Neda Sattarnezhad

Endovascular treatment of very small and very large ruptured aneurysms of the anterior cerebral circulation: a single-center experience.

Introduction: Endovascular treatment of aneurysms has been introduced as a less invasive method for decreasing the rate of aneurysm rerupture and subsequent subarachnoid hemorrhage. The outcome and complication rate for endovascular treatment of very small (≤3 mm) and very large (15-25 mm) intracranial aneurysms has been controversial. Here we report our experience with endovascular coiling of very small and very large ruptured aneurysms of the anterior cerebral circulation. Methods: Patients were included in the study if the maximum dimension of the intracranial ruptured aneurysm was reported to be ≤3 mm or 15-25 mm and if the aneurysm was within the anterior cerebral circulation. The largest dimension was calculated using CT angiography and was confirmed by digital subtraction angiography. Endovascular coiling was performed using Guglielmi detachable coils. All patients underwent follow-up contrast MR angiography every 6 months. Results: A total of 40 cases (18 females and 22 males) were included in this single-center study. Twenty-one very small and 19 very large ruptured aneurysms were analyzed. Preprocedural Hunt and Hess grades were determined. Endovascular coiling was performed successfully in most cases (97.5%), with unsuccessful coiling in 1 patient with a very small ruptured aneurysm. In the very small aneurysm group, the most common location was the anterior communicating artery and, in the large aneurysm group, the most common location was the middle cerebral artery (MCA) bifurcation. The mean follow-up time was 15.08 months (range: 6-30 months). The 6th month modified Rankin scale (mRS) values for very small aneurysm cases were 0 (no symptoms at all) in 16 cases (76.2%) and 1 (no significant disability despite symptoms) in 5 cases (23.80%). For the very large aneurysm cases, the mRS values were 1 in 2 cases (10.5%), 2 in 7 cases (36.8%), 3 in 6 cases (31.6%), 4 in 3 cases (15.8%) and 6 in 1 case (died due to vasospasm 72 h later; 5.2%). The immediate complications that were observed were MCA branch occlusion in 1 very small aneurysm patient and early vasospasms in 3 very large aneurysm patients. The late complication that was observed was recanalization in 1 very small aneurysm case (1/21, 4.76%) and in 5 very large aneurysm cases (5/18, 27.77%). Conclusion: Endovascular treatment of very small aneurysms is an effective method of treatment with acceptable immediate and long-term outcomes. Immediate and long-term complications were more prevalent in very large ruptured aneurysms.

Agreement analysis comparing iPad LCVA and Sloan testing in multiple sclerosis patients

Background: Visual symptoms are common in multiple sclerosis (MS). Low-contrast visual acuity (LCVA) testing using Sloan charts has demonstrated increased sensitivity for visual deficits compared to high-contrast acuity testing. Computerized testing of visual acuity may facilitate use in the clinic setting. Objectives: To evaluate the agreement between an iPad-based and Sloan testing of LCVA in a cohort of MS patients. Methods: A total of 38 patients with relapsing-remitting MS were enrolled after providing informed written consent at Partners MS Center, Brigham and Women’s hospital. Monocular LCVA was measured using retroilluminated Sloan chart and iPad-based LogMAR chart. Number of correct letters and agreement between two measurements were assessed for each eye using Bland–Altman analysis and paired t-test. Results: For both eyes, there was no significant difference in number correct between the two measurements using a paired t-test, and there was high correlation between two measurements (oculus dextrus (OD) r = 0.89, p < 0.001; oculus sinister (OS) r = 0.78, p < 0.001). The limits of agreement were −7.9 to +8.5 letters for the right eye and −10.9 to +11.2 letters for the left eye. Conclusion: An iPad-based LCVA test shows good agreement with Sloan testing in MS patients.

