Significant Neurological Improvement Research Articles

Clinical features and treatment of paraneoplastic neurological syndrome associated with small cell lung cancer

The aim of this study is to explore the clinical characteristics, treatment and prognosis of pareneoplastic neurological syndrome (PNS) associated with small cell lung cancer (SCLC) in a single-center cohort. We retrospectively and consecutively reviewed 34 patients (22 male and 12 female, mean age 55.4 years old) diagnosed as PNS associated with SCLC in our hospital from 2001 to 2014 and investigated the clinical features, related antibodies, treatment and prognosis in this cohort. In a total of 34 patients, 31 (91.4%) presented with neurological symptoms prior to the diagnosis of cancer. Lambert-Eaton syndrome (13/34, 38.2%) was the most common subtype, followed by paraneoplastic sensory neuronopathy (10/34, 29.4%), paraneoplastic cerebellar degeneration (7/34, 20.6%), limbic encephalitis (6/34, 17.6%) and brainstem encephalitis (1/34, 3%). Anti-neuronal antibodies were positive in 9 out of a total of 24 patients (37.5%) who performed the tests. There were 28 (82.4%) patients who received the treatment for the primary tumor. Of them, operation of removing the tumor was performed in 4 patients. 5 patients received treatment of suppression of the immune response to PNS. Significant neurological improvement was found in a patient who received operation combined with immunotherapy after a 3-year follow-up. The majority of patients with PNS are unknown to have cancer at the time of diagnosis. Early recognition of PNS is helpful to the treatment of the tumor. PNS has diverse presentations, affecting both the central and peripheral nervous system, which makes the diagnosis hard. Operation of removing the tumor and immune suppression may slow the immune response, creating the greatest chance for neurologic improvement or symptom stabilization.

Intramedullary spinal cord abscess – an unusual presentation

Intramedullary spinal cord abscess (ISCA) is a rare infection in children. It is usually associated with congenital neuro-ectodermal abnormalities. Spastic paraparesis is the predominant clinical presentation. We report a child of ISCA who presented with acute flaccid paralysis of both lower limbs, an unusual presentation and yet showed significant neurological improvement.

Postoperative three-dimensional cervical range of motion and neurological outcomes in patients with cervical ossification of the posterior longitudinal ligament: Cervical laminoplasty versus laminectomy with fusion

ObjectiveLaminoplasty (LP) and laminectomy with fusion (LCF) are acceptable surgical options for cervical myelopathy caused by ossification of the posterior longitudinal ligament (OPLL). This study focused on evaluating cervical range of motion (ROM) on a three-dimensional basis as well as neurological outcomes after LP and LCF. MethodsThis prospective cohort study consisted of 38 patients undergoing LP (n=20) or LCF (n=18) from December 2010 to December 2012. Before surgery and at the 3rd, 6th, 12th month follow-up, patients were assessed with three-dimensional cervical ROM, Japanese Orthopaedic Association (JOA) scores, Visual Analogue Scale (VAS) and complications. ResultsThe patients in both groups had significant ROM loss after surgery in six directions of motion. At the 12th month follow-up, the LP group preserved more ROM than LCF in all directions except bilateral rotations. Major reduction was observed in extension, as with only 59.8% and 54.3% ROM preserved in LP and LCF groups. However, the most preserved ROM was witnessed in rotation, especially in the LP group (90.8%). For JOA and VAS, both groups showed significant improvements postoperatively, and the difference between the two groups was not statistically significant. ConclusionsPatients with OPLL had an obvious reduction in active cervical ROM following LP and LCF. Major reduction was observed in extension, and less impact was detected on rotation. Compared with LCF, LP had better ROM preserved. Both LP and LCF provided patients with significant neurological improvement.

Timing of surgical decompression for traumatic cervical spinal cord injury.

