G. Nohra

Impact of the lunar cycle on the incidence of intracranial aneurysm rupture: Myth or reality?

OBJECTIVE To analyze the impact of the lunar cycle and season on the incidence of aneurysmal subarachnoid hemorrhage (SAH). PATIENTS AND METHODS The medical records of 111 patients who were admitted over a 5-year period to our department because of aneurysmal SAH were retrospectively reviewed. The date of aneurysm rupture was matched with the corresponding season and moon phase. RESULTS An incidence peak for aneurysm rupture (28 patients) was seen during the phase of new moon, which was statistically significant (p < 0.001). In contrast, no seasonal variation in the incidence of SAH was observed. CONCLUSION The lunar cycle seems to affect the incidence of intracranial aneurysm rupture, with the new moon being associated with an increased risk of aneurysmal SAH.

What happens to Modic changes following lumbar discectomy? Analysis of a cohort of 41 patients with a 3- to 5-year follow-up period

OBJECT The natural history of Modic changes (MCs) in the lumbar spine is often marked by conversion from one type to another, but their course following lumbar discectomy remains unknown. The authors sought to study the impact of surgery on the natural history of these lesions. METHODS Forty-one patients treated with lumbar microdiscectomy between 2004 and 2005 were enrolled in this study and underwent clinical evaluation and repeat MR imaging after a median follow-up of 41 months (range 32-59 months). Preoperative and follow-up MR images were reviewed and the type, location, and extent of MCs at the operated level were recorded and compared. RESULTS The study population consisted of 27 men and 14 women with a mean age of 54 years (range 24-78 years). During the follow-up period, the prevalence of MCs increased from 46.3% to 78%, and 26 patients (63.4%) had Type 2 lesions at the operated level. Of the 22 patients without MCs, 4 (18.2%) converted to Type 1 and 9 (40.9%) to Type 2. Of the 5 Type 1 lesions, 3 (60%) converted to Type 2, and 2 (40%) remained Type 1 but increased in size. In contrast, none of the 14 Type 2 changes converted to another type, although 10 (71.4%) increased in extent. There were no reverse conversions to Type 0. CONCLUSIONS Following lumbar discectomy, most patients develop Type 2 changes at the operated level, possibly as a result of accelerated degeneration in the operated disc. Neither the preoperative presence of MCs nor their postoperative course appears to affect the clinical outcome.

Schwannoma of the Tentorium Cerebelli in a Child

Intracranial schwannomas not arising from a cranial nerve are very rare. Schwannomas of the dura are even rarer; in the literature, we found only two cases: a schwannoma of the falx and one of the torcula. We report a third case of a 9-year-old girl with a schwannoma of the tentorium cerebelli. The different theories concerning the origin of this tumor in this particular location are discussed.

Neurocytome central: À propos de quatre cas

Resume Nous rapportons 4 cas de neurocytomes traites a l’Hotel-dieu de France a Beyrouth entre 1994 et 2002. Il s’agit d’une tumeur ventriculaire benigne du sujet jeune a differenciation neuronale. Elle se revele le plus souvent par un tableau d’hypertension intracrânienne. Le diagnostic histologique peut parfois se montrer difficile, necessitant le recours aux techniques d’immunomarquage. Le traitement de choix est la resection chirurgicale complete. Le pronostic est le plus souvent excellent (cas n° 1 et 2). Toutefois, meme apres une exerese totale, certaines tumeurs peuvent recidiver (cas n° 3). Dans de rares cas (cas n° 4), cette tumeur peut avoir un comportement agressif, necessitant le recours a des traitements complementaires. La prise en charge des recidives ou des residus sera discutee.

Endoscopic Third Ventriculostomy: The Lebanese Experience

Background: Endoscopic third ventriculostomy (ETV) has gained wide popularity as a first-line treatment for obstructive hydrocephalus (OHC). We have been performing ETV since 1998. We report our experience with this technique in the management of OHC. Methods: Between 1998 and 2007, we performed 49 ETV procedures in 46 patients suffering from OHC. Medical records were retrospectively reviewed. Success was defined as shunt-free survival. Results: There were 29 males and 17 females with a mean age of 23 years (6 months–65 years). Aqueductal stenosis and tectal tumor were the most common etiologies (63%). Seven patients (15.6%) had early ETV failure. Of 38 patients with initial success and available follow-up, shunt independence was achieved in 29 patients (76.3%) after a mean follow-up of 37 months. Kaplan-Meier analysis yielded a 70% 5-year shunt-free survival rate. On multivariate analysis, no variables could predict early or late ETV failure. Transient complications occurred in 6 patients (13%), but there were no ETV-related deaths or permanent morbidity. Conclusion: ETV is a safe and effective treatment for OHC, resulting in a high rate of long-term shunt independence with a low risk of complications. ETV should be considered the treatment of choice for patients with OHC and its development as a substitute to shunt placement should be encouraged in neurosurgically developing countries.

