C.-H. Lu

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy.

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

Changing Epidemiology of Adult Bacterial Meningitis in Southern Taiwan: A Hospital-Based Study

Background:Many factors may influence the epidemiologic trend of adult bacterial meningitis (ABM). The objective of this study was to analyze recent epidemiologic trends of ABM in order to provide a better therapeutic strategy.Materials and Methods:The clinical features, laboratory data, and therapeutic outcomes of 181 ABM cases collected in the last 6.5 years (July 1999–December 2005) were analyzed. The results were compared with those of our previous study (202 cases, January 1986–June 1999).Results:The 181 cases consisted of 130 men (age range: 18–82 years) and 51 women (age range: 18–78 years). Monomicrobial infection and mixed infection were found in 165 cases and 16 cases, respectively. A preceding postneurosurgical state was noted in 56.9% (103/181) of cases. Despite a decrease in incidence, Klebsiella pneumoniae (25.5%, 42/165) was still the most common pathogen. A marked increase of Acinetobacter meningitis (11.5%, 19/165) was noted, which replaced Pseudomonas meningitis as the second most common Gram-negative pathogen in ABM. A marked increase in staphylococcal infection, accounting for 23% (38/165) of all cases, was also noted, of which 76% (29/38) were methicillin-resistant strains. The therapeutic result showed a mortality rate of 30.3% (55/181). Significant prognostic factors included septic shock and age at infection.Conclusions:This study revealed a change in the epidemiologic trend of ABM, with an increase in the number of patients with a postneurosurgical state and a rising incidence of Acinetobacter and staphylococcal infections. Clinicians should pay greater attention to these changes, which may affect their management of ABM.

Spinal epidural abscess in adults caused by Staphylococcus aureus: Clinical characteristics and prognostic factors

OBJECTIVEnSpinal epidural abscess (SEA) is a devastating infectious disease, which may result in neurologic sequelae. Staphylococcus (S.) aureus is a common pathogen of SEA. Here, we analyzed the clinical characteristics and laboratory data of adult patients with S. aureus SEA and compared the clinical characteristics of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) infections.nnnMETHODSnBetween 2003 and 2008, we collected data regarding 29 adult cases of S. aureus SEA and analyzed the clinical presentations, magnetic resonance (MR) imaging features, therapeutic outcome, and prognostic factors. Antibiotic susceptibility test results of 11 implicated MRSA strains were also further analyzed.nnnRESULTSnWe identified 17 MSSA strains and 12 MRSA strains. Lumbar and lumbosacral spine segments were the most commonly involved segments. All 29 patients had back pain. Other findings included sensory abnormalities (25), motor weakness (21), fever (16), bladder dysfunction (16), and altered consciousness (3). Disease onset at admission was acute in 6 cases and chronic in 23. The stages of disease severity were early stage in 9 and late stage in 20. After therapy, 21 patients had a good prognosis and 8 had a poor prognosis. Significant prognostic factors included older age (>70years), presence of diabetes mellitus, adrenal insufficiency, and MRSA infection. The prognosis alone was clinically different between patients with MSSA and MRSA infections.nnnCONCLUSIONSnPatients with localized back pain, particularly those with a fever and compromised immune system, should undergo MR imaging to ensure an early diagnosis and management.

Cerebrotendinous Xanthomatosis Patients With and Without Parkinsonism: Clinical Characteristics and Neuroimaging Findings

Parkinsonism in cerebrotendinous xanthomatosis (CTX) is rare. There are no published studies with imaging findings of dopamine transporter using 99mTc‐[2‐[[2‐[[[3‐(4‐chlorophenyl)‐8‐methyl‐8‐azabicyclo [3,2,1] oct‐2‐yl] methyl] (2‐mercaptoethyl) amino] ethyl] amino]‐ethanethiolato(3‐)‐N2,N2,S2,S2]oxo‐[1R‐(exo‐exo)] (99mTc‐TRODAT‐1) SPECT in CTX patients. This report is on the clinical details of five genetically‐proven CTX patients (two with and three without parkinsonism). Imaging findings using cranial magnetic resonance (MR) imaging and 99mTc‐TRODAT‐1 SPECT are also shown. Clinical correlation of neuroimaging findings and clinical presentations was made. A literature review of the clinical and neuroimaging features of eight CTX patients with parkinsonism reported in the English literature is also presented. The parkinsonian features of our two cases and the other eight reported cases occurred before the age of 50 years. The MR imaging study showed variable findings, in which, besides the common diffuse cerebral and cerebellar white matter lesions shown in CTX, several focal brain lesions were also noted. Of the focal lesions, substantia nigra abnormalities were seen only in the two cases with parkinsonism. The 99mTc‐TRODAT‐1 SPECT study showed different degrees of unilateral or bilateral abnormalities in the striatal binding in both visual and semiquantitative assessments. parkinsonism can be one of the neurologic presentations of CTX. Even though abnormal findings of the substantia nigra were detected in both of our CTX patients with parkinsonism, basal ganglion lesions have not been uniformly described in MR imaging findings of reported CTX patients with parkinsonism. 99mTc‐TRODAT‐1 SPECT study can be of value in the detection of striatal involvement, and the study results also suggest pre‐synaptic dopamine neuron involvement in CTX patients with parkinsonism.

