Neuro-psychiatric symptoms in directly and indirectly blast exposed civilian survivors of urban missile attacks

BACKGROUND

Blast-explosion may cause traumatic brain injury (TBI), leading to post-concussion syndrome (PCS). In studies on military personnel, PCS symptoms are highly similar to those occurring in post-traumatic stress disorder (PTSD), questioning the overlap between these syndromes. In the current study we assessed PCS and PTSD in civilians following exposure to rocket attacks. We hypothesized that PCS symptomatology and brain connectivity will be associated with the objective physical exposure, while PTSD symptomatology will be associated with the subjective mental experience.

METHODS

Two hundred eighty nine residents of explosion sites have participated in the current study. Participants completed self-report of PCS and PTSD. The association between objective and subjective factors of blast and clinical outcomes was assessed using multivariate analysis. White-matter (WM) alterations and cognitive abilities were assessed in a sub-group of participants (n = 46) and non-exposed controls (n = 16). Non-parametric analysis was used to compare connectivity and cognition between the groups.

RESULTS

Blast-exposed individuals reported higher PTSD and PCS symptomatology. Among exposed individuals, those who were directly exposed to blast, reported higher levels of subjective feeling of danger and presented WM hypoconnectivity. Cognitive abilities did not differ between groups. Several risk factors for the development of PCS and PTSD were identified.

CONCLUSIONS

Civilians exposed to blast present higher PCS/PTSD symptomatology as well as WM hypoconnectivity. Although symptoms are sub-clinical, they might lead to the future development of a full-blown syndrome and should be considered carefully. The similarities between PCS and PTSD suggest that despite the different etiology, namely, the physical trauma in PCS and the emotional trauma in PTSD, these are not distinct syndromes, but rather represent a combined biopsychological disorder with a wide spectrum of behavioral, emotional, cognitive and neurological symptoms.

Novel SBF1 splice-site null mutation broadens the clinical spectrum of Charcot-Marie-Tooth type 4B3 disease

Four siblings of consanguineous Bedouin kindred presented at infancy with an autosomal recessive syndrome of congenital microcephaly, facial dysmorphism, strabismus, developmental delay and ataxia with positive pyramidal signs. Toward the end of their first decade, they developed areflexia, multiple cranial neuropathies and severe polyneuropathy with progressive muscle weakness, affecting proximal and distal extremities. Physical assessment exhibited kyphoscoliosis, bilateral syndactyly and distal muscle wasting with drop-foot and pes cavus. Magnetic resonance imaging (MRI) showed profound cerebellar atrophy with highly unique findings at the pontine and mesencephalic levels, previously described as "fork and bracket" signs. Genome-wide linkage analysis identified a single ~1.5 Mbp disease-associated locus on chromosome 22q13.33. Whole exome sequencing identified a single novel homozygous deleterious splice-site mutation within this locus in SET binding factor 1 (SBF1). SBF1 missense mutations were shown to underlie Charcot-Marie-Tooth (CMT) type 4B3 disease, a rare autosomal recessive subtype of CMT4. The novel SBF1 null mutation highlights distinct severe phenotypic manifestations, broadening the clinical spectrum of SBF1-related neuropathies: cerebellar and pyramidal signs evident in the first months of life with peripheral polyneuropathy emerging only toward the end of the first decade, together with unique MRI findings.

Varix of the Vortex Vein Ampulla: A Small Case Series

PURPOSE

To report three cases of varix of the vortex vein ampulla.

METHODS

Observational small case series. During 2002, three patients were examined for suspected choroidal melanoma. In all cases, the lesions were located at the equator or the periphery.

RESULTS

The lesions became more prominent when the eyes were positioned in the direction of the lesion, and disappeared when firm pressure by ultrasound probe was applied on the globe, while the eye was in primary position, or fundus was examined with a three-mirror Goldmann contact lens. These dynamic characteristics were also demonstrated by color Doppler imaging.

CONCLUSIONS

Varix of the vortex vein ampulla is an extremely rare condition. This diagnosis should be considered when an elevated choroidal lesion disappears when the fundus is examined with contact lens.