Although there have been numerous studies aimed at determining the effects and safety of early vs. late surgical decompression for traumatic cervical spinal cord injury, controversies still exist regarding the optimal timing of surgery for this serious spinal trauma. This study was conducted to evaluate the effectiveness and safety of early vs. late surgical decompression for lower cervical spine trauma associated with spinal cord injury. A retrospective review of was performed on consecutive patients who underwent surgical decompression for lower cervical (C3-C7) spine trauma associated with spinal cord injury at six institutions across China from January 2007 to January 2012. These patients were analysed according to the timing of surgical intervention. The early group comprised patients who underwent surgery within the first 72 hours after being injured, whilst the late group comprised patients who underwent surgery after the first 72 hours. For analysis of neurologic improvement, patients who had completed a follow-up of at least six months were assessed. Other outcomes analysed were hospitalisation periods, complications and mortality. A total of 595 patients were identified (456 men and 139 women at an average age of 41.4 years), with 212 in the early group and 383 in the late group. Patients in both groups had made a significant neurologic improvement in the final follow-up, but no statistically significant difference was noted between groups. Patients in the early group had a significantly shorter hospital stay (15.4 vs. 18.3 days, p <0.001) but realised no benefits in terms of intensive care unit length of stay and ventilator days. No significant differences were identified between groups with regards complications (pneumonia, pulmonary embolism, wound infection, sepsis and urinary tract infection). Compared with the late group, the early group had a significantly higher incidence of postoperative neurological deterioration (6.6 vs. 0.7 %, p <0.001) and mortality (7.1 vs. 2.1 %, p = 0.003). The timing of surgery for patients sustaining traumatic lower cervical spine injury with neurological involvement did not affect neurological recovery. Early surgical intervention was associated with a higher incidence of mortality and neurological deterioration compared with late surgical intervention, indicating that surgery after the first 72 hours might be relatively safe.

Incidence and risk factors analysis of heterotopic ossification after cervical disc replacement

Background Cervical disc replacement (CDR) as a substitute for traditional fusion surgery has been widely used in treating degenerative cervical disc diseases. The objectives of this study were to assess the clinical and radiological findings for patients with heterotopic ossification (HO) following CDR and to detect the risk factors of HO after CDR. Methods A total of 125 patients with symptomatic cervical single- or double-level disc diseases, who underwent CDR procedure with Discover prosthesis in Department of Spine Surgery, Changzheng Orthopedics Hospital from March 2009 to March 2011, were enrolled in this retrospective study. Occurrence of HO was defined by the McAfee classification on cervical lateral X-rays in this study. Prosthesis vertebral ratio (PVR) was used to determine the matching degree between the cervical disc prosthesis and cervical vertebra. Logistic regression analyses were performed to determine the risk factors of HO. Variables evaluated for their association with HO occurrence included age, gender, high-intensity signal in spinal cord, preoperative range of motion (ROM), postoperative ROM, operation level number, and PVR. Results Mean follow-up time was (26.4±5.8) months. All the patients had significant symptoms and neurological function improvements during the follow-up period. The ROM of the operated segment from the preoperative period to the last follow-up was relatively well maintained. The rate of HO in this cohort of patients, who underwent Discover disc, was 27.92% per surgical level and 24.8% per patient by the last follow-up. There were 19 patients (19.79%) with HO in the single-level group while 12 patients (41.38%) in the double-level group. Conclusions We identified preoperative high-intensity signal in spinal cord, postoperative ROM of surgical level, number of operation level, and PVR as significant risk factors for postoperative HO occurrence.

Optic Neuropathy, Myelopathy, Anemia, and Neutropenia Caused by Acquired Copper Deficiency After Gastric Bypass Surgery

Malabsorptive bariatric surgery is rapidly becoming a major cause of copper deficiency given the increasing prevalence of these procedures for morbid obesity. Acquired copper deficiency can present with clinically significant hematologic and neurological manifestations. Although hematologic manifestations of copper deficiency are rapidly reversible, significant neurological improvement after copper supplementation therapy is unusual and many patients remain debilitated and may only experience, at best, stabilization of the neurological manifestations. Here we present a case of an undiagnosed copper deficiency several years after bariatric gastric bypass surgery, in a patient who concomitantly used zinc-containing denture cream for several years, associated with anemia, neutropenia, myelopathy, respiratory failure, and bilateral optic neuropathy, which caused major vision loss. This patient was also a heterozygote carrier of the 5,10-methylenetetrahydrofolate reductase A1298C gene polymorphism, which may affect copper metabolism. Intravenous copper repletion resulted in rapid correction of hematologic indices. However, neurological manifestations, including vision loss responded only modestly to copper supplementation, despite achieving normal blood copper concentrations. Clinicians should consider copper deficiency in patients at risk, as in this case, as a delayed diagnosis can lead to irreversible disability due to neurological manifestations.