Risk factors and outcome of seizures after spontaneous aneurysmal subarachnoid hemorrhage

Background and purpose:u2002 Seizures are important neurologic complications of spontaneous aneurysmal subarachnoid hemorrhage (SAH). A better understanding of the risk factors of seizures following aneurysmal SAH is needed to predict those who will require treatment.

Clinical characteristics and therapeutic outcome of Gram-negative bacterial spinal epidural abscess in adults

Gram-negative (G(-)) bacterial spinal epidural abscess (SEA) in adults is uncommon. Of the 42 adult patients with bacterial SEA admitted to the Chang Gung Memorial Hospital - Kaohsiung, between 2003 and 2007, 12 with G(-) SEA were included in this study. Of these 12 patients, seven were men and five were women; their ages ranged between 17 years and 81 years (median=72.5 years, mean=62.5 years). The patients were admitted at different stages of symptom onset (four were in the acute stage and four each in the subacute and chronic stages) and at different levels of neurologic deficit severity, ranging from back pain to paraplegia. Of these 12 patients, 11 had a medical and/or neurosurgical condition as the preceding event and four had a concomitant infection at other sites. Back pain (83%, 10/12) was the most common clinical presentation, followed by paraparesis (50%, 6/12), radiating pain (33%, 4/12), and urinary retention (25%, 3/12). The following causative G(-) pathogens were detected: Klebsiella pneumoniae (three patients), Salmonella spp. (three), Escherichia coli (two), Enterobacter spp. (two), Aeromonas hydrophila (one), and Prevotella melaninogenica (one). Both Enterobacter strains were resistant to multiple antibiotics. Of the 12 patients, eight (66.7%) had spontaneous SEA, whereas the remaining four had postneurosurgical SEA. Thoracic, lumbar, and thoracolumbar spine segments were the most commonly affected. After receiving medical and/or surgical treatment, 10 of the 12 patients (83%) survived, and all 10 recovered well. In conclusion, G(-) bacterial SEA accounted for 28.5% (12/42) of adult SEA. The causative G(-) pathogens found in this study were different from those reported in Western countries, and the strains noted in our study had multiple antibiotic resistance. Our findings suggest that the choice of initial empirical antibiotics for SEA should be carefully considered.

The value of serial plasma nuclear and mitochondrial DNA levels in adult community-acquired bacterial meningitis

BACKGROUNDnIncreased levels of plasma nuclear and mitochondrial DNA have been reported in critically ill patients. We tested the hypothesis that plasma nuclear and mitochondrial DNA are substantially increased in acute bacterial meningitis and decrease after antimicrobial therapy, and that plasma nuclear and mitochondrial DNA levels can predict treatment outcomes.nnnMETHODSnWe examined serial plasma nuclear and mitochondrial DNA levels in 22 adult community-acquired bacterial meningitis (ACABM) patients. The plasma nuclear and mitochondrial DNA levels were also evaluated in 11 aseptic meningitis patients and 22 volunteer subjects during the study period.nnnRESULTSnAll of the both bacterial and aseptic meningitis groups had a higher plasma DNA levels on admission as compared with those of volunteer groups. Levels of plasma nuclear and mitochondrial DNA in ACABM cases were significantly increased initially and substantially decreased thereafter. Both plasma nuclear DNA and plasma mitochondrial DNA levels at presentation are significantly negative correlate with modified Barthel Index (average) (r = -0.639, P = 0.004 and r = -0.551, P = 0.018) at 3 months after discharge (average), respectively, in this study. Both higher plasma nuclear (cutoff value of >169 ng/ml) and mitochondrial DNA levels (cutoff value of >58.9 ng/ml) at presentation were associated with poor outcome in ACABM patients.nnnCONCLUSIONnBased on our results, the higher plasma DNA levels were associated with a poorer outcome. Therefore, we look forward to more prospective multicenter investigations specifically to confirm the predictive value of plasma DNA levels in outcome prediction.