Automated Cross-Sectional Measurement Method of Intracranial Dural Venous Sinuses

BACKGROUND AND PURPOSE

MRV is an important blood vessel imaging and diagnostic tool for the evaluation of stenosis, occlusions, or aneurysms. However, an accurate image-processing tool for vessel comparison is unavailable. The purpose of this study was to develop and test an automated technique for vessel cross-sectional analysis.

MATERIALS AND METHODS

An algorithm for vessel cross-sectional analysis was developed that included 7 main steps: 1) image registration, 2) masking, 3) segmentation, 4) skeletonization, 5) cross-sectional planes, 6) clustering, and 7) cross-sectional analysis. Phantom models were used to validate the technique. The method was also tested on a control subject and a patient with idiopathic intracranial hypertension (4 large sinuses tested: right and left transverse sinuses, superior sagittal sinus, and straight sinus). The cross-sectional area and shape measurements were evaluated before and after lumbar puncture in patients with idiopathic intracranial hypertension.

RESULTS

The vessel-analysis algorithm had a high degree of stability with <3% of cross-sections manually corrected. All investigated principal cranial blood sinuses had a significant cross-sectional area increase after lumbar puncture (P ≤ .05). The average triangularity of the transverse sinuses was increased, and the mean circularity of the sinuses was decreased by 6% ± 12% after lumbar puncture. Comparison of phantom and real data showed that all computed errors were <1 voxel unit, which confirmed that the method provided a very accurate solution.

CONCLUSIONS

In this article, we present a novel automated imaging method for cross-sectional vessels analysis. The method can provide an efficient quantitative detection of abnormalities in the dural sinuses.

Intracranial nonjugular venous pathways: a possible compensatory drainage mechanism

BACKGROUND AND PURPOSE

The IJVs are considered to be the main pathway draining the intracranial venous system. There is increasing evidence for the existence of alternative venous pathways. Studies using extracranial sonography techniques have demonstrated a nonjugular venous system. In the current study, we used MR images to investigate the NJV drainage system and its components (vertebral plexus, pterygopalatine plexus). The exact visualization and measurement of the intracranial NJVs could be of diagnostic importance and may have clinical importance.

MATERIALS AND METHODS

A total of 64 participants with no history of neurologic disease were included in the study. All participants underwent scanning with a 2D time-of-flight, multisection sequence in the supine position. Image processing software was developed to identify and quantify the size of the IJVs and NJVs in the plane of the internal JF. For evaluation of software accuracy, all images were reviewed by a neuroradiologist experienced in neurovascular imaging preprocessing and postprocessing.

RESULTS

The CSA of the NJVs correlated inversely with the CSA of the IJVs (r(2) = 0.25; P < .0001). An inverse correlation was also significant when comparing IJV with NJV components (vertebral plexus: r(2) = 0.19; P = .0004; pterygopalatine plexus: r(2) = 0.11; P = .0069). Furthermore, only NJV cumulative CSA correlated inversely with participant age (r(2) = 0.2; P = .0002).

CONCLUSIONS

Our study indicates that the NJVs might serve as a compensatory drainage mechanism in the intracranial compartment. This mechanism appears less significant as the age of the patient progresses.

Blood-brain barrier disruption in post-traumatic epilepsy

BACKGROUND

Traumatic brain injury (TBI) is an important cause of focal epilepsy. Animal experiments indicate that disruption of the blood-brain barrier (BBB) plays a critical role in the pathogenesis of post-traumatic epilepsy (PTE).

OBJECTIVE

To investigate the frequency, extent and functional correlates of increased BBB permeability in patient with PTE.

METHODS

32 head trauma patients were included in the study, with 17 suffering from PTE. Patients underwent brain MRI (bMRI) and were evaluated for BBB disruption, using a novel semi-quantitative technique. Cortical dysfunction was measured using electroencephalography (EEG), and localised using standardised low-resolution brain electromagnetic tomography (sLORETA).

