Cerebrospinal fluid purinomics as a biomarker approach to predict outcome after severe traumatic brain injury

Severe traumatic brain injury (TBI) is associated with high rates of mortality and long-term disability linked to neurochemical abnormalities. Although purine-derivatives play important roles in TBI pathogenesis in preclinical models, little is known about potential changes in purine levels and their implications in human TBI. We assessed cerebrospinal fluid (CSF) levels of purines in severe TBI patients as potential biomarkers that predict mortality and long-term dysfunction. This was a cross-sectional study performed in 17 severe TBI patients (Glasgow Coma Scale < 8) and 51 controls. Two to four hours after admission to ICU, patients were submitted to ventricular drainage and CSF collection for quantification of adenine and guanine purine-derivatives by HPLC. TBI patients survival was followed up to 3 days from admission. A neurofunctional assessment was performed through the modified Rankin Scale (mRS) two years after ICU admission. Purine levels were compared between control and TBI patients, and between surviving and non-surviving patients. Relative to controls, TBI patients presented increased CSF levels of GDP, guanosine, adenosine, inosine, hypoxanthine, and xanthine. Further, GTP, GDP, IMP, and xanthine levels were different between surviving and non-surviving patients. Among the purines, guanosine was associated with improved mRS (p=0.042; r= -0.506). Remarkably, GTP displayed predictive value (AUC=0.841, p=0.024) for discriminating survival vs. non-survival patients up to three days from admission. These results support TBI-specific purine signatures, suggesting GTP as a promising biomarker of mortality, and guanosine as an indicator of long-term functional disability.

Image-guided Temporal Bone Dissection Course

Introduction  Temporal bone anatomy is complex and demands a profound anatomical knowledge. Association between surgery and imaging helps in the process of learning three-dimensional (3D) anatomy and surgical techniques. High definition temporal bone imaging can play an important role in dissection training. Objective  To describe a computed tomography (CT) image-guided temporal bone dissection course for surgical training in otolaryngology and to verify the satisfaction level of the students with the course. Methods  Descriptive research. The course took place at a research laboratory, with three experienced temporal bone surgeons. The participants were 12 otolaryngology residents. The laboratory has 7 modern workstations with microscope and monitors linked with a computerized video system. Cadaveric temporal bones were donated to the university. Imaging acquisition of the cadaveric temporal bones used in the course was performed in a multislice CT scanner. The CT images of cadaveric temporal bones were available with real-time access on the laboratory monitor's screens during dissections. Results  A total of 13 temporal bones were included for dissection. Students had the opportunity to view on the same screen, simultaneously, both the dissection video and the respective CT images of their temporal bone anatomical specimens. This allowed correlating surgical and imaging aspects of temporal bone anatomy. At the end of the course, participants answered a satisfaction survey. Conclusion  Considering imaging methods are routinely used during most otologic surgeries, detailed knowledge of CT imaging should be explored in conjunction with the temporal bone anatomical dissection.

Vascularization of the uncus - Anatomical study and clinical implications

Background:

The objective of this paper was to describe the arterial supply of the uncus and quantify the branches directed to the anteromedial aspect of the human temporal cortex.

Methods:

We studied 150 human cerebral hemispheres identifying main afferent arteries supplying the anteromedial temporal cortex with particular attention to the uncus, determining the territory supplied by each artery through either cortical or perforating branches.

Results:

The uncus was supplied by 419 branches of the anterior choroidal artery (AChA), 210 branches of the internal carotid artery (ICA), 353 branches of the middle cerebral artery (MCA), and 122 branches of the posterior cerebral artery (PCA). The total of supplying vessels was 1104 among the 150 hemispheres studied, which corresponds to 7.36 arteries per uncus. The average of branches per hemisphere was as follows: 2.79 from AChA, 1.40 from ICA, 2.35 from MCA, and 0.81 from PCA. The relative contribution of each artery for the total of specimens studied was as follows: 38% from AChA, 19% from ICA, 32% from the MCA, and 11% from the PCA. We identified cortical anastomoses mostly between the MCA and PCA (27 cases).