Congestive myeloradiculopathy in a patient with Cowden syndrome

We present a patient with newly diagnosed Cowden syndrome and congestive myeloradiculopathy secondary to spinal dural arteriovenous fistula (SDAVF). This patient illustrates the difficulties that can be encountered in diagnosing SDAVF and emphasises the need to pursue the diagnosis in the appropriate clinical setting, as treatment can lead to significant neurological improvement. To our knowledge this is also the first reported case of an association between Cowden syndrome and SDAVF.

Magnetic resonance imaging in lumbar gunshot wounds: an absolute contraindication?

Performance of MR imaging in patients with gunshot wounds at or near the lumbar spinal canal is controversial. The authors reviewed the literature on the use of MR imaging in gunshot wounds to the spine. They discuss the results from in vitro and clinical studies, analyze the physical properties of common projectiles, and evaluate the safety and indications for MR imaging when metallic fragments are located near the spinal canal. A review of the English-language literature was performed. Data from 25 articles were analyzed, including 5 in vitro studies of the interaction between 95 projectiles and the MR system's magnetic fields, and the clinical outcomes in 22 patients with metallic fragments at or near the spinal canal who underwent MR imaging. Properties of 95 civilian and military projectiles were analyzed at a magnet strength of 1, 1.5, 3, and 7 T. The most common projectiles were bullets with a core of lead, either with a copper jacket or unjacketed (73 [76.8%] of 95). Steel-containing (core or jacket) projectiles comprised 14.7%. No field interaction was evident in 78 (96.3%) of the 81 nonsteel projectiles. All steel projectiles showed at least positive deflection forces, longitudinal migration, or rotation. Heating of the projectiles was clinically insignificant. Image artifact was significant in all 9 steel bullets tested, but was not significant in 39 (88.6%) of the 44 nonsteel bullets tested. Overall, 22 patients with complete (82%) and incomplete (14%) spinal cord injury secondary to a projectile lodged inside the spinal canal underwent MR imaging. Discomfort and further physical or neurological deficits were not reported by any patient. Two patients with spinal cord injuries underwent MR imaging studies before surgical decompression and had subsequent, significant neurological improvement. Metallic implants near or at the spinal canal are a relative contraindication for MR imaging. However, safe MR imaging might be feasible when a projectile's properties and a patient's individualized clinical presentation are considered.

A new strategy of CyberKnife treatment system based radiosurgery followed by early use of adjuvant bevacizumab treatment for brain metastasis with extensive cerebral edema.

Bevacizumab blocks the effects of vascular endothelial growth factor in leakage-prone capillaries and has been suggested as a new treatment for cerebral radiation edema and necrosis. CyberKnife is a new, frameless stereotactic radiosurgery system. This work investigated the safety and efficacy of CyberKnife followed by early bevacizumab treatment for brain metastasis with extensive cerebral edema. The eligibility criteria of the patients selected for radiosurgery followed by early use of adjuvant bevacizumab treatment were: (1) brain tumors from metastasis with one solitary brain lesion and symptomatic extensive cerebral edema; (2) >18 years of age; (3) the patient refused surgery due to the physical conditions and the risk of surgery; (4) no contraindications for bevacizumab. (5) bevacizumab was applied for a minimum of 2 injections and a maximum of 6 injections with a 2-week interval between treatments, beginning within 2 weeks of the CyberKnife therapy; (6) Karnofsky performance status (KPS) ≥30. Tumor size and edema were monitored by magnetic resonance imaging (MRI). Dexamethasone dosage, KPS, adverse event occurrence and associated clinical outcomes were also recorded. Eight patients were accrued for this new treatment. Radiation dose ranged from 20 to 33 Gy in one to five sessions, prescribed to the 61-71 % isodose line. Bevacizumab therapy was administered 3-10 days after completion of CyberKnife treatment for a minimum of two cycles (5 mg/kg, at 2-week intervals). MRI revealed average reductions of 55.8 % (post-gadolinium) and 63.4 % (T2/FLAIR). Seven patients showed significant clinical neurological improvements. Dexamethasone was reduced in all patients, with five successfully discontinuing dexamethasone treatment 4 weeks after bevacizumab initiation. Hypertension, a bevacizumab-related adverse event, occurred in one patient. After 3-8 months, all patients studied were alive and primary brain metastases were under control, 2 developed new brain metastases and underwent salvage CyberKnife treatment. Recurrent edema and emerging radiation necrosis were not observed. CyberKnife radiosurgery followed by early use of bevacizumab is promising and appears safe for treatment of brain metastases with extensive cerebral edema.

