To what extent does frailty mediate the association between age and the outcomes of brain reperfusion following acute ischemic stroke?

Objective

We evaluated the extent to which frailty mediated the association between age, poor functional outcomes, and mortality after acute ischemic stroke when patients were treated with brain reperfusion (thrombolytic therapy and/or thrombectomy).

Materials and methods

This retrospective cohort study included patients diagnosed with ischemic stroke who had undergone intravenous cerebral reperfusion therapy and/or mechanical thrombectomy. We created a mediation model by analyzing the direct natural effect of an mRS score > 2 and death on age-mediated frailty according to the Frailty Index.

Results

We enrolled 292 patients with acute ischemic stroke who underwent brain reperfusion. Their mean age was 67.7 ± 13.1 years. Ninety days after the stroke ictus, 54 (18.5%) participants died, and 83 (28.4%) lived with moderate to severe disability (2 < mRS < 6). In the mediation analysis of the composite outcome of disability (mRS score > 2) or death, frailty accounted for 28% of the total effect of age. The models used to test for the interaction between age and frailty did not show statistically significant interactions for either outcome, and the addition of the interaction did not significantly change the direct or indirect effects, nor did it improve model fit.

Conclusion

Frailty mediated almost one-third of the effect of age on the composite outcome of disability or death after acute ischemic stroke.

Assessment of medical students' Surgery knowledge based on Progress Test

Progress Testing (PT) is an assessment tool whose use has grown throughout Brazil in the last decade. PT makes it possible to assess the students' knowledge gain throughout the undergraduate course and, for their interpretations to be valid, their items (questions) must have adequate quality from the point of view of content validity and reliability of results. In this study, we analyzed the psychometric characteristics of the items and the performance of students in the content area of surgery from 2017 to 2023. For the analyses, we used the assumptions of Classical Test Theory, Bloom's taxonomy and Cronbach's alpha reliability coefficient. The items were easy (average difficulty index between 0.3-0.4), with fair to good discrimination (discrimination index between 0.3-0.4) and with a predominance of medium to high taxonomy. Reliability remained substantial over the years (>0.6). Students' knowledge gain in surgery was found to be progressive and more important from the 3rd year of the undergraduate course, reaching approximately 70-75% in the 6th year. This measurements framework can be replicated in other contexts for a better understanding of student learning and for qualification of evaluation processes.

Sexual dimorphism in the murine model of extraparenchymal neurocysticercosis

Neurocysticercosis is a heterogeneous disease, and the patient's sex seems to play a role in this heterogeneity. Hosts' sexual dimorphism in cysticercosis has been largely explored in the murine model of intraperitoneal Taenia crassiceps cysticercosis. In this study, we investigated the sexual dimorphism of inflammatory responses in a rat model of extraparenchymal neurocysticercosis caused by T. crassiceps. T. crassiceps cysticerci were inoculated in the subarachnoid space of Wistar rats (25 females, 22 males). Ninety days later, the rats were euthanized for histologic, immunohistochemistry, and cytokines studies. Ten animals also underwent a 7-T magnetic resonance imaging (MRI). Female rats presented a higher concentration of immune cells in the arachnoid-brain interface, reactive astrogliosis in the periventricular region, in situ pro-inflammatory cytokine (interleukin [IL]-6) and anti-inflammatory cytokine (IL-10), and more intense hydrocephalus on MRI than males. Intracranial hypertension signals were not observed during the observational period. Overall, these results suggest sexual dimorphism in the intracranial inflammatory response that accompanied T. crassiceps extraparenchymal neurocysticercosis.

Survival in patients undergoing surgical resection for brain metastasis from lung cancer and utility of different prognostic scales

Brain metastases (BM) from lung cancer are among the most common intracranial tumors. Several studies have published scales to estimate the survival of patients with BM. Routine access to molecular diagnostics and modern oncologic treatments, including targeted therapy and immunotherapy, is limited in low- and middle-income countries (LMICs); therefore, incorporating them into recent prognostic scales may diminish the reliability of the scales in LMICs. This retrospective study aimed to determine the survival of 55 patients who were surgically treated for BM from lung cancer at a Brazilian public tertiary teaching hospital between 2012 and 2022. We determined clinical factors associated with survival, and compared observed survival rates with the estimated survival on prognostic scales. The mean overall survival (OS) was 9.3 months (range:0.2-76.5). At univariate analysis, female sex and improved postoperative Karnofsky performance status (KPS) score were associated with longer survival. The median survival did not differ between groups when classified using the Graded Prognostic Assessment (GPA)-2008, Lung-molecular GPA-2017, and Lung-GPA-2021 scales. According to the Diagnosis-Specific (DS)-GPA-2012 scale, there was a significant difference between the groups. In the multivariate Cox regression survival analysis, a higher DS-GPA-2012 and improved postoperative KPS score remained significantly associated with longer survival. In conclusion, this cohort showed a mean OS of < 1 year. Improved KPS score after surgery was associated with increased survival. This cohort DS-GPA scale demonstrated the highest concordance with observed survival, indicating its potential as a valuable tool for patient stratification in surgical treatment decision-making in LMICs.

