bluuebunny/crossref_metadata_2025 huggingface dataset:
Transient Hemifacial Sensory Loss with Xerophthalmia following Temporal Lobectomy
Authors: Thomas Ajith J. , Elisevich Kost , Smith Brien
Published: December 2014

Objective and importance:

The occurrence of a unilateral sensory loss in the second trigeminal distribution and the inability to tear following an ipsilateral temporal lobectomy has not been noted despite a number of reports of cranial nerve compromise under similar situations.

Clinical presentation:

A 48-year-old woman experienced complex partial seizures over three years attributable to the presence of cavernous malformations of the right temporal lobe.

Intervention:

An anterior temporal extrahippocampal resection was performed. The surgery was marked by the need for electrocoagulation of the dural base of the temporal lobe where numerous bleeding points were encountered. Postoperatively, the patient experienced an ipsilateral maxillary division sensory loss, absence of tearing, and diminished nasal congestion for an eight-month period until resolution.

Conclusion:

Injury of the fibers of the maxillary division of the trigeminal nerve and the adjacent greater superficial petrosal nerve appears to be the cause. No prior account of such an occurrence has been published.
Rabies
Authors: Jackson Alan C.
Published: December 2014

Rabies is an important disease in wildlife in the United States and Canada, and dog rabies is still a major public health problem in many developing countries of the world. Rabies virus is transmitted in saliva by animal bites. Bats transmitted most recent cases of human rabies in the United States, often without known exposures. There have been recent developments in our understanding of rabies pathogenesis. Characteristic clinical features should raise the possibility of a diagnosis of rabies and initiation of appropriate diagnostic tests. Therapy of human rabies has been futile except in four patients who were immunized with rabies vaccine prior to the onset of their disease. Rabies can be prevented after an exposure in unimmunized patients with local wound cleansing and administration of rabies vaccine and human rabies immune globulin.
Doubts, Fears and Misconceptions. What is the Future of Thrombolysis in Acute Stroke?
Authors: Barber Philip A. , Hill Michael D. , Demchuk Andrew M. , Buchan Alastair M.
Published: December 2014

Alteplase for acute ischemic stroke may be the first stroke intervention to have a significant public health impact. In February 1999, this therapy was conditionally licensed in Canada for acute ischemic stroke within three hours of symptom onset. However, considerable controversy exists regarding its safety, its wider applicability outside clinical trials, and its ultimate availability. In this article we review the thrombolytic literature, attempt to answer many of the concerns, provide new guidelines for its use, and cite the need for more information about whom we should and should not be treating with this therapy.
Familial Autoimmune Myasthenia Gravis: Four Patients Involving Three Generations
Authors: Marrie R.A. , Sahlas D.J. , Bray G.M.
Published: December 2014

Background:

Familial autoimmune myasthenia gravis (MG) is rare, although a genetic role for the development of autoimmune MG is suggested by concordance in monozygotic twins and the increased frequency of other autoimmune diseases in family members of myasthenics.

Methods:

A patient with a family history of MG was evaluated in hospital. Relatives were interviewed and medical records examined for details regarding the diagnosis of MG in three other family members.

Results:

The index case first experienced symptoms of MG at age 75 years. She developed generalized MG and required corticosteroids and immunosuppressive therapy to control her disease. Her father developed predominantly bulbar symptoms of MG at age 75 years. He died of complications experienced following a gastrostomy placed for continued difficulty swallowing. His brother developed similar symptoms of MG in his early 60s and died shortly after thymectomy. A 46-year-old nephew of the index case is also beginning to exhibit signs of generalized MG. Acetylcholine receptor antibodies were strongly positive in the index case and her nephew. (The assay was not available for her father and uncle).

Conclusion:

Four individuals in three successive generations had diagnoses of autoimmune MG. Study of familial cases such as these may clarify the contribution of genetic factors to the development of this disease.
Correlation between Tapping and Inserting of Pegs in Parkinson's Disease
Authors: Müller Thomas , Schäfer Sandra , Kuhn Wilfried , Przuntek Horst
Published: December 2014

Background:

Various investigators have developed complex quantitative instrumental procedures for objective assessment of parkinsonian motor impairment, since drawbacks of rating scales are interrater variability, subjective impression, and insensitivity to subtle modifications. Objectives: To determine whether performance of inserting of pegs and tapping (i) correlates with each other (ii) differentiates between parkinsonian subjects and healthy controls and (iii) reflects severity of Parkinson's disease (PD). Subjects and

Methods:

In 157 previously untreated idiopathic parkinsonian patients and healthy controls, we measured (i) the total time taken to insert 25 pegs from a rack into a series of appropriate holes in a Purdue pegboard-like apparatus and (ii) the number of taps on a contact board with a contact pencil for a period of 32 seconds for assessment of fine motor skills.

Results:

Results of both tests correlated with each other, differed between parkinsonian subjects and controls and reflected scored severity of PD. Better correlation with intensity of PD was noted with the Purdue pegboard-like task.

