George Stranjalis

Elevated Serum S-100B Protein as a Predictor of Failure to Short-Term Return to Work or Activities after Mild Head Injury

Protein S-100B is an established serum marker of primary and secondary brain damage and stroke. A group of patients after mild head injury (MHI) develop post-concussion symptoms that interfere with the ability in the short-term to return to work or undertake certain activities. The aim of this study was to examine the correlation of serum S-100B with short-term outcome after MHI. We studied 100 subjects who were referred to the Emergency Department (ED) after a MHI. All subjects had a GCS of 15 either with or without loss of consciousness (LOC) and/or post-traumatic amnesia (PTA). Serum S-100B was collected within 3 h from the injury and a value of > or = 0.15 microg/L was considered as abnormal. Subjects with other injuries, including scalp or cervical spine, were excluded, as well as those with alcohol/narcotic drug consumption or history of serious physical/mental illness. An independent observer measured the return to work/activities within one week. Thirty-two (32%) subjects had elevated S-100B. The failure to return to work/activities was significantly correlated with elevated S-100B: subjects with increased S-100B had a failure rate of 37.5% versus 4.9% of those with normal values (p = 0.0001). In MHI, the elevated S-100B seemed to correlate with an unfavorable short-term outcome. This might be useful in (1) selecting patients who need closer observation, hospitalization, and further investigations (such as CT scan or MRI), and (2) the prognosis of genuine post-concussion symptoms, that interfere with return to work or activities, versus other causes such as premorbid personality, labyrinthine dysfunction, whiplash syndrome, postinjury stress, occupational injury, litigation, and malingering.

CT-guided stereotactic biopsies of brain stem lesions: personal experience and literature review

Abstract.Appropriate therapy of brain stem lesions should be guided by an accurate diagnosis. Clinical evaluation combined with modern neuroimaging techniques may nowadays approach the diagnosis but not always with accuracy, thus leading to erroneous treatment. We report a series of 11 patients who underwent stereotactic biopsy for brain stem lesions. In 8 patients, the lesion was approached transfrontally. In the remaining 3 patients, the lesion was approached via the suboccipital transcerebellar route. There was no surgical mortality. Precise histological diagnosis was achieved in all patients. Three patients (27.2%) suffered complications attributed to the procedure and were successfully treated conservatively. Histological results were in accordance with preoperative diagnosis in 9 patients (81.8%). Despite the limited number of patients, our data suggest that stereotactic biopsy of brain stem lesions is a safe technique that can obtain adequate tissue for histological diagnosis, thus providing each patient with the best available treatment.

Outcome in 1,000 head injury hospital admissions: the Athens head trauma registry

BACKGROUND The aim of this study was to establish a head trauma registry to (a) examine demographics, etiology, severity, clinical course, and outcome; (b) compare results with previous published series; (c) identify causes of bad outcomes; and (d) propose methods to improve therapy and prognosis. METHODS The following data were collected on 1,000 consecutive victims with head injury over 14 years of age admitted during a 4-year period: demographic characteristics, cause of injury, clinical variables, neuroimaging, therapy data, and outcome in 6 months. RESULTS Seventy-four percent were men, and mean age was 43 years. Seventy-one percent suffered injuries due to road crashes, 14% due to alcohol, and 2% due to substances. The secondary transfer rate was 49%. For severe injuries, the time intervals from incident to hospital and subsequently to neurosurgical unit were 35 minutes and 4 hours, respectively. In 65% and 72% of cases, there was no record of preresuscitation hypoxia or hypotension, respectively, whereas suspected or definite episodes of hypoxia and hypotension were 27% and 13%, respectively. Most cases were mild trauma (63%), the remaining were severe (26%) and moderate (11%) injuries. Severe systemic trauma coexisted in 18%. Cranial surgery rate was 19% and it increased to 39% in severe trauma. The 6-month overall good outcome was 71%, with lower rates in moderate (58%) and severe (24%) injuries. CONCLUSIONS The organization of Greeces first head injury registry offered an important preliminary core data concerning brain trauma etiology, management, and long-term outcome.