Conclusion:

We described and quantified the uncus’ vascularization, including anatomical variations. This updated, detailed description of the mesial temporal vascularization is paramount to improve the treatment of neurosurgical conditions.

Magnetic resonance imaging findings of the posterior fossa in 47 patients with mucopolysaccharidoses: A cross-sectional analysis

BACKGROUND

Mucopolysaccharidoses (MPS) is a group of hereditary multisystemic lysosomal disorders. Most neuroimaging studies in MPS have focused on the supratentorial compartment and craniocervical junction abnormalities, and data regarding posterior fossa findings are scarce in the literature. Thus, our purpose is to describe posterior fossa findings on magnetic resonance imaging (MRI) of MPS patients.

METHODS

We reviewed routine MRI scans of MPS patients being followed up at our institution (types I, II, III, IV, and VI), focusing on posterior fossa structures.

RESULTS

Forty-seven MPS patients were included. MRI-visible perivascular spaces were commonly found in the midbrain and adjacent to the dentate nuclei (85% and 55% of patients, respectively). White-matter lesion was not identified in most cases. Its most frequent localizations were in the pons and cerebellum (34% and 30% of patients, respectively). Enlargement of cerebrospinal fluid (CSF) spaces in the posterior fossa was present in 55% of individuals and was more frequent in neuronopathic patients (73% vs 40%; P = .02). Cerebellar volume was classified as normal, apparent macrocerebellum, atrophic, and hypoplastic in 38%, 38%, 21%, and 3% of patients, respectively. A depression of the posterior fossa floor in the midline sagittal plane was found in 22 patients (47%), which was statistical significantly associated with enlargement of CSF spaces (P = .02) and with apparent macrocerebellum (P = .03).

CONCLUSION

The present study compiled the main posterior fossa findings in MPS patients. Classically described in the supratentorial compartment, MRI-visible perivascular spaces, white matter lesions, and enlarged perivascular spaces were also found in the posterior fossa. However, atrophy, which commonly affects cerebral hemispheres, was not the most frequent cerebellar morphology found in our study. Moreover, potential findings for future research were described.

Hippocampal vascularization: Proposal for a new classification

Background:

Anatomy of the hippocampal arterial supply is key to successful surgeries in this area. The goal of the current study is to present the results we obtained from our microsurgical dissections of the temporal lobe and to propose a new classification for the hippocampal arteries (HAs).

Methods:

Fifty-six brain hemispheres were analyzed. All dissections in this study were made using 3–40× at the surgical microscope.

Results:

The hippocampal arterial vasculature can be divided into six groups, according to their frequencies: Group A: mixed arterial vasculature originating from the anterior choroidal artery anterior choroidal artery, posterior cerebral artery (PCA), anterior infratemporal artery (AIA), and splenic artery (SA). Group B: Main origin at the temporal branches – main inferotemporal trunk, middle inferotemporal artery, posterior inferotemporal artery, AIA, or main branch of PCA. Group C: AIA as the main branch of the hippocampus. Group D: HAs originating from the main branch of PCA. Group E: A single hippocampal artery with the origin at the main branch of PCA. This single artery covered all of the structure and is named Ushimura’s artery. Group F: The hippocampal vessels arose exclusively from the parieto-occipital artery, calcarine artery (CA), and the SA.

Conclusion:

This study proposes a new classification for the hippocampal vascularization, according to the origin of HAs. One of the groups has not yet been described in the literature – in which the HAs arise from the parieto-occipital artery, SA, and CA.