Conclusion:

Both tapping and inserting of pegs represent useful tools for objective evaluation of severity of PD. Peg insertion correlated better with disease severity. Both approaches may be useful in future clinical studies.
Autoantibodies in Childhood Post-Varicella Acute Cerebellar Ataxia
Authors: Adams Coleen , Diadori Paola , Schoenroth Leeanne , Fritzler Marvin
Published: December 2014

Background:

Anti-Purkinje cell antibodies have been reported in cerebellar ataxia following Epstein-Barr virus (EBV) infection. We investigated autoantibody responses, including anti-Purkinje cell antibodies, and the clinical course in eight children who developed post-varicella ataxia, five of their siblings with uncomplicated varicella, one child with post-EBV ataxia, two children with acute disseminated encephalomyelitis (ADEM) and one with neuroblastoma associated ataxia, and in age and gender matched controls.

Methods:

Autoantibodies were tested by indirect immunofluorescence (IIF) on cryopreserved cerebrum and cerebellum sections. Other autoantibodies were measured by conventional IIF protocols using HEp-2 cells as a substrate. Antibodies to myelin associated glycoprotein (MAG), asialo-GM1, b2 glycoprotein 1, cardiolipin and myelin basic protein (MBP) were measured by ELISA.

Results:

Three of eight children with acute post-varicella ataxia, one child with post-EBV ataxia, one child with ADEM and one child with uncomplicated varicella, had high titer autoantibodies (<1/160) that reacted with cerebrum and cerebellar tissue. This reactivity was not seen in one child with ADEM, in one with neuroblastoma and ataxia, in the remainder of the children with uncomplicated varicella or age and gender matched controls. Autoantibodies were not seen in CSF from two children with post-varicella ataxia. The punctate staining seen on cerebrum and cerebellum sections co-localized with rabbit antibodies to the centrosome protein pericentrin. All patients with strong reactivity with cerebrum and cerebellar tissue by IIF had elevated levels of anti-MAG that was not confirmed by absorption assay. No reactivity was seen with asialo-GM1, MBP, b2 glycoprotein 1 or cardiolipin. None of the sera had autoantibodies directed against endosomes, the Golgi complex, or the paraneoplastic autoantigens Hu and Yo.

Conclusion:

Some children with post-viral ataxia develop antibodies that have strong reactivity with cerebral and cerebellar tissue. Some of the antigenic reactivity co-localized with the centrosome protein pericentrin.
How Often Does Routine Pediatric EEG Have an Important Unexpected Result?
Authors: Camfield Peter , Camfield Carol
Published: December 2014

Background:

Electroencephalogram recordings are requested for the assessment of many childhood disorders. To assess the utility of the EEG in children, we studied how often routine EEG results can be correctly predicted from the EEG requisition.

Method:

Five hundred consecutive initial EEG requests from the IWK Grace Health Centre from two time epochs were examined. All EEGs were 16 channel (10-20 electrode system). Based only on the requisition (patient demographics, referring physician, and reason for EEG), we coded our prediction of the result and then the actual result. When results were discordant from prediction, a judgment was made about the potential importance of the result.

Results:

Overall, EEG results were correctly predicted in 81%. Prediction for all nonepilepsy reasons was accurate in 91% (n=320) and 96% for paroxysmal nonepileptic events (n=158) but only 59% for epileptic disorders (n=141) (p<0.0001). Neurologists ordered 45% of EEGs, pediatricians 32%, and GP's 17%. Predictions were least accurate for neurologists'requests (p<0.006) however, neurologists were more likely to request EEG for epileptic disorders (p<0.0001). Age of the child and urban versus rural address did not affect the accuracy of prediction.

Conclusion:

Results of routine pediatric EEG for most nonepilepsy reasons appear highly predictable and therefore, possibly of little value to an experienced clinician. When requested for epilepsy, this “ancient” test remains full of surprises.
Diagnosis, Classification and Natural History of Degenerative Dementias
Authors: Feldman H. , Kertesz A.
Published: December 2014

The release of the first approved medications for the treatment of Alzheimer’s disease in Canada has highlighted the renewed need and importance of diagnostic accuracy and understanding of the spectrum of the dementias. The epidemiological scope of the problem of dementia in Canada including risk factors, caregiving patterns and costs of care have been well-characterized through the Canadian Study of Health and Aging (CSHA 1991-1996) with some of the key findings reviewed here. Beyond Alzheimer’s disease the phenotypes and genotypes of the other degenerative dementias have been emerging with proposed operational diagnostic criteria that should facilitate their recognition in clinical practice. This paper reviews the clinical phenotypes of the most common causes of dementia with a proposed classification scheme and with discussion of their relevance from a differential treatment standpoint. This paper served as a background document for the working group of the Consensus Conference on Dementia (C3D) in February 1998 and has been revised subsequently for this publication.
Screening for Cognitive Impairment and Dementia in the Elderly
Authors: Patterson Christopher J.S. , Gass David A.
Published: December 2014

Objective:

To review the evidence available to support or refute the recommendation to screen for cognitive impairment (cognitive deficits which do not affect daily function) and dementia in primary care.

Data Sources:

Medline search using terms listed at the end of this article; consultation with experts in the field; review of other published recommendations.