Oral contraceptives and MS disease activity in a contemporary real-world cohort:

Background: There is uncertainty regarding the effect of oral hormonal contraceptives (OC) on multiple sclerosis (MS) course. Objective: To evaluate the hypothesis that OC use is associated with decreased risk of relapses in an observational study of women of childbearing age with new-onset MS starting a first-line injectable disease-modifying therapy (DMT). Methods: From our CLIMB longitudinal observational study, we identified 162 women with MS or CIS with known OC use who initiated injectable DMT within two years of symptom onset, and categorized OC use at DMT onset as past, ever or never. Our primary analysis was comparison of annualized relapse rate from baseline DMT start across the three OC use categories using a negative binomial regression model. Results: In this cohort of 162 women, 81 were treated with interferon therapy and 81 with glatiramer acetate. Mean ages for current-, past-, and never-OC users were 31.4 (n = 46), 40.3 (n = 66), and 37.9 (n = 50) years, respectively (p < 0.05); mean disease duration (1.0 years) and median baseline EDSS (1.0) did not differ between groups. Prior OC users had significantly lower relapse rates than never-users (p = 0.031); the lower annualized relapse rate in current-users relative to never-users was not significant (p = 0.91). Annualized relapse rate was not significantly different across the OC groups (p = 0.057, three-group comparison). Results: These observations provide reassurance for women newly diagnosed that OC use, past or current, does not appear to be associated with greater risk of relapses.

Correlation of Fracture Depression Level and Dural Tear in Patients With Depressed Skull Fracture

Introduction: Trauma is the leading cause of morbidity and mortality worldwide, 80% of which is due to head trauma. Simple depressed cranial fractures are being treated conservatively; however, dural tear is an indication of surgical intervention. Computed tomography (CT) scan is the method of choice for initial evaluation of patients with head trauma. This study was designed to evaluate the correlation of dural tear and level of depression in cranial fractures, considering surgical findings as gold standard. Materials and Methods: A total of 40 patients with depressed skull fracture were admitted to the trauma center of Tabriz University of Medical Sciences, who were candidates for surgery and underwent cranial CT scan; the level of fracture depression was calculated. Surgical findings and status of dural integrity was recorded for each patient. Finally, surgical findings and mean level of depression in both groups were compared. Results: The mean age of cases was 26.4±16.9 years. There was no statistically significant difference between the groups considering the cause of fracture. The most prevalent symptom on admission was headache. Mean Glascow Coma Scale score was significantly lower in the group with torn dura. Mean levels of depression, based on CT findings, were 14.7±4.6 mm in patients with intact dura and 23.5±8.9 mm in patients with dural tear, which was considerably higher in the patients with torn dura. Conclusions: There was remarkable correlation between the level of fracture depression and dural tear; fracture depression level was considerably higher in patients with dural tear than in cases with intact dura. The cutoff point was 14 mm with 77% sensitivity.

Fatty acid binding protein-4 is associated with disability in multiple sclerosis patients:

Background: Increased adiposity is a risk factor for multiple sclerosis (MS) and is associated with increased disability scores. Adipokines may mediate the effects of adiposity on MS disease course. Objective: The objective of this study is to examine the association between the adipokines (leptin and fatty acid binding protein-4, FABP4) and clinical course in individuals with MS. Methods: Subjects (18–65 years) with relapsing-remitting MS or clinically isolated syndrome and <10 year disease duration were selected from a longitudinal clinical study. Cross-sectional and longitudinal models assessed the relationship between two adipokines (leptin and FABP4) and disease severity in women and men, adjusting for age, disease duration and disease type, Vitamin D level, testosterone level, and as well by body mass index (BMI). Results: Mean age of subjects (N = 163, 56% women) was 39.3 years. Higher FABP4 levels were associated with higher Expanded Disability Status Scale (EDSS) scores in women in both univariate and multivariate analyses (odds ratio: 1.30; p = 0.005). In men, higher FABP4 level was significantly associated with change in EDSS over time (estimate: 0.0062; p = 0.035). We found no association of FABP4 levels with time to next relapse or a measure of processing speed. Conclusion: FABP4 levels may be associated with increased disability in both men and women with MS independent of effects of BMI and other hormones. Future studies should expand these analyses and further explore downstream mechanisms of adiposity-related effects in MS.