CD73 as a target to improve temozolomide chemotherapy effect in glioblastoma preclinical model

Glioblastoma is the most devastating primary brain tumor and effective therapies are not available. Treatment is based on surgery followed by radio and chemotherapy with temozolomide (TMZ), but TMZ increases patient survival only by 2 months. CD73, an enzyme responsible for adenosine production, emerges as a target for glioblastoma treatment. Indeed, adenosine causes tumor-promoting actions and CD73 inhibition increases sensitivity to TMZ in vitro. Here, a cationic nanoemulsion to nasal delivery of siRNA CD73 (NE-siRNA CD73) aiming glioblastoma treatment was employed alone or in combination with TMZ. In vitro, two glioblastoma cell lines (C6 and U138MG) with a chemo-resistant profile were used. Treatment alone with NE-siRNA CD73 reduced C6 and U138MG glioma cell viability by 70% and 25%, respectively. On the other hand, when NE-siRNA + TMZ combined treatment was employed, a reduction of 85% and 33% of cell viability was observed. Notably, treatment with NE-siRNA CD73 of glioma-bearing Wistar rats reduced tumor size by 80%, 60% more than the standard chemotherapy with TMZ, but no synergistic or additive effect was observed in vivo. Additionally, NE-siRNA CD73, TMZ or combined therapy decreased adenosine levels in liquor confirming the importance of this nucleoside on in vivo GB growth. Finally, no hemolytic potential was observed. These results suggest that nasal administration of NE-siRNA CD73 exhibits higher antiglioma effect when compared to TMZ. However, no synergistic or additive in vivo was promoted by the therapeutic regimen employed in this study.

Ruptured aneurysm in the posterior communicating segment of carotid artery presenting with contralateral oculomotor nerve palsy

Background:

Brain aneurysms are mostly discovered during the investigation of subarachnoid hemorrhage (SAH). Some patients present neurological signs that may suggest the aneurysm’s topography, and the oculomotor nerve palsy (ONP) of the same side of the aneurysm is the most common sign. Only one case report of contralateral palsy was previously described in the medical literature.

Case Description:

Authors describe a patient who presented a classic manifestation of SAH associated with complete ONP, whose vascular investigation demonstrated a brain aneurysm located in the contralateral intracranial carotid. The patient was surgically treated with great neurologic outcome, and late angiography did not evidence other vascular abnormalities.

Conclusion:

The ipsilateral ONP is a common sign found in posterior communicating artery aneurysms; however, such aneurysm can have different presentations due to the elevation of intracranial pressure, and, in rarer cases, the ONP cannot be operated as a localizing sign.

Acute Spontaneous Subdural Hematoma in Posterior Fossa: Great Outcome

BACKGROUND

Acute subdural hematomas are frequently seen in brain trauma-injured patients. However, spontaneous subdural hematomas are uncommon, especially those localized in the posterior fossa, where fewer than 10 case reports have been described in the medical literature.

CASE DESCRIPTION

We describe a patient who suddenly had a headache and progressed rapidly to coma and signs of brainstem compression. She was diagnosed with posterior fossa subdural hematoma after image examinations that were endorsed by surgical findings. A posterior fossa craniectomy was performed and was associated with blood drainage.

CONCLUSIONS

The patient had a great outcome, with no neurologic deficits at hospital discharge and the 1-year follow-up.

A comparative study on the recruitment of shoulder stabilizing muscles and types of exercises

The shoulder is susceptible to disturbances caused by microtraumas due to direct contact of the surrounding skeletal structures or failure of the soft parts of the rotator cuff and other muscles inserted into the glenohumeral joint. The purpose of the study was to compare the electromyographic signal in the stabilizing muscles of the shoulder during the diagonal elevation exercise as recommended by the proprioceptive neuromuscular facilitation (PNF) method and dumbbell exercise. This study is classified as Quase-experiment. Subjects were instructed to perform diagonal standard exercises and the electromyographic signal was detected from pectoralis muscles, middle and upper trapezius of dominant limb in each subject. We observed greater muscular recruitment when the PNF method was adopted in comparison with the dumbbell workouts for the trapezius upper and middle fiber muscles and for the major pectoralis (267,30 μv/181,02 μv; 235,76 μv/;164,47 μv; 299,87 μv/148,69 μv; P<0.001). The PNF method promotes a greater recruitment of the shoulder dynamic stabilizing muscles during diagonal elevation exercises. Being so, such kinesiotherapeutic technique may be effectively used in the prevention, treatment and rehabilitation of shoulder disorders.