Association between Clinical and Histopathological Findings in Intestinal Neuronal Dysplasia Type B: An Advance towards Its Definition as a Disease

INTRODUCTION

Intestinal neuronal dysplasia type B (IND-B) is a controversial entity that affects the submucosal nerve plexus of the distal intestine. The lack of definition of the causal relationship between histological findings and clinical symptoms has been identified as the primary point to be elucidated in the scientific investigation related to IND-B, which is essential for it to be considered a disease.

OBJECTIVE

To investigate the relationship between histopathological findings and symptoms in a series of patients with IND-B.

METHODS

Twenty-seven patients with histopathological diagnosis of IND-B, according to the Frankfurt Consensus (1990), who underwent surgical treatment through colorectal resections were included. Data from medical records regarding the clinical picture of the patients at the time of diagnosis, including the intestinal symptom index (ISI) and a detailed histopathological analysis of the rectal specimens, were retrieved. Exploratory factor analysis was performed, applying the principal components method for clusters with Varimax rotation.

RESULTS

Two factors were determined: the first, determined by histopathological and clinical variables, and the second, composed of the main symptoms presented in patients with IND-B, including ISI. Factorial rotation showed the association between the two factors and, through a graph, demonstrated the proximity between ISI values and histopathological alterations.

CONCLUSION

There was evidence of an association between the clinical features presented by patients with IND-B and the histopathological findings of the rectal samples. These results support the understanding of IND-B as a disease.

Neurocysticercosis: A Review into Treatment Options, Indications, and Their Efficacy

Neurocysticercosis, due to the localization of Taenia solium larvae in the Central Nervous System, is a neglected tropical disease still endemic in much of Latin America, Asia and sub-Saharan Africa. The therapeutic management of NC has gradually improved with the establishment of neuroimaging studies (CT and MRI) in endemic countries and with the demonstration of the efficacy of albendazole and praziquantel in the 1980s. But the morbidity and mortality of this preventable disease remain an unacceptable fact. In this scoping review, we will revise the different treatment options and their indications.

Polycystic Liver Disease: Pathophysiology, Diagnosis and Treatment

Polycystic liver disease (PLD) is a clinical condition characterized by the presence of more than 10 cysts in the liver. It is a rare disease Of genetic etiology that presents as an isolated disease or assoc\iated with polycystic kidney disease. Ductal plate malformation, ciliary dysfunction, and changes in cell signaling are the main factors involved in its pathogenesis. Most patients with PLD are asymptomatic, but in 2–5% of cases the disease has disabling symptoms and a significant reduction in quality of life. The diagnosis is based on family history of hepatic and/or renal polycystic disease, clinical manifestations, patient age, and polycystic liver phenotype shown on imaging examinations. PLD treatment has evolved considerably in the last decades. Somatostatin analogues hold promise in controlling disease progression, but liver transplantation remains a unique curative treatment modality.

Transcranial doppler as screening method for sickling crises in children with sickle cell anemia: a latin America cohort study

Background

Sickle cell anemia (SCA) is the leading cause of childhood stroke. We aimed to evaluate whether altered cerebral flow velocities, as measured by transcranial Doppler (TCD), are associated with vaso-occlusive complications in addition to stroke in pediatric SCA patients.

Methods

We evaluated 37 children aged between 2 and 16 years with SCA who underwent screening for TCD between January 2012 and October 2018. Genotypic profiles and demographic data were collected, TCD examinations were performed during follow-up, and the presence of sickling crises was compared. Survival analyses were performed using simple frailty models, in which each predictor variable was analyzed separately in relation to the occurrence of a sickling crisis.

Results

The variables related to sickle cell crises in the univariate analysis were peak systolic velocity (PSV) in the middle cerebral artery (MCA), hazard ratio (HR) 1.01 (1.00—1.02) p = 0.04; end-diastolic velocity (EDV) in the MCA, HR 1.02 (1.01—1.04) p = 0.01; time average mean maximum velocity (TAMMV) in the basilar artery (BA), HR 1.02 (1.00—1.04) p = 0.04; hemoglobin, HR 0.49 (0.38—0.65) p < 0.001; hematocrit, HR 0.78 (0.71—0.85) p < 0.001; leukocyte counts, HR 1.1 (1.05—1.15) p < 0.001; platelets counts, HR 0.997 (0.994—0.999) p = 0.02; and reticulocyte numbers, HR 1.14 (1.06—1.23) p < 0.001.

