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Chronic venous insufficiency (CVI) is a disease of the vein due to valve dysfunction, venous obstruction, or both. This results in increased vein pressure and related to disruption in the vein system.

The main purpose of this research is for identifying the relevant market, analyzing homecare requests to the relevant patient (identify buyer, willingness to buy), determining the segment of homecare interest during covid-19. This research uses an analytic description by using a quantitative approach. The research population is posted hospitalizing patients in RSUD Pare. Data collection was gotten by disseminating questionnaires to the patient in RSUD Pare which shows the identification of respondents to the homecare during covid-19 based on demography, geography, illness, hospitalization class, patient desire. The final result of the research is found that the amount of post-hospitalizing patients with high interest is 102 respondents (59,3%), 59 respondents (34,3%) very high, and 11 respondents (6,4%) medium. Homecare can ease society to get maximal health service, which is provable by the high number of social interest to join the homecare program.

An arterial tourniquet is a pneumatic device consisting of an inflated cuff connected to a supply of compressed gas. The most common use for these tourniquets is in surgical procedures on the extremities, where the tourniquet is very useful in optimizing the operating conditions by creating a bloodless surgical field. However, the exsanguination process followed by ischemia will result in physiological problems with local and systemic consequences. The patient in the case to be discussed is a 54-year-old woman with a diagnosis of implant loosening et causa nonunion left Montegia fracture who was scheduled for implant revision surgery. From these cases, it is possible that the patient experienced tourniquet-induced hypertension, which is one of the systemic complications that can arise due to the use of the tourniquet. It is said that tourniquet-induced hypertension is often difficult to control and is resistant so it is difficult to lower it. Emerging hypertension may not present a significant problem in young, noncomorbid patients, but in these patients with comorbid of hypertensive heart disease (HHD), elevated blood pressure can be very detrimental. Preoperative ketamine, clonidine, or lidocaine has been used to prevent tourniquet pain, which can lead to increased arterial pressure that is difficult to control. The anesthetist is also obliged to monitor the duration and pressure applied by the tourniquet so that it is not excessive so that detrimental complications can be prevented.

Olfactory Schwannomas (OS) are a rare, benign tumour entity. Throughout literature, only few cases have been reported. We describe here a case of a 75-year-old female with a contrast enhanced mass ...

Background Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). Objective To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. Methods Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. Results Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. Conclusion This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.

Background: Skeletal Class III malocclusions can vary in severity, with different levels of treatment available to reflect this variance. In cases of moderate to severe skeletal discrepancy, orthodontic treatment in conjunction with orthognathic surgery is a common treatment option. This case report outlines an orthosurgical treatment approach for a patient with severe skeletal Class III malocclusion. Case Report: A 23-year-old female presented with skeletal Class III malocclusion. Pre-surgical orthodontic treatment was done after 1.5 years. The lateral profile view showed a concave profile, incompetent lip closure, deficiency in paranasal area, acute nasolabial angle, and obtuse labiomental fold. Intraorally, she had a negative 5.5 mm overjet and 2 mm overbite. The surgical procedures performed included high-level Le Fort I osteotomy, bilateral intraoral vertical ramus osteotomies (IVRO), and genioplasty. Conclusion: The treatment of skeletal Class III dentofacial deformity should be planned according to the malocclusion and facial profile to achieve a functional and esthetic outcome. A systematic treatment plan that takes into consideration the patient’s expectations and concerns must be created and implemented for a satisfactory outcome.

Research shows that higher dietary protein of up to 1.2 g/kgbodyweight/day may help prevent sarcopenia and maintain musculoskeletal health in older individuals. Achieving higher daily dietary protein levels is challenging, particularly for older adults with declining appetites and underlying health conditions. The negative impact of these limitations on aging muscle may be circumvented through the consumption of high-quality sources of protein and/or supplementation. Currently, there is a debate regarding whether source of protein differentially affects musculoskeletal health in older adults. Whey and soy protein have been used as the most common high-quality proteins in recent literature. However, there is growing consumer demand for additional plant-sourced dietary protein options. For example, pea protein is rapidly gaining popularity among consumers, despite little to no research regarding its long-term impact on muscle health. Therefore, the objectives of this review are to: (1) review current literature from the past decade evaluating whether specific source(s) of dietary protein provide maximum benefit to muscle health in older adults; and (2) highlight the need for future research specific to underrepresented plant protein sources, such as pea protein, to then provide clearer messaging surrounding plant-sourced versus animal-sourced protein and their effects on the aging musculoskeletal system.

