Clinical Neurology and Neurosurgery - Articles in Press

CSF dynamics analysis in patients with post-traumatic ventriculomegaly - Corrected Proof

2012-05-17

Abstract: Objective: The management of post-traumatic ventriculomegaly (PTV) is controversial. This is due to the difficulty to determine whether PTV is related to an atrophic process or to a true “active” hydrocephalus. The purpose of this study is to analyze the CSF-dynamics in patients with PTV and, possibly, to identify parameters that correlate with prognosis.Methods: 15 patients with PTV were treated following this protocol: 1-frontal ventriculostomy (with Rickham reservoir); 2-CSF-dynamics evaluation; 3-ventriculo-peritoneal shunt. CSF dynamics evaluation was based on an intraventricular infusion test (performed three to five days after ventriculostomy). Outflow Resistance (R-out) and Intracranial Elastance Index (EI, i.e. the reciprocal of intracranial compliance) were calculated. Patients were classified according to response to shunt into: 1-fast responders: rapid clinical improvement, i.e. within days/one month from surgery; 2-slow responders: patients presenting little clinical improvement occurring after months (despite neurorehabilitation); 3-non responders: no clinical improvement.Results: Seven patients (46.7%) were classified as fast-responders, three patients were classified as slow-responders (20%) and five patients were classified as non-responders (33.3%). Opening CSF pressure was less than 15mmHg for all patients. R-out (cut-off >10mmHg/ml/min) had 100% sensitivity, 50% specificity, 100% negative predictive value and 63.6% positive predictive value. EI (cut-off value >0.3) had 100% specificity, 42.4% sensitivity, 100% positive predictive value and 66.7% negative predictive value.Conclusions: Based on these considerations, we can suggest that, for patients with normal pressure PTV, analysis of CSF dynamics could be of help in selecting patients for CSF-shunt. A combination of Intracranial Elastance and of R-out could help predicting shunt responsiveness.

Gamma knife radiosurgery for skull base malignancies - Corrected Proof

Jian Pan, A-Li Liu, Zhong-Cheng Wang — 2012-05-14

Abstract: Background: Skull base malignancies are problematic. We evaluated the efficacy and toxicity of gamma knife radiosurgery (GKRS) in the treatment of patients with primary and secondary malignancies in the skull base.Methods: The data of 43 patients were retrospectively analyzed. Sixteen of these patients had a primary skull base malignancy, and 27 patients had skull base metastasis or an invasion from other cancers. The median tumor volume was 7.2cm3 (range, 0.6–33.4). The median prescription margin dose was 14.0Gy (range, 10–16). Nine patients with tumor regrowth after initial reduction received another treatment.Results: The median follow-up time was 14 months (range, 1–60). Following GKRS, the progression-free survival was 89% and 62% at 1 and 2 years, respectively, and the overall survival rate was 74% and 45% at 1 and 2 years, respectively. Nineteen (44%) patients reported an improvement following GKRS. One patient (2%) reported decreased vision, which was considered to be a side effect from cumulative GKRS doses.Conclusion: Gamma knife radiosurgery is an effective treatment for primary and secondary malignant tumors in the skull base as initial monotherapy or as an adjunct therapy to surgery or radiotherapy.

Thoracic sensory level as a false localizing sign in cervical spinal cord and brain lesions - Corrected Proof

Mark A. Hellmann, Ruth Djaldetti, Judith Luckman, Ron Dabby — 2012-05-10

Abstract: Background: In rare cases of cervical myelopathy, there may be a discrepancy between the sensory level and the site of cord lesion. This phenomenon is not well recognized. This study sought to investigate the characteristics of patients presenting with a false localizing thoracic sensory level.Methods: The databases of the neurology clinics of two major tertiary medical centers were reviewed for all patients who presented in 2000–2010 with a main complaint of paraparesis and a thoracic sensory level. Those whose initial thoracic magnetic resonance scan showed no spinal cord pathology were included in the study.Results: Twelve patients (mean age, 52±31 years) met the study criteria. In all cases, the pathological lesion was visualized on magnetic resonance imaging of the cervical spine or brain. Eight patients had a compressive lesion of the spinal cord and 4 had demyelinating lesions. The difference between the false localizing sensory level and the level of the cervical lesion ranged from 6 to 11 segments.Conclusion: Patients with a sensory thoracic level and normal findings on thoracic magnetic resonance imaging should be further evaluated with cervical spinal cord and, sometimes, brain imaging to search for potentially treatable lesions.

A rare case of POEMS syndrome initially presenting with trigeminal neuralgia - Corrected Proof

Xiaofei Zhang, Kangning Chen, Shugui Shi, Zhaohong Liu, Yanqing Jin, Jun Hu — 2012-05-07

POEMS syndrome is a multisystem complication of plasma cell dyscrasia originally characterized by the presence of polyneuropathy, organomegaly, endocrinopathy, monoclonal or M-protein and skin changes. Although almost all cases show polyneuropathy during the course of the disease, the cranial nerve pairs are spared, and cases initially presenting with cranial nerve damage are seldom reported. Herein, we report a unique case of POEMS syndrome initially presenting with trigeminal neuralgia symptoms. To our knowledge, this is the first report of such a case.

Association between common genetic variants of α2A-, α2B-, and α2C-adrenergic receptors and ischemic stroke - Corrected Proof

2012-05-07

Abstract: Background: The alpha2-adrenergic receptor (α2-AR) mediates physiological responses to endogenous catecholamine, and genetic variants of α2-AR may predispose to clinical vascular diseases. We evaluated whether common genetic variants of each three subtype of alpha2-adrenergic receptor (ADRA2A, ADRA2B, and ADRA2C) were associated with ischemic stroke.Methods: A total of 616 patients with ischemic stroke and 512 controls were genotyped for the ADRA2A 1780G>A, ADRA2B 301–303 I/D, and ADRA2C 322–325 I/D polymorphisms. Logistic regression analyses, adjusting for multiple comparisons, were used to determine the association between the minor allele of each of three ADRA2 genes and the risk of ischemic stroke and pathophysiological subtypes.Results: The ADRA2B 301–303 D allele was more prevalent in the stroke group, compared to controls (DD vs. II, OR: 1.78, 95% CI: 1.18–2.69; recessive, OR: 1.55, 95% CI: 1.06–2.26). A subgroup analysis revealed that this association was found only in the small vessel diseases (SVD) type (DD vs. II, OR: 1.92, 95% CI: 1.11–3.33). The ADRA2A and ADRA2C polymorphisms did not contribute to an increased risk of ischemic stroke or any pathophysiological subtype.Conclusions: The ADRA2B 301–303 D allele confers an increased risk of overall ischemic stroke and SVD subtype.

