The “Brain Stress Timing” phenomenon and other misinterpretations of randomized clinical trial on aneurysmal subarachnoid hemorrhage

Clipping and coiling are currently the two alternatives in treatment of ruptured cerebral aneurysms. In spite of some meritorious analysis, further discussion is helpful to understand the actual state of art. Retreatment and rebleeding rates clearly favors clipping, although short-term functional outcome seems to be beneficial for clipping, while this different is not such if we perform the comparison at a longer follow up. Longterm follow ups and cost analysis are mandatory to have a clear view of the current picture in treatment of subarachnoid hemorrhage. Treatment strategy should be made by a multi-disciplinary team in accredited centers with proficient experience in both techniques.

The treatment of Parkinson's disease with deep brain stimulation: current issues

Deep brain stimulation has become a well-established symptomatic treatment for Parkinson＇s disease during the last 25 years. Besides improving motor symptoms and long-term motor complications, positive effects on patients＇ mobility, activities of daily living, emotional well-being and health-related quality of life have been recognized. Apart from that, numerous clinical trials analyzed effects on non-motor symptoms and side effects of deep brain stimulation. Several technical issues and stimulation paradigms have been and are still being developed to optimize the therapeutic effects, minimize the side effects and facilitate handling. This review summarizes current therapeutic issues, i.e., patient and target selection, surgical procedure and programming paradigms. In addition it focuses on neuropsychological effects and side effects of deep brain stimulation.

Joint Multi-modal Parcellation of the Human Striatum:Functions and Clinical Relevance

The human striatum is essential for both lowand high-level functions and has been implicated in the pathophysiology of various prevalent disorders,including Parkinson's disease(PD)and schizophrenia(SCZ).It is known to consist of structurally and functionally divergent subdivisions.However,previous parcellations are based on a single neuroimaging modality,leaving the extent of the multi-modal organization of the striatum unknown.Here,we investigated the organization of the striatum across three modalities—resting-state functional connectivity,probabilistic diffusion tractography,and structural covariance—to provide a holistic convergent view of its structure and function.We found convergent clusters in the dorsal,dorsolateral,rostral,ventral,and caudal striatum.Functional characterization revealed the anterior striatum to be mainly associated with cognitive and emotional functions,while the caudal striatum was related to action execution.Interestingly,significant structural atrophy in the rostral and ventral striatum was common to both PD and SCZ,but atrophy in the dorsolateral striatum was specifically attributable to PD.Our study revealed a cross-modal convergent organization of the striatum,representing a fundamental topographical model that can be useful for investigating structural and functional variability in aging and in clinical conditions.

Aβ淀粉样蛋白相关性脉管炎:伴有脑血管淀粉样改变的中枢神经系统原发性脉管炎

Idiopathic or primary angiitis of the CNS (PACNS) and cerebral amyloid angiopa thy (CAA) are unusual vasculopathies generally regarded as unrelated disorders. A few case reports have,however, described granulomatous angiitis in patients wi th sporadic,amyloid βpeptide (Aβ)-related CAA. Here we describe the clinical, neuroradiological and neuropathological features of nine patients with Aβ-rel ated angiitis (ABRA). Combining these with the individual case reports drawn fro m the literature has allowed us to define ABRA as a clinical entity and to compa re its features with those of PACNS. The mean age of presentation of ABRA (67 ye ars) is higher than that of PACNS but lower than that of sporadic non-inflammat ory Aβ-related CAA.Alterations in mental status (59%), headaches (35%), seiz ures and focal neurological deficits (24%) are common. Hallucinations are a pre senting manifestation in 12 %of cases. Most patients have white matter hyperint ensities on MRI but these are of similar appearance to those in PACNS. Cerebrosp inal fluid usually shows modest elevation of protein and pleocytosis.Neuropathol ogy reveals angiodestructive inflammation,often granulomatous, and meningeal lym phocytosis. Aβis consistently present in abundance in affected blood vessels bu t usually scanty within the parenchyma of the cerebral cortex.However, the corte x includes numerous activated microglia,occasionally in a plaque-like distribut ion and containing cytoplasmic Aβ. The cerebral white matter shows patchy glios is and rarefaction, in some cases marked. Our findings (i) help to dissect one s eparate clinicopathological entity from what is likely to be a spectrum of prima ry angiitides of the CNS;(ii) have important therapeutic implications for one ca tegory of patients with amyloid-related vasculopathy; and (iii) may provide val uable insights into the development of amyloid-associated inflammation, of rele vance not only to ABRA but also to Aβ-immunization-related encephalitis and t o Alzheimer’s disease.

