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Intracerebral hemorrhage (ICH) is a common and severe neurological disorder associated with high morbidity and mortality rates. Despite extensive research into its pathology, there are no clinically approved neuroprotective treatments for ICH. Increasing evidence has revealed that inflammatory responses mediate the pathophysiological processes of brain injury following ICH. Experimental ICH was induced by direct infusion of 100 μL fresh (non‐heparinized) autologous whole blood into the right basal ganglia of Sprague–Dawley rats at a constant rate (10 μL/min). The simvastatin group was administered simvastatin (15 mg/kg) and the combination therapy group was administered simvastatin (10 mg/kg) and ezetimibe (10 mg/kg). Magnetic resonance imaging (MRI), the forelimb use asymmetry test, the Morris water maze test, and two biomarkers were used to evaluate the effect of simvastatin and combination therapy. MRI imaging revealed that combination therapy resulted in significantly reduced perihematomal edema. Biomarker analyses revealed that both treatments led to significantly reduced endothelial inflammatory responses. The forelimb use asymmetry test revealed that both treatment groups had significantly improved neurological outcomes. The Morris water maze test revealed improved neurological function after combined therapy, which also led to less neuronal loss in the hippocampal CA1 region. In conclusion, simvastatin–ezetimibe combination therapy can improve neurological function, attenuate the endothelial inflammatory response and lead to less neuronal loss in the hippocampal CA1 region in a rat model of ICH.

ObjectivesThe present nationwide population-based cohort study aims to assess the effectiveness of gamma knife radiosurgery (GKS) on ruptured and unruptured brain arteriovenous malformations (AVMs) by evaluating the haemorrhage rates.DesignA nationwide, retrospective cohort study.SettingTaiwan National Health Insurance Research Database (NHIRD).ParticipantsAn observational study of 1515 patients who were diagnosed with brain AVMs between 1997 and 2013 from the Taiwan NHIRD.Primary outcome and secondary outcome measuresWe performed a survival analysis using the Kaplan-Meier method. Multivariate Cox proportional hazards regression models were used to explore the relationship between treatment modalities (GKS vs non-GKS) and haemorrhage, adjusted for age and sex.ResultsThe GKS and non-GKS groups included 317 and 1198 patients, respectively. Patients in the GKS group (mean±SD, 33.08±15.48 years of age) tended to be younger than those in the non-GKS group (37.40±17.62) (p40 years of age (aHR 3.21; 95% CI 1.12 to 9.14).ConclusionsGKS is safe and it reduces the risk of haemorrhage in patients with ruptured AVMs. The administration of GKS to patients with unruptured AVMs who are above the age of 40 years old male might increase the risk of haemorrhage.

Olfactory dysfunction is related to several clinical neurodegenerative diseases, such as Alzheimer’s disease, multiple sclerosis, degenerative ataxias, Parkinson’s disease, and so on. Owing to the individual difference in the sensory adaption of human smell function, the olfactory responses usually exhibit large inter-individual difference and change over time after repeated stimulations. The traditional analysis tools, such as statistical parametric mapping (SPM) in functional magnetic resonance imaging technique (fMRI) analysis, utilize the paradigm-based linear correlation and statistical techniques to discriminate the activation areas from background activities. However, these traditional approaches extract olfactory-induced responses using the stereotypic template or paradigm generated model. The olfactory-induced hemodynamic responses affected by internal/external events, such as changes of smell fatigue and attention, are not considered and therefore could result in misleading results. In this paper, owing to the stochastic characteristic of olfactory-induced responses, we adopted multivariate empirical mode decomposition (MEMD) to extract olfactory-induced hemodynamic responses in MRI blood-oxygen-level dependent (BOLD) signals. The MEMD is an efficient data-driven approach to extract nonlinear and non-stationary signals, which is an improved method to expand traditional empirical mode decomposition (EMD) from one channel to multi-channel processing. We applied MEMD to decompose time series of BOLD signals from each slice into multivariate intrinsic mode functions (IMF). The MEMD enables common features of different scales in an image slice to be arranged in distinct IMFs. Each IMF is an analytic, self-constructed, well-defined, and data-driven function with time-varying frequencies. Each IMF was examined by checking its correlation with the paradigm-generated template. The task-related IMFs were chosen to reconstruct olfactory-induced hemodynamic responses. The group analysis of MEMD-processed data showed olfactory-induced activations in the anterior cingulate cortex and middle frontal gyrus.