Brain proteomics identifies potential simvastatin targets in acute phase of stroke in a rat embolic model

Finding an efficient neuroprotectant is of urgent need in the field of stroke research. The goal of this study was to test the effect of acute simvastatin administration after stroke in a rat embolic model and to explore its mechanism of action through brain proteomics. To that end, male Wistar rats were subjected to a Middle Cerebral Arteria Occlusion and simvastatin (20mg/kg s.c) (n=11) or vehicle (n=9) were administered 15min after. To evaluate the neuroprotective mechanisms of simvastatin, brain homogenates after 48h were analyzed by two-dimensional fluorescence Difference in Gel Electrophoresis (DIGE) technology. We confirmed that simvastatin reduced the infarct volume and improved neurological impairment at 48h after the stroke in this model. Considering our proteomics analysis, 66 spots, which revealed significant differences between groups, were analyzed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry allowing the identification of 27 proteins. From these results, we suggest that simvastatin protective effect can be partly explained by the attenuation of the oxidative and stress response at blood-brain barrier level after cerebral ischemia. Interestingly, analyzing one of the proteins (HSP75) in plasma from stroke patients who had received simvastatin during the acute phase, we confirmed the results found in the pre-clinical model. Our aim was to study statins benefits when administered during the acute phase of stroke and to explore its mechanisms of action through brain proteomics assay. Using an embolic model, simvastatin-treated rats showed significant infarct volume reduction and neurological improvement compared to vehicle-treated group. Analyzing their homogenated brains by two-dimensional fluorescence Difference in Gel Electrophoresis (DIGE) technology, we concluded that the protective effect of simvastatin can be attributable to oxidative stress response attenuation and blood-brain barrier protection after cerebral ischemia.

Neuro-behçet disease in an african american adolescent.

An 18-year-old African American adolescent presented with 1 week of fever, headache, and left arm and leg weakness. On examination, he had scrotal ulcers, left hemiparesis, dysarthria, and bilateral dysmetria. There was no uveitis or papilledema, but he had a history of recurrent oral ulcers. The cerebrospinal fluid (CSF) was remarkable for moderate lymphocytic pleocytosis to 175/µL but was negative for infectious etiologies. Oligoclonal bands were absent from the CSF and an immunoglobulin index was normal. A serum workup for rheumatological disease including erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, rheumatoid factor, angiotensin-converting enzyme, anti-Ro, and anti-La antibodies was unrevealing. Magnetic resonance imaging of the brain showed T2-weighted hyperintensities with enhancement from the left internal capsule to the pons. Additionally, there were nonenhancing foci of T2-weighted hyperintensities in the right paracentral lobule, left corona radiata, hippocampi, and cervical spine (Figure 1A and ​andB).B). A head magnetic resonance venogram revealed near occlusion of the superior sagittal sinus (Figure 1D). A hypercoagulable workup including antiphospholipid antibodies was negative. Based on the clinical presentation and radiographic findings, a diagnosis of neuro-Behcet disease (NBD) was made. Treatment with therapeutic low-molecular-weight heparin, high-dose intravenous corticosteroids, and cyclophosphamide resulted in significant neurological improvement. Figure 1. Neuroimaging in neuro-Behcet disease: fluid-attenuated inversion recovery (FLAIR) sequence (A) shows hyperintensities in the right cerebral peduncle and hippocampi. T1-postcontrast sequence (B) shows enhancement in the right thalamus. Cervical ... Neurological complications of Behcet disease are rare, typically reported as a 1% to 3% incidence in all cases of Behcet disease.1 This case illustrates some of the typical manifestations of NBD, which often include meningoencephalitis, parenchymal lesions, cerebral venous thrombosis, and aneurysm formation.1,2

Co-grafting of neural stem cells with olfactory en sheathing cells promotes neuronal restoration in traumatic brain injury with an anti-inflammatory mechanism.

