Saber H, Silver B, Santillan A, Azarpazhooh MR, Misra V, Behrouz R. Role of emergent chest radiography in evaluation of hyperacute stroke. Neurology. 2016;87(8):782–785. doi:10.1212/WNL.0000000000002964.
Despite evidence supporting the prompt administration of IV rtPA, fewer than one-third of acute ischemic stroke patients receive this medication within the target window of 60 minutes or less. Patient and technical factors often contribute to delays in the so-called door-to-needle time or the period from hospital presentation to initiation of treatment. Given this background, the authors compared features of patients who had a CXR done before IV thrombolytics with those who did not. Rates of cardiopulmonary adverse events, intubation, and in-hospital mortality were also compared. Logistic regression analysis was performed to evaluate the association of CXR performance with door-to-needle time greater than or equal to 60 minutes. In the cohort of 615 patients, 243 had CXR done before IV thrombolytics. Patients with CXR before treatment had significantly higher admission neurologic deficit and initial respiratory rates. Patients with CXR done before treatment had longer mean door-to-needle times than those without pretreatment radiography (75.8 vs 58.3 minutes). The performance of CXR before IV thrombolytics prolongs door-to-needle time in acute ischemic stroke patients. CXR before treatment should be reserved for situations wherein acute cardiopulmonary conditions would otherwise preclude the administration of IV thrombolytics.
Banwell B. Pediatric multiple sclerosis. Neurology. 2016;87(8):822–826. doi:10.1212/WNL.0000000000003014.
This is the 2015 Sydney Carter Award Lecture in which Dr. Banwell summarizes the learning curve and milestones achieved in pediatric multiple sclerosis care and research to date.
Dr. Banwell notes that the available MS diagnostic criteria proposed by Poser in 1983 specifically excluded the diagnosis of MS in persons younger than ten years, and did not formally comment on MS in youth. Further complicating the diagnosis and care of pediatric patients with MS is the fact that approximately 70% of pediatric patients with acute demyelination will have a transient illness without clinical or MRI evidence of new lesions over time. Acute disseminated encephalomyelitis (ADEM) typifies monophasic demyelination, particularly in young children. Distinguishing such patients from the 30% ultimately confirmed to have MS has been the focus of much of the research performed in the last 15 years.
Recent research has allowed several key observations regarding pediatric MS: (1) children and adolescents experience relapsing neurologic deficits typical of adult-onset relapsing-remitting MS but do not appear to experience primary progressive MS; (2) CSF analysis reveals the presence of intrathecal oligoclonal bands, a hallmark of MS in adults, in 60%–95% of pediatric patients, but less commonly in younger children (3) over 95% of pediatric patients with MS recover well, in terms of physical functioning, from acute episodes early in their disease; (4) cognitive impairment occurs in approximately 30% of pediatric patients with MS and correlates with MRI measures (reduced brain volume, altered resting state and functional connectivity, and reduced tissue integrity); (5) pediatric patients with MS have higher relapse frequency in the first few years post onset, as compared to patients with adult-onset MS; and (6) time from first attack to secondary progressive MS (a stage of the disease characterized by progressive accrual of neurologic impairment not linked to discrete relapses) appears to take approximately 10 years longer in pediatric-onset patients.
Glassman SD, Carreon LY, Ghogawala Z, McGirt MJ, Asher AL. Benefit of Transforaminal Lumbar Interbody Fusion vs Posterolateral Spinal Fusion in Lumbar Spine Disorders: a Propensity-Matched Analysis from the National Neurosurgical Quality and Outcomes Database Registry. Neurosurgery. 2015;79(3):397–405. doi:10.1227/NEU.0000000000001118.