Background and aims Renal dysfunction is a potent risk factor for cardiovascular diseases, including stroke. This study aimed to evaluate the impact of admission estimated glomerular filtration rate (eGFR) levels on short-term (1-month) and long-term (1-year) mortality in patients with acute ischemic stroke. Methods From the Taiwan Stroke Registry data, we classified ischemic stroke patients, identified from April 2006 to December 2015, into 5 groups by eGFR at admission: ≥ 90, 60–89, 30–59, 15–29, and Results Among 52,732 ischemic stroke patients, 1480 died within one month. The 1-month mortality rate was over 5-fold greater in patients with eGFR Conclusions After acute ischemic stroke, patients with reduced eGFR are at elevated risks of short-term and long-term deaths in a graded relationship.

Background: Duroplasty has been widely used in cranial surgery when primary closure is not possible. The goal is to protect the cerebrum and thereby ensure that complications were as few as possible. We reviewed a single-institution experience with a variety of dural substitutes in craniotomy and analyzed the risk factors for duroplasty-associated hemorrhagic complications. Patients and Methods: Patients who received dural replacement after craniotomy or craniectomy between July 2004 and June 2009 were enrolled into this study. Medical records were reviewed for diagnosis, procedure, and type of dural replacement. Clinical courses were reviewed for hemorrhagic complications, including subdural hematoma, extradural hematoma, and subarachnoid hemorrhage. Logistic regression models were used to analyzed the risk factors of duroplasty-associated hemorrhagic complications. Results: Two hundred and twelve patients were included in the study. Overall, the hemorrhagic complication rate was 4.7% (10 patients). Complications were seen for microporous polyester urethane, expanded polytetrafluoroethylene monolayer, polyester silicone, and Biomesh in 4.1%, 0%, and 38.5% of patients, respectively. Patients who received duroplasty with Biomesh had a higher hemorrhagic complication rate with the odds ratio of 24.75 (95% confidence interval, 4.33–141.41) in comparison of those with microporous polyester urethane group after adjusting for individual confounders. Conclusion: The increased risk of hemorrhagic complications associated with craniotomy is modified by choice of dural replacement. Our results could assist clinicians in their decision-making with respect to the optimal timing for synthetic dural substitutes in patients with tumor infiltration of the patient's dura, severe brain swelling in traumatic brain injury, or a result of shrinkage from exposure and electrocautery.

The aggregation and deposition of transactivation response DNA-binding protein 43 (TDP-43) in neurons and astrocytes is characteristic in a number of neurodegenerative diseases including Alzheimer's disease, frontotemporal lobar degeneration, and amyotrophic lateral sclerosis. Nevertheless, the exact role of TDP-43 in astrocytes is unknown. Recently, TDP-43 was identified in neurons but not astrocytes after traumatic brain injury (TBI) in humans. In the present study, we evaluated TDP-43 expression and proteolysis in astrocytes in a rat model of TBI. We assessed TDP-43 fragment expression, astrocyte morphology, neuronal population numbers, and motor function after TBI with or without intracerebroventricular administration of a caspase-3 inhibitor. Motor dysfunction was observed after TBI in potential association astrocytic TDP-43 short fragment mislocalization and accumulation, astrogliosis, and neuronal loss. Notably, caspase-3 inhibition prevented these changes after TBI. Our findings suggest that TDP-43 proteolysis in astrocytes is related to astrogliosis and subsequent neuronal loss in TBI, and that TDP-43 may be an important therapeutic target for preventing motor dysfunction after TBI.