A second case of isolated gait apraxia from an acute unilateral parasagittal lesion - Corrected Proof

Matthew S. Robbins, Joe Verghese, Daniel Antoniello — 2012-05-07

We reported a novel patient who experienced the acute onset of gait apraxia (GA) from a unilateral parasagittal lesion affecting the supplementary motor area . We recently encountered a second case of sudden onset GA, but with a different clinical semiology, neuroradiographic abnormality, and etiology.

Levofloxacin neurotoxicity and non-convulsive status epilepticus (NCSE): A case report - Corrected Proof

Debora Mazzei, Jennifer Accardo, Alessandra Ferrari, Alberto Primavera — 2012-05-01

Levofloxacin is a third generation fluorinated quinolone antibiotic with a broad spectrum of antibacterial activity. It is generally well tolerated, with a very low rate of clinically important neurological adverse events. Fluoroquinolone-associated neurotoxicity may manifest as seizures, delirium or encephalopathy. Here we describe the first case of levofloxacin-induced NCSE in a woman without history of neurological diseases.

Acquired hepatocerebral degeneration with middle cerebellar peduncles lesions: Case report and review of the literature - Corrected Proof

Kazuhiro Ishii, Ayako Shioya, Kuniaki Fukuda, Kensaku Mori, Akira Tamaoka — 2012-05-01

Acquired hepatocerebral degeneration (AHD) is a progressive neurological syndrome characterized by parkinsonism, ataxia, and other movement disorders caused by various progressive liver diseases, especially those characterized by portosystemic shunt . Cerebellar symptoms such as pathological cerebellar changes are observed in some patients with AHD; however, cerebellar lesions, especially in the middle cerebellar peduncles (MCP), are rarely observed on brain MR imaging . We found MCP lesions in an AHD patient whose cerebellar symptoms completely disappeared and whose MCP lesions reduced after balloon-occluded retrograde transveneous obliteration (BRTO) for the portosystemic shunt. We successfully followed the chronological changes of these lesions in response to the treatment.

An unusual focal leg dystonia in descending stairs responsive to anticonvulsants – A comment - Corrected Proof

Christina Karosin, Markus Kofler, Leopold Saltuari — 2012-05-01

With great interest we read the recent case report by Yamamoto et al. about task-specific focal dystonia which responded well to low doses of antiepileptic drugs (AEDs). This 36-year-old woman presented with dystonia in her right foot, which appeared only while descending stairs facing forward, and not when walking flat over ground, ascending stairs, or descending stairs backwards. Clinical examination was otherwise unremarkable. The only abnormality was found on [18F]fluoro-2-deoxy-d-glucose (18F-FDG) positron emission tomography (PET) of the brain, which showed hypoperfusion of the left putamen and thalamus compared to the contralateral side. Carbamazepine ameliorated the symptoms but had to be replaced by clonazepam due to adverse effects (skin rash, leukopenia, thrombopenia) . The authors suggested that their patient might have presented with a subtype of paroxysmal kinesigenic dyskinesia (PKD), which is induced by sudden movements or startles and responds well to low doses of AEDs .

Reply: Idiopathic hypertrophic pachymeningitis mimicking neurosarcoidosis - Corrected Proof

2012-05-01

We read with great interest the article by Christakis et al. . The authors reported an interesting case with multiple cranial neuropathies who underwent extensive evaluation consistent with neurosarcoidosis, but whose dural biopsy revealed idiopathic hypertrophic pachymeningitis (IHP). However, we raise some questions regarding the interpretation of their data.

Occurrence and recurrence of spontaneous chronic subdural haematoma is associated with a factor XIII deficiency - Corrected Proof

2012-04-30

Abstract: Objective: In some patients, chronic subdural haematoma (cSDH) appears to occur spontaneously with frequent re-bleeding events. The pathophysiology of this phenomenon is still poorly understood. Because coagulation factor XIII (FXIII) is known to be involved in vascular integrity, endothelial barrier function and wound healing, we evaluated the role of FXIII in spontaneous cSDH.Methods: We prospectively scrutinised the origin of cSDH in 117 patients and identified a subgroup of patients suffering from spontaneous cSDH who were included in this study. We analysed the plasma activity of FXIII and standard coagulation parameters and compared these data to age- and sex-matched healthy controls. We assessed the occurrence of re-bleeding events using clinical and imaging data and compared FXIII activity in patients with and without re-bleeding events.Results: Out of 117 cSDH patients, 18 individuals suffered from spontaneous cSDH in this study. The patients with spontaneous cSDH showed significantly lower FXIII activity than the control group (65% [52.75, 80.25] (median [IQR]) vs. 93% [81, 111], P=0.001), whereas standard coagulation parameters did not differ significantly between the groups. Six patients developed re-bleeding events after haematoma evacuation, and these patients expressed significantly lower FXIII activity compared to the other 12 patients (47.5% [33.5, 64] vs. 78.5% [58, 87], P=0.005). The patient group with FXIII≤68.5% differed significantly from the group with FXIII>68.5% when categorised by the occurrence of re-bleeding events (n=6/9 vs. n=0/9, P=0.009). This cut-off value predicted the re-bleeding events with a sensitivity of 100% and a specificity of 75% (positive predictive value: 66%, negative predictive value: 100%).Conclusion: FXIII deficiency may play a pathophysiological role in spontaneous cSDH, so we suggest investigating FXIII activity because it may predict re-bleeding events after treatment. In individuals with considerably low FXIII activity, FXIII substitution may mitigate the chronic nature of this disease.

Anti-glutamate receptor δ2 antibody-positive migrating focal encephalitis - Corrected Proof

2012-04-27

In recent years, increasing attention has been given to acute and subacute encephalitis related to glutamate receptors (GluR). GluRs are involved in excitatory neurotransmission on cell membrane surfaces of the spinous processes in dendrites of mammalian central nervous systems. Abnormal activity of GluR channels is thought to contribute to the neuronal death observed in acute and chronic encephalitis. GluRs have two types: ionotropic and metabotropic (). Ionotropic GluRs are classified pharmacologically as N-methyl-d-aspartate (NMDA)-type, non-NMDA-type (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid {AMPA}-type, kainate-type), and δ-type with unknown ligands. NMDA-type GluR ɛ2 antibody is frequently found in acute limbic encephalitis or widespread encephalitis . Moreover, NMDA receptor-related encephalitis is well known to be associated with ovarian teratoma. Much remains unknown regarding the pharmacological properties of the GluR δ2 subunit that is localized in the forebrain after birth, but it is known to be selectively expressed in cerebellar Purkinje cells.