Neurofilament light chain serum levels correlate with 10-year MRI outcomes in multiple sclerosis

To assess the value of annual serum neurofilament light (NfL) measures in predicting 10‐year clinical and MRI outcomes in multiple sclerosis (MS).

Effects of Citicoline on Level of Consciousness, Serum Level of Fetuin-A and Matrix Gla- Protein (MGP) in Trauma Patients with Diffuse Axonal Injury (DAI) and GCS≤8

BACKGROUND Citicoline, a neuroprotective drug, has been suggested to improve level of consciousness, mitigating secondary to brain damage and ectopic vascular calcification, following post-traumatic neurogenesis and angiogenesis, inducing calcification modulators, like fetuin-A and matrix Gla-protein (MGP). This study aimed to investigate effects of citicoline on levels of consciousness, serum levels of fetuin-A and MGP in patients with severe traumatic brain injury. METHODS This double blind randomized controlled trial (RCT) was conducted on patients with diagnosis of diffuse axonal injury (DAI) and GCS≤8. The cases were treated with citicoline (500 mg every 6 hours) intravenously for fifteen days. Daily GCS assessment and intermittent blood sampling were done for both cases and controls. RESULTS Fifty-eight patients were included in the study and during the study period, mean GCS levels improved in both groups; however, the difference was inconsiderable (p>0.05). Serum levels of fetuin-A, a negative phase reactant, increased in the group treated with citicoline (p=0.012), while these changes were insignificant for the controls (p=0.455). Serum levels of MGP, a calcification inhibitor, increased in the cases (p=0.046). The alterations were inconsequential in the control group (p=0.405). CONCLUSION The findings of this study suggest neutral effects of citicoline on level of consciousness and GCS. Through increasing levels of fetuin-A and MGP, citicoline may have protective effects against inflammatory damage and vascular calcification secondary to head trauma.

Visuospatial Abilities in Children Operated Upon for Myelomeningocele

Background:Myelomeningocele is a complex congenital spinal abnormality. Patients with myelomeningocele present with a spectrum of impairments, with cognitive dysfunctions being one of them. Nonverbal learning disability (NLD) is an aspect of learning abnormality in which the verbal-related contexts and intelligence quotient are spared. Visuospatial disabilities, a distinctive series of NLD, are proposed to be prominent in children with myelomeningocele; however, enough supporting data are lacking. This study aimed at evaluating the visuospatial abilities of children operated upon for myelomeningocele. Materials and Methods:In a case-control setting, we evaluated 15 children operated upon for myelomeningocele in Emam-Reza Hospital of Tabriz University of Medical Sciences during a 14-month period. Fifteen age-matched and sex-matched healthy children were included as controls. The parents of the children were interviewed using the visuospatial skills section of the NLD questionnaire. The rate of NLD (visuospatial disability) was determined for both groups and compared. A scoring system was designed for the questionnaire (the higher the score, the more tendency to have visuospatial disability) and the mean scores were also compared between the 2 groups. Results:Fifteen patients, 11 boys and 4 girls with a mean age of 4.47±0.52 (3.5 to 5) years, and 15 controls, 8 boys and 7 girls with a mean age of 4.23±0.62 (3 to 5) years, were enrolled (P=0.256 and 0.274, respectively). There were 2 (13.3%) patients with NLD in the case group, with no NLD case in the control counterparts (P=0.483). The mean score of the NLD questionnaire was significantly higher in children operated upon for myelomeningocele compared with the control group (2.00±1.13 vs. 1.07±0.79; P=0.015); that is, the trend of the mean score was significantly high toward the presence of NLD in the case group. Conclusions:The current study showed that the rate of NLD was not higher in patients operated upon for myelomeningocele; however, the score was significantly in favor of this condition. This may be due to the small sample size recruited; therefore, further studies with larger sample sizes are recommended.