Electromyographic analysis of constraint-induced movement therapy effects in patients after stroke in chronic course

[Purpose] The purpose is to analyze the effects of Constraint-induced Movement Therapy in post stroke patients in chronic course. [Subjects and Methods] This is a Quasi-experiment study and the adopted protocol consisted of a three-hour therapy for ten consecutive working days applied to a constraint intact upper limb. Surface Electromyography, Motor Activity Log, Wolf Motor Function Test and Functional Independence Measure were used for evaluating the experiment. [Results] The individuals showed reduction in the degree of spasticity, confirmed by Surface Electromyography. In relation to Motor Activity Log this study showed an increase in amount and in quality of the paretic upper limb movement. The Wolf Motor Function Test showed reduction in the average time to perform the tasks and a functional improvement was identified through the Functional Independence Measure. [Conclusion] Constraint Induced Movement Therapy proved to be a relevant method to improve motor function in chronic hemiparesis post stroke reducing the spasticity, maximizing and improving the use of committed upper limb.

Cell Index in the Diagnosis of External Ventricular Drain-Related Infections

BACKGROUND

The use of an external ventricular drain is required for the treatment of many diseases, such as traumatic brain injury and subarachnoid hemorrhage (SAH). Meningitis and ventriculitis are frequent complications arising from the use of external ventricular drain therapy. This study aimed to determine the sensitivity, specificity, and cutoff point for cell index (CI) in patients with traumatic brain injury, SAH, and hemorrhagic stroke.

METHODS

Our study population consisted of patients with different underlying diseases and few culture-positive cerebrospinal fluid samples. The diagnosis of infection was based on Centers of Disease Control and Prevention criteria.

RESULTS

Overall CI analysis showed an area under the curve (AUC) of 0.982. The cutoff of 2.9 for overall CI provided a sensitivity of 95% and a specificity of 92.9%. In patients with SAH, the AUC was 1.0 for a CI of 2.8; furthermore, sensitivity and specificity were 100%. The relative variation of the CI was also assessed. This analysis revealed an AUC of 0.882, and a 4.33-fold increase was found be indicative of infection (P = 0.002), findings similar to those in the literature. In addition, a heatmap analysis demonstrated that the CI is unlikely to return to normal in patients with meningitis, even after treatment.

CONCLUSIONS

Therefore, CI is valuable for the diagnosis of infection, but was inadequate for monitoring treatment. We hope to use the new cutoff point proposed by this study in our institution to improve patient clinical outcome.

External Ventricular Drain-Related Infection in Spontaneous Intracerebral Hemorrhage

OBJECTIVE

We aimed to analyze infection rates in patients with spontaneous intracranial hemorrhage who underwent surgical external ventricular drain (EVD) placement.

METHODS

This prospective study included 94 consecutive patients who required an EVD for spontaneous intracranial hemorrhage at the Neurosurgery Department of Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil.

RESULTS

The mean duration of EVD use was 7 days. Overall sample mortality was 45%, and overall infection rate was 36%. Patients who had an EVD in place >10 days had higher odds of infection than patients who had an EVD in place ≤10 days (odds ratio = 3.1, 95% confidence interval, 1.1-8.7). Culture positivity rate was 5.3%.

CONCLUSIONS

Our findings suggest that EVD infection is a very common complication, occurring in 36.2% of cases. We adopted ventriculitis as the standard diagnosis, as advocated by the U.S. Centers for Disease Control and Prevention. Considering the high lethality associated with intracranial hemorrhage, use of a more aggressive treatment protocol for this patient population might improve morbidity and mortality rates.