Association of mesial temporal sclerosis and moyamoya syndrome - Corrected Proof

Bradley A. Gross, Alexander E. Ropper, Rose Du — 2012-04-27

The moyamoya phenomenon is a progressive intracranial arteriopathy with concomitant formation of fragile collateral vessels, leading to ischemic and hemorrhagic events . Moyamoya disease specifically refers to idiopathic, bilateral disease. Unilateral idiopathic disease or arteriopathy in association with known medical conditions is termed moyamoya syndrome . Moyamoya syndrome has been associated with a history of cranial radiation, neurofibromatosis, Down syndrome, sickle cell disease, congenital cardiac anomalies, renal artery stenosis, and hyperthyroidism . To our knowledge, the association of moyamoya syndrome and mesial temporal sclerosis has not been well-reported.

Pleural effusion accumulating in the epidural space: Recurrent cord compression in a patient with progressive lung adenocarcinoma - Corrected Proof

Russell G. Strom, Stephen P. Kalhorn, Stephen M. Russell, Paul P. Huang — 2012-04-26

Pleural effusions are common in patients with advanced carcinoma, particularly of the lung and breast. While the spinal column lies adjacent to the pleura, to our knowledge there is no reported case of a pleural effusion causing cord compression. The epidural space is normally isolated from the pleural space by the parietal pleura, spinal column, ribs, and associated soft tissue.

Opinion survey of health care providers towards psychogenic non epileptic seizures - Corrected Proof

Kinshuk Sahaya, Swapan A. Dholakia, David Lardizabal, Pradeep K. Sahota — 2012-04-26

Abstract: Objectives: Psychogenic non epileptic seizures (PNES) are challenging conditions to diagnose and manage. Previous workers have investigated the opinion of health care providers towards PNES; still several lacunae remain to be stressed. Amongst health care professionals, opinion of nurses has not been adequately explored. We attempted to identify areas which need more emphasis to provide optimal care to the patients.Patients and methods: We approached 417 health care providers (HCP; primary care, neurology and in-patient nurses) with a questionnaire regarding their opinion of PNES.Results: Total 115 respondents responded to our survey. We found one-thirds of respondent favoured “non-epileptic seizure” as the preferred diagnostic term. Although majority (61%) of responders felt that PNES were involuntary, 48% of nurses felt that PNES are ‘fake’ and patients have voluntary control over them. Neurologists and nurses expressed high level of confidence in managing patients of PNES. About 1/3rd (35%) of responders did not feel video EEG (vEEG) to be always required for the diagnosis of PNES. Only a minority (15%) of healthcare providers favor unrestricted driving by patients of PNES in setting of ongoing seizures.Conclusion: Our findings highlight areas where more emphasis needs to be placed regarding PNES amongst HCPs. More emphasis needs to be placed on the involuntary nature of these episodes within the HCP community. It might be necessary to more strongly address the education of nurses and residents for this condition.

Facial nerve dysfunction after drainage of cerebrospinal fluid during vestibular schwannoma surgery - Corrected Proof

Tetsuya Hiraishi, Masafumi Fukuda, Makoto Oishi, Yukihiko Fujii — 2012-04-26

During vestibular schwannoma (VS) surgery, compound muscle action potentials (CMAP), continuous electromyography (EMG), and EMG evoked by continuous direct electrical stimulation of the facial nerve are useful as intraoperative monitoring and have increased the preservation of facial nerve function . Recently, facial motor evoked potentials (FMEPs) elicited by transcranial electrical stimulation have been used for facial nerve evaluation and monitoring during skull base surgery . We have also demonstrated that FMEP monitoring allows evaluation of ongoing facial nerve function and prediction of facial nerve outcome . Herein, we describe a VS patient in whom FMEP decreased after cerebrospinal fluid (CSF) drainage despite manipulation of neither the tumour itself nor the facial nerve.

The influence of surgery on recurrence pattern of glioblastoma - Corrected Proof

2012-04-26

Abstract: Objectives: Glioblastoma recurs within 2cm from the primary tumor's margins in 90–95% of cases. Natural history of recurrence is not well defined. The aim of this study was to verify if pattern of recurrence can be influenced by the extent of surgery.Patients and methods: 131 patients with glioblastoma underwent tumor removal, followed by standard adjuvant radio-chemotherapy. Depending on the amount of apparently normal white matter measured around the tumor in the surgical specimen, the extent of surgery was classified into: “border resection” (BR, resection margins at the level of tumor border) or “extended resection” (ER, resection margins 1–2cm far from tumor border). 88 patients had no residual tumor at post-operative MRI. Among these, 60 patients had a local recurrence (LR) – within 2cm from the primary tumor's margins, 15 patients had a distant recurrence (DR), 13 patients had no recurrence. Survival curves were obtained through the Kaplan–Meier method. Dichotomous data were compared with the chi-square test.Results: Patients who underwent ER presented a LR in 67% of cases. Patients who underwent BR presented a LR in 87.5% of cases (p=0.03). Survival for 60 patients with LR was 16 months vs 35 months for 15 patients with DR (p=0.06). PFS for patients with LR was 9 months vs 21 months for patients with DR (p=0.05).Conclusions: If tumor grows far from eloquent areas, ER may increase the probability to obtain a gross total resection, a greater number of patients with DR and, therefore, a longer survival.

CSF containing cystic lesion of the clivus—Case report and review of the literature - Corrected Proof

2012-04-25

Lesions of the clivus include meningiomas, chordomas, metastatic lesions, chondrosarkomas, teratoma and pituitary adenomas. Cystic lesions of the clivus however are mainly chordomas or immature teratomas. Only some cases of meningoceles, metastases and pituitary adenomas presenting as cystic lesions of the clivus have been described . We discuss the case of an extended CSF containing cystic lesion of the clivus.

Leptomeningeal carcinomatosis: Prognostic value of clinical, cerebrospinal fluid, and neuroimaging features - Corrected Proof

2012-04-25

Abstract: Introduction: Leptomeningeal carcinomatosis (LC) is a devastating complication occurring in 5% of all patients with cancer. To date there are no well-established prognostic markers in patients with LC, except for the presence of cerebrospinal fluid (CSF) blocks and the Karnofsky performance status scale (KPS). We aimed to identify clinical, neuroradiologic and CSF prognostic factors related to LC survival and to develop an easy-to-use Prognostic Scoring Scale (PSS) to identify patients who are more likely to benefit from receiving treatment.Methods: Single-center retrospective study evaluating patients who had a diagnosis of LC during a 10-year period. Diagnosis was made by malignant cytology or imaging; suspicious cases treated as LC were also included.Results: Fifty patients with LC were analyzed (58% women). Median age was 54.4 years, and KPS was 60%. The most common types of tumor were breast (35%), lung (24%), and hematologic malignancies (16%). Thirty-two percent of patients were diagnosed by imaging, 22% by cytology, and 40% by both. Median overall survival (OS) was 10 weeks (95% confidence interval 5.1–14.9). Median OS for patients who received specific treatment was 21.2 weeks vs. 6.38 weeks for patients receiving supportive care only (p<0.001). In multivariate analysis, initial KPS, initial CSF protein level (<112mg/dL) and time from diagnosis of primary tumor to diagnosis of LC (>67 weeks) were significant and independent predictors of increased survival.Conclusions: Prognosis remains poor in LC. The predictive factors for patients with LC here identified could help to improve the selection of patients who are more likely to benefit from receiving treatment.

