Complex hydrocephalus
JD MA Pickard1
MAY 20, 1994
Clinical Neuroscience - 1994;47(05-06)
JD MA Pickard1
MAY 20, 1994
Clinical Neuroscience - 1994;47(05-06)
The majority of patients with acute symptomatic hydrocephalus are treated perfectly satisfactorily on the basis of clinical history, a CT scan and a conventional shunt. However, more chronic forms of hydrocephalus in all age groups may be difficult to distinguish from cerebral atrophy of various types on the basis of clinical symptoms/signs and CT scan alone, although Hakim's classical triad of gait disorder, urinary incontinence and dementia (mental dullness and recent memory loss) is very useful. Various forms of CSF tap test (Wikkelso, Hakim, continuous drainage) will reveal the immediate responders but not those who improve with shabunting only after some weeks or even months. Subdural collections remain a considerable threat following conventional shunting. Finally, 80% of shunts fail by 12 years and many patients return with a variety of symptoms attributed to shunt dysfunction which are very difficult to elucidate including headache and cognitive decline. How far have new investigations and shunt tech- niques helped manage these intractable problems that can lead on occasion to disaster?
Clinical Neuroscience
In opposite of the benign biological behaviour of the posterior fossa epidermoids the operation of these tumours a great challenge for the surgeon both theoretical and surgical point of view. We analysed our 14 operated cases clinico pathologically in this retrospective study.
Clinical Neuroscience
This paper is a shortened version of an invited lecture given at the Karolinska Institute, Stockholm, on 17th September, 1993, illustrated with 120 slides.
Clinical Neuroscience
Brain stem gliomas are rare, predominantly pediatric tumours. Histologically, they are comparable to adult supratentorial astrocytomas. Most of the pediatric brain stem tumours were classified as low-grade astrocytoma (WHO II), anaplastic astrocytoma (WHO III) or glioblastoma multiforme (GBM, WHO IV). Survival of patients with malignant brain stem gliomas as WHO grade III and IV rarely exceeds more than two years. Recently developed molecular genetic techniques gave new insights in tumour biology. Oncogenes and tumour suppressor genes are genetic alterations which can cause tumorous transformation and furthermore malignant progression. Molecular genetic studies of malignant brain stem gliomas have rarely been investigated. Therefore, we set out to study 12 such tumours clinically and 2 by molecular biological methods.
Clinical Neuroscience
Long lasting intracranial hypertension is considered to be a major pathogenic factor of syringomyelia in patients with a Chiari malformation or posterior fossa tumor.
Clinical Neuroscience
Cerebral autoregulation was investigated in the cerebral and cerebellar cortex, and subcortical gray matter (caudate nucleus) of the rat by means of Laser-Doppler flowmetry. As the vascular architecture of the basal ganglia, the cerebral cortex and the cerebellar cortex have substantial geometrical, onto genetical and pathological differences (3), we tested the working hypothesis that autoregulation of the blood supply to these areas may also be different. Laser-Doppler flowmetry has an ideal time resolution, and it enables analysis of flow-pressure curves (1, 2). The dependency of autoregulation on the rate of change in systemic blood pressure (SABP) in all three regions were confirmed. Control of CBF was significantly different in the subcortical gray matter and the neocortex. Interestingly, no autoregulatory capacity of the cerebellar vasculature was found.
Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.
Lege Artis Medicinae
[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, because “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]
Clinical Neuroscience
After carpal tunnel surgery, some patients report complaints such as edema, pain, and numbness. Purpose – The aim of this study was to evaluate autonomic nervous system function in patients with a history of carpal tunnel surgery using sympathetic skin response (SSR). Thirty three patients (55 ±10 years old) with a history of unilateral operation for carpal tunnel syndrome were included in the study. The SSR test was performed for both hands. Both upper extremities median and ulnar nerve conduction results were recorded. A reduced amplitude (p=0.006) and delayed latency (p<0.0001) were detected in the SSR test on the operated side compared to contralateral side. There was no correlation between SSR and carpal tunnel syndrome severity. Although complex regional pain syndrome does not develop in patients after carpal tunnel surgery, some of the complaints may be caused by effects on the autonomic nervous system.
Clinical Neuroscience
We aimed to analyze the clinical, laboratory and neuroimaging findings in patients with sporadic Creutzfeldt-Jakob disease (CJD) in a single center as well as to review other published cases in Turkey. Between January 1st, 2014 and June 31st, 2017, all CJD cases were evaluated based on clinical findings, differential diagnosis, the previous misdiagnosis, electroencephalography (EEG), cerebrospinal fluid and cranial magnetic resonance imaging (MRI) findings in our center. All published cases in Turkey between 2005-2018 were also reviewed. In a total of 13 patients, progressive cognitive decline was the most common presenting symptom. Two patients had a diagnosis of Heidenhain variant, 1 patient had a diagnosis of Oppenheimer-Brownell variant. Seven patients (53.3%) had been misdiagnosed with depression, vascular dementia, normal pressure hydrocephalus or encephalitis. Eleven patients (87%) had typical MRI findings but only 5 of these were present at baseline. Asymmetrical high signal abnormalities on MRI were observed in 4 patients. Five patients (45.4%) had periodic spike wave complexes on EEG, all appeared during the follow-up. There were 74 published cases in Turkey between 2005 and 2018, with various clinical presentations. CJD has a variety of clinical features in our patient series as well as in cases reported in Turkey. Although progressive cognitive decline is the most common presenting symptom, unusual manifestations in early stages of the disease might cause misdiagnosis. Variant forms should be kept in mind in patients with isolated visual or cerebellar symptoms. MRI and EEG should be repeated during follow-up period if the clinical suspicion still exists.
Clinical Neuroscience
[Brain abscesses are potentially serious, life-threatening diseases that pose a complex diagnostic challenge not only to neurosurgeons but also to clinical microbiologists, neurologists, psychiatrists, infectologists. The etiology of brain abscess is usually polymicrobial, most commonly involving a variety of aerobic and obligate anaerobic bacteria. Epidemiological studies on the anaerobic etiology of brain abscesses are common between the time period of 1960s and 1980s, but today there are very few new publications on the subject. The role of anaerobic bacteria in this disease was presumably underdiagnosed for a very long time, as many laboratories did not have the adequate laboratory capabilities for their cultivation and identification. The purpose of this review is to summarize the available literature on the etiology of obligate anaerobic bacteria in brain abscesses, including their prevalence and current therapeutic recommendations.]
1.
2.
3.
4.
Journal of Nursing Theory and Practice
[Correlations Between Burnout and Socio-demographic and Workplace Related Factors Among Health-care Workers During The Covid-19 Pandemics]5.
Journal of Nursing Theory and Practice
[Operational Efficiency Investigation from APN Perioperative Perspective]1.
Journal of Nursing Theory and Practice
[Nutritional Therapy in the Stroke Ward: Treatment of Dysphagia in Acute Care of Stroke Patients ]2.
3.
4.
Journal of Nursing Theory and Practice
[A possible role of Advanced Practice Nurses in primary care - the possibility of screening for retinopathy in patients with diabetes]5.
COMMENTS
0 comments