77.7% of IVF patients have high anxiety and 83.3% of patients have failed IVF programs. The strong desire to have a biological child and the process of IVF that is not easy, makes patients protective of the IVF process that is being undertaken. If patients experience health complaints, then patients immediately communicate with fertility doctors through the existing communication media. However, the slow time doctors give answers to patients, is a cause of increased anxiety of patients. Doctors have a strong desire to be able to quickly answer questions from patients, but are constrained by other medical activities that are the responsibility of doctors. Research aims to find a smart system method that can help IVF patients control anxiety and help fertility doctors answer questions from IVF patients. Primary data triangulation to obtain valid data, strengthened by validity testing and reliability testing. Secondary data to obtain evidence of the accuracy of a case-based reasoning (CBR) smart system and the challenges of producing quality system outputs. Based on the results of primary and secondary data analysis, a CBR modification was carried out by adding the role of patient feedback as a quality controller for system output. Anova test resulted in the value of F = 9902 and the coefficient test resulted in a value of t = 3147. The result of the research is a modified CBR for a smart system that helps IVF patients control anxiety and helps fertility doctors answer IVF patient anxiety questions quickly and accurately.

Background: Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the intervention is near the atrioventricular junction. Objective: The aim of this systematic review and meta-analysis is to compare the effectiveness of amiodarone, dexmedetomidine, and magnesium in preventing JET following congenital heart surgery. Methods: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, where 11 electronic databases were searched from the date of inception to August 2020. The incidence of JET was calculated with the relative risk of 95% Confidence Interval (CI). Quality assessment of the included studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement. Results: Eleven studies met the predetermined inclusion criteria and were included in this meta-analysis. Amiodarone, dexmedetomidine, and magnesium significantly reduced the incidence of postoperative JET [Amiodarone: risk ratio 0.34; I2= 0%; Z=3.66 (P=0.0002); 95% CI 0.19-0.60. Dexmedetomidine: risk ratio 0.34; I2= 0%; Z=4.77 (P Conclusion: All three drugs have shown promising results in reducing the incidence of JET. Our systematic review found that dexmedetomidine is better in reducing the length of ICU stays as well as mortality. In addition, dexmedetomidine also has the least pronounced side effects among the three. However, it should be noted that this conclusion was derived from studies with small sample sizes. Therefore, dexmedetomidine may be considered as the drug of choice for preventing JET.

Homecare as a part of healthcare at home, it can give a freedom for society to get the best healthcare which is appropriate to use. The factor which influences an interest of homecare needs a deep analysis. The aim of this research is for analyzing homecare interest in pandemic covid-19 period based on disease case in Indonesia. This research uses cross-sectional approach. The research population is all of patients in RSUD Pare and the sample is 172 respondents with simple random sampling technique. The data collection is in questionnaire form of homecare interest and disease data of patient, then doing a multivariant analysis of regression linier test. The result of T-Test in each variable where diabetes melitus, innervation case, heart, lungs, fracture, gastrointestinal, and another cases have negative t value with p value > 0,05 which means there is not any influence to the homecare interest, but in the bladder case has T-Test -2,109 value (p value 0,036, α < 0,05) which means the bladder case has influence to the homecare interest, such as the post operation case which has T-Test 2,112 value (p value 0,036, α < 0,05), it means that the post operation has influence to homecare interest. Someone interest of homecare is not influenced by disease case, except the cases which need more detail care in hospital. Post operation, bladder, and diabetes melitus needs homecare.

Objective Indonesia’s dramatic rise in chronic disease belies their relatively low obesity prevalence. This study provides normative iDXA and anthropometry measures in an Indonesian cohort. We also compare obesity prevalence determined by traditional measures. Methods 2623 Indonesian adults were measured by an iDXA and had waist and hip circumferences collected. Normative data were stratified by sex and age. Obesity prevalence was compared using body mass index (BMI) and body fat percentage (BF%). Specificity, sensitivity, and Youden’s Index evaluated the ability of cut-off values to identify individuals with high visceral adipose tissue (VAT). Results Overweight and obese prevalence by BF% was 72 % for males and 63 % for females. BMI incorrectly categorized 40 % of obese individuals as normal/overweight. Waist circumference provided the highest Youden’s Index (0.69–0.73), identifying 91 % of Indonesians with high VAT mass. Conclusions Normative BF% and VAT mass are higher among Indonesians when compared with Caucasian populations. This highlights the rise of chronic disease is potentially due to high BF% and VAT mass. Compared with criterion iDXA BF%, obesity prevalence is severely underestimated by BMI. Measuring waist circumference is recommended in clinical settings due to its ability to identify participants with high VAT mass.