Outcome following severe traumatic brain injury TBI correlates with serum S100B but not brain extracellular fluid S100B:An intracerebral microdialysis study

S100B protein is released by astrocytes into the brain extracellular fluid following acute brain injury and elevated levels in CSF and serum have been shown to correlate with patient outcome following traumatic brain injury. A prospective study of brain extracellular fluid (ECF) and serum S100B levels in 12 patients with severe head injury (GCS ≤ 8) was undertaken using intracerebral microdialysis to investigate whether a correlation with ECF S100B and outcome could be confirmed. Patient outcomes were assessed at 6 months using the Glasgow Outcome Scale (GOS) and divided into two outcome groups: group A, 8 survivors with either a good recovery or moderate disability (GOS scores of 4 or 5);and group B, 4 patients who died (GOS 1). Peak serum levels of S100B were significantly greater in group B (mean 6.03 ng/ml) compared with group A (mean 0.73 ng/ml) (P = 0.009). Group A had a mean peak S100B in the extracellular compartment of 186 ng/ml compared to 150 ng/ml in group B. There was no significant difference between the mean peak brain ECF S100B concentrations for the 2 outcome groups (P = 0.932). We confirm that intracerebral microdialysis can be used to sample S100B concentrations from brain extracellular fluid and our results suggest that the ECF S100B levels were variable and that there was no significant difference between the good outcome and poor outcome groups. In contrast, the serum levels of S100B of patients with a poor outcome were significantly higher than those with a good outcome.

与部位无关的脑白质病变影响额叶功能

Objective: To analyze the effect of white matter lesions in different brain regions on regional cortical glucose metabolism, regional cortical atrophy, and cognitive function in a sample with a broad range of cerebrovascular disease and cognitive function. Methods: Subjects (n = 78) were recruited for a study of subcortical ischemic vascular disease (SIVD) and Alzheimer disease (AD) contributions to dementia. A new method was developed to define volumes of interest from high resolution three dimensional T1 weighted MR images. Volumetric measures of MRI segmented white matter signal hyperintensities (WMH) in five different brain regions were related to regional PET glucose metabolism (rCMRglc) in cerebral cortex, MRI measures of regional cortical atrophy, and neuropsychological assessment of executive and memory function. Results: WMH was significantly higher in the prefrontal region compared to the other brain regions. In all subjects, higher frontal and parietal WMH were associated with reduced frontal rCMRglc, whereas occipitotemporal WMH was only marginally associated with frontal rCMRglc. These associations were stronger and more widely distributed in nondemented subjects where reduced frontal rCMRglc was correlatedwithWMH for all regions measured. In contrast, there was no relationship between WMH in any brain region and rCMRglc in either parietal or occipitotemporal regions. WMHs in all brain regions were associated with low executive scores in nondemented subjects. Conclusions: The frontal lobes are most severely affected by SIVD. WMHs are more abundant in the frontal region. Regardless of where in the brain these WMHs are located, they are associated with frontal hypometabolism and exe cutive dysfunction.