Conclusions

Our results indicate PSV and EDV in the MCA and TAMMV in the BA as markers of risk for the occurrence of sickling crises in SCA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03429-5.

Contralateral Anterior Interhemispheric–Transcallosal–Transrostral Approach for the Resection of a Subcallosal Cavernous Malformation: A Case Report and an Operative Video

This case report demonstrates the surgical resection of a cerebral cavernous malformation located in the subcallosal region. The authors present a detailed operative video explaining the steps to successfully remove the lesion through a contralateral interhemispheric–transcallosal–transrostral approach with the patient in lateral decubitus. The surgical procedure was uneventful, and the patient had no postoperative deficits and no residual lesions in a three-month follow-up.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil

Objectives

Cerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke.

Materials and Methods

This retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments.

Results

Patients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069-13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376-9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients.

Conclusion

Altogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Occipital Interhemispheric Transtentorial Approach for a Pineal Region Meningioma with Pseudobulbar Palsy

Meningiomas represent 8%-10% of all pineal region (PR) tumors. When they arise from the falx, tentorium, or tentorial incisura, they are not always considered a true PR tumor, as they do not originate from it but instead only grow toward the region. The true meningioma of PR must be originated from the arachnoid envelope of the pineal gland or from the 2 leaflets of the velum interpositum. In both conditions there are no dural attachments.^1,2 Occipital interhemispheric transtentorial and supracerebellar infratentorial are the 2 main approaches for tumors within this region. Aside from the surgeon's preference, the position of the venous system and the direction of the tumor growth guide the approach choice. Endoscope assistance can help reach areas unable to be visualized under the microscope.^3-5 We report the case of a 37-year-old female with a large PR meningioma (velum interpositum) presenting with intense dysphagia, dysphonia, and bilateral tongue palsy. Given the affected bilateral upper motor tracts associated with bulbar symptoms, a diagnosis of pseudobulbar palsy was considered.^6,7 Preoperative imaging also showed compression of the deep venous system. The patient underwent a total resection of the tumor via an occipital interhemispheric transtentorial approach and exhibited a dramatic recovery of neurologic symptoms after the surgery (Video 1). Postoperative venogram showed restoration of the usual deep venous system pattern, which may be associated with significant neurologic improvement. Careful management of the deep veins is mandatory during the resection of PR meningiomas. The venous system improvement after the surgery may be associated with the dramatic recovery seen in this unique case. The patient consented to publication of her images.

Exploring pooled analysis of pretested items to monitor the performance of medical students exposed to different curriculum designs

Several methods have been proposed for analyzing differences between test scores, such as using mean scores, cumulative deviation, and mixed-effect models. Here, we explore the pooled analysis of retested Progress Test items to monitor the performance of first-year medical students who were exposed to a new curriculum design. This was a cross-sectional study of students in their first year of a medical program who participated in the annual interinstitutional Progress Tests from 2013 to 2019. We analyzed the performance of first-year students in the 2019 test and compared it with that of first-year students taking the test from 2013 to 2018 and encountering the same items. For each item, we calculated odds ratios with 95% confidence intervals; we also performed meta-analyses with fixed effects for each content area in the pooled analysis and presented the odds ratio (OR) with a 95% confidence interval (CI). In all, we used 63 items, which were divided into basic sciences, internal medicine, pediatrics, surgery, obstetrics and gynecology, and public health. Significant differences were found between groups in basic sciences (OR = 1.172 [CI95% 1.005 CI 1.366], p = 0.043) and public health (OR = 1.54 [CI95% CI 1.25-1.897], p < 0.001), which may reflect the characteristics of the new curriculum. Thus, pooled analysis of pretested items may provide indicators of different performance. This method may complement analysis of score differences on benchmark assessments.

The Impact of Age on Mortality and Disability in Patients With Ischemic Stroke Who Underwent Cerebral Reperfusion Therapy: A Brazilian Cohort Study

Introduction: The main driver for increased stroke prevalence is the aging of the population; however, the best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Therefore, the aim was studying the association of age with clinical outcomes (mortality and functional disability) in stroke patients who underwent cerebral reperfusion therapy at hospital discharge and 90 days after ictus.