Introduction: Tempeh consumption has been linked to the improvement of cognitive function in older people. However, to what extent the amount of microorganism or the size of tempeh serving consumed per day influences the benefit to cognitive functions has not yet been studied. Methods: This experimental study involved a total of 90 respondents, who were divided into 3 groups: group A (consuming 100 g of Tempeh A/day), group B (consuming 100 g of Tempeh B/day), and group C (control). Intervention was given for 6 months. Cognitive assessments were done before and after the intervention. Blood uric acid level was checked at the end of intervention to examine the effect of tempeh consumption on this. The inclusion criteria were respondents aged 60 years or over with mild cognitive impairment (MCI) who agreed not to consume other fermented food during the study period. Respondents with diabetes were excluded. Results: There were 84 subjects at the end of the study, majority being female (71.4%) and aged over 65 years (72.6%). An increase in global cognitive scores was found in both groups A and B. The increase in language domain scores was found only in group A. Conclusion: Both Tempeh A or Tempeh B consumption for 6 months appeared to be beneficial in improving global cognitive function of older people with MCI. Consuming Tempeh A, which had a lower number of microorganisms, was also associated with an improvement in the language domain.

Background Bone fragility and an increase in susceptibility to fracture osteoporosis is characterized by a reduction in bone mass and the micro-architectural deterioration of bone tissue. There is no previous study regarding the effect of Cinnamomum burmanini Blume on osteoporosis. Objective This study was aimed to investigate the effect of C. burmanini Blume on bone turnover marker, mineral elements, and mesostructure of ovariectomized rats. Materials and methods Thirty female Wistar rats were randomly divided into five groups, which included a control group (sham surgery), ovariectomy group (OVX), and ovariectomy groups in the presence of ethanolic extract of C. burmanini Blume (EECB) at doses of 12.5; 25; 50 mg/kg body weight (BW). Analysis of serum C-telopeptide collagen type I (CTX) and osteocalcin (OC) were done by enzyme-linked immunosorbent assay (ELISA). Tibia mineral elements and mesostructure were analyzed by X-ray Fluorescence and Scanning Electron Microscopy, respectively. In silico study was performed by modeling protein structure using SWISS-MODEL server and Ramachandran plot analysis. Results The increase in OC and CTX were significantly attenuated by treatments of EECB. Ovariectomy significantly decreased Cu/Zn ratio compared to sham-operated rats (p, Highlights • Administration EECB significantly increased OC and CTX level compared to OVX group. • The ratio of Cu/Zn was lower significantly in OVX rats compared to sham-operated rats. • Hydroxyapatite crystal growth can reach at the highest dose of Cinnamon.

Object:Stroke, one of the most devastating diseases, is a leading cause of death and disability throughout the world and is also associated with emotional and economic problems. The main goal of this study was to investigate the clinical outcome of the intraventricular transplantation of bone marrow mesenchymal stem cells (BM-MSCs) in post-haemorrhagic stroke patients.Method:This study was done consisting of eight patients with supratentorial haemorrhagic stroke, who had undergone 24 weeks of standard treatment of stroke with stable neurological deficits. All of the patients received stem cell transplantation intraventricularly using autologous BM-MSCs. Six months and Twelve months after stem cells treatment, the clinical outcomes were measured using the National Institute of Health Stroke Scale (NIHSS) and adverse effect also observed.Result:The results of this study showed improvement of NIHSS score values before and after the treatment in five patients. No adverse effects or complications were detected during the 1-year observation.Conclusion:Intraventricular transplantation of BM-MSCs has shown benefits in improving the functional status of post-haemorrhagic stroke patients with no adverse effect.

Background: Compared to trauma cases, the publication of non-traumatic events is much less, although the incidence is estimated to be as much as a traumatic event. This case report presents spinal cord tumors together with arteriovenous malformation (AVM) in young men, where there are no previous case reports that the authors can find. Case Report: A 22-year-old male patient with complaints of pain in the back (NPRS 8-9), followed by difficulty moving the lower limb accompanied by a burning sensation, problem in defecation, and urination. We found motor weakness in the lower extremities (1/1), positive pathological reflexes, and sensibility disorders on physical examination. Discussion: According to history taking, physical examination, and MR Imaging, the spastic paraparesis symptom in this patient is likely due to a spinal cord tumor, which is meningioma (according to histopathological examination). Where back pain rarely presents in the patient with spinal AVM. Laminectomy and tumor destruction were the gold standards of therapy, and the symptom was relieved. Conclusion: A complete examination is the main key in determining the appropriate therapy for the patient's disease. In this case, the manifestation of spastic paraparesis was likely to be caused by meningioma rather than spinal AVM. Laminectomy and extirpation of the spinal meningioma were done as the gold standard of therapy, and the symptom was relieved. In contrast, spinal AVM was not performed­ and is still under observation.

Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. National Institute of Neurological Disorders and Stroke and Genentech. [Abstract copyright: Copyright © 2019 Elsevier Ltd. All rights reserved.]

Fractures of condylar process of mandible are common fractured encountered in mandible bone. Although the treatment options of condylar fractures is still debatable. Majority of surgeons seem to favor nonsurgical treatment of condylar fracture because of its minor post-operative complications. However, nonsurgical treatment may still yield serious complications like post-traumatic malocclusion. Herein, we present the case of 19 years old male presented with post-traumatic malocclusion due to fractures of bilateral condylar process and symphysis mandible that treated with combination of open reduction and internal fixation for symphysis mandible fracture and closed reduction with application of bite raising appliance and intermaxillary fixation for bilateral condylar process fracture. No symptomatology within one month of the follow-up period. The outcomes of this protocol therapy are effective and satisfying in treating the post-traumatic malocclusion in bilateral condylar and symphysis mandible fractures.

Background Meningioma growing into an arachnoid cyst is an extremely rare event. Only 3 cases are reported in the literature. In 2 of them, an operative procedure in or near the arachnoid cyst preceded tumor growth. Case Description We report a case of a patient requiring marsupialization of an arachnoid cyst of the middle cranial fossa. On follow-up, 3 years postoperatively he showed no signs of recurrence or tumor growth. One year later, the fourth year after surgery on the cyst, he presented with large tumor growth into the former cyst's cavity. Pathologic workup after resection revealed an atypical meningioma (World Health Organization grade II). Conclusions We discuss the possible pathogenesis in light of the scarce published literature, as well as the differential diagnosis of this rapidly growing tumor.

It is known that conventional chemotherapy has average success rate of less than 25%, which seems to suggest that we need a better therapy for cancer. Chemotherapy and radiation employ non-specific toxic effects to inhibit the proliferation of both normal and tumor cells. In this regard, specific low frequency EMT has been reported to restore the homeostatic function of genes involved with controlling cell growth. Here I discuss possibility of a novel approach of cancer treatment using various applications of electromagnetic frequency.

Rett syndrome (RTT) is a severe X-linked dominant inheritance disorder with a wide spectrum of clinical manifestations. Mutations in Methyl CpG binding protein 2 (MECP2), Cyclin dependent kinase-like 5 (CDKL5) and Forkhead box G1 (FOXG1) have been associated with classic and/or variant RTT. This study was conducted to identify the responsible gene(s) in atypical RTT patient, and to examine the effect of the mutation on protein function. DNA sequence analysis showed a novel heterozygous mutation in CDKL5 identified as c.530A>G which resulted in an amino acid substitution at position 177, from tyrosine to cysteine. Genotyping analysis indicated that the mutation was not merely a single nucleotide polymorphism (SNP). We also revealed that patient's blood lymphocytes had random X-chromosome inactivation (XCI) pattern. Further examination by bioinformatics analysis demonstrated the mutation caused damage or deleterious in its protein. In addition, we demonstrated in vitro kinase assay of mutant protein showed impairment of its activity. Taken together, the results suggested the mutant CDKL5 was responsible for the disease.

Brain metastases (BM) represent the main cause of intracranial neoplasms in adults, while being relatively less common in children. Today, better treatment options of the primary malignancy lead to higher remission rates as well as prolonged stable clinical conditions. This may in part explain the increased incidence of BM. Morbidity and mortality rates in patients with malignancies deteriorate significantly in cases of metastatic involvement of the central nervous system. Nowadays, especially modern management using surgical, medical, and radiotherapeutic options for treatment of BM tends to improve survival rates and enhance quality of life. Nonetheless, almost all treatment options are considered as palliative. In this review, we outline current knowledge of the incidence, diagnostic facilities, and therapeutic management of rare BM, with consideration of the basic aspects of the primary malignancy.