Coexistence of transthyretin familial amyloid polyneuropathy and hereditary neuropathy with liability to pressure palsy - Corrected Proof

Isabel Conceição, Hipólito Nzwalo, Mamede de Carvalho — 2012-04-23

Transthyretin familial amyloid polyneuropathy (TTR-FAP) and hereditary neuropathy with liability to pressure palsy (HNPP) are two rare autosomal dominant neuropathies. TTR-FAP is the most common inherited amyloidotic polyneuropathy, which presents as a progressive, sensori-motor and autonomic, length-dependent neuropathy that ultimately leads to death 9–11 years after disease onset . Liver transplantation suppresses the main source of the mutated-TTR production, halting disease progression . HNPP is caused by a peripheral myelin protein (PMP22) gene deletion in chromosome 17p11.2. This condition is clinically characterized by recurrent episodes of painless focal mononeuropathies, often with an underlying progressive sensori-motor neuropathy . Currently, there is no effective treatment to HNPP, but appropriate management is essential to decrease the risks of repeated episodes.We report a single patient affected by both HNPP and TTR-FAP in whom the diagnosis was challenging due to overlapping clinical features.

Imaging in young adults with intracerebral hemorrhage - Corrected Proof

Matthew A. Kirkman, Pippa J. Tyrrell, Andrew T. King, Hiren C. Patel — 2012-04-23

Abstract: Objective: Vascular malformations are a common yet treatable cause of intracerebral hemorrhage (ICH) in the young. The goal of this study was to review the implementation of appropriate secondary angiographic/venographic imaging to identify vascular malformations in young adults with ICH at our specialist neuroscience center.Methods: A retrospective analysis was undertaken of five years of prospectively recorded referral data to the on-call neurosurgery service at the Greater Manchester Neuroscience Centre.Results: The authors identified 111 ICH patients aged 18–40 over the five-year period, with a wide etiologic spectrum. When assessing the implementation of secondary imaging, they focused on 90 individuals, incorporating those without an identifiable precipitant for their ICH and those with recent recreational drug use and hypertension. Of these 90, 52 (58%) were admitted to the neuroscience center for further management; when excluding three with bilateral fixed and dilated pupils, the remaining 49 all underwent appropriate secondary imaging. Of the 38 subjects not accepted to the neuroscience center, 13 (34%) had bilateral fixed and dilated pupils, 10 (26%) underwent appropriate secondary imaging, and 15 did not – all but two of these 15 were referred outside of normal working hours. The positive yield from secondary imaging was 63%.Conclusion: Young adults with ICH are more likely to get appropriate imaging to identify vascular malformations in a specialist neuroscience center compared to a non-specialist center. Out of hours care appears to be a significant contributor to this shortfall. This study suggests a need for service redevelopment and specialist neuroscience center input for all cases of young ICH.

Bilateral fornix injury due to cerebral infarct and traumatic intraventricular hemorrhage: A case study - Corrected Proof

Hyeok Gyu Kwon, Sung Ho Jang — 2012-04-23

The fornix is an important structure of the Papez circuit and carries information on episodic memory between the mamillary body and the medial temporal lobe . Assessment of the fornix is difficult due to its anatomical characteristics of a long and thin neural tract located in the deep portion of the brain. In addition, some portions of the fornix cannot be discriminated from adjacent structures on conventional brain MRI. Recently developed diffusion tensor tractography (DTT), which is derived from diffusion tensor imaging (DTI), allows for three-dimensional visualization of the fornix. DTT is now used in demonstration of fornix injury in various diseases, including traumatic brain injury, cerebral infarct, schizophrenia, or brain tumor .

Intra-luminal stent navigation for embolization of cerebral aneurysms with marked angular acuity of incorporated branch vasculature - Corrected Proof

Ajeet Gordhan — 2012-04-20

Neuroform stent parent vessel reconstruction has significantly advanced the endovascular management of wide neck cerebral aneurysms. Delivery of the rigid stent system across the neck in complex configuration aneurysms by conventional methods is not possible, if marked angularity between the parent vessel and efferent incorporated branch vessel is present. We present two such cases in which safe intra-aneurismal passage of the stent delivery system was achieved for subsequent coil embolization. This potentially has a high risk for aneurysm perforation and needs to be carefully considered against the benefit.

Intraosseous lipoma of the skull base, involving the sphenoclival region: Case report - Corrected Proof

2012-04-20

Around 13% of the lipomas arise in the head and neck regions, nevertheless intracranial lipomas represent only 0.34–0.46% of all brain tumors ; intraosseous lipomas of the skull are even more rare and there are only few cases reported in the main literature , of which only two involving the clivus and the sphenoid bone body, so far . Usually these lesions are asymptomatic so that are disclosed as incidental findings on imaging studies, especially MRI. These lesions do not present any specific signal characteristics so that radiological appearance could be misleading and several differential diagnoses should be taken into account.

High-dose methotrexate and temozolomide associated with intrathecal liposomal cytarabine for the treatment of primary or secondary central nervous system lymphoma: A preliminary experience - Corrected Proof

Lorenzo Falchi, Marco Gunnellini, Lucia Ferranti, Anna Marina Liberati — 2012-04-20

Treatment of central nervous system (CNS) lymphoma remains a challenge for clinicians. Historically, whole-brain radiotherapy (WBRT) has been the cornerstone of treatment for brain lymphomas. However, after initial response, virtually all patients relapsed within short periods of time. The addition of systemic cytotoxic chemotherapy has significantly improved the outcome of CNS lymphoma patients, but is often burdened with severe acute and/or delayed neurotoxicity. Particularly in the over-60 population. Moreover, deferring radiotherapy to the time of relapse may reduce or postpone the risk of severe neurotoxicity, without apparent detrimental effect on overall survival (OS). Finally, a recent randomized trial suggested that there may not be an OS benefit from the addition of radiation to systemic cytotoxic therapy .

