Anastasia Tasiou

IL-1RN and IL-1B gene polymorphisms and cerebral hemorrhagic events after traumatic brain injury.

Objective: To investigate the association of (variable number tandem repeat) interleukin (IL) 1RN and (-511) IL-1B gene polymorphisms with brain hemorrhagic events after traumatic brain injury (TBI). Methods: Data from brain CT, Glasgow Coma Scale (GCS) at admission, and 6-month Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) were collected for 151 prospectively recruited patients with TBI. IL-1RN and IL-1B genotypes were determined using standard methods. Presence vs absence of any type of brain hemorrhage was the main outcome. Type of brain hemorrhage, GCS at admission, and 6-month GOS and mRS were secondary outcomes. Odd ratios (ORs) and corresponding 95% CI were calculated using logistic regression analyses. In adjusted models, the associations were controlled for age, gender, diffuse brain edema, volume of intracranial hematoma, neurosurgical intervention, and GCS at admission. p values less than 0.01 were considered significant. Results: Compared with noncarriers, IL-1RN allele 2 carriers had higher odds of having cerebral hemorrhages after TBI (adjusted OR = 4.57; 95% CI = 1.67 to 12.96; p = 0.004). The associations for (-511) IL-1B polymorphism were not significant. Conclusion: There is an association between the presence of interleukin-1RN allele 2 and posttraumatic brain hemorrhage.

Serum and cerebrospinal fluid C-reactive protein levels as predictors of vasospasm in aneurysmal subarachnoid hemorrhage. Clinical article.

OBJECT Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. The C-reactive protein (CRP) constitutes a highly sensitive inflammatory marker. The association of elevated systemic CRP and coronary vasospasm has been well established. Additionally, elevation of the serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between elevated CRP levels in the serum and CSF and the development of vasospasm in patients with aSAH. METHODS A total of 41 adult patients in whom aSAH was diagnosed were included in the study. Their demographics, the admitting Glasgow Coma Scale (GCS) score, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum and CSF CRP measurements were obtained on Days 0, 1, 2, 3, 5, 7, and 9. All patients underwent either surgical or endovascular treatment within 48 hours of their admission. The outcome was evaluated using the Glasgow Outcome Scale and the modified Rankin Scale. RESULTS The CRP levels in serum and CSF peaked on the 3rd postadmission day, and the CRP levels in CSF were always higher than the serum levels. Patients with lower admission GCS scores and higher Hunt and Hess and Fisher grades had statistically significantly higher levels of CRP in serum and CSF. Patients with angiographic vasospasm had higher CRP measurements in serum and CSF, in a statistically significant fashion (p < 0.0001). Additionally, patients with higher CRP levels in serum and CSF had less favorable outcome in this cohort. CONCLUSIONS Patients with aSAH who had high Hunt and Hess and Fisher grades and low GCS scores showed elevated CRP levels in their CSF and serum. Furthermore, patients developing angiographically proven vasospasm demonstrated significantly elevated CRP levels in serum and CSF, and increased CRP measurements were strongly associated with poor clinical outcome in this cohort.

Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations.

OBJECT In addition to difficulties with anesthetic and medical management, transsphenoidal operations in patients with longstanding acromegaly are associated with inherent intraoperative challenges because of anatomical variations that occur frequently in these patients. The object of this study was to review the overall safety profile and anatomical/technical challenges associated with transsphenoidal surgery in patients with acromegaly. METHODS The authors performed a retrospective analysis of 169 patients who underwent endoscopic transsphenoidal operations for growth hormone-secreting adenomas to assess the incidence of surgical complications. A review of frequently occurring anatomical challenges and operative strategies employed during each phase of the operation to address these particular issues was performed. RESULTS Of 169 cases reviewed, there was no perioperative mortality. Internal carotid artery injury occurred in 1 patient (0.6%) with complex sinus anatomy, who remained neurologically intact following endovascular unilateral carotid artery occlusion. Other complications included: significant postoperative epistaxis (5 patients [3%]), transient diabetes insipidus (5 patients [3%]), delayed symptomatic hyponatremia (4 patients [2%]), CSF leak (2 patients [1%]), and pancreatitis (1 patient [0.6%]). Preoperative considerations in patients with acromegaly should include a cardiopulmonary evaluation and planning regarding intubation and other aspects of the anesthetic technique. During the nasal phase of the transsphenoidal operation, primary challenges include maintaining adequate visualization and hemostasis, which is frequently compromised by redundant, edematous nasal mucosa and bony hypertrophy of the septum and the nasal turbinates. During the sphenoid phase, adequate bony removal, optimization of working space, and correlation of imaging studies to intraoperative anatomy are major priorities. The sellar phase is frequently challenged by increased sellar floor thickness, distinct patterns of tumor extension and bony invasion, and anatomical variations in the caliber and course of the internal carotid artery. Specific operative techniques for addressing each of these intraoperative challenges are discussed. CONCLUSIONS Transsphenoidal surgery in patients with longstanding acromegaly frequently poses greater challenges than operations for other types of sellar lesions, yet these challenges may be safely and effectively overcome with the anticipation of specific issues and implementation of various intraoperative techniques.