Mucopolysaccharidosis II (Hunter syndrome), a lysosomal storage disorder caused by a deficiency of iduronate-2-sulfatase (IDS), has variable clinical phenotypes. Total by nearly 400 different mutations have been identified in IDS gene from patients with Hunter syndrome. Herein, we reported a patient who has a novel mutation in IDS gene with a severe clinical phenotype. Genetic analysis of the IDS gene revealed a novel 1-bp deletion in position c.1053T in exon 8 and resulting in a frameshift with a premature stop codon. Enzyme replacement therapy (ERT) using idursulfase (Elaprase®) was conducted to the patient and it improved hepatosplenomegaly, white blood cells and platelets number, and decreased the level of urinary glycosaminoglycan. ERT was proved to be effective at least in part in even an adult patient with severe type of Hunter syndrome.

Objective: Dysplastic gangliocytoma of the cerebellum (Lhermitte-Duclos disease) is a rare hamartomatous lesion of the cerebellar cortex. The pathogenesis of the disease is still poorly understood. Lhermitte-Duclos disease was recently considered to be part of a multiple hamartoma-neoplasia syndrome (Cowden disease). We add two further cases to this rare entity. Patients: A 24-year old woman presented with occipital headaches, blurred vision, diplopia and ataxia of gait. Physical examination revealed turricephaly. The second patient was a 37-year old woman, who presented with progressive occipital headache with nausea and vomiting. Physical examination revealed congenital facial asymmetry. Computed tomography and NMR-imaging, respectively demonstrated a space occupying mass of a cerebellar hemisphere in both cases. Results: Suboccipital craniotomy and complete removal of the infratentorial tumour were performed in both patients. Histopathological findings clinched the diagnosis of Lhermitte-Duclos disease. Postoperative course was uneventful in the first and complicated by progressive occlusive hydrocephalus in the second patient, necessitating permanent surgical shunt drainage. Both patients were discharged free of complaints. Conclusions: Dysplastic cerebellar gangliocytoma is commonly associated with progressive mass effects in the posterior fossa and typically presents with headaches, cerebellar dysfunction, occlusive hydrocephalus and cranial nerve palsies. The disease usually manifests in young adults, but the age at presentation ranges from birth to the sixth decade. There is no sex predilection. NMR-imaging became a useful clue to the diagnosis within the last decade. Therapy consists of decompression of the posterior fossa by total surgical removal of the tumour mass.

Deep spontaneous vasodilatatory events are frequently recorded in various cerebral diseases, causing dramatic increases (A-waves) in intracranial pressure (ICP) and subsequently provoking ischemic brain insults, The relationship between fluctuations in CBF, ICP, and arterial blood pressure (ABP) is influenced by properties of cerebrovascular control mechanisms and the cerebrospinal pressure-volume compensation, The goal of this study was to construct a mathematical model of this relationship and to assess its ability to predict the occurrence and time course of A-waves, A group of 17 severely head-injured patients were included in the study, In our model ICP was derived from the ABP waveform using a linear signal transformation. The transformation was modified during the simulation by a relationship between ABP and flow velocity, i.e., by the characterization of the cerebrovascular bed. In this way the ICP could be calculated from the ABP waveform. This model was verified by comparison of simulated and directly measured ICP during A-waves recorded in seven of the patients. In all simulations, plateau elevations of ICP were well replicated. The mean absolute error between real and simulated ICP was 8.3 ± 5.4 mm Hg at the baseline and 7.9 ± 4.3 mm Hg at the top of plateau waves. The correlation coefficient between real and simulated increase in ICP was R = 0.98; P < .001. Similarly, correlation between real and simulated increase in pulse amplitude of ICP was highly significant (R = 0.94; P < .001). The mathematical model of the relationship between ABP, flow velocity, and ICP is of potential clinical use for the noninvasive detection of A-waves in patients in whom invasive ICP assessment is not conducted.

Superficial siderosis of the central nervous system is a very rare disease related to hemosiderin deposits in the brain, brainstem, cerebellum and spinal cord due to chronic subarachnoid hemorrhage. Chronic increased intracranial pressure develops in about one-third of affected cases. We report a patient with superficial siderosis and sudden intracranial pressure crisis. A 29-year-old man experienced a subacute episode of headache, tinnitus and blurred vision. Magnetic resonance imaging of the brain revealed hemosiderin deposits characteristic of superficial siderosis. Extensive diagnostic work-up excluded causative pathologies of bleeding. Lumbar puncture and continuous intra-ventricular cerebrospinal fluid (CSF) pressure monitoring revealed continuous CSF pressure increase. Implantation of a ventriculo-peritoneal shunt led to complete clinical recovery. Our case emphasizes that patients with superficial siderosis may present with sudden elevation of intracranial pressure due to chronic intracranial hypertension. In this situation permanent CSF drainage provides a useful therapeutic option.