BackgroundWe sought to investigate the effects of co-grafting neural stem cells (NSCs) with olfactory ensheathing cells (OECs) on neurological behavior in rats subjected to traumatic brain injury (TBI) and explore underlying molecular mechanisms.MethodsTBI was established by percussion device made through a weight drop (50 g) from a 30 cm height. Cultured NSCs and OECs isolated from rats were labeled by Hoechst 33342 (blue) and chloromethyl-benzamidodialkyl carbocyanine (CM-Dil) (red), respectively. Then, NSCs and/or OECs, separately or combined, were transplanted into the area surrounding the injury site. Fourteen days after transplantation, neurological severity score (NSS) were recorded. The brain tissue was harvested and processed for immunocytochemistry, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL), and reverse transcription-polymerase chain reaction (RT-PCR).ResultsSignificant neurological function improvement was observed in the three transplant groups, compared to the TBI group, and co-transplantation gave rise to the best improvement. Morphological evaluation showed that the number of neurons in cortex from combination implantation was more than for other groups (P <0.05); conversely, the number of apoptotic cells showed a significant decrease by TUNEL staining. Transplanted NSCs and OECs could survive and migrate in the brain, and the number of neurons differentiating from NSCs in the co-transplantation group was significantly greater than in the NSCs group. At the molecular level, the expressions of IL-6 and BAD in the co-graft group were found to be down regulated significantly, when compared to either the NSC or OEC alone groups.ConclusionThe present study demonstrates for the first time the optimal effects of co-grafting NSCs and OECs as a new strategy for the treatment of TBI via an anti-inflammation mechanism.

English

We report a case of a 47 year old man who presented with head injury due to road traffic accident, with CT scan suggestive of large left sided acute SDH with comminuted fracture of occipital bone. Within a few hours, patient showed significant neurological improvement. Follow -up CT scan revealed rapid spontaneous resolution and redistribution of the acute SDH. The proposed hypothesis explaining this rare phenomenon suggests intracranial and extra cranial redistribution as the cause of spontaneous resolution of acute SDH. The intracranial phenomenon is more common of the two. To our knowledge, this is the first case in the literature where both intracranial and extracranial phenomenon played a role in the same patient leading to rapid spontaneous resolution of acute SDH.

Mid-term results of computer-assisted cervical reconstruction for rheumatoid cervical spines

Study designA retrospective single-center study. Summary and backgroundWe routinely have used C1–C2 transarticular and cervical pedicle screw fixations to reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions. However, there is little data on mid-term results of surgical reconstruction for rheumatoid cervical disorders, particularly, cervical pedicle screw fixation. ObjectivesThe purpose of this study was to evaluate the mid-term surgical results of computer-assisted cervical reconstruction for such lesions. MethodsSeventeen subjects (4 men, 13 women; mean age, 61±9years) with RA cervical lesions who underwent C1–C2 transarticular screw fixation or occipitocervical fixation, with at least 5years follow-up were studied. A frameless, stereotactic, optoelectronic, CT-based image-guidance system, was used for correct screw placement. Variables including the Japanese Orthopaedic Association (JOA) score, Ranawat class, EuroQol (EQ-5D), atlantodental interval, and Ranawat values before, and at 2 and 5years after surgery, were evaluated. Furthermore, screw perforation rates were evaluated. ResultsThe lesions included atlantoaxial subluxation (AAS, n=6), AAS+vertical subluxation (VS, n=7), and AAS+VS+subaxial subluxation (n=4). There was significant neurological improvement at 2years after surgery, as evidenced by the JOA scores, Ranawat class, and the EQ-5D utility weight. However, at 5years after surgery, there was a deterioration of this improvement. The Ranawat values before, and at 2 and 5years after surgery, were not significantly different. Major screw perforation rate was 2.1%. No neural and vascular complications associated with screw insertion were observed. ConclusionsSubjects with rheumatoid cervical lesions who underwent C1–C2 transarticular screw fixation or occipitocervical fixation using a pedicle screw had significantly improved clinical parameters at 2years after surgery. However, there was a deterioration of this improvement at 5years post surgery.