Study Selection:

There were no articles which described a randomized controlled trial of screening versus no screening. Studies were therefore chosen which aided in the definition; natural history; interventions and outcomes including possible negative effects.

Data Synthesis:

No systematic synthesis was performed. Background papers were circulated to a panel of experts prior to the Canadian Consensus Conference on Dementia and conclusions endorsed by consensus.

Conclusion:

1. There is insufficient evidence to recommend for or against screening for cognitive impairment or dementia. (C); 2. Memory complaints should be evaluated and the individual followed to assess progression. (B); 3. When caregivers or informants describe cognitive decline in an individual, these observations should be taken very seriously; cognitive assessment and careful follow-up are indicated. (A) (See Appendix).
Cultural Aspects of Dementia
Authors: Herbert Carol P.
Published: December 2014

This paper critically reviews current knowledge regarding culture and dementia in order to identify unanswered questions in the field. Medline was searched from 1993-2000. One hundred nine articles were identified, of which 59 were critically reviewed, augmented by additional references from experts and by books. Limited research evidence was identified in four areas: 1) the recognition of dementia across cultures 2) cultural specificity of screening tools 3) identification of differences in risk factors, incidence, onset and prevalence across culture 4) culturally related issues in decision making about management. Implications for research and practice are described.
Depressive Syndromes in Dementia
Authors: Thorpe Lilian , Groulx Bernard
Published: December 2014

Background:

Depressive syndromes in dementia are common, treatment is challenging and controlled intervention studies are small in number. The goal of this paper is to review known information about the etiology, epidemiology and treatment of these syndromes, as summarized at the recent Canadian Consensus Conference on Dementia.

Methods:

A number of Medline searches were performed (most recently updated in October 2000) using the subject categories dementia and depression, or apathy or emotional lability and other relevant articles were also reviewed. The background article was edited and amended at the Consensus Conference on Dementia. Final recommendations appearing in the summary article by Patterson et al were accepted by the group consensus process. Clinical discussion and informational updates were added for the current text by the authors.

Results:

Depressive syndromes, ranging in severity from isolated symptoms to full depressive disorders, increase in dementia. While clear-cut depressive disorder is increased in this population, sub-syndromal disorders are even more common and cause considerable distress. Antidepressant treatment may improve the quality of life in depressed, demented people, although it is less successful than in those without cognitive impairment and carries more risk of iatrogenic effects.

Conclusion:

Physicians should be alert to the presence of depressive syndromes in dementia. Depressive illness should be treated and, when necessary, referral should be made to an appropriate specialist. Treatment must minimize iatrogenic effects. Although there is some support for treatment of syndromes that do not meet criteria for depressive disorder or dysthymia, the first line of intervention in these situations should involve nonpharmacological approaches.
Status of Current Clinical Trials in Diabetic Polyneuropathy
Authors: Bril Vera
Published: December 2014

Peripheral polyneuropathy is the most frequent complication of diabetic mellitus. In spite of many clinical trials of different specific interventions for diabetic polyneuropathy, intensive glycemic control remains the only effective specific therapy currently available for this troublesome complication. This systematic overview reports the status of current clinical trials in diabetic polyneuropathy with an emphasis on those interventions directed towards specific pathophysiological derangements. A discussion of clinical trials of agents directed towards relieving painful symptoms of diabetic polyneuropathy concludes this overview.
Methodology for the Canadian Activase for Stroke Effectiveness Study (CASES)
Authors: Hill Michael D. , Buchan Alastair M. , Investigators The CASES
Published: December 2014

Background:

Intravenous recombinant tissue plasminogen activator (tPA, alteplase) was conditionally licensed for the treatment of acute ischemic stroke (AIS) in Canada on February 17, 1999. As a condition of licensure, the Canadian Activase for Stroke Effectiveness Study (CASES) was established to monitor the use of alteplase for AIS in Canada. The study involves multiple stakeholders.

Methods:

CASES is a prospective registry of patients treated with alteplase for AIS. The purposes of this registry are to ensure the safety of the drug in the Canadian context, to assess effectiveness of alteplase for AIS and to gather further information to try to establish which patients are most likely to benefit from treatment.

Results:

Both community (n=25) and tertiary centres (n=35) have enrolled a total of 944 patients to date. Early results suggest that thrombolytic stroke treatment is both safe and effective among these centres.

Conclusion:

This paper outlines the development of and methods for the CASES study. The study is an example of a multi-stakeholder collaboration to advance the care of patients with acute stroke.
Prospective Analysis of Relationships of Outcome Measures for Ulnar Neuropathy at the Elbow
Authors: Munro Catherine A. , Midha Rajiv , Ho Peter H. , Szalai John Paul , Noble Jason , Patel Vivek
Published: December 2014

Background:

We undertook a prospective study to investigate relationships between outcome measures of ulnar neuropathy at the elbow.

