracerebral hemorrhage (N = 12). DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated using Brunnstrom stage (six-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions when patients were discharged from a long-term rehabilitation facility 3-7 months after onset. In addition, the motor component of the functional independence measure (FIM-motor) was scored. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the clinical data (Spearman's rank correlation test, P < 0.05). Analysis revealed a statistically significant relationship between rFA and upper extremity function (R = 0.863 for shoulder/elbow/forearm; 0.834 for wrist/hand). Although statistically significant, the relationship between rFA and lower extremity function was less evident (R = 0.609). In contrast, analysis of rFA and FIM-motor scores did not reveal statistical significance. FA values within the cerebral peduncle are tightly associated with long-term outcomes of upper extremity function.

Diffusion tensor imaging for intracerebral hemorrhage outcome prediction: comparison using data from the corona radiata/internal capsule and the cerebral peduncle.

BACKGROUND: Magnetic resonance-diffusion tensor imaging (DTI) was used to predict motor outcome for patients with intracerebral hemorrhage. We compared the predictive accuracy of data sampled from the cerebral peduncle with data from the corona radiata/internal capsule. This study included 32 subjects with thalamic or putaminal hemorrhage or both. METHODS: DTI data were obtained on days 14 to 18. Mean values of fractional anisotropy (FA) within the cerebral peduncle and the corona radiata/internal capsule were analyzed using a computer-automated method. Applying ordinal logistic regression analyses, the ratios between FA values in the affected and unaffected hemisphere (rFA) were modeled in relation to motor outcome scores at 1 month after onset, assessed using the Medical Research Council (MRC) scale (0 = null to 5 = full). RESULTS: For both cerebral peduncle and corona radiata/internal capsule, the relationships between rFA and MRC matched logistic probabilities. While cerebral peduncle rFA values had statistically significant relationships with MRC scores (upper extremity R(2) = 0.271; lower extremity R(2) = 0.191), rFA values for the corona radiata/internal capsule showed less significant relationships (upper extremity R(2) = 0.085; lower extremity R(2) = 0.080). When estimated cerebral peduncle rFA values were <0.7, estimated probability of MRC 0 to 2 was close to 85% for the upper and 60% for the lower extremities. Meanwhile, when estimated rFA values were >0.9, estimated probability for MRC 4 to 5 nearly equaled 50% for the upper and 60% for the lower extremities. CONCLUSIONS: FA values from within the cerebral peduncle more accurately predicted motor outcome and is a promising technique for clinical application.

Diffusion tensor imaging of idiopathic normal pressure hydrocephalus: a voxel-based fractional anisotropy study.

Diffusion tensor imaging (DTI) using a 3.0 tesla magnetic resonance scanner was used to investigate white matter changes caused by idiopathic normal pressure hydrocephalus (INPH) in 10 patients diagnosed by clinical symptoms (gait disturbance, dementia, and/or urinary incontinence) and Evans index >0.3, and compared with findings for 10 age-matched controls (≥60 years). Then, using a computer-automated method, fractional anisotropy (FA) brain maps were generated and finally transformed into the standard space. Voxel-based FA values within two regions of interests (ROIs), the forceps minor and corticospinal tracts, were then separately evaluated. Within each ROI, statistical comparisons of results from the INPH and control groups were performed. In addition, for INPH patients, grading scores for clinical symptoms and FA values were correlated. The forceps minor mean FA value was much smaller for the INPH group (0.504) than for the control group (0.631). The corticospinal tract mean FA value was slightly smaller for the INPH group (0.588) than for the control group (0.632). Additional analyses indicated that lower FA values within the forceps minor tended to be associated with clinical symptoms such as urinary incontinence and gait disturbance. Our findings indicate FA values decreased in the forceps minor of INPH patients. We also found that lower values were associated with severer clinical symptoms, implying that DTI techniques may be developed for more accurate diagnosis.

Motor outcome for patients with acute intracerebral hemorrhage predicted using diffusion tensor imaging: an application of ordinal logistic modeling.

This study examined the clinical usefulness of magnetic resonance-diffusion tensor imaging (DTI) for predicting motor outcome in patients with intracerebral hemorrhage. We studied 15 subjects (age range, 31-81 years) diagnosed by conventional computed tomography with thalamic hemorrhage, putaminal hemorrhage, or both. DTI data were obtained on days 14-18 after diagnosis. Mean fractional anisotropy (FA) values within the right and left cerebral peduncles were estimated by a computer-automated method. Using logistic regression analyses, the ratios of FA values in the affected and unaffected hemispheres (rFA) were modeled in relation to motor outcome scores at 1 month after onset, assessed using the Medical Research Council (MRC) scale (0 = null to 5 = full). The rFA values ranged from 0.628 to 1.001 (median value, 0.856). Analyses showed that the relationships between rFA and MRC scale matched the logistic probabilities for both the upper extremities (R(2) = 0.272; P < .001) and lower extremities (R(2) = 0.247; P < .001). When estimated rFA values were <0.7, the estimated probability of an MRC score of 0-1 was close to 80% for the upper extremities and 65% for the lower extremities. Meanwhile, when estimated rFA values were >0.9, the estimated probability of an MRC score of 3-5 was close to 60% for the upper extremities and 80% for the lower extremities. Our data indicate that for patients with intracerebral hemorrhage, DTI is a useful tool for quantitatively predicting motor outcome, suggesting wider clinical applicability of this method for outcome prediction.