Glioblastoma research 2006–2010: Pattern of citation and systematic review of highly cited articles - Corrected Proof

Carsten Nieder, Sabrina T. Astner, Anca L. Grosu — 2012-04-20

Abstract: High and continuously increasing research activity related to different aspects of pathogenesis, epidemiology, diagnosis and treatment of glioblastoma has been performed between 2006 and 2010. Different measures of impact, visibility and quality of published research are available, each with its own pros and cons. For this review, article citation rate was chosen. Articles were identified through systematic search of the abstract database PubMed followed by analyses of total number of citations and proportion of highly cited articles, arbitrarily defined as those with ≥100, 50–99, and 25–49 citations, respectively (citation database Scopus). Overall 5831 scientific articles on the subject were published during this time period. 1.5% of all articles accumulated at least 100 citations, 3.2% were cited between 50 and 99 times, and 7.5% were cited between 25 and 49 times. Among the 10 most cited articles, 7 reported on genomic analyses, molecular subclasses of glioblastoma and/or stem cells. Overall, 18 randomized clinical trials were published between 2006 and 2010, including those with phase II design. Thirty-nine percent of them accumulated at least 50 citations and 72% were cited at least 25 times. In general, annual citation rate appeared to gradually increase during the first 2–3 years after publication before reaching high levels. A large variety of preclinical and clinical topics achieved at least 25 citations. However, areas such as quality of life, side effects, and end-of-life care were underrepresented. Efforts to increase their visibility might be warranted.

Association of HLA-DR/DQ polymorphism with myasthenia gravis in Tunisian patients - Corrected Proof

Najiba Fekih-Mrissa, Sarra Klai, Jamel Zaouali, Nasreddine Gritli, Ridha Mrissa — 2012-04-20

Abstract: Background and objective: Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction. MG has been shown to be associated with many human leukocyte antigens (HLA) in different populations. The aim of this study was to investigate the probable association between HLA-DR/DQ alleles and MG in Tunisian patients.Patients and methods: HLA DR/DQ genotyping was performed using polymerase chain reaction sequence-specific primers (PCR-SSP) with 48 MG patients and 100 healthy individuals serving as the control group.Results: Myasthenia gravis in Tunisian patients was found to be associated with the following alleles (pc denotes Bonferroni corrected probability values): HLA-DRB1*03 (pc<10−3), DRB1*04 (pc=0.005), DQB1*02 (pc=0.002) and, DQB1*03 (pc=0.007).Conclusion: Our data demonstrated a new HLA-MG predisposition with DRB1*04. The DRB1*03, DRB1*04, DQB1*02, and DQB1*03 alleles also could be predisposing genetic factors for MG in the Tunisian population.

Transient Tournay's pupillary phenomenon in a patient with a vertebrobasilar TIA - Corrected Proof

Judith van Vliet, Wim I.M. Verhagen, Aad Verrips — 2012-04-19

The occurrence of anisocoria during lateral gaze was first described in 1907 by Gianelli and later by Tournay . It was called Tournay's pupillary phenomenon (TPP). During lateral gaze, the pupil of the abducted eye becomes larger than the pupil of the adducted eye. It is considered a rare but physiological phenomenon without clinical significance, which is usually present bilaterally and long-lasting . Here, we describe a case with a vertebrobasilar TIA, who showed temporary TPP simultaneously with other vertebrobasilar signs, that all disappeared within 12h. This is the first case in which TPP is transient and considered to be pathologic. We speculate about possible mechanisms for this intriguing sign.

Anti-cholinergics for axial symptoms in Parkinson's disease after subthalamic stimulation - Corrected Proof

2012-04-19

Abstract: Objective: We studied the effect of anti-cholinergic therapy on axial symptoms that show a tendency to worsen over time after deep brain stimulation of the subthalamic nucleus (STN-DBS) in patients with Parkinson's disease (PD).Patients and methods: We conducted a prospective study of 20 consecutive patients treated with the anti-cholinergic agent trihexyphenidyl after bilateral STN-DBS and assessed the effect of anti-cholinergic therapy on parkinsonism 1 month after its initiation using the Unified Parkinson's Disease Rating Scale (UPDRS).Results: After a mean post-operative follow-up period of 22.3 months, the scores of axial symptoms on UPDRS part II (ADL score) and part III (motor score) deteriorated by 87% and 54% (baseline), respectively, compared with the pre-operative scores (P<0.001 for both comparisons). After adding trihexyphenidyl to dopaminergic medication with stimulation, the scores of axial symptoms on UPDRS part II and part III improved from baseline by 33% and 39%, respectively (P<0.001 for both comparisons).Conclusions: Our findings demonstrated that the anti-cholinergic agent trihexyphenidyl shows positive effect for a patient population developing deterioration of axial symptoms after STN-DBS. The results in the present study may provide insights into the mechanism of emergence or progression of axial symptoms in patients with PD after STN-DBS.

Acute bilateral medial medullary infarct with hypoplastic vertebral artery - Corrected Proof

Mei-Ling Sharon Tai, Elliyyn Katiman, Kartini Rahmat, Chong Tin Tan — 2012-04-18

Medial medullary infarct (MMI) or Dejerine Syndrome presents as ipsilateral hypoglossal nerve palsy, contralateral hemiparesis with facial sparing and contralateral loss of deep sensation . Bilateral MMI is relatively uncommon. We would like to present a patient with bilateral MMI and hypoplastic left vertebral artery.

Cerebral ganglioneuroblastoma of adult onset: Two patients and a review of the literature - Corrected Proof

2012-04-17

Abstract: Ganglioneuroblastoma is a rare tumor variant of neuroblastoma. Only five cases have been observed in the adult brain, and we report here on two more adult patients with cerebral ganglioneuroblastoma. Additionally, a review was carried out on all 50 published adult cases with ganglioneuroblastoma, located in the adrenal gland (9), mediastinum (8), retroperitoneal area (7), the brain parenchyma (7), or the spinal cord (3). Median age at onset was 39 years, and 52% of patients were female. For extracranial locations, treatment usually consisted of surgery followed by radiotherapy and adjuvant chemotherapy. Of the cases with cerebral involvement only one patient did not receive any treatment. The other six patients underwent surgical resection and radiation therapy, in four cases followed by chemotherapy with temozolomide. The median survival of cerebral ganglioneuroblastomas was 14 months and did not differ from the whole group of ganglioneuroblastomas (12 months). For cerebral ganglioneuroblastoma, the preferred regimen would seem to be neurosurgical removal, followed by chemoradiotherapy including temozolomide.

