Amnat Kitkhuandee

Pineal Calcification Is Associated with Symptomatic Cerebral Infarction

BACKGROUND Pineal calcification and low melatonin have been shown to be risk factors for stroke in animal studies; however, there are limited clinical data on the association of pineal calcification and stroke in humans. METHODS All computed tomographic (CT) scans of the brains of patients >15 years of age during the year 2011 at a university teaching hospital were retrospectively reviewed. Patient medical charts were used to obtain the risk factors for stroke, including diabetes, hypertension, dyslipidemia, age, and sex. Cerebral infarction was identified by having clinical syndromes of stroke and a positive CT scan. Patients with embolic or hemorrhagic stroke were excluded. Pineal calcification was evidenced by the CT scans. The association of various stroke risk factors and cerebral infarction were calculated using logistic regression analysis. RESULTS A total of 1614 patients were included, and symptomatic cerebral infarction was identified in 620 patients (38.4%). Regarding stroke risk factors in symptomatic cerebral infarction patients, the majority of patients were male (356 [57.4%]), >50 years of age (525 [84.7%]), and had hypertension (361 [58.2%]); some had diabetes (199 [32.1%]) and dyslipidemia (174 [28.1%]). Pineal calcification was found in 1081 patients (67.0%), with a male:female ratio of 1.5:1. Significant factors related to cerebral infarction by univariate logistic regression were age >50 years, hypertension, diabetes, dyslipidemia, and pineal calcification. Pineal calcification as a risk factor for cerebral infarction had an adjusted odds ratio of 1.35 (95% confidence interval 1.05-1.72). CONCLUSIONS Pineal calcification may be a potential new contributor to cerebral infarction.

Application of Recombinant Gnathostoma spinigerum Matrix Metalloproteinase-Like Protein for Serodiagnosis of Human Gnathostomiasis by Immunoblotting

Matrix metalloproteinase (MMPs) is the extracellular zinc-dependent endopeptidase and is secreted for degrading extracellular matrix molecules of host tissues. A cDNA encoding MMP-like protein of Gnathostoma spinigerum larvae was amplified by reverse transcription-polymerase chain reaction, and was cloned into a prokaryotic expression vector, and expressed in Escherichia coli. Total immunoglobulin G class (total IgG) antibody responses to the recombinant MMP-like protein were analyzed by immunoblot diagnosis of human gnathostomiasis. Serum samples from proven and clinically suspected cases of gnathostomiasis, other parasitic diseases patients, and from healthy volunteers were tested. The immunoblotting gave high sensitivity (100%) and specificity (94.7%). Positive and negative predictive values were 85.4% and 100%, respectively. Recombinant MMP-like protein can be used as a diagnostic antigen and potentially replace native parasite antigens to develop a gnathostomiasis diagnostic kit.

Pineal calcification is associated with pediatric primary brain tumor.

Melatonin has been associated with various tumors, including brain tumor, and shown to inhibit growth of neuroblastoma cells and gliomas in animal models. Likewise, patients with glioblastoma receiving melatonin reported better survival than controls. Pineal calcification may lead to a decreased production of melatonin by calcified glands. This study assessed association between pineal calcification and primary brain tumor in pediatric/adolescent patients.

MR findings in spinal tuberculosis in an endemic country

Spinal tuberculosis (TB) accounts for 50% or more of skeletal tuberculosis. MRI is a helpful tool for spinal TB. MR findings in spinal TB however, may have several different patterns.

A Recombinant Matrix Metalloproteinase Protein from Gnathostoma spinigerum for Serodiagnosis of Neurognathostomiasis