Methods: This was a retrospective (stroke databank analysis) cohort study of participants who had been diagnosed with ischemic stroke and undergone intravenous cerebral reperfusion therapy or mechanical thrombectomy. The variable of interest was patient age, which was categorized into four groups: (1) up to 59 years; (2) 60 to 69 years; (3) 70 to 79 years old; and (4) above 79 years. The primary outcome was mortality at hospital discharge and 90 days after stroke, and the secondary outcome was functional capacity at hospital discharge and 90 days after stroke.

Results: A total of 281 patients was included in the study (235 treated by thrombolysis alone, and 46 treated with mechanical thrombectomy). The mean age of the total sample was 67 ± 13.1 years. The oldest patients had the most unfavorable outcomes, except for mortality rate, at hospital discharge (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001) and 90 days after stroke (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001).

Conclusion: Cerebral reperfusion was a viable treatment for ischemic stroke in both elderly and very elderly patients, as it did not increase mortality. However, it was observed that older individuals had worse functional outcomes at hospital discharge and 90 days after stroke.

What are the barriers to participation in a neuromodulation pilot trial for aphasia after stroke?

PURPOSE

Aphasia is a common and debilitating manifestation of stroke. Transcranial electrical stimulation uses low-intensity electric currents to induce changes in neuronal activity. Recent evidence suggests that noninvasive techniques can be a valuable rehabilitation tool for patients with aphasia. However, it is difficult to recruit patients with aphasia for trials, and the reasons for this are not well understood. This study aimed to elucidate the main difficulties involved in patient's recruitment and inclusion in a randomized clinical study of neuromodulation in aphasia.

METHODS

We evaluated the reasons for the exclusion of patients in a pilot, randomized, double-blinded clinical trial in which patients diagnosed with motor aphasia after stroke were recruited from March to November 2018. A descriptive statistical analysis was performed.

RESULTS

Only 12.9% (4) of patients with ischemic stroke were included in the clinical trial. A total of 87.1% (27) of the 31 recruited patients were excluded for various reasons including: sensory aphasia (32.2%), dysarthria (25.8%), spontaneous clinical recovery (16.1%), previous stroke (6.4%), and death or mutism (3.2%).

CONCLUSION

The presence of other types of aphasia, dysarthria, spontaneous recovery, deaths, and mutism were barriers to recruiting patients evidenced in this neuromodulation study.

Microscopic resection of a giant epidermoid tumor of the pineal region via supracerebellar infra and transtentorial approach with endoscope assistance

The authors present a case of a 22-year-old male who developed hydrocephalus symptoms related to a giant epidermoid tumor at the pineal region. The surgical approach and technique for a large epidermoid tumor in this area are extensively discussed. A paramedian contralateral supracerebellar infratentorial and transtentorial approach was performed, with the patient in a semisitting position. The tumor was removed using a microscopic technique, and endoscope assistance was used in order to reach the areas unable to be visualized under the microscope. The patient was neurologically intact at his 2-year follow-up, and postoperative MRI showed a significant decrease in the tumoral volume.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2128.

Use of artificial intelligence as an instrument of evaluation after stroke: a scoping review based on international classification of functioning, disability and health concept

Introduction: To understand the current practices in stroke evaluation, the main clinical decision support system and artificial intelligence (AI) technologies need to be understood to assist the therapist in obtaining better insights about impairments and level of activity and participation in persons with stroke during rehabilitation. Methods: This scoping review maps the use of AI for the functional evaluation of persons with stroke; the context involves any setting of rehabilitation. Data were extracted from CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, PEDRO Web of Science, IEEE Xplore, AAAI Publications, ACM Digital Library, MathSciNet, and arXiv up to January 2021. The data obtained from the literature review were summarized in a single dataset in which each reference paper was considered as an instance, and the study characteristics were considered as attributes. The attributes used for the multiple correspondence analysis were publication year, study type, sample size, age, stroke phase, stroke type, functional status, AI type, and AI function. Results: Forty-four studies were included. The analysis showed that spasticity analysis based on ML techniques was used for the cases of stroke with moderate functional status. The techniques of deep learning and pressure sensors were used for gait analysis. Machine learning techniques and algorithms were used for upper limb and reaching analyses. The inertial measurement unit technique was applied in studies where the functional status was between mild and severe. The fuzzy logic technique was used for activity classifiers. Conclusion: The prevailing research themes demonstrated the growing utility of AI algorithms for stroke evaluation.

Safety of the effective radiation dose received during stroke hospitalization

Background

Neuroimaging is widely used for diagnosis and treatment of stroke. However, little is known about whether the radiation doses received by patients comply with international safety guidelines.

