Salam Koussa

Prediction of the survival and functional ability of severe stroke patients after ICU therapeutic intervention

BackgroundThis study evaluated the benefits and impact of ICU therapeutic interventions on the survival and functional ability of severe cerebrovascular accident (CVA) patients.MethodsSixty-two ICU patients suffering from severe ischemic/haemorrhagic stroke were evaluated for CVA severity using APACHE II and the Glasgow coma scale (GCS). Survival was determined using Kaplan-Meier survival tables and survival prediction factors were determined by Cox multivariate analysis. Functional ability was assessed using the stroke impact scale (SIS-16) and Karnofsky score. Risk factors, life support techniques and neurosurgical interventions were recorded. One year post-CVA dependency was investigated using multivariate analysis based on linear regression.ResultsThe study cohort constituted 6% of all CVA (37.8% haemorrhagic/62.2% ischemic) admissions. Patient mean(SD) age was 65.8(12.3) years with a 1:1 male: female ratio. During the study period 16 patients had died within the ICU and seven in the year following hospital release.The mean(SD) APACHE II score at hospital admission was 14.9(6.0) and ICU mean duration of stay was 11.2(15.4) days. Mechanical ventilation was required in 37.1% of cases. Risk ratios were; GCS at admission 0.8(0.14), (p = 0.024), APACHE II 1.11(0.11), (p = 0.05) and duration of mechanical ventilation 1.07(0.07), (p = 0.046). Linear coefficients were: type of CVA – haemorrhagic versus ischemic: -18.95(4.58) (p = 0.007), GCS at hospital admission: -6.83(1.08), (p = 0.001), and duration of hospital stay -0.38(0.14), (p = 0.40).ConclusionTo ensure a better prognosis CVA patients require ICU therapeutic interventions. However, as we have shown, where tests can determine the worst affected patients with a poor vital and functional outcome should treatment be withheld?

Congenital brain tumor in a neonate conceived by in vitro fertilization

Abstract Congenital brain tumors are very rare; their incidence is estimated at 0.34 per million live births. We report a case of congenital gliosarcoma in a neonate conceived by in vitro fertilization (IVF). One other case of brain tumor (medulloblastoma) is reported in a child born after assisted conception. Whether these tumors are causally related to the IVF remains obscure.

Neurobrucellosis Presenting with Diffuse Cerebral White Matter Lesions

121 General examination was normal. Neurological examination showed scanning dysarthria, horizontal nystagmus in the lateral gaze, severe bilateral dysmetria in the upper and lower limbs, bilateral dysdiadochokinesis, severe gait ataxia and inability to maintain the sitting posture. Muscle stretch reflexes were normal and the plantar response was flexor. There was no sensitive impairment. Cognitive examination was normal (MNSE). Hemogram, ESR, routine clinical chemistry, urinalysis, coagulation, copper studies, C3, C4, and serum levels of lactate, vitamin B12, vitamin E, folic acid, ·-tocopherol, total protein, albumin and thyroid hormones were normal. Serum proteinogram showed polyclonal hypergammaglobulinemia. ANAs, rheumatoid factor, ·-fetoprotein, CEA, Ca 15.3, CA 125, CA 19.9, Ca 72.4, anti-Hu, anti-Yo antibodies and serological studies for hepatitis C, syphilis, brucella, cytomegalovirus, cryptococcal antigen and HbsAg were negative. Anti-HBc and anti-HBs IgG, antitoxoplasma IgG and anti-HIV antibodies (ELISA and Western blot) were positive. CD4: 18/mm3, viral load: 216,628 copies of HIV RNA/ml. Blood cultures, stool cultures and parasite cultures in feces, acid-fast bacilli, Pneumocystis carinii in the sputum were negative. Routine CSF analysis was normal, anti-Hu, anti-Yo, serological studies and cultures (brucella, syphilis, cryptococcus, bacteria, mycobacteria, fungi, JC virus, neurotropic viruses – HSV-I, HSV-II, ZVV, EBV, CMV, enteroviruses) in CSF were negative. CSF IgG and IgG index was elevated and oligoclonal bands were present. Chest radiographs, mammography and thoracoabdominal CT were normal. Cranial MRI showed an important cerebellar atrophy, more marked in the vermis, without cerebral atrophy (fig. 1). Antiretroviral therapy (triple therapy) was started but there was no improvement of the neurological symptoms after 2 months of follow-up.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis: the Middle East North Africa Committee for Treatment and Research In Multiple Sclerosis (MENACTRIMS).

Abstract With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need re-evaluation and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate multiple sclerosis (MS) therapy selection is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, secondary progressive MS, and primary progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

C1 arch regeneration, tight cisterna magna, and cervical syringomyelia following foramen magnum surgery

BACKGROUND Although bone regrowth following craniocervical decompression has been rarely reported to cause late recurrence of Chiari symptoms, syringomyelia has not been observed in such cases. We report a unique case of cervical syringomyelia resulting from spontaneous regeneration of the posterior C1 arch after foramen magnum decompression. CASE DESCRIPTION A 38-year-old male patient underwent resection of a symptomatic foramen magnum meningioma. Three years later, he developed neuropathic pain in his left upper extremity with worsening dysphagia and dysphonia. MRI revealed regeneration of the posterior arch of C1 with tight tonsillar impaction of the foramen magnum and extensive cervical syringomyelia. Surgical exploration was undertaken. Neo-ossification of the posterior arch of C1 and thick arachnoid adhesions were found to obstruct cerebrospinal fluid flow through the foramen of Magendie. Foramen magnum decompression, arachnoid dissection, and duraplasty were thus performed and cerebrospinal fluid flow was reestablished through the foramen of Magendie. Postoperatively, patients symptoms improved dramatically and repeat MRI showed complete resolution of the syrinx cavity. CONCLUSION Spontaneous bone regrowth and arachnoid scarring may lead to the development of cervical syringomyelia several years after foramen magnum surgery. Neurosurgeons should be aware of this rare complication whose management is similar to that of Chiari malformations, namely craniocervical decompression and establishment of a patent foramen of Magendie.