Importance of Cerebral Artery Recanalization in Patients With Stroke With and Without Neurological Improvement After Intravenous Thrombolysis

Recanalization status after intravenous thrombolysis (IVT) in patients with ischemic stroke is a reference point to proceed with a rescue reperfusion intervention, although early neurological improvement (NI) may preclude endovascular procedures. We aimed to evaluate the importance of restoration of blood flow at the arterial occlusion site in subgroups of patients with stroke stratified by early NI after IVT. The following patients were recruited from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register: (1) with baseline vessel occlusion documented by computed tomographic (CT) or magnetic resonance (MR) angiography and follow-up angioimaging between 22 and 36 hours after IVT available; and (2) with dense cerebral artery sign on admission CT scan and results of follow-up CT reported. Recanalization at 24 hours was defined as absence of vessel occlusion or as resolution of dense cerebral artery sign on follow-up 22- to 36-hour imaging. NI was assessed at 2 hours and 24 hours after IVT and was defined as improvement by 20% from baseline National Institute of Health Stroke scale score. Primary outcome measure was independence, defined as modified Rankin scale score 0 to 2 after 3 months. Of 28136 cases registered between December 2003 and November 2009, 5324 cases (19%) met the inclusion criteria. Patients with both NI at 2 hours post-treatment and vessel recanalization had the best chances to achieve independence at 3 months (adjusted odds ratio, 15.8; 95% confidence interval, 12.5-20.0), followed by those who had NI despite persistent occlusion (adjusted odds ratio, 4.7; 95% confidence interval, 3.6-6.1); and those without NI despite recanalization (adjusted odds ratio, 2.7; 95% confidence interval, 2.2-3.3). Recanalization of an occluded artery in acute stroke is associated with favorable functional outcome both in patients with and without NI after IVT. In future evaluations of mechanical thrombectomy and other additional strategies, recanalization should be considered in patients with persisting occlusion after IVT even after significant NI.

Outcome of surgical versus conservative management of cervical spine myelopathy secondary to cervical tuberculosis

Cervical spine tuberculosis is a rare infectious disease that is not yet discussed well regarding the optimal method of its management. This is a prospective study of a total of 29 patients with cervical spine tuberculosis with a mean follow-up of 14 months (range, 10-21); they were classified randomly into two groups: group I, patients who underwent anterior cervical decompression and fixation and followed by the anti-tuberculous medications (16 patients) and group II, patients who had conservative anti-tuberculous medications only without surgical intervention (13 patients). All patients had complete clinical assessments using Nurick scale and the modified Japanese Orthopaedic Association score for myelopathy and the visual analogue scale for assessment of cervical pain. We had also neuro-radiographic assessment (cervical spine X-ray and MRI) at the first presentation and at 3, 6, and 12 months later. At final follow-up, significant neurological improvement was demonstrated in both management approaches, more obvious in the surgical group. Cervical pain showed a statistically significant improvement (P < 0.05) in surgical group rather than in conservatively treated group. In the surgical group, the mean Cobb angle showed a significant change from a preoperative mean of -3.1 ± 1.6° to postoperative mean of 16.6 ± 5.4°, significantly correlated to the improvement of cervical pain (P = 0.004), while it was changed from a mean of -0.8 ± 2.2 to a mean of 9.2 ± 3.8 1 year after starting of medical treatment in group II. In spite of the conservative trend in the management of Pott's disease, surgical management of cervical spine myelopathy secondary to cervical tuberculosis could be the optimal treatment even in an early stage of the disease.

Thrombolysis for Acute Ischemic Stroke in South Africa

Stroke is an important cause of death and disability in sub-Saharan Africa. Thrombolysis with recombinant tissue plasminogen activator (tPA) is the only effective therapy for acute ischaemic stroke. Essential requirements for stroke thrombolysis include availability of CT scanning and arrival at hospital within 4.5 hours of symptom onset. However, in developing countries where the prerequisites are met at certain centres, the efficacy and safety of thrombolysis have not been firmly established. We aimed to evaluate the early outcomes and safety of stroke thrombolysis in a South African setting. We conducted a prospective observational study of all stroke patients receiving tPA for thrombolysis over the period January 2000 to February 2011. The primary outcome measure was the proportion of patients achieving significant early neurological recovery defined as an improvement of four or more points on the NIHSS score at discharge. The safety endpoint was the rate of symptomatic intracranial haemorrhage (SICH) and death. Forty-two patients received thrombolysis over the study period. Sixty-seven percent achieved significant neurological improvement. The majority of patients (53.8%) were discharged home, and by the time of discharge 17 (40.5%) were functionally independent. SICH occurred in 2 (4.8%) patients with an overall mortality rate of 7.1%. Our findings indicate that the use of thrombolysis in routine clinical practice in a South African setting has similar safety and early efficacy outcomes to developed and other developing countries.