RESULTS

Spectral EEG analyses revealed significant slowing in patients with TBI, with no significant differences between patients with epilepsy and those without. Although bMRI revealed that patients with PTE were more likely to present with intracortical lesions (p = 0.02), no differences in the size of the lesion were found between the groups (p = 0.19). Increased BBB permeability was found in 76.9% of patients with PTE compared with 33.3% of patients without epilepsy (p = 0.047), and could be observed years following the trauma. Cerebral cortex volume with BBB disruption was larger in patients with PTE (p = 0.001). In 70% of patients, slow (delta band) activity was co-localised, by sLORETA, with regions showing BBB disruption.

CONCLUSIONS

Lasting BBB pathology is common in patients with mild TBI, with increased frequency and extent being observed in patients with PTE. A correlation between disrupted BBB and abnormal neuronal activity is suggested.

Clearance of a status aurae migraenalis in response to thrombendarterectomy in a patient with high grade internal carotid artery stenosis

We report a patient with high grade internal carotid artery (ICA) stenosis who had frequent migrainous aura-like symptoms for a period of 3 weeks (Latin: status aurae migraenalis). This syndrome has been described previously but it was unclear whether ischaemic damage was associated with it. Using MRI, we demonstrated widely scattered focal laminar cortical infarcts. Importantly, after ICA thrombendarterectomy, the status aurae migraenalis abruptly ceased which supports the concept that high grade ICA stenosis can be the cause of status aurae migraenalis.

The vein of Labbe masquerading as an epidural abscess

The occipitotemporal vein (OTV) courses over the temporal lobe, connecting the superficial middle cerebral vein and the transverse sinus. This vein is rarely identifiable on computerized tomography (CT) scans and a large amount of contrast is needed to identify such a relatively small vessel. We present a 12-month-old male with acute coalescent mastoiditis and a subperiosteal abscess. An epidural abscess was suspected on pre-operative CT scan. No abscess was found on surgery. Based on the surgical finding, we determined that this misdiagnosis was due to a vascular variant, the occipitotemporal vein (vein of Labbe) that masqueraded as an abcess on the CT scan. Recognition of the vein of Labbe on CT scan is therefore essential for the appropriate management of otological and neurotological disease.

Transvenous treatment of cranial dural arteriovenous fistulas with hydrogel coated coils

SUMMARY

Intracranial dural arteriovenous fistulas (DAVF) with cortical venous reflux may become symptomatic due to venous congestion or intracranial hemorrhage. Venous congestion in the orbit can also occur resulting in proptosis, chemosis, double vision and progressive visual loss. The transvenous approach has been used for selective disconnection of the venous drainage to eliminate the venous congestion and future risk of intracranial bleeding and/or neurological deficit. Hydrogel coated coils (Hydro- Coil(R)) expand after contact with blood causing the coils to swell up to five to 11 times a standard 10-system bare platinum coil. Due to this property, HydroCoils could have an advantage over platinum coils in the transvenous approach to embolization of DAVFs. Ten patients with symptomatic cranial DAVF underwent a transvenous embolization using HydroCoils as the only embolic agent or in a combination with bare platinum coils. The patients' characteristics, symptoms, angioarchitecture of the DAVF, treatment, complications and results were analyzed. All the treated DAVFs were disconnected at the end of the procedure. All the patients with orbital symptoms had complete or significant improvement. There were no periprocedural complications. Nine patients had radiological follow-up showing cure. HydroCoils can be used effectively and safely to treat intracranial DAVFs transvenously. The volume expansion of Hydrocoils may have significant advantage over bare platinum coils given the large venous spaces that need to be filled. The use of HydroCoils may decrease the procedure time and consequently reduce the radiation dose to the patient.

Postmenopausal HRT is not independent risk factor for dural sinus thrombosis

While a dural sinus thrombosis (DST), is a well-known consequence of the use of oral contraceptives, the role of hormone replacement therapy (HRT) in DST was not previously evaluated. We report two postmenopausal women, presenting with DST under HRT. Antiphospholipid antibodies in one case and borderline protein S deficiency in another were diagnosed. Only five cases of DST under HRT were previously reported and in two of them additional prothrombotic risk factors were found. According to these and previous cases, HRT is not an independent risk factor for DST.

