Neuroimaging in dementia

SummaryDespite the fact that the diagnosis of dementia is mainly based on clinical criteria, the role of neuroimaging is still expanding. Among other imaging techniques, magnetic resonance imaging (MRI) plays a core role in assisting with the differentiation between various dementia syndromes and excluding other underlying pathologies that cause dementia, such as brain tumors and subdural hemorrhages. This article gives an overview of the standard MRI protocol and of structural radiological reporting systems in patients who suffer from dementia. Moreover, it presents characteristic MRI features of the most common dementia subtypes.

Hemorrhage in long segment cervical schwannoma; case report and literature review

Background: Although hemorrhages associated with cervical and thoracic intraspinal schwannomas are typically localized to the subarachnoid hemorrhages (SAH) or subdural hemorrhages (SDH) compartments, rare intratumoral bleeds may also occur. Methods: In the literature, we found and analyzed multiple factors for 13 cases (e.g., epidemiological, clinical, and pathological) of cervical schwannomas with intratumoral hemorrhages (ITH). We added the 14th case of a 35-year-old female with along segment cervical schwannoma with ITH who presented with acute quadriplegia and respiratory decompensation. Results: These 14 patients averaged 51.77 years of age, 60% were male, and the tumor involved 2.83 segments. The incidence of SAH and ITH was noted in five cases each, while SDH’s were very rare. The pathological characteristics were consistent with the diagnosis of cellular schwannomas with S-100 positivity. The clinical outcomes were good (100%) in all the cases, including the one presented (modified McCormick score III). Conclusion: Cervical schwannomas with ITH are rare, and the surgical outcomes in such patients are good-excellent (>90%). The histopathology is always of prime importance and decisive in establishing and confirming the etiology of such ITH.

Minimally Invasive, Endoscopic-Assisted Device for Subdural Electrode Implantation in Epilepsy

BACKGROUND Subdural grids and strip electrodes provide wide coverage of the cerebral cortex, precise delineation of the extent of the seizure onset zone, and improved spatial sampling to perform functional mapping for eloquent cortex. OBJECTIVE To describe a novel device that allows for a minimally invasive approach to implantation of subdural grid and strip electrodes. METHODS A skull mounted device was created to allow for implantation of subdural electrodes through a keyhole craniotomy with direct visualization using the aid of a flexible neurovideoscope. The initial studies in preparation for grid development performed on cadaveric skulls were analyzed to determine the size of craniotomy required for deployment, maximal distance of strip electrode deployment from center of craniotomy, and visual inspection of the cortex was performed for any underlying damage. RESULTS The device allowed for the placement of subdural electrodes through a 40-mm craniotomy. Subdural electrodes were deployed in multiple directions to a distance of a 70-mm radius from the center of the craniotomy. There was no visual damage to the underlying cortex after the procedures were completed. CONCLUSION Large craniotomies are typically desired to provide direct visualization of the implantation of subdural electrodes, but can increase the risk of subdural hemorrhages and infections. This study describes a novel minimally invasive endoscopically assisted device for the implantation of subdural strip electrodes under direct visualization. With this device, we are able to limit the size of the craniotomy, avoid incision through the temporalis muscle, and implant subdural electrodes with visualization of the cortex.

Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin

BackgroundIntracranial hemorrhage is the most devastating complication in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC). It can be either spontaneous or caused by head trauma. We sought to address the prevalence, clinical characteristics, and prognosis of traumatic and spontaneous intracranial hemorrhages in AF patients on OAC.MethodsMulticenter FibStroke registry of 5,629 patients identified 592 intracranial hemorrhages during warfarin treatment between 2003 and 2012.ResultsA large proportion (40%) of intracranial hemorrhages were traumatic. Of these, 64% were subdural hemorrhages (SDHs) and 20% intracerebral hemorrhages (ICHs). With respect to the spontaneous hemorrhages, 25% were SDHs and 67% ICHs. Patients with traumatic hemorrhage were older (81 vs 78 years, p = 0.01) and more often had congestive heart failure (30% vs 16%, p < 0.01) and anemia (7% vs 3%, p = 0.03) compared to patients with spontaneous hemorrhage. Admission international normalized ratio (INR) values (2.7 vs 2.7, p = 0.79), as well as CHA2DS2-VASc (median 4 vs 4, p = 0.08) and HAS-BLED (median 2 vs 2, p = 0.05) scores, were similar between the groups. The 30-day mortality after traumatic hemorrhage was significantly lower than after spontaneous hemorrhage (25% vs 36%, p < 0.01).ConclusionsA significant proportion of intracranial hemorrhages in anticoagulated AF patients were traumatic. Traumatic hemorrhages were predominantly SDHs and less often fatal when compared to spontaneous hemorrhages, which were mainly ICHs. Admission INR values as well as CHA2DS2-VASc and HAS-BLED scores were similar in patients with spontaneous and traumatic intracranial hemorrhage.Clinicaltrials.gov identifierNCT02146040.

Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces

OBJECTIVEChildren who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.METHODSThe authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.RESULTSOf 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.CONCLUSIONSThe high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.

Variation in management of in-hospital newborn falls: a single-center experience

OBJECTIVEThere are only 3 small case series in the literature that report on the management of in-hospital newborn falls (NFs), and recommendations are unclear. The authors performed a retrospective review to determine outcome and differences in management and to understand why management of NFs varies at their institution.METHODSAll NFs occurring within the authors’ institution over a 3.5-year period were reviewed. Post-fall management and outcomes of each incident were compared.RESULTSThere were 24 NFs out of 40,349 deliveries (5.9 NFs/10,000 deliveries). The mechanism of injury was nearly identical in 22 of 24 falls (the newborn fell to the floor from a parent in a bed or chair), and physical examination findings were normal or benign in all cases. Unexplained management variation based solely on clinician preference was noted, including observation only (in 13 cases), skull radiograph (in 7), head CT scan (in 6), bone survey (in 4), and head ultrasound examination (in 1), with some babies having more than 1 study. Two babies had nondepressed linear parietal fractures diagnosed by skull radiograph, and 2 babies had small subdural hemorrhages diagnosed by head CT scan. All 24 babies had normal findings on examination at discharge.CONCLUSIONSThere is a high incidence of nondepressed linear parietal skull fractures associated with NFs. However, since associated intracranial injury is uncommon, imaging studies may not be routinely performed. Neonatal intensive care unit admission, head CT, and neurosurgical evaluation are reserved for the rare baby with abnormal physical examination or neurological findings.