Lumbar microdiscectomy: a clinicoradiological analysis of outcome.

BACKGROUND The long-term outcome after lumbar microdiscectomy (LMD) may be affected by low back pain (LBP) and segmental instability, the determinants of which remain unclear. We sought to analyze the interaction between clinical, functional, and radiological variables and their impact on patient outcome. METHODS All patients who underwent LMD in 2004-2005 were invited to participate in this retrospective cohort study. Patients were re-evaluated clinically and radiologically after a three to five year follow-up. RESULTS Forty-one of 97 eligible patients were enrolled. Twelve patients (29.3%) reported moderate-to-severe sciatica, 12 (29.3%) had moderate LBP, and 13 (31.7%) exhibited clinical evidence of segmental instability. Thirty-eight patients (92.7%) had minimal disability and 3 (7.3%) had moderate disability. Twenty-three patients (56.1%) were fully satisfied, while 18 (43.9%) had only partial satisfaction, having expected a better outcome. Thirty-three patients (80.5%) returned to full-time work. Median disc space collapse (DSC) was 20% (range 5-66%) and L4-L5 was particularly affected. Prevalence of Modic changes increased from 46.3% to 78% with type 2 predominance. Multivariate logistic regression analysis identified the following negative prognostic factors: female sex, young age, lack of regular exercise, and chronic preoperative LBP. There was no correlation between the course of Modic changes, DSC, and patient outcome. CONCLUSION Although many patients may be symptomatic following LMD, significant disability and dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome.

Hématome intracérébral spontané du sujet jeune

Resume Introduction L’hemorragie intracerebrale spontanee (HICS) survient moins frequemment chez le sujet jeune que chez le sujet âge. Cependant, les consequences sont plus graves. Les causes de cette hemorragie sont variables d’une etude a l’autre. Le but de ce travail est d’analyser au sein d’un groupe de patients completement explores les differentes etiologies d’un HICS et d’en etablir le lien avec une hypertension arterielle. Materiels et methodes C’est une etude retrospective multicentrique portant sur 130 patients âges de 18 a 55 ans et regroupes dans 2 centres: 67 patients traites a l’Hotel-Dieu-de-France, a Beyrouth, entre 1983 et 2003, et 63 patients traites a l’Hopital de Yale — New Haven, dans l’Etat du Connecticut (Etats-Unis), entre 1995 et 1998. Nous avons inclus les patients presentant une hemorragie intracerebrale spontanee non traumatique. Les hemorragies meningees et ventriculaires isolees ont ete exclues. Les criteres permettant de considerer le bilan comme complet ont ete prealablement definis. Parmi les dossiers ayant satisfait a ces criteres, les differentes etiologies et leur rapport avec l’hypertension arterielle ont ete etudies. Resultats Quatre-vingt quatre patients (64 %) ont beneficie d’une investigation complete de l’origine de l’hemorragie. La moitie des cas incompletement investigues etait en rapport avec un deces precoce ou un etat neurologique grave. Le siege de l’hematome etait lobaire dans 59,2 % des cas, thalamo-capsulo-lenticulaire dans 26 % des cas, dans le tronc cerebral dans 8,7 % et cerebelleux dans 6,1 % des cas. Une etiologie a ete retrouvee dans pres de 70,4 % des cas (malformations arterio-veineuses (16,7 %), anevrismes (15,5 %), dyscrasies sanguines (13 %), cavernomes (10,7 %), tumeurs (4,8 %), transformation hemorragique d’un accident vasculaire cerebral ischemique (3,8 %), vascularites (2.3 %), thrombose veineuse cerebrale (1,2 %), angiome veineux (1,2 %) et fistule durale (1,2 %). Le nombre de patients chez qui aucune cause n’a ete retrouvee etait de 29,6 %. La relation avec l’hypertension arterielle a ete analysee. Dans un sous-groupe de 45 patients, 21 etaient hypertendus (46,7 %); parmi ces 21 patients, une etiologie sous-jacente a ete retrouvee dans 71 % des cas. Conclusion L’HICS peut avoir des consequences fatales chez le sujet jeune. Une recherche etiologique par un bilan complet est possible dans 64 % des cas. Elle permet d’etablir une cause dans pres de 70 % des cas, et cela independamment de la presence d’une hypertension arterielle.

