David T.F. Sun

Anaplastic oligodendroglioma with drop metastasis to the spinal cord.

Although cerebrospinal fluid spread by malignant brain tumors is well recognised, cases of drop metastasis to spinal cord by intracranial oligodendroglial tumors have only been rarely described. We described a 61-year-old man who developed diffuse spinal metastases and cord compression 20 months after resection of a frontal lobe anaplastic oligodendrogliomas. To our knowledge, this represents the eighth recorded case in the literature.

Phase I–II clinical trial assessing safety and efficacy of umbilical cord blood mononuclear cell transplant therapy of chronic complete spinal cord injury

Umbilical cord blood-derived mononuclear cell (UCB-MNC) transplants improve recovery in animal spinal cord injury (SCI) models. We transplanted UCB-MNCs into 28 patients with chronic complete SCI in Hong Kong (HK) and Kunming (KM). Stemcyte Inc. donated UCB-MNCs isolated from human leukocyte antigen (HLA ≥4:6)-matched UCB units. In HK, four patients received four 4-μl injections (1.6 million cells) into dorsal entry zones above and below the injury site, and another four received 8-μl injections (3.2 million cells). The eight patients were an average of 13 years after C5-T10 SCI. Magnetic resonance diffusion tensor imaging of five patients showed white matter gaps at the injury site before treatment. Two patients had fiber bundles growing across the injury site by 12 months, and the rest had narrower white matter gaps. Motor, walking index of SCI (WISCI), and spinal cord independence measure (SCIM) scores did not change. In KM, five groups of four patients received four 4-μl (1.6 million cells), 8-μl (3.2 million cells), 16-μl injections (6.4 million cells), 6.4 million cells plus 30 mg/kg methylprednisolone (MP), or 6.4 million cells plus MP and a 6-week course of oral lithium carbonate (750 mg/day). KM patients averaged 7 years after C3-T11 SCI and received 3–6 months of intensive locomotor training. Before surgery, only two patients walked 10 m with assistance and did not need assistance for bladder or bowel management before surgery. The rest could not walk or do their bladder and bowel management without assistance. At about a year (41–87 weeks), WISCI and SCIM scores improved: 15/20 patients walked 10 m (p = 0.001) and 12/20 did not need assistance for bladder management (p = 0.001) or bowel management (p = 0.002). Five patients converted from complete to incomplete (two sensory, three motor; p = 0.038) SCI. We conclude that UCB-MNC transplants and locomotor training improved WISCI and SCIM scores. We propose further clinical trials.

Spontaneous intracerebral haematoma with rapidly deteriorating level of consciousness: treatment by a mobile neurosurgeon.

Neurosurgical resources are concentrated inregional centres, towhichpatients withneurosurgical conditions fromdistrict general hospitals are transferred. This works well for stable patients. In neurosurgical emergencies, teleradiologyhas been showntostreamline inter-hospital management by significantly reducingunnecessarytransfer, facilitating the institutionof therapeutic interventions before transferanddecreasingthe incidenceof adverseevents during the transfer1,2. Inthe presence of anintracranial mass lesion, the transfer of a deteriorating patient toaneurosurgical centre for immediate decompressive surgeryhas been showntoresult inanunfavourable outcome3,4. We report a case inwhicharapidlydeteriorating level of consciousness anda unilateral dilating pupil was identified inthe accident andemergencydepartment. The operative andintensive-care management of this patient was carriedout inthe district general hospital bya mobile neurosurgical team, without transfer. A goodclinical outcome was achieved. The roles of an efficient 24hcomputerizedtomography(CT) service, teleradiology, operating roomfacilityandexpertise, anaesthetic andintensive-care expertise are equally important. Casereport ...............................................................................

Blessing or burden? Long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps: Long-term maintenance of baclofen pumps

The intrathecal baclofen pump is an effective treatment for spasticity. However, long‐term results have reported patients’ dissatisfaction and perception of disability. Potential causes include a frequent need for baclofen pump refill and risks of complications. The aim of the present study was to evaluate the long‐term maintenance, complications and clinical outcome of intrathecal baclofen pumps.

Impaired transcranial Doppler ultrasound cerebrovascular reactivity before carotid intervention is not predictive of a subsequent ischaemic event

Aim:  After carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) for patients with severe carotid stenosis, an ischaemic event may still happen in up to 9% of patients over a 2 year period. We aimed to investigate whether baseline cerebrovascular reactivity could predict a subsequent ischaemic event after intervention.

Ischemic events after carotid interventions in relationship to baseline cerebrovascular reactivity

BACKGROUND We aimed to investigate whether baseline cerebrovascular reactivity could predict subsequent ischemic event after intervention and identify the patient group for more aggressive medical and interventional management paradigms. METHODS Patients with more than 70% cervical carotid stenosis (from ultrasonography) were reviewed. Patients, who had baseline cerebrovascular reactivity test before intervention and had either carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) performed, were recruited for analysis. Transcranial Doppler ultrasonography was used to examine the reactivity of the middle cerebral artery in response to 5% carbon dioxide in oxygen. The mean follow up period was 66 months. FINDINGS Twenty-six patients had symptomatic carotid stenosis and ten patients had asymptomatic carotid stenosis. There were four subsequent ischemic events during follow up. None of the nine patients with impaired baseline ipsilateral cerebrovascular reactivity had subsequent ischemic event. CONCLUSIONS In this current study, impaired baseline cerebrovascular reactivity did not predict the subsequent stroke risk after carotid intervention. Cerebrovascular reactivity testing may not serve as an indicator for aggressive medical and surgical treatments.

Management of spinal injury

Spinal injury often affects young adults and results in debilitating neurological status, which in turn places a significant burden on society. This review article describes the current practice and controversies surrounding the management of spinal injury. General principles of pre-hospital management, resuscitation, medical treatment, surgical intervention and future advancement are reviewed.