Jia-Wei Lin

Intracranial pressure fluctuation during hemodialysis in renal failure patients with intracranial hemorrhage

Coagulopathy in renal failure patients often makes them vulnerable to intracranial hemorrhage. Emergency decompression to remove the hematoma and to stop bleeding is always indicated. After the surgery, hemodialysis (HD) should be arranged to maintain the BUN/Cr. level, and I/O balance. During HD, intracranial pressure in all of the patients in this study fluctuated. This phenomenon always resulted in neurological deterioration in acute or chronic renal failure. We present intracranial pressure (ICP) changes during HD in five acute or chronic renal failure patients with intracranial hemorrhage. They all underwent craniectomy or craniotomy with ICP monitors implantation. Different HD protocols were arranged for these patients and then we observed clinical results. ICP elevated during HD and resulted in severe brain swelling. This situation was one of the clinical presentations of dialysis disequilibrium syndrome (DDS). Four patients died because of this complication and one survived. ICP fluctuation seemed to be correlated with the fluid amount and frequency of HD. The prevalence and pathophysiology of DDS remain unclear. Renal failure patient with intracranial hemorrhage may be complicated with DDS when HD was performed. An attempt to reduce the fluid amount and to increase the frequency of HD might help these patients.

Clinical Evaluation of CyberKnife in the Treatment of Vestibular Schwannomas

Objective. This study assessed the posttreatment tumor control and auditory function of vestibular schwannoma (VS) patients after CyberKnife (CK) and analyzed the possible prognostic factors of hearing loss. Methods. We retrospectively studied 117 VS patients, with Gardner-Robertson (GR) classification grades I to IV, who underwent CK between 2006 and 2012. Data including radiosurgery treatment parameters, pre- and postoperative tumor size, and auditory function were collected and examined. Results. With CK, 117 patients had excellent tumor control rates (99.1%), with a mean imaging followup of 61.1 months. Excluding 52 patients (GR III-IV pretreatment), 53 (81.5%) of the remaining 65 patients (initial GR I-II) maintained GR I or II hearing after CK, with a mean audiometric followup of 64.5 months. Twelve patients experienced hearing degradation (91.6% were GR II pretreatment); they appeared to have significantly larger tumor sizes, significantly smaller cochlear sizes, and higher prescribed cochlear doses, compared to the patients with preserved hearing. Conclusion. Our data showed that CK treatment provided an excellent tumor control rate and a comparable hearing preservation rate in VS patients. Patients with pretreatment GR II hearing levels, larger tumor volumes, smaller cochlear sizes, and higher prescribed cochlear doses may have poor hearing prognoses.

Idiopathic syringomyelia: case report and review of the literature

Syringomyelia is an uncommon disease that is caused most often by type I Chiari malformation, which develops in the hindbrain, and less frequently by other factors which are not limited to the hindbrain, including trauma, infection, or scoliosis. Idiopathic syringomyelia is rare. We present in this article a patient with idiopathic syringomyelia characterized by hypoesthesia and progressive weakness in the left lower limb. Decompression was attempted by means of laminectomy and a syringoarachnoid shunt. Motor, sensory, and bladder functions were monitored by the change in Japanese Orthopedic Association scores, which increased from 10 points preoperatively to 14 points 30 days postoperatively. This case demonstrates the effectiveness of surgical decompression in a patient with remarkable neurological deficit.

Evaluation of optimal cerebral perfusion pressure in severe traumatic brain injury

Traumatic brain injury (TBI) is a major cause of death and disability. In the 2000 guidelines, one of the suggestions for TBI treatment was to maintain cerebral perfusion pressure (CPP) < or = 70 mmHg. But in the 2003 guidelines, the suggestion was changed to < or = 60 mmHg. There have been some discrepancies of opinions about this recommendation in recent publications. In this study, we retrospectively reviewed 305 severe TBI (STBI) patients with Glasgow Coma Scales (GCS) < or = 8 between January 1, 2002 and March 31, 2003. The study group was stratified according to use or nonuse of intracranial pressure (ICP) monitoring, ICP levels, ages, and GCS levels in order to test the correlation between CCP and the prognosis. The patients < 50-year-old, with higher GCS level, with ICP monitoring, and with ICP levels < 20 mmHg had lower mortality rates and better prognosis (GOS) (p < 0.05 or 0.001). The patients in the GCS 3-5 subgroup had a significantly lower mortality and better prognosis if the CPP value was maintained higher than 70 mmHg (p < 0.05) The optimal CPP maintained < or = 60 mmHg did not fit in all STBI patients. Our study concludes that it is critical to maintain CPP substantially higher in lower GCS level patients.