Treatment of a large and symptomatic septum pellicidum cyst with endoscopic fenestration in a child—Case report and review of the literature - Corrected Proof

2012-04-16

Septum pellucidum cysts (SPCs) are seen in 10% of adults and as many as 82% of neonates and are considered a normal variant that usually do not require any surgical treatment . The expansion of SPCs was reported to be as low as 0.04% in a database of a large number of magnetic resonance images (MRIs) . Expanding SPCs may become symptomatic, showing signs and symptoms of raised intracranial pressure and mass effect. Almost 100 cases of symptomatic SPCs have been reported so far in the literature .

Symptomatic orthostatic tremor with progressive cognitive impairment in spinal cord lesions - Corrected Proof

Hye Mi Lee, Do-Young Kwon, Moon Ho Park, Seong-Beom Koh, Se Hoon Kim — 2012-04-16

Orthostatic tremor (OT) is rare clinical condition and mostly idiopathic . In secondary OT, various neuroanatomical regions have been proposed in central nervous systems including brainstem, cerebellum and spinal cord, but the exact pathophysiological mechanisms and symptom correlation of OT have not been fully elucidated . We described a man whose initial symptom was impaired cognitive function and progressive orthostatic leg tremor developed several months later. In this patient, we found compressive spinal mass attributed to his clinical symptoms and immediate after surgical resection of the spinal tumor, both the orthostatic tremor and cognitive dysfunction disappeared. To our knowledge, this is the first report of a compressive spinal mass as a primary focus of complicated OT. Lesions anywhere in the central nervous system can lead to OT and thorough investigation to detect a primary focus is critical in clinical practice in complicated OT patient.

Acute pure motor demyelinating neuropathy with hyperreflexia and anti-GalNAc-GD1a antibodies - Corrected Proof

Jong Kuk Kim, Dae-Seong Kim, Susumu Kusunoki, Sang-Jin Kim, Bong-Goo Yoo — 2012-04-16

There has been a report about acute motor neuropathy with partial conduction block (CB), retained muscle stretch reflexes and positive anti-ganglioside antibodies as a variant of Guillain–Barre syndrome (GBS) . While patients with classical demyelinating GBS invariably show a reflexia, several reports have described some patients with the acute motor axonal neuropathy (AMAN) form of GBS who have hyperreflexia during the acute or early recovery phase, and have suggested a correlation between hyperreflexia and anti-GM1 immunoglobulin (Ig) G antibody. In this report, we describe a patient with acute pure motor demyelinating neuropathy (APMDN) with hyperreflexia and high titers of Ig G anti-GalNAc-GD1a antibody.

Ventriculitis revealing Bing-Neel syndrome in a patient without Waldenstrom's macroglobulinemia - Corrected Proof

2012-04-16

Ventriculitis is a significant finding as it often indicates an underlying disease requiring quick medical attention. With immunocompetent patients, it is mainly due to infections (bacterial, tuberculous ventriculitis), inflammatory diseases (sarcoïdosis) or tumoral process.

FDG PET findings leading to diagnosis of neurosarcoidosis - Corrected Proof

2012-04-16

Sarcoidosis is a multisystemic inflammatory disease of unknown aetiology characterized by the accumulation of non-caseating epithelioid granulomas in involved organs. The most common locations are the lung, the skin and the eye . The nervous system is estimated to be involved in 5–15% . Clinical diagnosis of neurosarcoidosis is often delayed due to its heterogenous manifestations. Cranial neuropathies, basal meningitis, hypophyseal and hypothalamic disorders are common. Spinal cord involvement, radiculopathy, peripheral neuropathy, isolated cauda-equina-syndrome and myopathy can also occur . We present a patient with findings of [18F]-fluorodeoxyglucose (F18-FDG) imaging which were the indication of discovering neurosarcoidosis and of initiating appropriate therapy.

Pontine and extrapontine myolinolysis associated with hypernatraemia - Corrected Proof

2012-04-13

Osmotic myelinolysis is a disorder of unknown etiology often caused by a too rapid correction of hyponatremia. Therefore, in such cases a targeted increase in serum sodium concentration of <12mmol/l/day is generally recommended . Here we present the case of a patient with osmotic myelinolysis in which no correction of hyponatremia but rapid increase of normal serum sodium to severe hypernatremia is the assumed cause of myelinolysis.

Reduced percentage of neurocysticercosis cases among patients with late-onset epilepsy in the new millennium - Corrected Proof

Oscar H. Del Brutto, Victor J. Del Brutto — 2012-04-13

Abstract: Objective: To determine if the number of neurocysticercosis cases among patients with late-onset epilepsy has decreased over the past two decades.Design: Retrospective cohort study of 431 consecutive patients with recurrent seizures starting after the age of 20 years evaluated at our Institution from 1990 to 2009.Methods: Patients were classified according to the year in which they were first seen. Group I included 129 patients evaluated between 1990 and 1994, Group II included 108 patients evaluated between 1995 and 1999, Group III included 106 patients evaluated between 2000 and 2004, and Group IV included 88 patients evaluated between 2005 and 2009. We correlated the percentage of persons with cryptogenic and symptomatic epilepsy between the groups to determine if there was any change in the causes of late-onset epilepsy.Results: One hundred seventy-one patients had cryptogenic and 260 had symptomatic epilepsy. Common causes of symptomatic epilepsy were neurocysticercosis in 120 cases, cerebrovascular disease in 68, and brain tumors in 40. We found a reduction in the number of patients with symptomatic epilepsy (p=0.0007) as well as a reduction in the number of neurocysticercosis cases (p=0.0004) over the study years. There was a reduction in the weight of neurocysticercosis as an etiological factor for symptomatic late-onset epilepsy related to a drop in the number of patients with this condition evaluated between 2005 and 2009 (p=0.0045).Conclusion: The number of neurocysticercosis cases among patients with late-onset epilepsy has changed over the years. This parasitic disease is no longer the most common cause of symptomatic late-onset epilepsy in our population.

Myotonic dystrophy type 2 and multiple sclerosis: Case report - Corrected Proof

Edvard Ehler, Alena Novotná, Miroslav Mareš, Zuzana Mušová, Milan Mrklovský — 2012-04-13

Myotonic dystrophy type 2 (DM2) is an autosomal dominant multisystem disorder that manifests itself as myotonia, weakness, cataracts, impaired testicular function, impaired glucose tolerance, hypogammaglobulinemia, and heart conduction defects. When compared with myotonic dystrophy type 1 (DM1), cerebral symptoms develop much less frequently. These cerebral symptoms include seizures, and the symptoms that occur during attacks of focal (stroke-like) symptoms, parkinsonian symptoms, and hypersomnia. MRI imaging typically shows white matter abnormalities, and SPECT shows areas of hypoperfusion in the frontal and parieto-occipital areas. Compared with DM1, the clinical course of DM2 is less severe. The concurrent development of another brain or spine disorder is rare. To date, we have found only one case report in the literature describing the development of multiple sclerosis (MS) in a 37-year-old man who had been monitored for dystrophic myotonia since the age of 13. In our neuromuscular clinic, a large family with DM2 has been followed. A 31-year-old woman from this family experienced an attack of central symptoms and was subsequently diagnosed with MS.