Methods:

Thirty-one patients (mean age 52.6, range 20-80), with clinically and electrically verified ulnar neuropathy at the elbow, were seen independently by a neurosurgeon and a physiotherapist. All tests were administered to all patients on each visit. Data collected included measures of sensory (monofilament, two-point discrimination, vibration) and motor function (grip, key-pinch, muscle atrophy), pain (visual analogue scale (VAS)) and impact on lifestyle (Levine's questionnaires (function status score - FSS, symptom severity score - SSS)), disability of the arm, shoulder and hand module (DASH) and patient-specific measures (PSM). Parametric and non-parametric correlation and factor analysis were done.

Results:

Outcome analysis was available for 63 patient visits, with follow-up obtained for 20 patients (mean 8.5 months). Lifestyle and pain instruments (FSS, SSS, DASH, PSM and VAS) all correlated well with each other (r> 0.6, p< .01). DASH was moderately to highly correlated to nine of the 11 measures. Some tests correlated poorly, for example, Semmes-Weinstein monofilament with other sensory measures and muscle atrophy with almost all measures. Factor analysis revealed that there are two principal factors, accounting for 77% of the variance. Factor 1 relates to impact on lifestyle and pain while Factor 2 relates to strength and function.

Discussion/Conclusions:

Intraclass measures, particularly ones assessing lifestyle and pain instruments are strongly correlated. Factor analysis revealed two principal factors that account for the majority of the variance; future studies with a larger sample size are needed to validate this analysis.
Spontaneous Internal Carotid Artery Dissection with Lower Cranial Nerve Palsy
Authors: Guy N. , Deffond D. , Carriere N. , Dordain G. , Clavelou P. , Gabrillargues J.
Published: December 2014

Background:

Typical presentation of spontaneous internal carotid artery (ICA) dissection is an ipsilateral pain in neck and face with Horner's syndrome and contralateral deficits. Although rare, lower cranial nerve palsy have been reported in association with an ipsilateral spontaneous ICA dissection.

Case studies:

We report three new cases of ICA dissection with lower cranial nerve palsies.

Results:

The first symtom to appear was headache in all three patients. Examination disclosed a Horner's syndrome in two cases (1 and 2), an isolated XIIth nerve palsy in two patients (case 1 and 3) and IX, X, and XIIth nerve palsies (case 2) revealing an ipsilateral carotid dissection, confirmed by MRI and angiography. In all cases, prognosis was good after a few weeks.

Conclusion:

These cases, analysed with those in the literature, led us to discuss two possible mechanisms: direct compression of cranial nerves by a subadventitial haematoma in the parapharyngeal space or ischemic palsy by compression of the ascending pharyngeal artery.
Progress in Clinical Neurosciences: The Evidence for ALS as a Multisystems Disorder of Limited Phenotypic Expression
Authors: Strong Michael J.
Published: December 2014

Traditionally, amyotrophic lateral sclerosis (ALS) is considered to be a unique neurodegeneration disorder in which motor neurons are selectively vulnerable to a single disease process. Our current understanding of ALS, however, suggests that this is far too limited an approach. While motor neuron degeneration remains the central component to this process, there is considerable phenotypic variability including broad ranges in survivorship and the presence or absence of cognitive impairment. The number of familial variants of ALS for which unique genetic linkage has been identified is increasing, attesting further to the biological heterogeneity of the disorder. At the cellular level, derangements in cytoskeletal protein and glutamate metabolism, mitochondrial function, and in glial interactions are clearly evident. When considered in this fashion, ALS can be justifiably considered a disorder of multiple biological processes sharing in common the degeneration of motor neurons.
Listeria Spinal Cord Abscess Responsive to Trimethoprim-Sulfamethoxazole Monotherapy
Authors: Okun Michael S. , Rossi Fabian H. , Triggs William J , White Jennifer , Quisling Ronald
Published: December 2014

Objective:

To describe an alternative antibiotic regimen for the treatment of central nervous system Listeria monocytogenes infection.

Background:

Classical treatment of listeria infections of the brain and spinal cord has included ampicillin in combination with gentamicin and chloramphenicol. Antibiotic resistance to L. monocytogenes is extraordinarily low, and the combined risks of nephrotoxicity, ototoxicity, and agranulocytosis in an already critically ill patient make the potential use of trimethoprim-sulfamethoxazole monotherapy for coverage or treatment of listeria an important alternative.

Methods:

Case report.

Results:

A 58-year-old woman presented with a two-week history of progressive quadriplegia. Gadolinium enhanced MRI showed diffuse edema of the cervical and thoracic spine with ring-enhancing lesions. Cerebrospinal fluid and blood cultures both grew L. monocytogenes. Spinal cord biopsy of the lesion revealed inflammation with necrosis and also grew listeria. Intravenous trimethoprim-sulfamethoxazole (8 mg/kg in four divided doses) was administered for six weeks with resultant arrest of neurological symptoms and stabilization of the clinical course. Although the patient was quadraparetic she was able to be discharged to a rehabilitation facility.