Early dysautonomia detected by heart rate variability predicts late depression in female patients following mild traumatic brain injury

Depression is one of the frequent complications following a mild traumatic brain injury (mTBI). Recent research indicated that abnormalities in the autonomic nervous system (ANS) can be evaluated by a noninvasive power spectral analysis of the heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV was correlated with late depression in mTBI patients. In total, 181 patients diagnosed with mTBI and 83 volunteers as healthy controls were recruited in 2010-2014. Beck Depression Inventory (BDI) scores were used to evaluate depression in the 1st week of assessment and at 1.5-, 3-, 6-, 12-, and 18-month follow-ups. Correlation and logistic regression analyses of the 1st week HRV parameters with BDI scores at 18 months were performed in individual female mTBI patients. Female mTBI patients were more vulnerable to depression accompanied by reduced HRV compared to healthy controls. Over time, depression was aggravated in female mTBI patients but was alleviated in male mTBI patients. A significantly lower parasympathetic proportion of the ANS was noted at 18 months with respect to the 1st week in female mTBI patients. In addition, depression in female mTBI patients at 18 months after injury was significantly correlated with a decrease in the parasympathetic proportion of the ANS in the 1st week (ρ = -0.411; p < .05). Dysautonomia resulted in higher risks of depression in female mTBI patients. We concluded that early dysautonomia following an mTBI contributes to late depression in female mTBI patients.

Heart rate variability and serum level of insulin-like growth factor-1 are correlated with symptoms of emotional disorders in patients suffering a mild traumatic brain injury

OBJECTIVE Patients who have experienced a mild traumatic brain injury (mTBI) are susceptible to symptoms of anxiety or depression. To explore the potential biomarkers for emotional disorders in mTBI patients, we analyzed the frequency domain of heart rate variability (HRV) and serum concentrations of four neurohormones. METHODS We assessed mTBI patients on their first visit and follow-up. Symptoms were evaluated by the Beck Anxiety Inventory and the Beck Depression Inventory, respectively. Serum levels of adrenocorticotropic hormone (ACTH), melatonin, cortisol, and insulin-like growth factor (IGF)-1 and HRV follow-ups were measured and compared. RESULTS mTBI patients were more vulnerable to symptoms of anxiety or depression than healthy controls. Reduced HRV was noted in mTBI patients compared to healthy controls. The mTBI patients demonstrated higher serum levels of ACTH, lower IGF-1 compared to healthy controls. In correlation analysis, only IGF-1 was positively correlated with HRV in mTBI patients. Both HRV and IGF-1 were correlated with symptom of depression while only HRV was correlated with symptom of anxiety in mTBI patients. CONCLUSIONS We infer that HRV may be more significantly correlated with emotional disorders than is IGF-1 in mTBI patients. SIGNIFICANCE The study is relevant for specific diagnostic markers in mTBI patients.

Novel Consensus of Management Guidelines for Severe Traumatic Brain Injury in Asia

Management guidelines for severe traumatic brain injury (STBI) (Brain Trauma Foundation, 1996) have been in place in the United States since 1995. Since that time, the Society of Neurosurgery in Taiwan has made efforts to educate neurosurgeons in Taiwan about these guidelines, encourage integration of these concepts into clinical practice, and to lobby the National Health Institute to pay for STBI treatment. Due to differences in cultural background and traditional practice customs, we found several discrepancies during this period of transition to widespread use of the guidelines in Taiwan, and thus saw a need for locally developed guidelines for use in Asia. In July 2008, more than 300 neuroscience experts in Asia participated in the first Asia-Oceania Neurotrauma Society (AONTS) congress. Specialists discussed differences in the management of STBI and differences among the guidelines published in China, Korea, Japan, and Taiwan. Novel consensus agreements were proposed for four key topics, including the management of intracranial pressure (ICP) (Bratton et al., 2007) and cerebral perfusion pressure (CPP) (Chang et al., 2009; Lin et al., 2008; Sviri et al., 2009), and the use of decompressive craniectomy (DC) (Howard et al., 2008; Timofeev et al., 2008) and sedatives (Chiu et al. 2006). New consensus guidelines recommend that ICP should be considered as a treatment concept rather than just a monitoring tool. For those patients indicated for ICP monitoring, external ventriculostomies are the best choice for the most accurate and cost-effective management. They also allow the dual functions of monitoring and cerebrospinal fluid (CSF) drainage. In addition, ICP data as measured by ventriculostomy are more representative of the overall intracranial condition than intraparenchymal, subdural, or extradural insertion (Bratton et al., 2007). The consensus recommendation for CPP is that it should be maintained at 60 mm Hg for most patients. However, it is advisable to maintain CPP > 70 mm Hg for extremely severe TBI patients, such as patients with Glasgow Coma Scale (GCS) scores of 3–5 (Lin et al., 2008), despite the high complication rates associated with the inotropic drugs used to maintain CPP. In this subgroup, the recovery of cerebral autoregulation is also poor compared to patients with GCS scores 6 (Sviri et al., 2009). Maintaining these higher CPP values provides improved survival rates and long-term prognosis for these patients. Decompressive craniectomies are thought to be clinically effective in lowering ICP in those with refractory intracranial hypertension (Timofeev et al., 2008), and prophylactic DC may also be useful in those requiring urgent evacuation of intracranial hemorrhage and other conditions. Thus DCs should be considered and used soon after primary therapy is complete, and in some cases sooner (Howard et al., 2008). The guidelines for the use of sedatives recommend the use of short-term sedation, and analgesics are indicated for acute and ventilated STBI patients with adequate monitoring. We plan to build on these initial four consensus guidelines proposed by the first AONTS congress, and more advanced prospective studies of STBI will be conducted in Asia to help refine them.