Prevalence and determinants of depression in Mexican patients with Parkinson's disease - Corrected Proof

2012-04-13

Abstract: Objective: To assess the prevalence and associated factors of depression in a Mexican Parkinson's disease (PD) population.Background: Depressive symptoms are frequent in PD and have been recognized as a major determinant of quality of life. Only two previous studies have partially addressed depression in Mexican PD patients.Methods: One hundred forty-seven non-demented PD patients were recruited at the movement disorder specialist clinic at the National Institute of Neurology and Neurosurgery, Mexico City. The following sociodemographic variables were collected: gender, age, age at onset, disease duration and disease severity in terms of Hoehn and Yahr stage. PDQ-8, NMSQuest and Beck Depression Inventory (BDI) were applied to all participants.Results: One hundred forty-seven patients were included (49.7% female). The mean age of the sample was 62.1±11.7 years, the mean age at diagnosis was 55.8±12.3 and the mean duration of the disease was 6.3±5 years. A total of 49 (33.3%) patients were diagnosed with current depression. Depressed patients also scored higher in the NMSQuest even when depression/anxiety items were excluded. Differences were found in gender, UPDRS III score and HY stage, but after the logistic regression analysis was performed only the NMSQuest score and low education remained as statistically significant factors for depression in Mexican PD patients.Conclusions: Depression prevalence in PD Mexican patients is similar to other international reports. The main associated factor was the presence of non-motor symptoms.

Simultaneous combined single stage removal of immature teratoma at anterior skull base: A case report - Corrected Proof

Rakesh Redhu, Surinder Singhal, Siddharth Rajput, Swetha H — 2012-04-13

Immature teratoma consists of immature and undifferentiated fetal tissues and has a high potential to undergo malignant change. Immature teratoma at anterior skull base with extension into anterior cranial fossa and nasal cavity is a rare entity. Differential diagnosis of tumors at this site includes olfactory neuroblastoma, juvenile angiofibroma, fungal granuloma and dermoid cyst. Malignant tumors arising from nasal and sinus mucosa like adenocarcinoma and squamous cell carcinoma, sarcomas of anterior skull base, bony tumor like chondrosarcoma and metastatic deposits are other rare differential diagnoses to be included in the list .

Decompressive craniectomy after intravenous tissue plasminogen activator administration for stroke - Corrected Proof

2012-04-13

Abstract: Objective: Intravenous tissue plasminogen activator (IV tPA) is an approved treatment for acute ischemic stroke. However, the effects of decompressive craniectomy (DC) after IV tPA administration for ischemic stroke are still largely unknown. The aim of this study was to investigate the safety and outcomes of DC after IV tPA administration.Methods: We retrospectively reviewed patients who underwent DC for malignant hemispheric infarction. We compared 20 patients who underwent DC after IV tPA administration with another 20 patients who underwent DC without prior IV tPA administration.Results: The patient characteristics did not differ between the DC patients with and without prior IV tPA administration. New intracranial bleeding or worsening of pre-existing ICH occurred in two patients (10%) in each group. Furthermore, the rates of an mRS score of 4–6, 5 or 6, and 6 did not differ significantly between the two groups.Conclusion: DC may be a safe and useful surgical procedure for space-occupying edema after IV tPA administration for acute stroke.

Spine and brain malformations in a patient obligate carrier of MTHFR with autism and mental retardation - Corrected Proof

2012-04-12

We report a patient obligate carrier of methylene-tetrahydrofolate reductase (MTHFR) in whom spine and brain MRI displayed a type 1 diastematomyelia involving the vertebrae from C7 to T1, and cerebellar vermis hypoplasia, respectively. In addition, the child showed clinical signs of central and peripheral involvement, with autism and severe mental retardation being the main features. We think that the clinical anomalies reported in this patient on the basis on recent acquisitions may be pathogenetically related

Short latency afferent inhibition associated with cortical compression and memory impairment in patients with chronic subdural hematoma - Corrected Proof

2012-04-09

Abstract: Objective: To evaluate the cortical excitability in patients with mild cortical compression.Methods: The present study used short interval intracortical inhibition (SICI), intracortical facilitation (ICF), and short latency afferent inhibition (SAI) to evaluate motor cortex excitability in 16 chronic subdural hematoma (CSDH) patients with memory impairment and compared the data with those of 16 healthy controls.Results: SAI was reduced in patients compared with controls (99±14 vs. 47±11% of the test size; p<0.0001, unpaired t-test). CSDH patients tended to have a high resting motor threshold and less pronounced SICI and ICF than controls, but these differences were not significant. Treatment of hematoma improved memory impairment and SAI in CSDH patients with wide individual variations that ranged from an increase of 74% to 17% of test size.Conclusion: These findings suggest that measuring SAI may provide a means of probing the integrity of cortical cholinergic networks in a compressed human brain.

Unilateral pallidal stimulation in a patient with truncal dystonia - Corrected Proof

Michał Sobstyl, Mirosław Ząbek, Sebastian Dzierzęcki, Wojciech Górecki — 2012-04-09

The stimulation of the internal globus pallidus (GPi) is an established stereotactic target in alleviating not only primary generalized dystonia but also segmental or even focal dystonia . Deep brain stimulation (DBS) of the GPi also revealed a very effective treatment modality for dystonia affecting mainly neck and truncal musculature, e.g. camptocormia, camptocephalia or disabling dystonic spinal hyperextension . In most of these cases with disabling forms of truncal dystonia the DBS electrodes were implanted simultaneously bilaterally because of axial involvement of truncal musculature by dystonic movements . There have been only few scattered reports on the outcomes of unilateral GPi stimulation for focal or segmental dystonia . We report here about a patient with dystonia affecting symmetrically the truncal musculature and both upper limb girdles who underwent unilateral GPi stimulation.