Conclusions:

Trimethoprim-sulfamethoxazole monotherapy may be a potential alternative option for critically ill patients with central nervous system L. monocytogenes infection.
Invited Review: Clinical and Basic Neurophysiology of Generalised Epilepsies
Authors: Blume Warren T.
Published: December 2014

Electroencephalography (EEG) clarifies several aspects of generalised epileptic seizures and epilepsies. For the clinician, it assists in the diagnosis of the epileptic condition and helps assign the disorder to an appropriate syndrome. This assignation and the quantity of epileptic discharges estimate severity and prognosis. When combined with relevant basic science investigations, EEG studies may disclose significant pathophysiological mechanisms. Therefore, this paper first describes EEG characteristics of the several disorders included under the broad category of “generalised”. The review then relates these phenomena to germane experimental data intending that this binocular survey will provide a more meaningful perspective of these disorders.
Carotid Dissection: Technical Factors Affecting Endovascular Therapy
Authors: Albuquerque Felipe C. , Han Patrick P. , Spetzler Robert F. , Zabramski Joseph M. , McDougall Cameron G.
Published: December 2014

Background and Purpose:

To delineate factors associated with the successful endovascular treatment of extracranial carotid dissections, the authors review their management of 13 cases.

Methods:

The records of 12 patients with 13 dissections were assessed with reference to mechanism of dissection, preoperative symptoms, presence of a pseudoaneurysm, treatment success, and etiology of treatment failure. Patients were followed prospectively and included six men and six women, ranging in age from 27 to 62 years.

Results:

Angioplasty and stenting were performed successfully in 11 of 13 procedures (10 of 12 patients). Follow-up in these 10 patients demonstrated excellent patency through the stented segment in nine of the 11 treated vessels. Two patients, both of whom suffered their original dissection as a result of endarterectomy, required further angioplasty and stenting for stenosis outside the previously treated arterial segment. Regarding the treatment failures, a stent deployment device could not navigate a tortuous loop in one, while a microwire could not be advanced beyond a pseudoaneurysm in the second. Six patients had pseudoaneurysms, four of which were treated only with stenting across the dissected arterial segment. All pseudoaneurysms treated in this fashion resolved. No permanent complications occurred as a result of endovascular therapy.

Conclusions:

Angioplasty and stenting can be performed safely to manage carotid dissection. A pseudoaneurysm or tortuous anatomy can preclude therapy although the former typically resolves if angioplasty and stenting are feasible. Dissections secondary to endarterectomy may be associated with a higher rate of restenosis after stenting and may require further treatment.
Parkinsonism in Ontario: Physician Utilization
Authors: Guttman M. , Slaughter P.M. , Theriault M-E. , DeBoer D.P. , Naylor C.D.
Published: December 2014

Background:

Patients with Parkinsonism have a progressive disorder requiring substantial expertise to manage effectively.

Methods:

Over a six-year period we evaluated physician utilization and related costs for a large, unselected cohort of 15,304 Parkinsonian patients from the general population, comparing them to 30,608 age- and sex-matched controls within a universal health care system in Ontario, Canada.

Results:

On average, 45% of Parkinsonian patients saw neurologists annually. The cumulative rate of at least one neurological consultation was only 59.5% over the six years. Patients aged <65 had a much greater likelihood of consulting a neurologist (73.3%) compared to those ≥65 (37.2%). Most Parkinsonian patients (97.2%), regardless of age, saw family physicians/general practitioners each year; 50.4% saw internal medicine consultants.

Conclusions:

Parkinsonian patients had increased likelihood of utilizing neurologists, primary care physicians and internists compared to controls; related costs of physicians’ services were higher. Further research is necessary to evaluate differences in outcomes and costs between neurologists and other physician service providers.
High-Dose Methylprednisolone for Acute Closed Spinal Cord Injury - Only a Treatment Option
Authors: Hugenholtz H. , Cass D.E. , Dvorak M.F. , Fewer D.H. , Fox R.J. , Izukawa D.M.S. , Lexchin J. , Tuli S. , Bharatwal N. , Short C.
Published: December 2014

Background:

A systematic review of the evidence pertaining to methylprednisolone infusion following acute spinal cord injury was conducted in order to address the persistent confusion about the utility of this treatment.

Methods:

A committee of neurosurgical and orthopedic spine specialists, emergency physicians and physiatrists engaged in active clinical practice conducted an electronic database search for articles about acute spinal cord injuries and steroids, from January 1, 1966 to April 2001, that was supplemented by a manual search of reference lists, requests for unpublished additional information, translations of foreign language references and study protocols from the author of a Cochrane systematic review and Pharmacia Inc. The evidence was graded and recommendations were developed by consensus.

Results:

One hundred and fifty-seven citations that specifically addressed spinal cord injuries and methylprednisolone were retrieved and 64 reviewed. Recommendations were based on one Cochrane systematic review, six Level I clinical studies and seven Level II clinical studies that addressed changes in neurological function and complications following methylprednisolone therapy.

Conclusion:

There is insufficient evidence to support the use of high-dose methylprednisolone within eight hours following an acute closed spinal cord injury as a treatment standard or as a guideline for treatment. Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body weight over fifteen minutes within eight hours of closed spinal cord injury, followed 45 minutes later by an infusion of 5.4 mg per kilogram of bodyweight per hour for 23 hours, is only a treatment option for which there is weak clinical evidence (Level I- to II-1). There is insufficient evidence to support extending methylprednisolone infusion beyond 23 hours if chosen as a treatment option.
Spontaneous Intracranial Hypotension in the Absence of Magnetic Resonance Imaging Abnormalities
Authors: Schoffer Kerrie L. , Benstead Timothy J. , Grant Ian
Published: December 2014

Background:

Spontaneous intracranial hypotension (SIH) is a neurologic syndrome of unknown etiology, characterized by features of low cerebral spinal fluid (CSF) pressure, postural headache and magnetic resonance imaging (MRI) abnormalities.