Neurognathostomiasis is a severe form of human gnathostomiasis which can lead to disease and death. Diagnosis of neurognathostomiasis is made presumptively by using clinical manifestations. Immunoblotting, which recognizes antigenic components of molecular mass 21 kDa and 24 kDa in larval extracts of Gnathostoma spinigerum (Gs 21/24), has high sensitivity and specificity for diagnosis of neurognathostomiasis. However, only very small amounts of the Gs 21/24 antigens can be prepared from parasites harvested from natural or experimental animals. To overcome this problem, we recently produced a recombinant matrix metalloproteinase (rMMP) protein from G. spinigerum. In this study, we evaluated this rMMP alongside the Gs 21/24 antigens for serodiagnosis of human neurognathostomiasis. We studied sera from 40 patients from Srinagarind Hospital, Khon Kaen University, Thailand, with clinical criteria consistent with those of neurognathostomiasis, and sera from 30 healthy control adults from Thailand. All sera were tested for specific IgG antibodies against both G. spinigerum crude larval extract and rMMP protein using immunoblot analysis. The sensitivity and specificity for both antigenic preparations were all 100%. These results show that G. spinigerum rMMP protein can be used as an alternative diagnostic antigen, in place of larval extract, for serodiagnosis of neurognathostomiasis.

Detection of Gnathostoma spinigerum Antibodies in Sera of Non-Traumatic Subarachnoid Hemorrhage Patients in Thailand

Gnathostoma spinigerum can cause subarachnoid hemorrhage (SAH). The detection of specific antibodies in serum against G. spinigerum antigen is helpful for diagnosis of neurognathostomiasis. There is limited data on the frequency of G. spinigerum infection in non-traumatic SAH. A series of patients diagnosed as non-traumatic SAH at the Srinagarind Hospital, Khon Kaen University, Thailand between January 2011 and January 2013 were studied. CT or MR imaging of the brain was used for diagnosis of SAH. Patients were categorized as aneurysmal subarachnoid hemorrhage (A-SAH) or non-aneurysmal subarachnoid hemorrhage (NA-SAH) according to the results of cerebral angiograms. The presence of specific antibodies in serum against 21- or 24-kDa G. spinigerum antigen was determined using the immunoblot technique. The detection rate of antibodies was compared between the 2 groups. Of the 118 non-traumatic SAH patients for whom cerebral angiogram and immunoblot data were available, 80 (67.8%) patients had A-SAH, whereas 38 (32.2%) had NA-SAH. Overall, 23.7% were positive for specific antibodies against 21- and/or 24-kDa G. spinigerum antigen. No significant differences were found in the positive rate of specific antibodies against G. spinigerum in both groups (P-value=0.350).

Gender and Population Variation in Craniometry and Freehand Pass Ventriculostomy

BACKGROUND Ventriculostomy using the freehand pass method is subject to complications arising from misplacement of the catheter tip. This method may require multiple passes for successful catheterization. Methods of determining the burr-hole location (known as the Kocher point) were derived historically from European patients and may not be appropriate for other populations with different cranial shapes. This study examines the possibility that anatomic variation in interpopulation variation together with sexual dimorphism in cranial size and shape may contribute to this problem. METHODS Sagittal and parasagittal measurements of the frontal bone were taken of 300 Thai (150 female, 150 male) crania and 300 American white (150 female, 150 male) crania. These measurements were compared to determine sexual dimorphism and interpopulation variation in size and shape. RESULTS The measurements were statistically significantly larger in males than in females and on the right side than the left in both sexes in both Thai and American white samples. The frontal bone is significantly longer at the sagittal plane in Europeans of both sexes than in Thai, but in the parasagittal plane, there is no difference. This finding indicates a difference in frontal bone shape between the 2 populations and between males and females. CONCLUSIONS The dimensions of the frontal bone vary between males and females and can vary among populations. The optimal location for the burr hole in freehand pass ventriculostomy may depend on both the gender and the ancestry of the patient.

Preoperative MRI evaluation of meningioma consistency: A focus on detailed architectures