Background. Cerebral vasospasm is one of the leading courses for disability in aneurysmal subarachnoid hemorrhage. Effective treatment of vasospasm is therefore one of the main priorities for these patients. We report about a case series of continuous intra-arterial infusion of the calcium channel antagonist nimodipine for 1–5 days on the intensive care unit.Methods. In thirty patients with aneurysmal subarachnoid hemorrhage and refractory vasospasm continuous infusion of nimodipine was started on the neurosurgical intensive care unit. The effect of nimodipine on brain perfusion, cerebral blood flow, brain tissue oxygenation, and blood flow velocity in cerebral arteries was monitored.Results. Based on Hunt & Hess grades on admission, 83% survived in a good clinical condition and 23% recovered without an apparent neurological deficit. Persistent ischemic areas were seen in 100% of patients with GOS 1–3 and in 69% of GOS 4-5 patients. Regional cerebral blood flow and computed tomography perfusion scanning showed adequate correlation with nimodipine application and angiographic vasospasm. Transcranial Doppler turned out to be unreliable with interexaminer variance and failure of detecting vasospasm or missing the improvement.Conclusion. Local continuous intra-arterial nimodipine treatment for refractory cerebral vasospasm after aSAH can be recommended as a low-risk treatment in addition to established endovascular therapies.

BACKGROUND Although population age increases, published evidence on meningioma treatment in the elderly is scarce. OBJECTIVE In order to improve selection for surgery, we investigated our patients' collective, using 2 proposed risk assessment systems, the Clinical-Radiological Grading System (CRGS) and the SKALE score (sex, Karnofsky, American Society of Anesthesiology [ASA] score, location, edema). METHODS We retrospectively assessed morbidity and mortality in 164 patients aged ≥ 65, operated on for an intracranial meningioma. Medical and surgical records were reviewed and analyzed. CRGS and SKALE scores were calculated. The ability of both CRGS and SKALE and all single factors to predict death within 12 months was analyzed by the use of multivariate logistic regression modeling. RESULTS Eleven patients died (6.7%). Logistic regression for CRGS/SKALE showed a significant relationship with 12 months mortality. Age, Simpson resection grade, and sex were not significant predictors when investigated alone. In multivariate logistic regression, including all proposed factors, only concomitant disease and edema (CRGS) as well as ASA score and preoperative Karnofsky Performance Scale (SKALE) showed a significant relationship to mortality. After stepwise reduction of the full multivariate regression model to its significant terms, only concomitant disease and ASA remained significant for CRGS (P < .001) and SKALE (P = .003), respectively. CONCLUSION Meningioma resection in the elderly is possible with some mortality. We were unable to reproduce the utility of 2 proposed grading systems for mortality prediction when extending to younger patients. In single-factor analysis, only concomitant disease and ASA score remained significant. The decision whether to operate should be taken individually. Patients with severe concomitant disease or high ASA score should be advised not to undergo surgical therapy independently from other factors.

Adult hydrocephalus is a syndrome that is not yet fully understood. For almost a century Dandy’s observations in dogs paved the way to hydrocephalus being referred to as obstructive or communicating. Our knowledge of hydrocephalus has developed stepwise, based on fundamental inventions in diagnostic procedures such as pneumoencephalography, cisternography, computed tomography (CT), and magnetic resonance imaging (MRI).

Neurosurgery is defined as a special field of operative treatment of space-occupying lesions, such as tumors, infection, or hematomas, malformations, degenerative changes, injuries, and other surgically reachable entities of the central, peripheral, and vegetative nervous system and the associated necessary diagnostic procedures.

Minimal invasive neurosurgery is becoming more and more standard in neurosurgical procedures. Several types of lesions are now approached endoscopically. The surgical planning and intraoperative orientation during endoscopic surgical procedures are sometimes difficult. To solve this problem, a combination of the endoscopic procedure with a frameless, armless neuronavigation system is used in our service. The combination of the endoscope and the frameless navigation system was used in tumour surgery, ventriculostomies and arachnoid cyst operations. All procedures were performed successfully. The combination of both systems has proved to be advantageous because of safe surgical planning using the frameless stereotactic technique and the possibility of real time orientation of the endoscope. This technique is very useful in removing intraventricular and large brain mass lesions.