Theoretical advantages of transforaminal lumbar interbody fusion (TLIF) include increased fusion rate, a complete foraminal decompression, better correction of deformity, and more effective treatment of discogenic pain. Importantly, TLIF also facilitates the use of minimally invasive strategies. Despite these multiple potential benefits, prior studies have often failed to document improved clinical outcomes with TLIF vs posterolateral spinal fusion. The authors compared the outcomes of TLIF with posterolateral spinal fusion (PSF) in patients with spondylolisthesis, spinal stenosis, and adjacent level disease using the National Neurosurgical Quality and Outcomes Database which was queried for patients who had a lumbar fusion. Eighty-five percent (1722) of enrolled cases had 12-month follow-up data. There were 306 PSF patients and 1230 TLIF patients. TLIF generated more favorable Oswestry Disability Index outcomes than posterolateral spinal fusion for patients with spondylolisthesis, but not for patients with spinal stenosis or adjacent segment disease. There was equivalence in operating room time and estimated blood loss between TLIF and PSF, potentially altering the long-standing assumption that PSF is a simpler procedure. They conclude that the explanation for greater ODI improvement with TLIF in the spondylolisthesis subgroup was not completely clear and is probably multifactorial.
Munich SA, Hall SL, Cress MC, et al. To Treat or Not to Treat M2 Occlusions? The Question (and Answer) From a Single Institution. Neurosurgery. 2016;79(3):428–436. doi:10.1227/NEU.0000000000001182.
Although affecting far less territory than M1 occlusions, M2 occlusions still may result in significant clinical deficit and functional impairment, particularly when they occur in the dominant hemisphere. The necessity of M2 recanalization was questioned by a subgroup analysis of the Interventional Management of Stroke (IMS) II trial, which demonstrated low rates of recanalization but high rates of good clinical outcome.
The authors retrospectively examined radiographic and clinical data of 53 patients presenting with M2 occlusions. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b or 3) was achieved in 40 patients (76.9%). No symptomatic intracranial hemorrhage occurred. The mean NIH Stroke Scale score at discharge was 6.4. Although not considered large-vessel occlusion, M2 occlusions can manifest with significant clinical deficits. Endovascular treatment of M2 occlusions is associated with considerable improvement in NIHSS score. Although post-procedural ICH may occur, it is rarely symptomatic. There was no difference based on the endovascular technique used. This lack of statistical significance may be a result of the wide variety of techniques used, thereby diluting the number of patients treated with each technique. They conclude that the study shows that endovascular treatment of M2 occlusions is safe.
Sender R, Fuchs S, Milo R. Revised Estimates for the Number of Human and Bacteria Cells in the Body. PLOS Biol. 2016;14(8):e1002533. doi:10.1371/journal.pbio.1002533.
How many cells are in the human body? The oft-quoted statements regarding the number of bacteria residing in our body (10:1) trace back to an old back-of-the-envelope calculation from 1972. The aim of this study is to critically revisit former estimates for the number of human and bacterial cells in the human body. The authors give up-to-date, detailed estimates where the calculation logic and sources are fully documented, and uncertainty ranges are derived.
Separate sidebar explanations are included on the crowd-pleasing topics of “The Volume of the Human Colon Content” and “Concentration of Bacteria in the Colon.” Bottom line: they estimate the total number of bacteria in the 70 kg “reference man” to be 3.8 X 1013.
For human cells, they identify the dominant role of the hematopoietic lineage to the total count (approximately 90%) and revise past estimates to 3.0 X 10 13 human cells. They update the widely-cited 10:1 bacteria to human cell ratio, showing that the number of bacteria in the body is actually of the same order as the number of human cells.
3 Tables and 3 Figures
Sariaslan A, Sharp DJ, D’Onofrio BM, Larsson H, Fazel S. Long-Term Outcomes Associated with Traumatic Brain Injury in Childhood and Adolescence: A Nationwide Swedish Cohort Study of a Wide Range of Medical and Social Outcomes. Hay PJ, ed. PLOS Med. 2016;13(8):e1002103. doi:10.1371/journal.pmed.1002103.
The authors analyzed a Swedish birth cohort between 1973 and 1985 of 1,143,470 individuals, and identified all those who had sustained at least one TBI (n = 104,290 or 9.1%) up to age 25 y and their unaffected siblings (n = 68,268) using patient registers. They assessed these individuals for the following outcomes using multiple national registries: disability pension, specialist diagnoses of psychiatric disorders and inpatient psychiatric hospitalization, premature mortality (before age 41 y), low educational attainment (not having achieved secondary school qualifications), and receiving means-tested welfare benefits. They found TBI consistently predicted the later risk of premature mortality, psychiatric inpatient admission, outpatient psychiatric visits, disability pension, welfare recipiency, and low educational attainment in the sibling-comparison analyses, and the effects were stronger for those with greater injury severity, recurrence, and older age at first injury. They conclude that consideration needs to be given to reviewing the cognitive, psychiatric, and social development all children and adolescents who sustain head injuries; guidelines should consider age-specific recommendations for follow-up, and the public health benefits of preventing TBIs should include social outcomes.