Bundle of Measures for External Cerebral Ventricular Drainage-associated Ventriculitis*

Objective:To assess the prevalence and outcome of external cerebral ventricular drainage-associated ventriculitis in neurocritical patients before and after the implementation of a bundle of external cerebral ventricular drainage-associated ventriculitis control measures. Design:Clinical prospective case series. Setting:University Hospital of Larissa, Greece. Patients:Consecutive patients were recruited from the ICU of the hospital. Patient inclusion criteria included presence of external ventricular drainage and ICU stay more than 48 hours. Intervention:The bundle of external cerebral ventricular drainage-associated ventriculitis control measures included 1) reeducation of ICU personnel on issues of infection control related to external cerebral ventricular drainage, 2) meticulous intraventricular catheter handling, 3) cerebrospinal fluid sampling only when clinically necessary, and 4) routine replacement of the drainage catheter on the seventh drainage day if the catheter was still necessary. The bundle was applied after an initial period (preintervention) where standard policy for external cerebral ventricular drainage-associated ventriculitis was established. Measurements:External cerebral ventricular drainage-associated ventriculitis prevalence, external cerebral ventricular drainage-associated ventriculitis events per 1,000 drainage days (drain-associated infection rate), length of ICU stay, Glasgow Outcome Scale at 6 months, and risk factors for external cerebral ventricular drainage-associated ventriculitis. Main Results:Eighty-two patients entered the study in the preintervention period and 57 patients during the intervention period. During the preintervention and intervention period, external cerebral ventricular drainage-associated ventriculitis prevalence was 28% and 10.5% (p = 0.02) and drain-associated infection rate was 18 and 7.1, respectively (p = 0.0001); mean (95% CI) length of ICU stay in patients who presented external cerebral ventricular drainage-associated ventriculitis was 44.4 days (36.4–52.4 d), whereas mean (95% CI) length of ICU stay in patients who did not was 20 days (16.9–23.2 d) (p < 0.001). Furthermore, the length of ICU stay was associated with length of drainage (p = 0.0001). Therefore, the presence of external cerebral ventricular drainage-associated ventriculitis and the length of drainage were the only variables associated with a prolonged ICU stay. Unfavorable outcome in Glasgow Outcome Scale at 6 months was not associated with the presence of external cerebral ventricular drainage-associated ventriculitis (p = 0.5). No significant differences were found when Glasgow Outcome Scale was analyzed according to the two study periods. Conclusions:The implementation of a bundle of measures for external cerebral ventricular drainage-associated ventriculitis control was associated with significantly decreased postintervention prevalence of the infection.

Endoscopic Endonasal Transsphenoidal Removal of Recurrent and Regrowing Pituitary Adenomas: Experience on a 59-Patient Series

OBJECTIVE The nature of the pituitary adenomas itself exposes the possibility of a recurrence of the tumor. The aim of this study was to evaluate the effectiveness of the endoscopic endonasal transsphenoidal approach for the removal of recurrent and residual pituitary adenomas, already treated by a microscopic or endoscopic transsphenoidal approach or by a transcranial route. METHODS A total of 59 adult patients with a recurrent or regrowing pituitary adenoma underwent surgery using a pure endoscopic endonasal transsphenoidal approach. Of these patients, 31 were previously operated on by a microsurgical transsphenoidal approach, 22 by means of an endoscopic transsphenoidal route, and 6 via a transcranial route. The patient series has been divided into 3 tiers according to the primary surgery, and the results were evaluated accordingly. RESULTS Gross total removal was achieved in 37 of our cases (62.7%). According to prior surgery at primary disease, we found that in the subgroup of patients who underwent a microsurgical transsphenoidal approach we achieved gross total removal in 23 cases (74.2%; 23 of 31), whereas in the group of patients who underwent the endoscopic endonasal approach, gross total removal was attained respectively in 13 cases (59.1%; 13 of 22) and in only 1 case of those who underwent the transcranial approach (16.7%; 1 of 6). Postoperative complications included 1 case (1.7%) of cerebrospinal fluid leak and meningitis, and 1 with an hematoma in the tumor field (1.7%); both needed surgical reoperation. CONCLUSIONS The endoscopic endonasal approach is a safe and effective procedure for the management of recurrent and/or regrowing pituitary tumors previously treated by either a microsurgical or an endoscopic approach.