Objectives

The aim of this study was to evaluate the effective radiation dose received while in hospital for stroke and analyze its safety according to current guidelines.

Methods

This cross-sectional study included 109 patients who were hospitalized and diagnosed with ischemic stroke. The National Institutes of Health Stroke Scale was used to evaluate stroke severity, the Bamford clinical classification was used for topography, and the TOAST classification was used for etiology. The computed tomography dose index and size-specific dose estimates were used to calculate the effective radiation dose (ERD) received while in hospital. A Mann-Whitney test was used to compare the ERD received by thrombolysed and non-thrombolysed patients. Non-parametric statistics were used to analyze the data with a 95% confidence interval.

Results

During the study period, the median ERD received was 10.9 mSv. Length of stay was not associated with radiation exposure. No differences were demonstrated in ERD according to stroke etiology or Bamford clinical classification. Patients who had CT perfusion (only or in addition to CT or angiotomography) received the highest ERD (46.5 mSv) and the difference compared to those who did not (10.8 mSv) was statistically significant (p<0.001). No differences were found in the ERD between thrombolysed and non-thrombolysed patients. There was no correlation between ERD while in hospital and stroke severity.

Conclusions

According to the current national guidelines, the protocol for examining images at our stroke unit is safe in terms of the ERD received by the patient while in hospital. There was no difference in the ERD received by patients stratified by thrombolytic treatment or stroke severity.

Long-term follow-up of patients undergoing decompressive hemicraniectomy for malignant stroke: Quality of life and caregiver's burden in a real-world setting

BACKGROUND AND PURPOSE

Decompressive hemicraniectomy is a life-saving procedure for the treatment of space-occupying middle cerebral artery infarctions (malignant stroke); however, patients may survive severely disabled. Comprehensive data on long-term sequelae outside randomized controlled trials are scarce.

METHODS

We retrospectively evaluated the survival rates, quality of life, ability to perform activities of daily living, and caregiver burden of 61 patients (aged from 37 to 83) who had previously undergone decompressive hemicraniectomy for malignant stroke between 2012 and 2017.

RESULTS

The mortality rate was higher among patients older than 60 years than among younger patients (71.0 % vs 36.7 %, p = 0.007; odds ratio 4.222, 95 % confidence interval 1.443-12.355). The mean survival time was 37.9 ± 6.0 months for 19 survivors of the younger group and 22.6 ± 5.7 months for 9 survivors of the older group. Among the 28 surviving patients, 22 (78.6 %) were interviewed, and we found that age was a determining factor for functional outcome (Barthel indices of 65.7 ± 10.6 for younger patients vs 48.0 ± 9.3 for older patients, p < 0.001), but not for quality of life. The caregiver burden was significantly correlated (R = -0.53, p < 0.01) with the severity of disability and age (R = 0.544, p = 0.011) of the patients.

CONCLUSION

Our findings show that the degree of impairment, as well as caregiver burden, is higher in patients older than 60 years than in younger patients.

Children's Anxiety and Factors Related to the COVID-19 Pandemic: An Exploratory Study Using the Children's Anxiety Questionnaire and the Numerical Rating Scale

The repercussions of the COVID-19 pandemic on children's lives deserve attention. This study aimed to assess the prevalence of anxiety among Brazilian children and its associated factors during social distancing during COVID-19. We used a cross-sectional design with an online survey from April to May 2020 in Brazil. We included children aged 6-12 years and their guardians. The Children's Anxiety Questionnaire (CAQ; scores 4-12) and the Numerical Rating Scale (NRS; scores 0-10) were used to measure anxiety. We enrolled 157 girls and 132 boys, with a mean age of 8.84 (±2.05) years; 88.9% of respondents were mothers. Based on CAQ ≥ 9, the prevalence of anxiety was 19.4% (n = 56), and higher among children with parents with essential jobs and those who were social distancing without parents. In logistic regression, the following variables were associated with higher CAQ scores: social distancing without parents; more persons living together in home; and education level of guardians. Based on NRS > 7, the prevalence of anxiety was 21.8% (n = 63); however, no associations with NRS scores were found with the investigated variables. These findings suggest the necessity of implementing public health actions targeting these parents and their children at the population level.

Relationship of spontaneous microembolic signals to risk stratification, recurrence, severity, and mortality of ischemic stroke: a prospective study

Introduction

The presence of microembolic signals (MES) during the acute phase of stroke is poorly understood, and its role and clinical application in relation to risk stratification and prognosis in patients remain uncertain. We assessed the prevalence of spontaneous MES in acute stroke and their relationship with risk stratification, stroke recurrence, morbidity, and mortality.