To evaluate tumor control and side effects associated with radiosurgery (RS) and stereotactic fractionated radiotherapy (SFR) for vestibular schwannomas (VSs) in a group of patients treated at the same institution.Between May 1997 and June 2007, 115 consecutive cases of VS were treated in our department. The SFR group (47 patients), including larger tumors (maximum diameter1.5 cm), received a total dose of 54 Gy at 1.8 Gy per fraction. The RS group (68 patients, maximum diameter1.5 cm) received a total dose of 12 Gy at the 100% isodose. Evaluation included serial imaging tests (magnetic resonance imaging) and neurologic and functional hearing examinations.The tumor control rate was 97.9% in the SFR group for a mean follow-up time of 32.1 months and 98.5% in the RS group for a mean follow-up time of 30.1 months. Hearing function was preserved after RS in 85% of the patients and after SFR in 79%. Facial and trigeminal nerve function remained mostly unaffected after SFR. After RS, new trigeminal neuropathy occurred in 9 of 68 patients (13%).A high tumor control rate and low number of side effects are registered after SFR and RS of VS. These results confirm that considering tumor diameter, both RS and SFR are good treatment modalities for VS.

We report the case of an iatrogenic tension pneumothorax related to the placement of a ventriculoperitoneal shunt, followed by pneumocephalus. The patient was pending cranioplasty and shunt placement after decompressive craniectomy for acute subdural hematoma and posttraumatic hydrocephalus. Facilitating the severe and potential life-threatening complication was a severe obesity of the patient as well as incorrect surgical technique.

Data on 233 children with congenital hydrocephalus who were operated on in our department from 1964 to 1984 were analyzed. The study was started in January 1990 and was based on questionnaire followed by a psychological examination. Thirty-two patients (13.7%) died during the follow-up period. The average number of operations during the observation period was 2.7; in 166 patients (= 71.2%) the shunt had to be revised at least once. The reason for revision was a mechanical problem in 79.4% and infection in 15.5%. The psychological evaluation in 115 patients showed a normal performance in 62.8%, while 29.8% had mild retardation, evident in speech impairment and/or impaired speech development, in memory and concentration, in poor intellectual performance and decreased performance in school. Severe retardation was seen in 7.4% of cases. Our results showed that the best outcome can be achieved with early shunt implantation. We did not, however, find any correlation between shunt revision rate and psychological results.

Stereotactic guided laser-induced interstitial thermotherapy (SLITT) is a minimal invasive method to produce thermo necrosis in cerebral tumor tissue. Clinical data about dose/response relationship and patients outcome is poor. Twenty-four patients with brain tumors were treated with SLITT, totally 30 laser procedures were performed. Under local anesthesia 600 micrometers laser-fiber were inserted by the stererotactic-guided technique. IN open MR the denaturation of the tumor by a Neodym-YAG-laser was monitored using T1-weighted 3D tumor FLASH sequences. Laser energy was applied in steps of 400 to 1200 Joules. Development of necrosis at a mean total energy-dose of 2979 Joules could be monitored in all procedures. Initial signal changes were seen after a mean of 1250 Joules. Mean max total lesion size was 21.2 mm. The higher the total energy, the larger the thermo lesion, but no linear relationship could be seen. Tumor tissue response showed no dependency form tumor grading. Although lesion-size basically is energy dependent, it should be applied individually, since thermo response in brain tumors varies due to different optical properties. Energy application in steps of 500 Joules monitored in near on-line modus in an open MR-system is safe and feasible. Conclusions about the clinical value of SLITT are not definite.© (2001) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Object. A mathematical model previously introduced by the authors allowed noninvasive intracranial pressure (nICP) assessment. In the present study the authors investigated this model as an aid in predicting the time course of raised ICP during infusion tests in patients with hydrocephalus and its suitability for estimating the resistance to outflow of cerebrospinal fluid (Rcsf).Methods. Twenty-one patients with hydrocephalus were studied. The nICP was calculated from the arterial blood pressure (ABP) waveform by using a linear signal transformation, which was dynamically modified by the relationship between ABP and cerebral blood flow velocity. This model was verified by comparison of nICP with “real” ICP measured during lumbar infusion tests. In all simulations, parallel increases in real ICP and nICP were evident. The simulated Rcsf was computed using nICP and then compared with Rcsf computed from real ICP. The mean absolute error between real and simulated Rcsf was 4.1 ± 2.2 mm Hg minute/ml. By the construction of simulations specific to different subtypes of hydrocephalus arising from various causes, the mean error decreased to 2.7 ± 1.7 mm Hg minute/ml, whereas the correlation between real and simulated Rcsf increased from R = 0.73 to R = 0.89 (p < 0.001).Conclusions. The validity of the mathematical model was confirmed in this study. The creation of type-specific simulations resulted in substantial improvements in the accuracy of ICP assessment. Improvement strategies could be important because of a potential clinical benefit from this method.

