神経学的障害

Introduction: The aim of surgical treatment of aneurysm is complete aneurysm obliteration and maintenance of a physiologic flow in the proximal and distal vessels. To avoid any risks of failing these aims intraoperative- angiography was introduced in neurosurgery first, followed by microdoppler-ultrasonography and lately with Indocyanine-Green-Videoangiography (ICG-VA). After reviewing the literature and analysing our own results with the different methods we propose an intraoperative paradigm to optimize aneurysm clipping with the least risk of vessel occlusion or residual aneurysm.

Patients and methods: Twenty-five incidental aneurysms (bleeding aneurysms were excluded) were clipped in 2012 in our hospital with intraoperative use of microdoppler and ICG-VA. All patients received postoperative cerebral angiography. The surgical results with use of these methods were compared to postoperative angiography. Review of literature has been performed and a procedural flow chart was created.

Results: In 20/25 (80%) patients the combination of microdoppler and ICG-VA led to an optimisation and repositioning of the clip intraoperatively. In the remaining 5 patients clip re-positioning was not necessary since optimal position was confirmed. Reasons for clip re-positioning were stenosis of the vessels related to the aneurysm or a residual aneurysm neck. None of the patients needed another surgery according to postsurgical angiography. Review of the literature implicates a complemental role for microdoppler, ICG-VA and intraoperative-angiography since every method has its own advantages and disadvantages. We propose a flow chart for the use of all three methods together.

Conclusion: Microdoppler, ICG-VA and intraoperative-angiography should be used in concert under special circumstances. Using them in a given order according to their simplicity, speed and cost effectiveness may reduce complications related to the microsurgical clip placement for intracranial aneurysms. However, prospective studies are needed to prove our observations

Background and Purpose: We investigated the association between critical stenosis of the internal carotid artery or the first segment of the middle cerebral artery and patterns of cerebral infarcts classified by their territorial distribution.

Methods: This cross-sectional study included patients with diffusion-weighted magnetic resonance-confirmed acute/early subacute infarcts in the middle cerebral artery territory who underwent head/neck magnetic resonance angiography. We grouped infarct patterns in two categories: shower/cortical watershed/superficial perforating territory and complete middle cerebral artery/cortical territorial/deep perforating territory.

Results: Seventeen and 33 patients, respectively, presented with shower/cortical watershed/superficial perforating territory infarcts and complete middle cerebral artery/cortical territorial/deep perforating territory infarcts. Eleven (64.7%) of the former and five (15.2%) of the latter had critical stenosis of the internal carotid artery or the first segment of the middle cerebral artery. A strong statistical association favoring the presence of critical stenosis in the shower/cortical watershed/superficial perforating territory group (P=.001) persisted on logistic regression analysis (P=.002).

Conclusions: The occurrence of diffusion-weighted magnetic resonance-confirmed acute/early subacute middle cerebral artery infarcts in the shower/cortical watershed/superficial perforating territory distribution is strongly associated with the presence of critical stenosis of the internal carotid artery or the first segment of the middle cerebral artery. Further prospective studies are needed to address the significance of this finding.

Objective: Since open surgical evacuation of basal ganglia hemorrhage (BGH) as had been proved did not lead to the desired benefit for the patients, we used minimally invasive clot lysis by injection of recombinant tissue-type plasminogen activator (rtPA).

Methods: Patients with spontaneous BGH with or without accompanied intraventricular hemorrhage were included in the study. Following diagnosis of BGH by CT scanning, a catheter was inserted through a small burr hole under neuro-navigation assistance into the centre of hemorrhage and three mg rtPA was injected for three consecutive days. CT scans were performed daily to determine the volume of the hemorrhage. The size of hemorrhage was calculated using the ABCs measuring method. The clinical condition of the patients was classified using the Glasgow coma scale (GCS) and Glasgow outcome scale (GOS). Statistical analysis was performed using the Fisher’s exact test and Chi-square with Yates’ correction. The p-values were calculated with two tails and statistical significance was estimated as p-value <0.05.

Results: The procedure was performed on 22 patients (11 females and 11 males). The mean age of the patients was 64 years (range: 44–80 years). Among the patients, 7 (31.8%) were considered in a poor clinical condition, 11 (50%) in an intermediate condition and 4 (18.2%) in a good clinical condition. The total mortality was calculated with n=3 (13.64%). The mean volume of hemorrhage before treatment was 35.14 mL (range 11.5 mL – 67.15 mL). After the third injection, a mean volume reduction of 73.05% could be achieved. Considering the accuracy of the neuro- navigation dataset, correct placement of the drainage in the assumed center of hemorrhage was confirmed in all cases by CT scanning after the first injection. Re-bleeding occurred in 4 cases (18.2%).