The hidden symbols of the female anatomy in Michelangelo Buonarroti's ceiling in the Sistine Chapel

A number of published articles have suggested that each element of Renaissance art contains an inner meaning. Some of these elements include the choice of theme and protagonists, faces selected for the characters, colors used, species of flowers and trees chosen, animals depicted, positions of the elements, posture of the characters and their gestures, juxtapositions in the scenes, and even the very scenario or landscape. All of these elements are thought to have hidden meanings. In this context, this manuscript presents a new hypothesis suggesting that Michelangelo Buonarroti (1475-1564) may have concealed symbols associated with female anatomy in the ceiling of the Sistine Chapel (painted 1508-1512) in Rome. Thus, this paper is useful to better understand the history of anatomy and corroborates recent descriptions that have suggested the possible existence of anatomic figures concealed in many of Michelangelo's works. Clin. Anat. 29:911-916, 2016. © 2016 Wiley Periodicals, Inc.

Abstract 52: Clinical Impairment in Patients Followed With or Without Interventional Therapy in a Randomized Trial of Unruptured Brain Avms (aruba)

Background and Purpose: A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA) compared outcome after interventional treatment of unbled brain AVMs with medical management. Follow-up data to assess pre-specified functional impairment after primary outcome events by treatment group and exploratory analyses by Spetzler-Martin grade are presented.

Methods: We examined functional impairment using the modified Rankin scale score (mRS ≥2) at the time of primary outcome (death or stroke) by treatment group, and an exploratory analysis with these outcomes by Spetzler-Martin Grade. Analyses were performed both by intention to treat (as randomized) and as treated.

Results: After a median of 42 months of follow-up, the median post-primary outcome event mRS for those ‘ as randomized ’ to medical management (MM) was 2 (IQR: 1,4) versus 3 (IQR: 1,5) in the interventional therapy (IT) arm. Values for those ‘ as treated’ , were 1 (IQR: 1,5) versus 4 (IQR: 2,5). The risk of functional impairment, as measured by an mRS ≥2 after a primary outcome event, was significantly lower for patients ‘ as randomized’ to MM (8/110, 7%) compared to IT (27/116, 23%) (HR 0.26, 95%CI 0.12, 0.57), and even lower for those ‘as treated’ (4/122, 3% vs 31/104, 30%; HR 0.09, 95% CI 0.03,0.27). Spetzler-Martin Grade and primary outcome events were not associated in the medical arm (p=0.80) but were so with increasing grades in the interventional arm (p=0.0002).

Conclusion: In ARUBA, a death or stroke with a significant increase in functional impairment was more common for patients undergoing preventive intervention compared to those randomized to medical management.

Neuron-specific enolase, S100B, and glial fibrillary acidic protein levels as outcome predictors in patients with severe traumatic brain injury

BACKGROUND

The availability of markers able to provide an early insight related to prognostic and functional outcome of patients with traumatic brain injury (TBI) are limited.

OBJECTIVE

The relationship of clinical outcome with CSF neuron-specific enolase (NSE), S100B and glial fibrillary acidic protein (GFAP) levels in patients with severe TBI was investigated.

METHODS

Twenty patients with severe TBI (7 days at unit care) and controls were studied. Patients were grouped according to the outcome: (1) nonsurvival (n=5): patients who died; (2) survival A (n=15): CSF sampled between 1st and 3rd day from patients who survived after hospital admission; and (3) survival B (n=7): CSF sampled between 4th and 7th day from patients who survived after hospital admission and were maintained with intraventricular catheter up to 7 days.