Methods:

Four symptomatic cases of SIH presented to our institution over a six-month period. Magnetic resonance imaging studies were performed in all four cases. Diagnostic lumbar puncture was done in all except one case.

Results:

All of the patients on whom lumbar punctures were performed demonstrated low CSF pressure and CSF protein elevation with negative cultures and cytology. Three out of the four patients exhibited MRI findings of diffuse spinal and intracranial pachymeningeal gadolinium enhancement and extradural or subdural fluid collections. One patient had no MRI abnormalities despite prominent postural headache and reduced CSF pressure at lumbar puncture. All patients recovered with intravenous fluids and conservative treatment.

Conclusion:

Magnetic resonance imaging abnormalities are found in most, but not all patients, with SIH. Cerebral spinal fluid abnormalities can be detected even in patients with normal MRI studies. It is important to recognize the variability of imaging results in this usually benign disorder.
Provincial Carotid Endarterectomy Outcomes
Authors: Feasby Thomas E. , Quan Hude , Ghali William A.
Published: December 2014

Background:

Outcomes must be measured as a first step toward improving performance. We sought to measure the national and provincial outcomes from carotid endarterectomy (CE) and explain provincial differences.

Methods:

We analyzed a large Canada-wide administrative hospital discharge database of all patients, except those in Québec, receiving CE in 1994-1997 and used logistic regression for risk adjustment to measure adverse outcomes nationally and by province. Our main outcome measures were in-hospital stroke and/or death.

Results:

A total of 14,268 patients underwent CE in the years 1994-1997. The overall death rate was 1.3% and the combined stroke and/or death rate was 4.1%. There was a trend towards improvement over the four years. The provinces of Saskatchewan and Newfoundland had significantly higher adverse event rates for the risk-adjusted combined outcome measure.

Conclusion:

The outcome of CE in Canada is good and showed improvement over four years. However, significant differences in provincial outcomes were found. This suggests that regionalization across provincial boundaries may be needed to promote higher surgeon and hospital case volumes and thus improve outcomes.
Launching a Research Initiative: The Canadian Pediatric Epilepsy Network (CPEN)
Authors: Whiting Sharon , Camfield Peter , Wiebe Samuel , Lassonde Maryse , Sauerwein Hannelore , Carmant Lionel
Published: December 2014

The Canadian Pediatric Epilepsy Network is a network of scientists and health care professionals in partnership with organizations which provide education and support to children with epilepsy. The objective of the network is to gain a better understanding of childhood epilepsy through collaborative research conducted with doctors, psychologists, nurses, social workers, educators and scientists across Canada. The network was launched at a meeting in Ottawa in the spring of 2000 where several oral presentations addressed the issues of the fundamental questions of epilepsy, the economic impact and the neuropsychology of childhood epilepsy. The intent was to provoke discussion on future areas of research for the network.
Progress in Clinical Neurosciences: Perioperative Ulnar Neuropathies: A Medicolegal Review
Authors: Stewart John D. , Shantz Stephen H.
Published: December 2014

Background:

Perioperative ulnar neuropathies have long been attributed to inappropriate arm positioning and padding during operations and have resulted in many lawsuits.

Methods:

A recent Canadian lawsuit is described and the literature regarding perioperative ulnar and other focal neuropathies reviewed.

Results:

The evidence strongly suggests that ulnar nerve damage is usually sustained in the postoperative rather than the intraoperative period. There is no evidence that positioning or padding of the arm during the operation prevents perioperative ulnar neuropathies.

Conclusions:

There should generally be no basis for a claim against medical or nursing staff or hospitals when an ulnar neuropathy develops following anesthesia and surgery.
Early Olfactory Involvement in Alzheimer’s Disease
Authors: Christen-Zaech S. , Kraftsik R. , Pillevuit O. , Kiraly M. , Martins R. , Khalili K. , Miklossy J.
Published: December 2014

Background:

In Alzheimer’s disease (AD) the olfactory system, including the olfactory bulb, a limbic paleocortex is severely damaged. The occurrence of early olfactory deficits and the presence of senile plaques and neurofibrillary tangles in olfactory bulb were reported previously by a few authors. The goal of the present study was to analyze the occurrence of AD-type degenerative changes in the peripheral part of the olfactory system and to answer the question whether the frequency and severity of changes in the olfactory bulb and tract are associated with those of the cerebral cortex in AD.

Material and Methods:

In 110 autopsy cases several cortical areas and the olfactory bulb and tract were analyzed using histo- and immunohistochemical techniques. Based on a semiquantitative analysis of cortical senile plaques, neurofibrillary tangles and curly fibers, the 110 cases were divided into four groups: 19 cases with severe (definite AD), 14 cases with moderate, 58 cases with discrete and 19 control cases without AD-type cortical changes.