Patients and methods

This was a prospective cohort study conducted in the Stroke Unit. The MES presence was evaluated by transcranial Doppler (TCD) in patients with ischemic stroke within 48 h. The outcomes (risk stratification, morbidity, mortality, and recurrence of a stroke) were followed up for 6 months. The relationship between risk stratification and MES was obtained by odds ratios and that between MES and stroke recurrence, morbidity, and mortality using multiple logistic regression; considering statistical significance at P < 0.05.

Results

Of the 111 patients studied, 70 were men (63.1%) and 90 were white (81.1%), with a median age of 68 years. The MES frequency was 7%. There was a significant relationship between MES and symptomatic carotid disease (OR = 22.7; 95% CI 4.1–125.7; P < 0.001), a shorter time to monitoring (OR = 12.4; 95% CI  1.4–105.4; P = 0.02), and stroke recurrence (OR = 16.83; 95% CI 2.01–141; P = .009).

Discussion

It was observed that the stroke recurrence adjusted for prior stroke was higher and earlier among patients with MES detection. In conclusion, MES demonstrated a significant correlation with symptomatic carotid disease and a shorter DELAY until monitoring, and could be a predictor for the early recurrence of stroke in the long term.

The Correlation Between Students' Progress Testing Scores and Their Performance in a Residency Selection Process

Brazil is currently seeing an increased number of medical schools, leading to high competition for medical residency vacancies. Public managers have thus considered Progress Testing scores potentially useful as part of the final decision in the medical residency selection process. We analyzed whether there is a correlation between students' Progress Testing scores and their performances in medical residency selection. We examined four subsequent cohorts of students who attempted Progress Testing yearly and compared their accumulated scores with their medical residency selection scores from Botucatu Medical School, Universidade Estadual Paulista. We included 212 students who finished the 6-year medical course in 2013, 2014, 2015, and 2016. The comparison between the area under the Progress Testing curve and the medical residency selection score was performed using a Pearson correlation, with a p value set at < 0.05. We found a positive association between the two scores (p < 0.05 for the 4 years). Next, the students were grouped according to their performance in Progress Testing: above one, within one, and below one standard deviation. A chi-square test was used to compare the rates of approval with the second step of the medical residency selection process. Approval rates were 91.7%, 69.2%, and 42.1%, respectively (p < 0.05). We conclude that, in fact, there is a correlation between students' performance on these measures. This is partially explained by the fact that both instruments measure cognitive competencies and knowledge. These data may support national policy changes for medical residency selection.

A Rat Model of Neurocysticercosis-Induced Hydrocephalus: Chronic Progressive Hydrocephalus with Mild Clinical Impairment

BACKGROUND

Hydrocephalus is the most common complication of extraparenchymal neurocysticercosis, combining obstructive and inflammatory mechanisms that impair cerebrospinal fluid circulation.

METHODS

We studied the long-term progression of neurocysticercosis-induced hydrocephalus in a rat model. We generated an experimental rat model of neurocysticercosis-induced hydrocephalus by cisternal inoculation of cysts or antigens of Taenia crassiceps and compared it with the classic model of kaolin-induced hydrocephalus. We used 52 animals divided into 4 groups: 1) control, 2) neurocysticercosis-induced hydrocephalus by cysts or 3) by antigens, and 4) kaolin-induced hydrocephalus. We studied behavioral, radiologic, and morphologic alterations at 1 and 6 months after inoculation by open field test, magnetic resonance imaging, and immunohistochemical localization of aquaporin-4 (AQP-4).

RESULTS

Behavioral changes were observed later in neurocysticercosis-induced than in kaolin-induced hydrocephalic rats (P = 0.023). The ventricular volume of hydrocephalus induced by experimental neurocysticercosis progressively evolved, with the magnetic resonance imaging changes being similar to those observed in humans. Periventricular inflammatory and astrocytic reactions were also observed. AQP-4 expression was higher in the sixth than in the first month after inoculation (P = 0.016) and also occurred in animals that received antigen inoculation but did not develop hydrocephalus, suggesting that AQP-4 may constitute an alternative route of cerebrospinal fluid absorption under inflammatory conditions.

CONCLUSIONS

Our neurocysticercosis-induced hydrocephalus model allows for the long-term maintenance of hydrocephalic animals, involving mild clinical performance impairments, including body weight and behavioral changes.