Frequent blood-brain barrier disruption in the human cerebral cortex

1. The blood-brain barrier (BBB) protects the brain from circulating xenobiotic agents. The pathophysiology, time span, spatial pattern, and pathophysiological consequences of BBB disruptions are not known. 2. Here, we report the quantification of BBB disruption by measuring enhancement levels in computerized tomography brain images. 3. Pathological diffuse enhancement associated with elevated albumin levels in the cerebrospinal fluid (CSF) was observed in the cerebral cortex of 28 out of 43 patients, but not in controls. Four patients displayed weeks-long focal BBB impairment. In 19 other patients, BBB disruption was significantly associated with elevated blood pressure, body temperature, serum cortisol, and stress-associated CSF 'readthrough" acetylcholinesterase. Multielectrode electroencephalography revealed enhanced slow-wave activities in areas of focal BBB disruption. Thus, quantification of BBB disruption using minimally invasive procedures, demonstrated correlations with molecular, clinical, and physiological stress-associated indices. 4. These sequelae accompany a wide range of neurological disorders, suggesting that persistent, detrimental BBB disruption is considerably more frequent than previously assumed.

[Management of nasal meningoencephaloceles and cerebrospinal rhinorrhea]

CSF rhinorrhea constitutes a diagnostic challenge. If unrecognized or incompletely managed, it can result in devastating complications. The physician must e aware to this entity and it's management. The conventional neurosurgical management of meningoencephaloceles and cerebrospinal rhinorrhea has been by the intracranial approach. Otolaryngologists have undertaken extracranial approaches for repair of these problems with fair results. In recent years, functional endoscopic sinus surgery has gained popularity and was advocated for the repair of nasal meningoencephaloceles and CSF fistulae. Between 1998 and 1999, five patients were operated by the senior author (M.P) by means of endoscopic sinus surgery. His success rate and lower morbidity make this approach the treatment of choice. The perioperative use of fluoroscein allows us to locate precisely the defect and to confirm complete sealing of the leak. We present our experience in managing 5 cases, 3 of which presented with meningoencephaloceles.

Gastric outlet obstruction by gallstone: Bouveret syndrome

Gallstone has rarely been described as a cause of gastrointestinal obstruction. However, the relative incidence of gallstone ileus increases significantly with age. The gastric outlet is very seldom the location of obstruction by a gallstone. The diagnosis of this condition is not difficult. Nevertheless, if treatment is delayed, high morbidity and mortality rates result. Comprehensive treatment aims to relieve the obstruction, to close the biliodigestive fistula and to prevent further gallbladder complications. The surgeon who deals with this type of illness should tailor the treatment plan according to the age, general condition, and intraoperative findings of the individual patient. This paper presents a case report of an 88-year-old woman with gastric outlet obstruction caused by a gallstone.

Perinatal vasoconstrictive renal insufficiency associated with maternal nimesulide use

A full-term newborn developed oliguric renal failure at 24 hr of life, which persisted for several days. Her mother ingested therapeutic doses of nimesulide, a non-steroidal anti-inflammatory (cyclo-oxygenase-2 inhibitor) drug, during the last 2 weeks of pregnancy. She was found at delivery to have developed oligohydramnion, esophagitis, and a bleeding peptic ulcer. The infant's fractional excretion of sodium was very low (0.5%) pointing for a severe vasoconstrictive mechanism involved. Renal sonogram showed hyperechogenic medullary papillae, which resolved during convalescence. This case emphasizes the importance of renal prostagandins in the control of vascular tone and sodium homeostasis. This is the first report of an adverse effect of fetal renal circulation by maternal ingestion of nimesulide.

[Ultrasonographic imaging of superior sagittal thrombosis]

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.

[Necrotizing soft tissue infection]

The dramatic course of necrotizing soft tissue infection represents a medical emergency, since it is limb- and life-threatening. Most necrotizing soft tissue infections are caused by mixed aerobic and anaerobic Gram-negative and Gram-positive organisms. Most case have been reported in immuno-compromised hosts after penetrating trauma or surgery. We describe a unique series of cases of necrotizing soft tissue infection. The mainstay of treatment is early and daily debridement of devitalized tissue and broad-spectrum antibiotics. Hyperbaric oxygen therapy should be considered.