Background Medical radiation is considered a factor responsible for cataractogenesis. However, the incidence of this ophthalmologic complication resulting from gamma knife radiosurgery (GKRS) has not yet been reported. The present study aimed to determine the risk of cataractogenesis associated with radiation exposure from GKRS. Methods This study used information from a random sample of one million persons enrolled in the nationally representative Taiwan National Health Insurance Research Database. The GK group consisted of patients who underwent GKRS between 2000 and 2009. The non-GK group was composed of subjects who had never undergone GKRS, but who were matched with the case group for time of enrollment, age, sex, history of coronary artery disease, hypertension, and diabetes. Results There were 277 patients in the GK group and 2770 matched subjects in the non-GK group. The GK group had a higher overall incidence of cataracts (10.11% vs. 7.26%; crude hazard ratio [cHR], 1.59; 95% CI, 1.07–2.36; adjusted hazard ratio [aHR], 1.25; 95% CI, 0.82–1.90) than the non-GK group. Patients who had undergone computed tomography and/or cerebral angiography (CT/angio) studies had a higher risk of developing cataracts than those who did not (10.82% vs. 6.64%; cHR, 1.74; 95% CI, 1.31–2.30; aHR, 1.65; 95% CI, 1.22–2.23). The age group between 30 and 50 years had the highest risk of cataractogenesis in both the GK and CT/angio groups (cHR, 3.50; 95% CI, 1.58–7.72; aHR, 2.43; 95% CI, 1.02–5.81; cHR, 2.96; 95% CI, 1.47–5.99; aHR, 2.27; 95% CI, 1.05–4.93, respectively). Conclusions Radiation exposure due to GKRS and CT/angio study may be independently associated with increased risk of cataractogenesis. We suggest routine dosimetry measurement of eye lens and proper protection for patients with benign lesions during GKRS. Regular follow-up imaging studies should avoid the use of CT/angio, and particular care should be taken in the 30–50-year-old age group, due to their significantly increased risk of cataract formation.

Background To determine the association of prior traumatic brain injury (TBI) with subsequent diagnosis of neurodegeneration disease. Methods All studies from 1980 to 2016 reporting TBI as a risk factor for diagnoses of interest were identified by searching PubMed, Embase, study references, and review articles. The data and study design were assessed by 2 investigators independently. A meta-analysis was performed by RevMan 5.3. Results There were 18 studies comprising 3,263,207 patients. Meta-analysis revealed a significant association of prior TBI with subsequent dementia. The pooled odds ratio (OR) for TBI on development of dementia, FTD and TDP-43 associated disease were 1.93 (95% CI 1.47–2.55, p

Background To investigate the association between primary insomnia and dementia using a Taiwanese population-based database. Methods This case-control study involved a subset of Taiwan’s National Health Insurance Research Database of reimbursement claims. We included 51,734 patients who were diagnosed with primary insomnia from 2002 to 2004 as the test group and 258,715 nonprimary insomnia participants aged 20 years or older as the reference group. We excluded patients under 20 and those with depression, post-traumatic stress disorder, and/or sleep disorders caused by organic lesion(s), drugs, or alcohol. We used a Cox proportional hazards model to assess the primary insomnia on the risk of developing dementia after adjusting for sociodemographic characteristics and comorbidities. Results The primary insomnia cohort had a higher prevalence of diabetes, dyslipidemia, hypertension, coronary heart disease, chronic liver disease, and chronic kidney disease at baseline. After adjusting for select comorbidities, primary insomnia remained a significant predisposing factor for developing dementia, and was associated with a 2.14-fold (95% confidence interval, 2.01–2.29) increase in dementia risk. We also found a higher risk of dementia in younger patients. Conclusions Taiwanese patients with primary insomnia, especially those under 40, had a higher risk of developing dementia than those without primary insomnia.