Results:

The number of cases with olfactory involvement was very high, more than 84% in the three groups with cortical AD-type lesions. Degenerative olfactory changes were present in all 19 definite AD cases, and in two of the 19 controls. The statistical analysis showed a significant association between the peripheral olfactory and cortical degenerative changes with respect to their frequency and severity (P<0.001). Neurofibrillary tangles and neuropil threads appear in the olfactory system as early as in entorhinal cortex.

Conclusion:

The results indicate a close relationship between the olfactory and cortical degenerative changes and indicate that the involvement of the olfactory bulb and tract is one of the earliest events in the degenerative process of the central nervous system in AD.
Selection of Neurosurgical Trainees
Authors: Myles S.T. , McAleer S.
Published: December 2014

Background:

Medical students in Canada must make career choices by their final year of medical school. Selection of students for a career in neurosurgery has traditionally been based on marks, reference letters and personal interviews. Studies have shown that marks alone are not accurate predictors of success in medical practice; personal skills and attributes which can best be assessed by letters of reference and interviews may be more important. This study was an attempt to assess the importance of, and ability to teach, personal skills and attitudes necessary for successful completion of a neurosurgical training program.

Methods:

A questionnaire was sent to 185 active members of the Canadian Neurosurgical Society, asking them to give a numerical rating of the importance of 22 personal skills and attributes, and their ability to teach those skills and attributes. They were asked to list any additional skills or attributes considered important, and rate their ability to teach them.

Results:

Sixty-six (36%) questionnaires were returned. Honesty, motivation, willingness to learn, ability to problem solve, and ability to handle stress were the five most important characteristics identified. Neurosurgeons thought they could teach problem solving, willingness to consult informed sources, critical thinking, manual dexterity, and communication skills, but honesty, motivation, willingness to learn and ability to handle stress were difficult or impossible to teach.

Conclusions:

Honesty, motivation, willingness to learn, ability to problem solve and handle stress are important for success in a neurosurgical career. This information should be transmitted to medical students at “Career Day” venues. Structuring letters of reference and interviews to assess personal skills and attributes will be important, as those that can’t be taught should be present before the start of training.
Neonatal Herpes Encephalitis: A Case Series and Review of Clinical Presentation
Authors: Toth Cory , Harder Sheri , Yager Jerome
Published: December 2014

Objective:

To describe the clinical and laboratory findings in cases of neonatal herpes simplex virus (HSV) encephalitis.

Background:

Neonatal HSV encephalitis is a devastating infection which requires a high degree of clinical suspicion and rapid initiation of antiviral therapy.

Methods:

We performed a retrospective search for all cases of HSV encephalitis within the two Saskatchewan pediatric tertiary care centers for the period of 1985-2001. Only those patients with consistent clinical presentations along with direct evidence of presence of HSV, such as positive cerebrospinal fluid (CSF) viral cultures, positive polymerase chain reaction (PCR) for HSV from CSF, or positive immunoglobulin G against HSV from neonatal blood, were selected.

Results:

Five male and four female infant patients were identified. At a mean age of presentation of 24±20 days, seizures occurred in six neonates, lethargy in six neonates, temperature changes in five neonates, and apnea in three neonates. Examination of CSF demonstrated an initial monocytosis or lymphocytosis, elevated CSF protein and depressed CSF glucose in 100% of patients. Electroencephalography (EEG) was abnormal in 100% of patients. Initial computerized tomography was abnormal in 55% of patients. Clinical follow-up over an average of two years demonstrated developmental delay in four patients and upper motor neuron findings in four patients. No patients suffered from postencephalitic epilepsy or mortality.

Conclusions:

Neonatal HSV encephalitis most commonly presents with seizures, lethargy, and dysthermia. Cerebrospinal fluid testing and EEG have 100% sensitivity in cases with laboratory confirmation of HSV presence. Improvements in morbidity and mortality as compared to previous reports may relate to better recognition of this illness and acyclovir therapy. The lack of postinfection epilepsy in our series may also relate to better recognition and acyclovir therapy within this series of patients.
MRI Contributes to the Differentiation Between MS and HTLV-I Associated Myelopathy in British Columbian Coastal Natives
Authors: Howard Andrew K. , Li David K.B. , Oger Joël
Published: December 2014

Background:

Human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) in British Columbian Coastal Natives has, to date, been a clinical and laboratory diagnosis. However, magnetic resonance imaging (MRI) abnormalities have been well-described in other populations in which HAM/TSP is endemic.

Methods:

In order to assess the usefulness of MRI as a diagnostic tool in this population, we compared scans of HAM/TSP patients with those of HTLV-I positive non-HAM/TSP British Columbian Coastal Natives (carriers) and multiple sclerosis patients presenting with progressive paraparesis.

Results:

The typical nonspecific findings of thoracic cord atrophy and increased signal in the periventricular and subcortical white matter on T2-weighted images were confirmed in the HAM/TSP patients. Despite a lack of specificity of the MRI findings between HAM/TSP patients and HTLV-I carriers, criteria that could effectively differentiate HAM/TSP patients from multiple sclerosis patients with similar clinical presentations were determined.