RESULTS

Up to 3 days, S100B and NSE levels (ng/mL) were significantly elevated in the nonsurvival compared with survival A group (S100: 12.45 ± 5.46 vs 5.64 ± 3.36; NSE: 313.20 ± 45.51 vs 107.80 ± 112.10). GFAP levels did not differ between groups. In the survival B group S100B, GFAP, and NSE levels were still elevated compared with control (4.59 ± 2.19, 2.48 ± 2.55, and 89.80 ± 131.10, respectively). To compare S100B and NSE for the prediction of nonsurvival and survival patients we performed receiver operating characteristic curves. At admission, CSF NSE level predicts brain death more accurately than S100B.

CONCLUSION

Early elevations (up to 3 days) of S100B and NSE secondary to severe TBI predict deterioration to brain death. However, this feature was more prominently associated with NSE than S100B.

Design and Fabrication of a Hybrid Diffractive Optical Device for Multiple-Line Generation over a Wide Angle

A new hybrid optical device that is capable of splitting a monochromatic laser beam into an arbitrary number of lines over a wide angle is presented. It consists of a binary surface-relief computer-generated phase hologram and a continuous parabolic surface-relief grating. In this device the phase hologram serves to generate three small, parallel lines while the continuous parabolic surface-relief phase grating acts as an array of diverging parabolic lenses to widen these lines. The binary surface-relief was generated into one side of a quartz substrate through a plasma-etching process, and the parabolic profile was generated into a thick photoresist deposited on the other side of the quartz substrate. Calculations showed that a diverging parabolic lens with a f-number of 0.5 would deliver the desired optical pattern of multiple beams distributed over 90 degrees . A surface-relief depth of 6.0 mum was calculated with consideration of the phase distributions of such lens. The parabolic profiles were fabricated in a 10-mum-thick photoresist, by use of a contact exposure through a mask with a space pattern of repetitive 4- and 6-mum lines. He-Ne laser light was passed through a device that generated three parallel lines over a 90 degrees angle. The resulting diffraction patterns were characterized, and a satisfying result was obtained. The resulting multiple-line pattern can be used in robot vision and other applications.

Anatomic variations of anterior cerebral artery cortical branches

The anterior cerebral artery (ACA) is a major vessel responsible for the blood supply to the interhemispheric region. The ACA segment after the anterior communicating artery (AComA) origin is called the distal ACA and has central and cortical branches. The cortical branches are distributed in the different regions of the orbital and medial part of the brain. The objects of this study are the anatomical variations found in the distal ACA. In 76 hemispheres the ACA distal branches were injected with latex and dissected under microscope magnification. Vessel diameters and distances between vessel origins and anterior communicating artery were recorded and analyzed. Microsurgical dissection was carried out to demonstrate anatomic variations of these vessels. Average diameter of ACA at origin was 2.61 +/- 0.34 mm and average diameter of cortical branches diameter ranged from 0.79 +/- 0.27 mm to 1.84 +/- 0.3 mm. Distances between vessel origin and AComA ranged from 7.68 +/- 3.91 mm (orbitofrontal) to 112.6 +/- 11.63 mm (inferior internal parietal). This study found anatomical variations: a single (azygos) ACA was present in one case and three in three cases. Crossing branches of the distal ACA to the contralateral hemisphere were present in 26% of the cases. In some cases a single ACA may supply the posterior hemispheric region through crossing branches. This calls attention to potential bilateral brain infarcts due to a single unilateral ACA occlusion.

Perforating and leptomeningeal branches of the anterior communicating artery: an anatomical review

The morphological variability, diameter, and length of the anterior communicating artery (ACoA) are important factors in clinical and surgical decisions. This artery presents branches that supply the optic nerves and chiasm, the lamina terminalis, the hypothalamus, and the subcallosal region. The ACoA has the most frequent incidence of saccular aneurysms in the anterior portion of the circle of Willis. Lesions to the ACoA's branches may be related to neuropsychological sequelae such as amnesia, confabulation and personality changes, besides other basal ganglia syndromes. In this paper, anatomical studies of the ACoA and its branches are reviewed and the results of an anatomical study carried out in our laboratory presented.