Ultrasound study shows nerve atrophy in post herpetic neuralgia - Corrected Proof

R. Renna, C. Erra, V. Almeida, L. Padua — 2012-04-06

Herpes zoster (HZ), or shingles, caused by reactivation of the latent varicella zoster virus (VZV) in the dorsal root or trigeminal ganglia, is most common after the sixth decade of life. It usually presents as a unilateral dermatomal vesicular rash, associated with severe pain. Painful rash eruption is usually localized to the thoracic nerves or to the ophthalmic division of the trigeminal nerve distribution. VZV usually persists asymptomatic in the sensory ganglia of anyone who has suffered from chickenpox. It reactivates in about 25% of people to travel along the sensory nerve fibers causing vesicular lesions in the dermatome supplied by the nerve. One of the most common and debilitating sequelae of HZ is post herpetic neuralgia (PHN), defined as pain persisting more than 3 months after the rash has healed. PHN is one of the most common causes of severe neuropathic pain. The diagnosis of both HZ and PHN is usually made clinically on the basis of the characteristic rash and patient's symptoms. We report the results of an ultrasonographic study of a patient with L5-S1 ganglionopathy due to VZV reactivation, followed by PHN.

Clinical safety and primary efficacy of bone marrow mesenchymal cell transplantation in subacute spinal cord injured patients - Corrected Proof

2012-04-05

Abstract: Background: In recent years, some studies were conducted to evaluate the effects of stem cells from different sources on patients with spinal cord injury (SCI). This study was carried out to evaluate the feasibility and therapeutic potential of autologous bone marrow cell (BMC) transplantation in 11 complete spinal cord injured patients at thoracic level.Methods and materials: This nonrandomized clinical trial compared the results of autologous BMC transplantation into cerebrospinal fluid (CSF) via lumbar puncture (LP) in 11 patients having complete SCI, with 20 patients as control group who received conventional treatment without BMC transplantation. The patients underwent preoperative and follow-up neurological assessments using the American Spinal Injury Association (ASIA) impairment scale. Then, the participants were followed for 12–33 months.Results: Eleven patients with the mean age of 33.2±8.9 years and 20 patients with the mean age of 33.5±7.2 years were enrolled in the study and in the control group, respectively. None of the patients in the study and control group experienced any adverse reaction and complications, neither after routine treatment nor after cell transplantation. Five patients out of 11 (45.5%) in the study group and three patients in the control group (15%) showed marked recovery, but the result was statistically borderline (P=0.095).Conclusion: We conclude that transplantation of autologous BMC via LP is a feasible and safe technique, but at the moment, no clear answer can be given regarding the clinical potential, despite a potential tendency to treat SCI patients, observed through statistics.

Postoperative changes in the superficial temporal artery and the external carotid artery duplex sonography after extra-intracranial bypass surgery in European Moyamoya disease - Corrected Proof

M. Kraemer, B. Schuknecht, A.K. Jetzer, Y. Yonekawa, N. Khan — 2012-04-05

Abstract: Introduction: Despite Duplex ultrasonography being a noninvasive, easily repeatable, readily available and economical tool, this examination and its normal ranges are rarely described in Moyamoya disease (MMD).Methods: Duplex ultrasonography examinations of the superficial temporal artery (STA) and external carotid artery (ECA) were performed preoperatively, postoperatively (within 30 days) and as follow-up exams (6 months postoperatively) after 32 cerebral revascularization procedures in 20 European patients with MMD.Results: A significant higher mean diastolic flow of STA compared to preoperative values was found in postoperative (p<.000) and follow-up exams (p<.001) in Duplex ultrasonography. Postoperative and follow-up Duplex sonography of STA also showed a significantly higher mean systolic flow compared to preoperative values (p<.05 and p<.05). Also ECA showed significantly changes after bypass surgery (p<.05).Conclusion: Duplex ultrasonography of STA is a reliable and non-invasive tool to investigate hemodynamic changes after bypass surgery and to detect bypass patency in European patients with MMD.

Central nervous system fungal infections: Observations from a large tertiary hospital in northern India - Corrected Proof

2012-04-05

Abstract: Objective: To report our observations regarding fungal infections of the brain over two years from a large tertiary hospital in northern India. To identify fungal infections in immunocompetent and immunocompromised patients and to compare the two groups with respect to their age of occurrence, demographic data, clinical profile, radiological findings, response to treatment and outcome.Methods: All consecutive cases of central nervous system (CNS) fungal infections admitted to the hospital over two years were included in this study. The patients were categorized as immunocompetent and immunocompromised, the predisposing factors, symptoms and clinical presentation were studied in detail and the outcomes of the two groups were compared.Results: Of the 50 cases, 25(50%) were that of mucormycosis, 17(34%) were cryptococcosis and 8(16%) cases were that of aspergillosis. 14(28%) cases were immunocompetent and 36(72%) were immunocompromised. The outcome studied was as follows: 28% died of which 4% were HIV positive, 12% were diabetics with severe rhinorbital involvement, 2% had idiopathic thrombocytopenic purpura (ITP), 6% had advanced cancer and 4% had no predisposing illness.Conclusions: We observed fungal infections of the brain in both immunocompetent and immunocompromised patients. In immunocompetent patients, early diagnosis and appropriate treatment frequently leads to recovery from the illness. The mortality and morbidity of fungal infections are less in the immunocompetent group of patients.

Recovery of posterior communicating artery aneurysm-induced oculomotor nerve paresis after endovascular treatment - Corrected Proof

Da-Qun Gu, Bin Luo, Xin Zhang, Xiao-Ao Long, Chuan-Zhi Duan — 2012-04-05

Abstract: Objective: Recovery of aneurysm-induced oculomotor nerve paresis (ONP) after endosaccular coiling has not yet been adequately assessed. The aim of this study was to investigate the factors that affect the outcome of ONP after endovascular treatment of posterior communicating artery (PcomA) aneurysms.Materials and methods: We retrospectively evaluated the clinical characteristics and the outcome of oculomotor nerve function in a series of 36 patients with ONP due to PcomA aneurysms treated by endovascular coiling. Univariate analysis was applied to test the association between ONP recovery and clinical variables.Results: Thirty-six consecutive patients (20 women, 16 men; mean age, 54.3±9 years) presenting with ONP underwent endosaccular coiling were enrolled in this study. Subarachnoid hemorrhage was present in 21 patients. The mean size of the aneurysms was 9.3±3.9mm. ONP was complete in 14 patients (38.9%) and partial in 22 patients (61.1%) at admission. Seventeen patients (47.2%) had complete recovery of oculomotor nerve function, 15 had incomplete recovery (41.7%), and 4 (11.1%) remained unchanged after treatment. Factors showing significant association with recovery of oculomotor nerve function were the length and degree of ONP before treatment (P=0.035 and P=0.019, respectively).Conclusions: Endosaccular coiling of PcomA aneurysms in patients with ONP resulted in cure or improvement of oculomotor nerve dysfunction in the majority of patients. The length and degree of preoperative ONP were the statistically significant predictors of complete ONP recovery.