Conclusion: Treatment with rt-PA in BGH seems an easy, safe and minimally invasive alternative to open surgical hematoma evacuation and it might be more favorable compared to conservative treatment. In our study, we achieved a mean volume of hemorrhage reduction of 73% after 3 days. Clot lysis alone was not the only predictive factor for a better outcome. Outcome prognosis should take several other co-factors into account such as the age of the patient and the GCS at the time of Admission. Large prospective and randomized trials are still necessary to answer these open questions

Patients with Klinefelter syndrome have a higher prevalence of postural and action tremor that the general population, but are typically diagnosed before developing tremor. We here report a 68 year old patient diagnosed with Klinefelter syndrome while being tested for FXTAS and review the available literature on this subject.

Object: Strychnine has been reported to develop seizure models. As its analogue, brucine may also have such property. The aim of the study was to create a chemoconvulsant model of seizures by fractionated administration of brucine.

Methods: Healthy male Sprague-Dawley rats (n=140) were allocated randomly into three groups: experimental group， normal saline control group and alcohol control group. Rats in experimental group were then randomly divided into six groups during the kindling process: three of the six subgroups were single-dose subgroups, while another three were fractionated-dose subgroups. Rats from three single-dose subgroups (n=20 for each subgroup) received single injection of brucine at three various dose levels (91 mg/kg, 100 mg/kg and 110 mg/kg, respectively); rats from the other three fractionated-dose subgroups (n=20 for each subgroup) received fractionated injections of brucine by three times with one third of the total dose each time. Rats from normal saline and alcohol control group were given normal saline and solvent injection (n=10 for each group). Seizure frequency and intensity (rated as stage 1-5 according to Racine scale), duration and electroencephalographic activity were recorded. Seizures were observed in all single-dose and fractionated-dose subgroups.

Results: As dose increased, higher frequency and intensity of seizures were observed. At the dose of 110mg/kg, all rats died after stage 5 seizures in both single and fractionated dose subgroups. At doses of 91mg/kg and 100mg/kg，in single-dose subgroups, 75.00-95.00% rats were observed stage 5 seizures, but the mortality was 75.00%-95.00%; In fractionated-dose subgroups, 50.00%-100.00% rats were observed stage 5 seizures, while the mortality was 0.00%-30.00%.

Conclusion: The study has provided a novel chemoconvulsant model of seizures induced by brucine, and established an appropriate method to develop the model that had not been found in previous literature review.

Multiple sclerosis is an inflammatory autoimmune-mediated disease of the Central Nervous System (CNS). Different treatment protocols, based on neurotropic viral infections and/or immunization with CNS proteins, have been implemented. Although there are encouraging outcomes, cure is still far from reach. Here, we discuss some of these treatment options.

Background: Iodine-123 metaiodobenzylguanidine ( ¹²³ I-MIBG) myocardial scintigraphy has been accepted as one of the most useful methods for the diagnosis of Parkinson’s disease (PD). Moreover, the accumulated evidence has indicated that the heart-to-mediastinum (H/M) ratio correlates with the disease severity of hypokinesia/ bradykinesia and rigidity. The present report describes the wearing-off predictions obtained from MIBG in patients with early-stage PD.

Methods: 13 males and 10 females with PD whose onset ages between 45 and 70 years were enrolled. They were separated into two groups according to their H/M ratios (less than 1.7 or 1.7 or higher). We generated Kaplan- Meier survival curves for the times of the onset of the wearing-off phenomenon, and survival differences were analyzed by the log-rank test. The onset of the wearing-off phenomenon was defined as an event during the 71- month observation.

Results: There was a significant difference in the wearing-off occurrence between the 2 groups that were divided by the H/M ratio (P=0.016). This result might reflect the existence of PD patients who do not show reductions in the H/M ratios at earlier stages and who do not manifest the wearing-off phenomenon later.

Conclusions: Our study suggests the possibility that patients with good prognoses represent those with almost normal H/M ratios, even though they are affected with PD. MIBG could be a valuable method for predicting prognoses as well as for diagnoses

Background: No single pharmacologic treatment has proven effective for the symptomatic management of progressive supranuclear palsy.

Methods: We report a case of postural instability and falls secondary to PSP of the Parkinson's subtype and initial monotherapy with donepezil 10 mg daily for 3 months followed by a novel investigation of selegiline in combination for 6 additional months. Fall frequency, clinical pull testing and computerized dynamic posturography were used to assess response.

Results: After 3 months of donepezil, fall frequency decreased from approximately 5 to 1 per week and an initially pathologic pull-test had normalized. Posturographic improvements occurred with donepezil monotherapy and after 3 and 6 months of combination therapy with selegiline. Clinical improvements were observed over the course of more than one year.

Conclusions: Improvements in clinical and posturographic measures of balance control were observed with donepezil monotherapy and, to a minimal extent, with the addition of selegeline.