OBJECTIVES Meningioma is one of the most common primary intracranial tumors. Diagnosis by imaging is not difficult. However evaluation of tumor consistency is an important factor affecting the surgical outcomes. The purpose of our study is to discover the relationship of different findings on pre-operative MRI, with a focus on detailed architectures, and different degrees of intra-operative stiffness of meningioma. Consistency of meningioma is also analyzed in compression to semi-quantitative pathological grading of fibrosis. PATIENTS AND METHODS Sixty patients who underwent pre-operative MRI and primary surgery at our hospital were included in prospective fashion. Pre-operative MRI parameters, including general data and detailed internal architectures, were recorded. Intra-operative grading of tumor consistency was performed by the neurosurgeon. Pathological report according to WHO 2007 was performed with additional semi-quantitative grading of fibrosis. This study is focused on correlation of operative grade and MRI findings. RESULTS Meningioma with hard consistency shows significant correlation with several features including en plaque appearance (p = 0.0427), higher ADC value (p = 0.0046) and ratio (p = 0.0016), absent of prominent enhanced rim (p = 0.0306), absent of enostotic spur (p = 0.0040) and absent of vascular core (p = 0.0133) in univariate analysis but no significant correlation is found in multivariate analysis in all except ADC ratio. Higher ADC ratio increase relative risk of hard consistency of meningioma by a factor of 41.22 (ORs = 41.22; 95%CI = 1.19-1426.24, P = 0.04). Good to very good inter-rater agreements are found. No significant correlation between tumor consistency and WHO grading was shown (p = 0.606). However, near significant p-value (p = 0.055) is found with increase degree of fibrosis in pathology as increase degree of tumor consistency. CONCLUSION We found that en plaque appearance, higher ADC value and ADC ratio, absent of prominent capsular enhancement and absent of vascular core were suggestive of hard consistency in univariate analysis but not independent factors. Additionally, semi-quantitative pathological grading of fibrosis showed near significant correlation with tumor consistent.

Predictive Model for Permanent Shunting in Cryptococcal meningitis

Cryptococcal meningitis may have long-term morbidity and requires a permanent cerebrospinal fluid shunt. This study aimed to evaluate the risk factors and create a predictive model for permanent shunt treatment in cryptococcal meningitis patients. This was a retrospective analytical study conducted at Khon Kaen University. The study period was from January 2005 to December 2015. We enrolled all adult patients diagnosed with cryptococcal meningitis. Risk factors predictive for permanent shunting treatment were analyzed by multivariate logistic regression analysis. There were 341 patients diagnosed with cryptococcal meningitis. Of those, 64 patients (18.7%) were treated with permanent shunts. There were three independent factors associated with permanent shunt treatment. The presence of hydrocephalus had the highest adjusted odds ratio at 56.77. The resulting predictive model for permanent shunt treatment (y) is (-3.85) + (4.04 × hydrocephalus) + (2.13 × initial cerebrospinal fluid (CSF) opening pressure (OP) > 25 cm H2O) + (1.87 × non-human immune deficiency vrus (HIV)). In conclusion, non-HIV status, initial CSF OP greater than or equal to 25 cm H2O, and the presence of hydrocephalus are indicators of the future necessity for permanent shunt therapy.

Spinal epidural hematoma and gnathostomiasis.

Typically, spinal gnathostomiasis is presented as radiculomyelitis.1 Here, we report a spinal epidural hematoma caused by Gnathostoma spinigerum. A 28-year-old man presented with acute chest pain for 1 hour. The pain was very severe, with dull aching on his left chest and toward his back. At the hospital, he developed paraplegia and sensory loss up to the T4 level. Physical examination revealed loss of proprioceptive sensation in both feet with loose rectal sphincter tone. Laboratory tests showed no peripheral eosinophilia, normal echocardiogram, and normal computed tomography (CT) angiogram of the aorta. Magnetic resonance imaging (MRI) of thoracic spine showed an isointensity lesion on the T1 weighted image (Figure 1) and mixed hyper- and hypointensity on the T2 weighted image at the left posterior aspect of the thoracic thecal sac (Figure 2). The lesion compressed to the thoracic spinal cord. The operative finding was epidural hematoma at the T4–T6 level. Blood serological study for gnathostomiasis using the immunoblotting technique was positive for the 24-kDa antigenic band.2 This diagnostic band has a sensitivity of 91.7% and a specificity of 100% compared with healthy control subjects.2 The patient received supportive treatment, and the weakness was gradually returned to normal within a few months. Figure 1. MRI of thoracic spine showed an isointensity lesion on the T1 weighted image at the posterior aspect of the thoracic thecal sac. Figure 2. MRI of thoracic spine showed a mixed hyper- and hypo-intensity lesion on the T2 weighted image at the left posterior aspect of the thoracic thecal sac. The lesion compressed the thoracic spinal cord.