Rusthoven CG, Koshy M, Sher DJ, et al. Combined-Modality Therapy with Radiation and Chemotherapy for Elderly Patients with Glioblastoma in the Temozolomide Era. JAMA Neurol. 2016;73(7):821. doi:10.1001/jamaneurol.2016.0839.
The author questioned what were the survival outcomes for elderly patients (>65 years) with glioblastoma treated with radiotherapy (RT), chemotherapy (CT), and combined-modality therapy with RT and CT? They evaluated a retrospective cohort of a prospectively maintained, multi-institutional national cancer registry (National Cancer Database) which was queried for elderly patients (>65 years) with newly diagnosed GBM from January 1, 2005, through December 31, 2011, with complete data sets for RT, CT, tumor resection. Survival by treatment cohort was estimated using the Kaplan-Meier method and analyzed using the log-rank test, univariate and multivariate Cox models. In this cohort study of more than 16,000 patients, combined-modality therapy was associated with significantly better median survival than RT alone or CT alone, with benefits that remained significant on multivariate analyses, propensity score matching, and in all age and tumor resection subgroups. Overall survival by treatment was 9.0 months with CMT (8435 patients), 4.7 months with RT alone (1693 patients), 4.3 months with CT alone (1018 patients), and 2.8 months with no therapy (5571 patients). This analysis supports the use of combined-modality therapy for elderly patients with newly diagnosed glioblastoma, similar to strategies used in younger patients.
Rovira A, de Stefano N. MRI monitoring of spinal cord changes in patients with multiple sclerosis. Curr Opin Neurol. 2016;29(4):445–452. doi:10.1097/WCO.0000000000000343.
In this review article, the authors discuss the technical aspects and some improvements of spinal cord MRI, the typical MRI features of the spinal cord in multiple sclerosis, and the clinical indications for this examination. They also analyze recent data on the value of different quantitative magnetic resonance techniques (cord atrophy assessment, magnetization transfer, DTI, fMRI and MR spectroscopy) for assessing the type and degree of spinal cord damage. 3 Tables and 1 Figure. Of note is Table 3 which gives the considerable limitations regarding current applicability of the advanced imaging techniques: (lack of specificity, poor reproducibility, and with regards to fMRI and MRS poor signal/noise).
Beckham JD, Pastula DM, Massey A, Tyler KL. Zika Virus as an Emerging Global Pathogen. JAMA Neurol. 2016;73(7):875. doi:10.1001/jamaneurol.2016.0800.
This is a clinical (and historical) review article on Zika virus. ZIKV is in the family Flaviviridae, a group of positive-sense, single-stranded, enveloped RNA viruses. Members of the Flavivirus genus within this family cause widespread human diseases, including yellow fever, dengue, Japanese encephalitis, West Nile virus disease, and ZIKV infections. The first isolation of ZIKV occurred in 1947 from the blood of a febrile sentinel rhesus monkey at the edge of the Zika forest of Uganda as part of a project to collect yellow fever virus isolates. Because it was unclear whether ZIKV could cause human disease, in 1956 a human volunteer who was previously vaccinated against yellow fever virus was inoculated with ZIKV-infected mouse brain suspension; the volunteer subsequently developed a 1-week syndrome of headache, fever, and malaise. Zika virus has rapidly emerged throughout the20th century and is causing a large epidemic of disease in the Americas that has concerning links to possible intrauterine infection of the brains of developing fetuses. There is no current therapy or vaccine for this infection, and the best approach to avoid complications from ZIKV is to avoid exposure to mosquitoes by using insect repellant, wearing long-sleeved shirts and pants, and using air conditioning and window screens to keep mosquitoes outside. For women traveling to regions undergoing a current outbreak of ZIKV, caution should be exercised regarding pregnancy as outlined by the CDC. For men and women living in the endemic region of the ZIKV outbreak, they need urgent solutions and study of this virus to produce interventions that can prevent birth defects now linked with acute ZIKV infection in pregnant women.