BACKGROUND The timing of surgery in patients suffering from subarachnoid hemorrhage grade IV and V according to Hunt and Hess, is still controversial. Several authors advocate early surgery for patients in poor clinical condition. Improved outcome and decreased mortality rates were reported. Others exclude patients in poor condition from early aneurysm surgery. METHODS Forty grade IV aneurysm patients were admitted to our department. After ventriculostomy and cerebral angiography, 28 of them were operated on within 72 hours. The postoperative treatment included hypertensive, hypervolemic, hemodilutional therapy (triple-H therapy) and intensive monitoring (intracerebral pressure, blood pressure, hemodynamic parameters). The mean follow-up time was 6 months. RESULTS Out of the 28 patients who underwent early surgery, 64% were in good health, 11% in poor health, 25% died; there were no survivors in a vegetative state. Twelve patients were treated conservatively; 50% died from infarction and rebleeding, before the operation was performed. Six underwent delayed aneurysm surgery after clinical improvement. In this group, 25% had good clinical outcome. CONCLUSIONS Our results favor an aggressive treatment of grade IV aneurysm patients by means of ventricular drainage, early surgery and triple-H therapy.

BACKGROUND Currently, there is an ongoing debate regarding the best treatment option for ruptured aneurysms. The International Subarachnoid Aneurysm Trial study suggests that an endovascular procedure is the best treatment. In some complex cases, or in patients with an additional large intracerebral hemorrhage, aneurysms require further microsurgical clipping. OBJECTIVE We introduce a new clip system to improve clipping procedures in especially complex aneurysms. METHODS The inverted opening mechanism of the clip in combination with the special clip applier provides the surgeon with a good overview in the operating field. The new design also enables a wider opening of the clip jaws in contrast to all other well-known titanium aneurysm clips. This should provide a better and safer application and decrease the danger of premature rupture. RESULTS From January 2006 to July 2008, 55 aneurysms were clipped in 45 patients. The most common aneurysm location was the anterior communicating artery (20 patients) followed by the M1 segment of the middle cerebral artery (16 patients). Four patients had 2, one had 3, and one had 5 aneurysms. Two clipping procedures were performed for an arteriovenous malformation-associated aneurysm. All aneurysms were clipped without any technical complication. CONCLUSION The use of the new clip system, especially in complex aneurysm surgery, has potential benefits because of the better surgical vision during clip application and the wider opening of the clip jaws. It is easy to handle and compatible with magnetic resonance imaging.

A child with hydrocephalus and macrocrania was treated by a shunt procedure. After placement of a bilateral ventriculo-atrial shunt subdural hematomas developed on both sides. Burr hole drainage and insertion of a pressure-adjustable valve were used to obliterate the subdural hematomas and to influence the outflow resistance of the shunt.

An injury to a peripheral nerve may cause life-long functional disabling deficits, and have a considerable impact on the patient’s quality of life. After a nerve injury outside the central nervous system, numerous reactions are initiated in the chain of neurones from the brain to the muscles and the peripheral receptors. In 1941 Cohen introduced a classification system that was later popularised by Seddon [1]. Sunderland extended the system in 1951 with the definition of five degrees to describe the severity of the injury to the nerve [2]. The classification is based on the normal anatomy of the nerve. Finally MacKinnon added one more pattern of pathology in 1988 introducing the partial lesion, often described as a sixth degree of nerve injury [3]. The classification is illustrated in Table 5.1.1.

Traumatic brain injury (TBI) occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain [4, 12]. A stroke or cerebrovascular accident (CVA) occurs when the blood supply to a part of the brain is suddenly interrupted by occlusion (ischemia), by hemorrhage, or other causes. Ischemia is a reduction of blood flow most commonly because of an obstruction. Hemorrhagic stroke occurs when a blood vessel in the brain bursts, spilling blood into the spaces surrounding the brain cells or when a cerebral aneurysm ruptures. A small proportion of strokes are watershed strokes caused by hypoperfusion or other vascular problems including vasculitis.