Therapeutic impact of eicosapentaenoic acid on ischemic brain damage following transient focal cerebral ischemia in rats

Long-chain n-3 polyunsaturated fatty acids, such as eicosapentaenoic acid (EPA), have been shown to reduce ischemic neuronal injury. We investigated the effects of ethyl-EPA (EPA-E) on ischemic brain damage using a rat transient focal cerebral ischemia model. Male Sprague–Dawley rats (n=105) were subjected to 90min of focal cerebral ischemia. EPA-E (100mg/kg/day) or vehicle was administered once a day for 3, 5 or 7 days prior to ischemia. Different withdrawal intervals of 3, 5, and 7 days prior to ischemia following 7-day pretreatment with EPA-E or vehicle were also examined. In addition, post-ischemic administration of EPA-E was investigated. Pretreatment with EPA-E for 7 and 5 days, but not 3 days, showed significant infarct volume reduction and neurological improvements when compared with vehicle pretreatment. In addition, withdrawal of EPA-E administration for 3 days, but not 5 and 7 days, also demonstrated significant infarct volume reduction and neurological improvements when compared with vehicle treatment. Post-ischemic treatment of EPA-E did not show any neuroprotection. Immunohistochemistry revealed that 7-day pretreatment with EPA-E significantly reduced cortical expression of 8-hydroxydeoxyguanosine (maker for oxidative DNA damage), 4-hydroxy-2-nonenal (maker for lipid peroxidation), phosphorylated adducin (marker for Rho-kinase activation) and von Willebrand factor (endothelial marker) when compared with vehicle pretreatment. In addition, phosphorylated adducin expression co-localized with von Willebrand factor immunoreactivity. The present study established the neuroprotective effect of EPA-E on ischemic brain damage following transient focal cerebral ischemia in rats, which may be involved in the suppression of oxidative stress and endothelial Rho-kinase activation.

Surgical Resection of Brain Metastases—Impact on Neurological Outcome

Brain metastases (BM) develop in about 30% of all cancer patients. Surgery plays an important role in confirming neuropathological diagnosis, relieving mass effects and improving the neurological status. To select patients with the highest benefit from surgical resection, prognostic indices (RPA, GPA) have been formulated which are solely focused on survival without considering neurological improvement. In this study we analyzed the impact of surgical resection on the neurological status in addition to overall survival in 206 BM patients. Surgical mortality and morbidity was 0.0% and 10.3% respectively. New neurologic deficits occurred in 6.3% of all patients. The median overall survival was 6.3 months. Poor RPA class and short time interval between diagnosis of cancer and the occurrence of BM were independent factors predictive for poor survival. Improvement of neurological performance was achieved in 56.8% of all patients, with the highest improvement rate seen in patients presenting with increased intracranial pressure and hemiparesis. Notably, the neurological benefits were independent from RPA class. In conclusion, surgical resection leads to significant neurological improvement despite poor RPA class and short overall survival. Considering the low mortality and morbidity rates, resection should be considered as a valid option to increase neurological function and quality of life for patients with BM.

The use of a zero-profile device compared with an anterior plate and cage in the treatment of patients with symptomatic cervical spondylosis

In a retrospective cohort study we compared the clinical outcome and complications, including dysphagia, following anterior cervical fusion for the treatment of cervical spondylosis using either a zero-profile (Zero-P; Synthes) implant or an anterior cervical plate and cage. A total of 83 patients underwent fusion using a Zero-P and 107 patients underwent fusion using a plate and cage. The mean follow-up was 18.6 months (SD 4.2) in the Zero-P group and 19.3 months (SD 4.1) in the plate and cage group. All patients in both groups had significant symptomatic and neurological improvement. There were no significant differences between the groups in the Neck Disability Index (NDI) and visual analogue scores at final follow-up. The cervical alignment improved in both groups. There was a higher incidence of dysphagia in the plate and cage group on the day after surgery and at two months post-operatively. All patients achieved fusion and no graft migration or nonunion was observed. When compared with the traditional anterior cervical plate and cage, the Zero-P implant is a safe and convenient procedure giving good results in patients with symptomatic cervical spondylosis with a reduced incidence of dysphagia post-operatively.