Conclusions:

Clinical and radiological correlations suggest that longitudinal MRI investigations charting the course of HAM/TSP may reveal the clinical significance of these lesions and further define the role of MRI in the diagnosis of this entity. Magnetic resonance imaging is an important supplement to immunological and clinical data in differentiating multiple sclerosis from HAM/TSP.
Pineal Apoplexy: Is it a Facilitator for the Development of Pineal Cysts?
Authors: McNeely P.D. , Howes W.J. , Mehta V.
Published: December 2014

Background:

The radiographic identification of pineal cysts has increased dramatically within the last two decades due to the advent of magnetic resonance imaging. Pineal cysts are often found incidentally with only a minority of these lesions ever becoming symptomatic and requiring treatment. Many theories attempting to explain the pathogenesis of these cysts exist.

Methods:

We describe a case of a 12-year-old girl who presents with a pineal hemorrhage of unknown etiology with associated hydrocephalus.

Results:

Her hydrocephalus was initially treated with an external ventricular drain followed by a third ventriculostomy. She had no evidence of elevated beta human chorionic gonadotropin or alpha-fetoprotein within the serum or cerebrospinal fluid. Follow-up imaging at seven weeks revealed resolution of her hemorrhage, however, there was development of a progressive cystic lesion within the pineal region. In order to make a definitive tissue diagnosis, a supracerebellar infratentorial surgical approach with complete resection was performed. During the resection, brownish fluid was aspirated from the cyst and the cyst wall was removed. The pathological diagnosis was a pineal cyst.

Conclusions:

Although cases have been described of pineal apoplexy with an underlying cyst, this case describes the development of a progressive pineal cyst secondary to a hemorrhage. This case demonstrates that pineal hemorrhage may be a promotor for the development or progression of pineal cysts.
Postoperative Reversal of Complete (Monocular) Blindness in Skull Base Meningioma: Case Report
Authors: Bampoe Joseph , Ranalli Paul , Bernstein Mark
Published: December 2014

Background:

Meningiomas of the anterior cranial fossa frequently present with impaired visual function. Recognition of this entity in the differential diagnosis of painless, progressive, and asymmetric optic neuropathy is important since reversal of visual loss is possible given timely surgical excision of the tumour.

Methods:

A 76-year-old man presented with no perception of light in his right eye and a reduced visual acuity of 20/60 in his left eye with a markedly constricted visual field. His visual deterioration had progressed over the previous three months and was not associated with headache. Ophthalmoscopy showed normal optic discs. MRI scanning showed a large frontal basal meningioma, which was subsequently resected.

Results:

The patient noticed an immediate improvement in his vision in his right eye. Visual acuity in his right eye improved to 20/50 at six weeks postoperatively and to 20/25 at five months, with corresponding improvement of the visual field.

Conclusion:

Complete monocular blindness due to tumour compressing or distorting the anterior visual pathways does not preclude recovery following timely decompressive surgery, especially when the appearance of the optic disc is normal.
p53 and MIB-1 Immunohistochemistry as Predictors of the Clinical Behavior of Nonfunctioning Pituitary Adenomas
Authors: Hentschel Stephen J. , McCutcheon Ian E. , Moore Wayne , Durity Felix A.
Published: December 2014

Background:

P53 expression and increased MIB-1 proliferation index have been shown to correlate with invasive behavior in pituitary adenomas. The purpose of this study was to determine whether these indices could be used to predict a higher likelihood of recurrence in clinically nonfunctional pituitary adenomas and thus guide adjuvant therapy.

Methods:

Fifty-one clinically nonfunctional pituitary adenomas were selected from the database at the Vancouver Hospital and Health Sciences Center between the years 1990-1998. Included were 32 nonrecurrent and 19 recurrent adenomas.

Results:

The mean initial labelling index for p53 in nonrecurrent tumours was 0.38% (0-1.58%), while it was 0.46% (0-3.65%) for recurrent adenomas. The mean initial MIB-1 index for nonrecurrent tumours was 1.63% (0.08-9.36%), while for recurrent tumours it was 1.92% (0-7.76%). The percentage of p53 positive adenomas was 66% for nonrecurrent tumours and 68% for recurrent tumours. None of the differences in the labelling indices between the recurrent and nonrecurrent groups was statistically significant. As 12 patients (38%) in the nonrecurrent group had undergone radiotherapy as initial adjuvant therapy after surgery and none of the recurrent group had done so, patients who did not receive radiotherapy in the nonrecurrent group were analyzed separately. Again, none of the differences in the labelling indices between the recurrent and nonrecurrent groups was statistically significant when the effect of radiotherapy was removed from the analysis.

Conclusions:

The results demonstrate no statistical difference in the p53 or MIB-1 labelling indices between recurrent and nonrecurrent nonfunctional pituitary adenomas. Concern should be raised in attaching too much clinical significance to these labelling indices, especially with respect to p53 as a predictor of the clinical behavior of nonfunctional pituitary adenomas.