The prognostic value of serum S-100B protein in spontaneous subarachnoid haemorrhage

SummaryBackground. Despite the major progress in neurophysiological monitoring, there are still difficulties in the early identification and quantification of cerebral damage after a stroke. In this prospective study we examined the associations between serum S-100B protein, a serum marker of brain injury, and initial neurological-neuroimaging severity, secondary deterioration, external ventricular drainage (EVD: therapeutic intervention) and outcome in patients with subarachnoid haemorrhage (SAH). Method. We recorded all pertinent clinical data of 52 patients with SAH and measured S-100B serum levels on admission and every 24 h for a maximum of 9 consecutive days. Mann–Whitney U-test and Kruskal Wallis analysis were employed to assess the association of S-100B levels with all variables of interest. Log-rank test was used to evaluate survival and Cox’s proportional hazard regression analysis to define the significant predictors of survival rate. Findings. Admission S-100B was statistically significantly associated with initial neurological status, neuroimaging severity, and one-year outcome (p = 0.0002, 0.001, and 0.017, Kruskal Wallis analysis). Admission S-100B above 0.3 µg/L predicted unfavourable outcome (p < 0.0001, log rank test) and constituted an independent predictor of short-term survival (p = 0.035 Cox’s proportional hazard regression analysis) with a hazard ratio of 2.2 (95% C.I.: 1.06–4.6) indicating a more than doubling of death probability. Secondary neurological deterioration associated with S-100B increase (p < 0.0001) and external ventricular drainage (EVD) with S-100B reduction (p = 0.003, Wilcoxon signed rank test). Conclusions. Serum S-100B protein seems to be a useful biochemical indicator of neurological – neuroimaging severity, secondary deterioration, EVD (therapeutic intervention), and outcome in patients with SAH.

Chiari malformation: CSF flow dynamics in the craniocervical junction and syrinx

SummaryBackground. A CSF flow study in patients with Chiari malformation (ChM) who undergo craniocervical junction decompression (CCJD). Methods. Using spatial modulation of magnetization (SPAMM), cerebrospinal fluid (CSF) flow velocities were measured at the prepontine (PP), anterior cervical (AC), and posterior cervical (PC) subarachnoid spaces (SAS) in healthy subjects (n = 11) and patients with Chiari malformation (ChM) before and/or after CCJD (n = 15). In the syringes, the intrasyrigeal pulsatile CSF motion was estimated qualitatively as present or absent. Findings. In normal subjects, the mean CSF velocities were 2.4 ± 0.2 cm/s (PP), 2.8 ± 0.3 cm/s (AC), and 2.4 ± 0.2 cm/s (PC). Velocities were significantly lower than normal in patients with ChM prior to CCJD, reduced by 38%, 25%, and 79% in the 3 regions, respectively (P<0.001). Post-CCJD, velocities were 20% (PP), 100% (AC), and 40% (PC) greater than preoperatively (P<0.001). Conclusions. In ChM, the posterior cervical CSF flow velocity was low, increased minimally after CCJD and, by itself, had limited predictive value. Post-CCJD, an increase of the sum of anterior and posterior cervical CSF flow velocities by more than 20% consistently preceded or coincided with marked headache improvement. After CCJD, the finding that the intrasyringeal CSF pulsatile motion had become absent was an earlier and more sensitive predictor of motor or sensory improvement than a reduction in syrinx’s size. SPAMM can be used to assess whether CCJD has restored CSF flow, predict outcome and provide pathophysiological insights in ChM and syringomyelia.

CT-guided stereotactic aspiration of brain abscesses.

The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.