Paramedian contralateral supracerebellar infratentorial approach to thalamic cavernous malformation

Cavernous malformations (CVMs) located in the thalamus are uncommon. However, they pose difficulties for resection because of their close proximity to eloquent areas of the brain and vascular structures, and all surgical corridors to access them are narrow. In this video, we report the case of a 19-year-old woman who presented with a long-standing history of right hemiparesis with recent deterioration. MRI revealed a large CVM located in the left thalamus, with signs of recent hemorrhage extending to the left cerebral peduncle. Resection was achieved with a paramedian contralateral supracerebellar infratentorial approach in a semisitting position, with an uneventful postoperative course. The video can be found here: https://youtu.be/Arvu52FkHOE.

Ancient Observation of Spinal Cord Injury: The Case of the Assyrian Lion

The description of paraplegia is considered a milestone in the history of neurology. The Egyptians provided excellent descriptions of spinal cord injuries, the Bible has several references to paraplegia, and, more recently, the pioneers of neurology described the classic syndromes related to spinal injuries and paraplegia. Here, we describe an ancient observation by the Assyrian people of paraplegia in an animal. In ancient Assyria, lion hunting was a ritualized activity conducted for political and religious purposes. The Lion Hunt of Ashurbanipal, a series of Assyrian palace reliefs from the North Palace at Nineveh dating from approximately 645 BCE, which is now in the British Museum in London, UK, shows King Ashurbanipal hunting lions. Applying modern knowledge of mammalian dermatomes to the images, we reveal a detailed and precise observation of paraplegia after spinal cord injury.

Functional Independence of Children With Myelomeningocele: Is It Associated With the Informal Caregivers' Burden?

PURPOSE

This study aims to evaluate the association between the functional independence of children after postnatal spinal dysraphism correction and informal caregivers' burden.

DESIGN AND METHODS

This is a cross-sectional study conducted in a child neurosurgery clinic at a University hospital. We included informal caregivers of children between six months and seven-and-a-half years old who were operated on for spinal dysraphism correction due to myelomeningocele. Functional independence was assessed using the Pediatric Evaluation of Disability Inventory (PEDI). Caregivers' burden was assessed through the Caregiver Burden Scale (CBS).

RESULTS

Twenty-six caregivers were assessed, all mothers, aged 18-42years. Five provided child care and engaged in paid work. Regarding functional independence, 23.1% of the children were classified as needing supervision, 23.1% moderate assistance, 42.3% maximal assistance, and 11.5% total assistance. Median value for the overall CBS was 27.0 (22.0-53.0). The mean global CBS score was 1.42 and the mean PEDI score was 1.95. Correlations between PEDI and CBS scores were very close to zero.

CONCLUSIONS

We found no association between the functional independence of children with myelomeningocele from 0 to 7years old and the burden of informal caregivers.

PRACTICE IMPLICATIONS

The effect of functional independence of children with myelomeningocele may be balanced by the caregivers' resilience so that caregivers' burden is not dependent upon the child's independence.

Taenia crassiceps injection into the subarachnoid space of rats simulates radiological and morphological features of racemose neurocysticercosis

PURPOSE

Neurocysticercosis is a major public health concern. Although its eradication appears feasible, the disease remains endemic in developing countries and has emerged again in Europe and in the USA. Basic studies on neurocysticercosis are needed to better understand the pathophysiologic mechanisms and, consequently, to improve treatment perspectives. Much has been published on experimental parenchymal neurocysticercosis, but there are no experimental models of racemose neurocysticercosis.

METHODS

Cysts of Taenia crassiceps were injected into the subarachnoid space of 11 rats. After 4 months, magnetic resonance imaging (MRI) was performed to verify the occurrence of ventricular dilatation and the distribution of cysts in the cerebrospinal fluid compartments. The histologic assessment was done focusing on changes in the ependyma, choroid plexus, and brain parenchyma.

RESULTS

MRI and histologic assessment confirmed the findings similar to those seen in human racemose neurocysticercosis including enlargement of the basal cisterns, hydrocephalus, and inflammatory infiltration through the ependyma and choroid plexus into cerebrospinal fluid spaces.

CONCLUSIONS

We developed a simple model of racemose neurocysticercosis by injecting cysts of T. crassiceps into the subarachnoid space of rats. This model can help understand the pathophysiologic mechanisms of the disease.

Decompressive Hemicraniectomy in a South American Population--Morbidity and Outcomes Analysis

BACKGROUND

Malignant cerebral artery strokes have a poor prognosis, with nearly 80% of mortality in some series despite intensive care. After a large randomized trial, decompressive hemicraniectomy has been performed more often in stroke patients. Here, we describe patients in a tertiary teaching hospital in Brazil, emphasizing the impact of age on outcomes.