Neurenteric cyst of the lower clivus.

OBJECTIVE: Neurenteric cysts (NCs) typically arise as benign ventral intradural extramedullary developmental malformations of the spine which contain heterotopic epithelium resembling the intestinal or respiratory tracts. Intracerebral NCs are extremely rare, though the frequency of symptomatic reports and incidental findings is increasing, perhaps because of advances in neuroimaging. Recognition of the unique radiographic and histopathologic features of this entity is of growing importance in the treatment of cysts of the neural axis. We present an unusual case of an NC arising at the lower clivus. CLINICAL PRESENTATION: A 58-year-old man presented with occipitalgia, diplopia, a bilateral hearing deficit, and mild dysphagia. Computed tomography and magnetic resonance imaging demonstrated a 5 x 2 x 3-cm extra-axial cystic midline mass anterior to the brainstem at the lower clivus with posterior cyst wall enhancement. INTERVENTION: The patient underwent a left lateral suboccipital total macroscopic resection of the lesion. Microscopic examination and histopathologic findings were consistent with a diagnosis of NC. CONCLUSION: We describe the clinical presentation, imaging, and histopathologic characteristics, and discuss the diagnosis and surgical treatment of this rare lesion and related pathologic entities. Because of the remote possibility of delayed recurrence, even in cases of apparent total cyst wall removal, long-term serial imaging and a consideration of reoperation for recurrences is advisable.

Development of a quick reference table for setting programmable pressure valves in patients with idiopathic normal pressure hydrocephalus.

Quick and reliable setting of programmable pressure valves (PPVs) is important in the treatment of idiopathic normal pressure hydrocephalus (iNPH), especially for reducing overdrainage complications and related medical costs. A new quick reference table (QRT) was developed for improved PPV control and outcome. Shunt control can be based on the pressure environment in the sitting condition, given as hydrostatic pressure (HP) = intracranial pressure + PPV setting + intraabdominal pressure (IAP). Using this relationship, and estimating HP and IAP from the patient's height and body mass index, respectively, a QRT was designed, consisting of a matrix of the patient's height and weight. The QRT was used to make initial PPV settings in 25 patients with iNPH and the clinical outcomes were evaluated. Postoperative readjustments of the PPV were not necessary in 15 of the 25 patients. At 1 month after operation, the PPV setting was decreased once in 5 patients and increased once in 2 patients. Four of these 7 patients improved after a single readjustment. Three patients required further readjustments. At 3 months after operation, another 3 patients required a single readjustment and all improved after this readjustment. The readjustment rate was 40% and readjustment number was 0.68 times/patient. The mean PPV setting at 1 year after operation was 15.5 +/- 3.9 cmH(2)O. Use of the QRT in non-bedridden iNPH patients results in a low incidence of PPV readjustment.

Spontaneous epidural pneumocephalus.

A 20-year-old male presented with an extremely rare spontaneous epidural pneumocephalus which was successfully treated by a single neurosurgical intervention. The patient had a habit of nose blowing and a 1-year history of progressive headache and nausea. Cranial computed tomography (CT) revealed a 2 x 7 cm right temporo-occipital epidural pneumocephalus with extensive hyperpneumatization of the mastoid cells. Right temporo-occipital craniotomy with a right superficial temporal artery and vein flap repair resulted in radiographic resolution of the pneumocephalus, and he remained neurologically free of symptoms at 1-year follow-up examination. Early identification and monitoring of symptomatic pneumocephalus followed by decompression and prevention of infection via closure of the bone defect can avoid possible serious consequences. The underlying mechanisms may involve a congenital petrous bone defect and a ball-valve effect due to excessive nose blowing in our case.

Development of a new irrigation sucker for microneurosurgery--technical note.

A new irrigation sucker (Delta Irrigation Sucker) was designed for microneurosurgery. The Delta Irrigation Sucker has a unique trigonal pyramid-shape thumb piece, providing a very stable grip. Irrigation is achieved easily by pushing a small button just behind the pressure-regulating pore. Stable hold of the sucker and easy handling of the irrigation button enable irrigation without unsteadiness of the sucker. The Delta Irrigation Sucker is available in six sizes, with diameters from 1.5 mm to 4.0 mm at 0.5 mm intervals. Irrigation force is provided by a pressure bag, and a normal sterile transfusion set can be used as the irrigation circuit. The Delta Irrigation Sucker was used in 20 cases of clipping for ruptured cerebral aneurysm, five cases of tumor resection, and three cases of anterior clinoidectomy and opening of the internal auditory meatus. Subarachnoid clot was easily removed and the bleeding points were easily confirmed. Irrigation, controlled by natural finger movement, did not cause unsteadiness of the sucker.