海德堡视网膜断层扫描随访青光眼视盘改变的图像分析

Background:The Heidelberg Retina Tomograph(HRT)is a commercially available instrument for the detection of glaucomatous damage by analysis of optic nerve head topography.The main purpose of the study was to investigate the ability of HRT to detect changes in optic disc topography indicating progression of optic neuropathy in eyes with open-angle glaucoma or,in eyes with ocular hypertension,conversion to open-angle glaucoma.Methods:Fifty-nine subjects(34 with ocular hypertension,25 with glaucoma)from the glaucoma service at Sahlgrenska University Hospital were included in this study.One eye of each patient was selected.All participants underwent thorough clinical examination,including HRT,high-pass resolution perimetry(HRP),and optic disk photography.After a mean follow-up time of 50 months,patients were re-examined.Based on analyses of optic disc photographs and HRP,eyes were classified into one of two groups:progressive or stable.Methods:The differences between baseline and follow-up HRT parameters in the two groups were analysed.The topographic HRT change images were also compared after digital image processing.A pixel ratio was calculated defined as the ratio between the area of pixels representing deepening of the disc surface and the total disc area.Receiver operating characteristic(ROC)curves for HRT parameters and pixel ratio were compared.Results:In the group judged to have progressive optic neuropathy,a statistically significant change between baseline and follow-up examination was found for the following HRT parameters:cup shape measurement,classification index,the third moment in contour,cup/disc ratio,cup area,rim area,and area below reference.In the stable group no HRT parameters had changed significantly.A well-defined distinction between the two groups was found by comparing digitally processed HRT change images.The area under the ROC curve was larger for pixel ratio than for any of the HRT parameters.Conclusions:The HRT is a useful tool for long-term follow-up of glaucomatous optic neuropathy.Digital image processing of HRT change images could facilitate the detection of progressive change.

健康和出生后窒息的足月新生儿爆发脑电图周期的光谱分析

Objective: To investigate whether the periodic EEG patterns seen in healthy an d sick full term neonates (tracéalternant and burst suppression, respectively) have different frequency characteristics. Methods: Burst episodes were selected from the EEGs of 9 healthy and 9 post asphyctic full term neonates and subject ed to power spectrum analysis. Powers in two bands were estimated; 0-4 and 4-3 0 Hz, designated low and highfrequency activity, respectively (LFA, HFA). The s pectral edge frequency (SEF) was also assessed. Results: In bursts, the LFA powe r was ower in periods of burst suppression as compared to those of tracéalterna nt. The parameter that best discriminated between the groups was the relative am ount of low and highfrequency activity. The SEF parameter had a low sensitivity to the group differences. In healthy neonates, the LFApower was higher over the posterior right as compared to the posterior left region. Conclusions: Spectral power of low frequencies differs significantly between the burst episodes of he althy and sick neonates. Significance: These results can be used when monitoring cerebral function in neonates.

中枢神经系统的严重炎症性脱髓鞘疾病的血浆置换疗法:6例病例报道

The standard therapy for episodes of severe acute inflammatory demyelinating disease of the central nervous system is high dose intravenous corticosteroids. A small proportion of patients fail to improve with this regime and their prognosis can become grave. A recent sham controlled double blind crossover trial in this group of patients demonstrated a significant benefit from plasma exchange. We report six patients with severe acute steroid- insensitive inflammatory demyelinating disease of the central nervous system treated with plasma exchange. We observed a clear improvement in five of these six patients. Whilst complications of plasma exchange occurred these did not outweigh the benefits. Our study supports the use of plasma exchange in severe acute steroid- insensitive inflammatory disease of the central nervous system.

病例回顾一位44岁女性的渐进性视力模糊

一名44岁的女性,因进展性视力模糊10周到她的视光医生处就诊。无头痛或呕吐。眼底镜检查显示双侧视乳头水肿。随后的头颅磁共振成像(MRI)(图1~3)显示前额部以硬脑膜为基底的一片大的病灶,累及上矢状窦,导致占位效应以及血管源性的水肿。