Antithrombotic Medication Use and Misuse Among Patients with Intracranial Hemorrhage: A 16-Year, Lebanese, Single-Center Experience

OBJECTIVE/BACKGROUND The use of antithrombotic medication (ATM) frequently is reported in patients with intracranial hemorrhage (ICH) and is associated with increased mortality. Unfortunately, ATMs sometimes are prescribed and/or used inappropriately. We sought to determine the rate of ATM misprescription/misuse among patients with ICH in a single-center retrospective study. METHODS All patients admitted with ATM-related ICH in 1998-2014 were included. Charts were reviewed and demographic, clinical, and radiologic variables were recorded. The type of ATM, dose, and duration of treatment were analyzed critically. The adequacy of ATM prescription/use was assessed in light of the recommendations and guidelines of the American Heart Association, American Stroke Association, and French National Authority for Health, in effect at the time of admission. RESULTS A total of 106 patients with mean age 68 years were identified. Aspirin (53.8%) was the most commonly used drug, followed by oral anticoagulants (31.1%) and clopidogrel (22.6%). In only 80 patients (75.5%), the use of ATM was in line with contemporary guidelines. In the remaining 26 (24.5%), the use of ATMs was inappropriate, including bad drug combination, wrong dose, poor indication, wrong drug class, and/or incorrect treatment duration. CONCLUSIONS In this Lebanese cohort of patients with ICH, the 24.5% rate of ATM misprescription and/or misuse is highly alarming and the origin of this problem is likely multifactorial. Immediate measures should be undertaken, and efforts should be focused on regaining tight control of ATM prescription and fulfillment, ensuring good patient education, and offering more vigilant oversight on physician licensure.

Deep brain stimulation in the management of pantothenate kinase-associated neurodegeneration: a missed or a new target?

Mikati et al reported another successful approach in the management of severe and intractable dystonia in pantothenate kinase-associate neurodegeneration (PKAN) with bilateral stimulation of internal pallidal nuclei (GPi). We think that they missed the intended part of the GPi and could have provided a preliminary evidence of DBS efficacy at an alternative site. Authors stated that they bilaterally targeted the posterolateroventral part of the internal pallidum (GPi) at x1⁄4þ14.59 mm, y1⁄4 5.64 mm, z1⁄4 2.06 mm, for the right side and x1⁄4 14.7 mm, y1⁄4 5.10 mm, z1⁄4 0.43 mm, for the left side, as referred to mid-commissural point. In their MRI-based morphometric analysis, Zhu et al found that pallidal nuclei were found at a median of 18 mm, and a minimum of 15 mm lateral (x axis) to AC-PC. Likewise, investigators depicted the preferred lead positioning in pallidal stimulation of children affected with dystonia and PKAN at a minimum of 19 mm lateral to AC-PC. In the axial (y) axis, posterior GPi was successfully targeted at a maximal 3 mm anterior to mid-AC-PC in adults and children as well. Positioning of the ventral GPi (z axis) was optimally reached 3–5 mm below AC-PC line in adults with primary torsion dystonia and children with dystonia and PKAN. Hence, Mikati et al’s targets lied more medially, anteriorly and dorsally than intended. On a rather more medial plane, Dormont et al localized the thalamic nucleus 10.5 1.07 mm lateral to mid-commissural point. The same applies to Balas et al. who targeted the ventral intermedial nucleus of thalamus (VIM), 11.6 mm lateral to midline in a 10-year-old boy. All above reports were accompanied by a postoperative MRI that confirmed the proper placement of electrodes in targets. Therefore, we believe that Mikati et al. could not have reached the posterolateroventral GPi. They probably have bypassed the lateral thalamic border and have stimulated the internal capsule or anteromedial part of the pallidum. Different sections of the internal capsule (IC) were targeted for the management of psychiatric disorders, pain and motor disorders. More evidence was however needed to confirm the efficacy of IC targeting in the management of dystonia and dyskinesia. Stimulation of the anterior pallidum modulated the firing of posteroventral neurons and reduced akinesia in a patient with Parkinson’s disease, yet, the more anterodorsal was the stimulation, the lesser improvement in trunk and arms dystonia was obtained. Stimulation of the anteroventral of GPi did not influence dystonia and dyskinetic features in a 16year-old boy with Lesch-Nyhan disease, but only behavioral disturbances. In the same theme, efficacy of bilateral stimulation of dorsal pallidum – generally within the external pallidum (GPe) or internal medullary laminaon dystonia was variable but generally modest when compared to ventral stimulation. Therefore, with the absence of a postoperative brain MRI, we missed the genuine location of stimulation points which was at the origin of 67% clinical improvement (Barry–Albright dystonia score before/after surgery: 24/8) of generalized dystonia in a girl with PKAN. The consideration of an alternative therapeutic target would then deserve a thorough discussion that sheds the light on the underlying neurobiology of the observed improvement. The paradoxical clinical improvement of dystonia obtained with the stimulation of a more anteromediodorsal target than conventionally determined denotes the widespread distribution of effective therapeutic stimulation points and the interindividual variability and heterogeneity of dysfunctioning circuitries in different forms of dystonia and dystoniaassociated diseases.