Alpha-1 Antichymotrypsin Gene Signal Peptide A/T Polymorphism and Primary Intracerebral Hemorrhage

Background/Aims: Alpha-1 antichymotrypsin (ACT), a serine proteinase inhibitor, has been implicated in vascular pathology. The TT genotype of the ACT signal peptide A/T polymorphism has been reported to confer susceptibility to primary intracerebral hemorrhage (PICH). We conducted a prospective study to test possible association of ACT signal peptide A/T polymorphism with PICH in a Greek cohort with enough power (80%) to detect a twofold increase in the odds ratio. Methods: We prospectively recruited 147 patients with PICH. ACT signal peptide A/T genotypes were determined in patients and 206 healthy, age- and sex-matched control subjects from the neurology outpatient clinic using the polymerase chain reaction restriction fragment length polymorphism method. Results: Our study did not show an association between ACT signal peptide A/T polymorphism and PICH. We also failed to find any influence on age at onset, the location and volume of PICH as well as on clinical severity at admission or 6-month outcome. Conclusion: Our data failed to confirm an association between ACT signal peptide A/T polymorphism and PICH. However, we cannot exclude the possibility that the TT genotype confers susceptibility at less than a twofold increase.

Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study

Idiopathic normal pressure hydrocephalus is a hydrodynamic disorder whose etiology remains unclear. The diagnosis is mainly clinical and the traditional treatment is cerebrospinal fluid shunt diversion. With the introduction of modern management strategies, endoscopic third ventriculostomy has become a viable alternative to shunting and constitutes a well-established method of treatment for obstructive hydrocephalus. The new hydrodynamic concept of hydrocephalus suggests that endoscopic third ventriculostomy (ETV) may be an effective treatment for communicative hydrocephalus. In our current review, the authors focus on the up-to-date knowledge regarding the consideration of endoscopic third ventriculostomy as a safe surgical option in the management of idiopathic normal pressure hydrocephalus.

An evidence-based approach towards the cranio-cervical junction injury classifications

PurposeThe cranio-cervical junction (CCJ) is an anatomically, functionally and biomechanically complex region. It is commonly involved in trauma of varying severity that can be managed with a multitude of treatment options and carry diverse prognosis. Our objective is to evaluate the quality of currently used CCJ injury classifications in an evidence-based approach.MethodsWe performed two consecutive literature reviews. In the first, we tried to find which classifications are currently used in CCJ injuries. In the second, we scrutinized the gathered classifications in terms of validity, reliability, severity grading, treatment guidance and prognosis assessment.ResultsTwenty classifications are currently used to describe the CCJ injuries and 72 individual injury patterns have been recognized. Almost a third of them can grade severity, guide treatment and assess prognosis. Only two classifications have been tested for validity and reliability.ConclusionsCCJ injuries are poorly described by the current classifications according to evidence-based criteria. There is an obvious need for a simple and reliable classification tool to guide patient management in the evidence-based medicine era.

Collagen type-I A2 gene polymorphisms and susceptibility to intracranial aneurysms: a meta-analysis of genetic association studies

ABSTRACT Background: The development, evolution and rupture of intracranial aneurysms are in part related to genetic factors. The role of collagen type-I a2 genetic polymorphisms has not been clarified yet. Material and methods: A meta-analysis was realized by means of a genotype model-fitting process (allele contrast, recessive, dominant, additive and co-dominant), and a model-free approach using the generalized odds ratio. The latter was assessed in association to the degree of dominance (h-index). Results: No statistically significant association was documented between EX28 G>C collagen type-I a2 variant and intracranial aneurysms (generalized odds ratio = 1.23, 95% confidence interval = 0.57, 2.63). Significant associations between INT46 T>G collagen type I a2 variant and intracranial aneurysms were documented in three models, the dominant [0.52 (0.38, 069)], the co-dominant [0.50 (0.32, 0.78)] and the allele contrast models [0.63 (0.49, 0.82)]. The generalized odds ratio was estimated to be as high as 1.94 (1.23, 3.06). The degree of dominance (h-index = −1.54) indicated that the TG genotype was characterized by lower risk of developing intracranial aneurysms compared to the TT genotype. Conclusions: The available literature data demonstrated that there is no association of collagen type-(2a) and intracranial aneurysms, through EX28 G>C (rs42524) polymorphism according to the model-fitting process and the model-free approach. Regarding the INT46 T>G (rs2621215) polymorphisms, the latter models indicated that there could be a protective effect of the G-allele against the development of intracranial aneurysms. However, the majority of studies are from East Asia, therefore the results are applicable primarily to that patient population.

Hemorrhagic transformation of posterior fossa ischemia after antithrombotic therapy for a blunt vertebral artery injury: a case report

We describe a rare case of a 69-year-old male who developed a hemorrhagic transformation of a posterior fossa ischemia after the initiation of antithrombotic therapy for the management of blunt vertebral artery injury (BVAI). To the best of our knowledge, this is the first reported case in the literature so far. Thus, we present our diagnostic approach, its associated treatment challenges, and its overall outcome.