Time course of cerebral hemodynamics in cryptococcal meningitis in HIV-negative adults.

To evaluate the cerebral hemodynamics in cryptococcal meningitis (CM) patients using non‐invasive studies. Serial trans‐cranial color‐coded sonography (TCCS) and magnetic resonance angiography (MRA) studies were performed to measure the cerebral vasculopathy of 12 HIV‐negative CM patients. With TCCS, 8 of the 22 middle cerebral arteries (MCAs) showed stenotic velocities, whereas the time‐mean velocity (Vmean) of the 20 anterior cerebral arteries (ACAs), 22 posterior cerebral arteries (PCAs), and 12 basilar arteries (BAs) did not. In total, five patients had stenotic velocities, three of whom had bilateral M1 stenosis (<50%), whilst two had unilateral M1 stenosis (<50%). The Vmean of MCA increased from day 1 to day 35 and substantially decreased thereafter. The mean Pulsatility Index (PI) in the studied vessels was higher during the study period. A mismatch of the findings between TCCS and MRA studies were also demonstrated. There was a high incidence and a longer time‐period of disturbed cerebral hemodynamics during the clinical course of CM. However, because of the limited case numbers for this study, further large‐scale studies are needed to delineate the clinical characteristics and therapeutic influence of cerebrovascular insults in HIV‐negative CM patients.

Postneurosurgical nosocomial bacterial brain abscess in adults.

Background:Bacterial brain abscess after a neurosurgical procedure has become an important occurrence in the hospital setting. However, no information about the frequency, clinical relevance, and the outcome has been reported.Patients and Methods:Over a period of 19 years (1986– 2004), a total of 31 patients were retrospectively identified as having brain abscesses after neurosurgical procedures and were enrolled in this study.Results:Those included in this study accounted for 0.17% (31/18600) of all neurosurgical procedures in the same period. There was an increased percentage of adult postneurological nosocomial brain abscess compared to all adult bacterial brain abscesses in recent years. The majority of cases were due to Gram-negative bacilli and polymicrobial infections, including both Gram-negative bacilli and Staphylococcus species. Furthermore, the appearance of multi-antibiotic resistant strains was also noted during the study period. The overall fatality rate was 16%.Conclusion:Post-neurosurgical states have become important predisposing factor for bacterial brain abscess. In patients that undergo neurosurgical procedures and develop smoldering fever, progressively disturbed consciousness, headache, and new onset focal neurologic signs, immediate neuro-imaging studies should be undertaken to determine whether bacterial brain abscess is present. Although mortality may be related to the primary brain pathology, early diagnosis and timely use of appropriate antibiotics based on antimicrobial susceptibility testing are also essential for survival.

Clinical relevance of intracranial arterial stenoses in tuberculous and cryptococcal meningitis

Objectives:Tuberculous and cryptococcal meningitis are two of the most common types of chronic meningitis. The study was performed to assess whether the occurrence of intracranial arterial stenosis is a risk factor for poor outcome in tuberculous and cryptococcal meningitis.Methods:The clinical relevance of intracranial arterial stenoses in tuberculous and cryptococcal meningitis was studied using transcranial color-coded sonography (TCCS) and magnetic resonance angiography (MRA) over the period of 1 year (2003). A comparison was made between patients with and those without intracranial arterial stenoses during hospitalization.Findings:There were 12 males and three females. Four patients (27%, 4/15) exhibited a stenosis of at least one cerebral artery, of which three had bilateral middle cerebral artery (MCA) stenosis and one had unilateral MCA stenoses. The stenoses were demonstrable during the whole observation period. After 6 months of follow-up, fatality rate was 50% (2/4) in those with intracranial arterial stenosis and 9% (1/11) in those without. Risk of poor outcome at a 6-month endpoint had an odds ratio of 5.3 for patients with intracranial arterial stenoses than those without (reference group).Conclusions:Intracranial arterial stenoses imply danger of cerebrovascular complications for the treatment of chronic meningitis during hospitalization. This study demonstrates that the frequency of intracranial stenosis in patients affected by chronic meningitis is high (27%) and it may be associated with poorer outcomes.