PlGF and sVEGFR-1 in chronic subdural hematoma: implications for hematoma development

OBJECT A considerable body of evidence indicates that inflammation and angiogenesis play a significant role in the development and progression of chronic subdural hematoma (CSDH). While various experimental and clinical studies have implicated placental growth factor (PlGF) in the processes that underpin pathological angiogenesis, no study has thus far investigated its expression in CSDH. The actions of PlGF and its related proangiogenic vascular endothelial growth factor (VEGF) are antagonized by a high-affinity soluble receptor, namely soluble VEGF receptor-1 (sVEGFR-1), and thus the ratio between sVEGFR-1 and angiogenic factors provides an index of angiogenic capacity. METHODS In the present study, using an automated electrochemiluminescence assay, levels of PlGF and sVEGFR-1 were quantified in serum and hematoma fluid obtained in 16 patients with CSDH. RESULTS Levels of PlGF and sVEGFR-1 were significantly higher in hematoma fluid than in serum (p < 0.0001). In serum, levels of sVEGFR-1 were higher than those of PlGF (p < 0.0001), whereas in hematoma fluid this difference was not apparent. Furthermore, the ratio of sVEGFR-1 to PlGF was significantly lower in hematoma fluid than in serum (p < 0.0001). CONCLUSIONS Given previous evidence indicating a role for PlGF in promoting angiogenesis, inflammatory cell chemotaxis, and stimulation, as well as its ability to amplify VEGF-driven signaling under conditions favoring pathological angiogenesis, enhanced expression of PlGF in hematoma fluid suggests the involvement of this factor in the mechanisms of inflammation and angiogenesis in CSDH. Furthermore, a reduced ratio of sVEGFR-1 to PlGF in hematoma fluid is consistent with the proangiogenic capacity of CSDH. Future studies are warranted to clarify the precise role of PlGF and sVEGFR-1 in CSDH.

Arachnoiditis ossificans with progressive syringomyelia and spinal arachnoid cyst

We present a 30-year-old man with progressive spastic paraparesis. Spinal imaging revealed extensive calcification of the thoracic cord and cauda equina arachnoid, an intradural extramedullary cyst and evidence of rapidly progressing syringomyelia. Radiological diagnosis was arachnoiditis ossificans and an attempt at surgical decompression was made because of progressive neurologic deterioration. Due to tenacious adhesion of the calcified plaques to the cord and roots, only cyst drainage was achieved; the patient had no clinical improvement. A literature review revealed only two other cases reported in the literature with co-existence of arachnoiditis ossificans and syringomyelia. In none of the previous cases was there an intradural extramedullary arachnoid cyst, nor did the syrinx progress in such a rapid fashion. An attempt is made to explain possible pathophysiological mechanisms leading to this unusual pathology.

Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature

BackgroundTo define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life.MethodsA systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews.ResultsForty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost.ConclusionsNo surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.

A Laboratory Manual for Stepwise Cerebral White Matter Fiber Dissection

OBJECTIVE White matter fiber dissection is an important method in acquiring a thorough neuroanatomic knowledge for surgical practice. Previous studies have definitely improved our understanding of intrinsic brain anatomy and emphasized on the significance of this technique in modern neurosurgery. However, current literature lacks a complete and concentrated laboratory guide about the entire dissection procedure. Hence, our primary objective is to introduce a detailed laboratory manual for cerebral white matter dissection by highlighting consecutive dissection steps, and to stress important technical comments facilitating this complex procedure. METHODS Twenty adult, formalin-fixed cerebral hemispheres were included in the study. Ten specimens were dissected in the lateromedial and 10 in the mediolateral direction, respectively, using the fiber dissection technique and the microscope. RESULTS Eleven and 8 consecutive and distinctive dissection steps are recommended for the lateromedial and mediolateral dissection procedures, respectively. Photographs highlighting various anatomic landmarks accompany every step. Technical recommendations, facilitating the dissection process, are also indicated. CONCLUSIONS The fiber dissection technique, although complex and time consuming, offers a three-dimensional knowledge of intrinsic brain anatomy and architecture, thus improving both the quality of microneurosurgery and the patients standard of care. The present anatomic study provides a thorough dissection manual to those who study brain anatomy using this technique.