METHODS

A retrospective cohort of patients, with malignant strokes which received a decompressive hemicraniectomy, from paper and electronic medical records, from January 2010 to December 2013 was divided into two groups according to age.

RESULTS

The final analysis included 60 patients. The overall mortality was higher among patients older than 60 yrs (67% vs. 41%; p = 0.039), whose group also had a worse outcome (76% with mRS 5 or 6) at 90 days (OR 3.91 CI95% 1.30-11.74), whereas only 24% had mRS of 0-4 (p = 0.015). All patients who presented with sepsis died (p = 0.003). The incidence of pulmonary infection was very high in the elderly group (76%) with significant intergroup differences (p = 0.027, OR 8.32 CI95% 0.70-98.48).

CONCLUSIONS

Older patients present more commonly with infections, more disabilities and a higher mortality, highlighting very poor results in elderly population. These results should be proved with a South American trial, and if confirmed, it can impact on future decisions regarding decompressive craniectomy for acute ischemic stroke in our region.

Development of an experimental model of neurocysticercosis-induced hydrocephalus. Pilot study

PURPOSE

To develop an experimental model of neurocysticercosis-induced hydrocephalus

METHODS

There were used 17 rats. Ten animals were inoculated with Taenia crassiceps cysts into the subarachnoid. Five animals were injected with 0. ml of 25% kaolin (a standard solution for the development of experimental hydrocephalus) and two animals were injected with saline. Magnetic resonance imaging (MRI) was used to evaluate enlargement of the ventricles after one or three months of inoculation. Volumetric study was used to quantify the ventricle enlargement.

RESULTS

Seven of the 10 animals in the cyst group developed hydrocephalus, two of them within one month and five within three months after inoculation. Three of the five animals in the kaolin group had hydrocephalus and none in the saline group. Ventricle volumes were significantly higher in the 3-months MRI cyst subgroup than in the 1-month cyst subgroup. Differences between cyst subgroups and kaolin group did not reach statistical significance.

CONCLUSION

The developed model may reproduce the human condition of neurocysticercosis-related hydrocephalus, which exhibits a slowly progressive chronic course.

Traumatic brain injury presenting with bilateral basal ganglia hemorrhage

CONTEXT

Traumatic basal ganglia hemorrhage (TBGH) is a rare presentation of traumatic brain injury. Bilateral lesions are even rarer. Only twelve similar cases were previously published.

CASE REPORT

We report the case of a patient with bilateral TBGH. He was managed conservatively. Long-term follow-up disclosed a cognitive dysfunctions attributed to associated diffuse axonal injury. Acceleration and deceleration forces may have torn pallidum arterial branches determining hemorrhage.

CONCLUSION

Bilateral TBGH is an uncommon presentation of traumatic brain injury. Associated diffuse axonal injury worsens the outcome.

Analysis of cerebrospinal fluid in racemose form of neurocysticercosis

The present work aimed to evaluate the pattern of CSF alterations in patients diagnosed with neurocysticercosis (NCC) in racemose form.Method This is a retrospective cohort study of patients with diagnosis of NCC in racemose form. CSF samples from 26 patients were analyzed. After patient-chart analysis was performed descriptive analysis of case studies and comparison between sexes in relation to variables were obtained with CSF by Mann-Whitney and Student's t-tests.Results The sexes did not differ statistically when compared to pleocytosis in CSF. Eosinophils were present in 31% in samples while the ELISA test presented 80% sensitivity in this case series. Of the patient total, 24 presented a meningitis pattern with lymphocytic predominance.Conclusion There was no difference in inflammatory pattern between the sexes, with predominance of lymphocytic meningitis and 80% sensitivity by ELISA test of CSF patients with racemose form of NCC.

A systematic review of anti-inflammatories for mild to moderate carpal tunnel syndrome

The purpose of this study was to evaluate anti-inflammatory drugs in the medium- and long-term management of mild to moderate carpal tunnel syndrome (CTS). The authors conducted a systematic review of the literature on the effectiveness of steroidal and nonsteroidal anti-inflammatory drugs for mild and moderate cases of CTS. There were included only randomized, double-blind clinical trials. Six publications referring to five trials were included in the review. No study on nonsteroidal anti-inflammatory drugs met our inclusion criteria. Although neurophysiological studies have not shown great differences resulting from the application of corticosteroids, the symptomatic benefit provided by such drugs is clear. In the short term, local infiltration provides better results than systemic administration of corticosteroids. Over a 1-year period, however, this difference does not persist. Further double-blind randomized trials evaluating therapeutic efficacy for a longer follow-up period are required to provide stronger evidence for both steroidal and nonsteroidal anti-inflammatories.