Empty sella, hypogonadism and hypopituitarism secondary to moyamoya disease.

We report the case of a young male who presented at the age of 34 years with intracranial hemorrhage due to moyamoya disease. He was later diagnosed with hypogonadism and hypopituitarism. Chromosomal evaluation revealed a normal karyotype. The results of further neuroradiological studies led to the diagnosis of empty sella syndrome.

Development of telmisartan in the therapy of spinal cord injury: pre-clinical study in rats

Background Decrease of peroxisome proliferator-activated receptors-δ (PPARδ) expression has been observed after spinal cord injury (SCI). Increase of PPARδ may improve the damage in SCI. Telmisartan, the antihypertensive agent, has been mentioned to increase the expression of PPARδ. Thus, we are going to screen the effectiveness of telmisartan in SCI for the development of it in clinical application. Methods In the present study, we used compressive SCI in rats. Telmisartan was then used to evaluate the influence in rats after SCI. Change in PPARδ expression was identified by Western blots. Also, behavioral tests were performed to check the recovery of damage. Results Recovery of damage from SCI was observed in telmisartan-treated rats. Additionally, this action of telmisartan was inhibited by GSK0660 at the dose sufficient to block PPARδ. However, metformin at the dose enough to activate adenosine monophosphate-activated protein kinase failed to produce similar action as telmisartan. Thus, mediation of adenosine monophosphate-activated protein kinase in this action of telmisartan can be rule out. Moreover, telmisartan reversed the expressions of PPARδ in rats with SCI. Conclusion The obtained data suggest that telmisartan can improve the damage of SCI in rats through an increase in PPARδ expression. Thus, telmisartan is useful to be developed as an agent in the therapy of SCI.

Validation of an Animal FDG PET Imaging System for Study of Glioblastoma Xenografted Mouse and Rat Models

Introduction: Because of the high incidence and poor prognosis of gliomas, the development of pre-clinically effective diagnostic tools is of great importance. The objective of this study is to validate the use of FDG PET imaging system for monitoring glioma proliferation in two rodent models. Methods: Two kinds of glioblastoma cells (human DBTRG-O5MG and rat RG2 tumor cells) were implanted intracerebrally to SCID mice and Wistar rats, respectively. To characterize the optimal scanning time required for effective detection of brain tumors, dynamic animal PET were acquired for 1 and 2 h immediately after intravenous injection of the FDG radiotracer to mice and rats, respectively. Test animals were then subjected to serial animal PET scans at day 7, 10, 14, and 17 after tumor cell implantation. Results: Mouse and rat brain tumors were first detected by FDG micro PET imaging at day 7 and 10 after tumor implantation, respectively. The smallest tumor size detectable was 2.5 mm in diameter. The peak tumor-to-background ratio was observed at 40 mm post-injection in the mouse model and at 90 mm post- injection in the rat study. Both the peak standard uptake value of FDG and the tumor-to-background ratios were found to increase as the tumors grew over time. Conclusion: A FDG PET scan protocol was validated for detecting and monitoring glioma tumor growth in both mouse and rat models. Optimal FDG uptake period required and optimal scanning times for experimental tests were hence established for future systematic studies in relevant animal models.