Objective When a cervical or thoracic benign intradural spinal tumor (BIST) coexists with lumbar degenerative diseases (LDD), diagnosis can be difficult. Symptoms of BIST-myelopathy can be mistaken as being related to LDD. Worse, an unnecessary lumbar surgery could be performed. This study was conducted to analyze cases in which an erroneous lumbar surgery was undertaken in the wake of failure to identify BIST-associated myelopathy. Methods Cases were found in a hospital database. Patients who underwent surgery for LDD first and then another surgery for BIST removal within a short interval were studied. Issues investigated included why the BISTs were missed, how they were found later, and how the patients reacted to the unnecessary lumbar procedures. Results Over 10 years, 167 patients received both surgeries for LDD and a cervical or thoracic BIST. In 7 patients, lumbar surgery preceded tumor removal by a short interval. Mistakes shared by the physicians included failure to detect myelopathy and a BIST, and a hasty decision for lumbar surgery, which soon turned out to be futile. Although the BISTs were subsequently found and removed, 5 patients believed that the lumbar surgery was unnecessary, with 4 patients expressing regrets and 1 patient threatening to take legal action against the initial surgeon. Conclusions Concomitant symptomatic LDD and BIST-associated myelopathy pose a diagnostic challenge. Spine specialists should refrain from reflexively linking leg symptoms and impaired ability to walk to LDD. Comprehensive patient evaluation is fundamental to avoid misdiagnosis and wrong lumbar surgery.

Object The reported incidence of hospital-acquired bacterial pneumonia in critically ill trauma patients varies from as low as 4% to as high as 87%, with fatality rates varying from 6% to 59%. Clinical studies have identified the risk factors for pneumonia. The authors undertook this retrospective study to evaluate the incidence, risk factors, and outcomes of hospital-acquired bacterial pneumonia in a group of patients with severe head injuries. Methods This was a retrospective review of consecutive adult patients admitted to the neurosurgical ICU in the authors' hospital because of severe head injury (Glasgow Coma Scale scores ≤ 8) between January 2008 and December 2010. Results During the study period, 290 patients were admitted to the neurosurgical ICU. Multivariate Cox regression analysis showed that age (HR 1.01, 95% CI 1.001–1.02), nasogastric tube insertion (HR 4.56, 95% CI 1.11–18.64), and hemiplegia or hemiparesis (HR 3.79, 95% CI 2.01–7.17) were significantly associated with the development of pneumonia. Conclusions The authors identified 3 risk factors (age, nasogastric tube insertion, and hemiplegia or hemiparesis) associated with the development of pneumonia in patients with severe head injury. This finding constituted the basis for developing a simple screening tool that can be used to assess the risk of occurrence of pneumonia in such patients.

Summary Background Percutaneous vertebroplasty has gained widespread popularity to treat painful osteoporotic vertebral compression fractures (VCFs). Radiation exposure during these operations has become the major concern in recent years. Aims Traditional percutaneous vertebroplasty for VCFs is associated with high operator radiation exposure. However, these procedures can be performed by fluoroscopy-based image guidance, which decreases the radiation exposure during vertebroplasty for VCFs. Methods The study subjects were divided into two groups: one underwent traditional vertebroplasty and the other had the C-Arm fluoroscopy-based, image-guided procedure. Four patients in the first group underwent traditional vertebroplasty using repeated intermittent anteroposterior and lateral fluoroscopy to position the cannula used for the vertebroplasty. Six patients in the second group had C-Arm fluoroscopy-based, image-guided surgery. The dose area product values, obtained by thermoluminescent dosimeters, were measured in both groups. Results The accuracy of the non-invasive fluoroscopy-based image-guided surgery was high, with a maximum error of 2 mm. The mean dose area product values of the operator’s eyes, hands, neck and chest were 20.28 mGy, 20.34 mGy, 21.87 Gy and 18.27 mGy in the first group, and 3.51 mGy, 3.70 mGy, 3.02 mGy and 3.68 mGy in the second group, respectively, with fluoroscopy-based, image-guided surgery; the differences were statistically significant ( p Conclusion The results of this preliminary study showed that noninvasive, fluoroscopy-based, image-guided surgery was accurate and was associated with reduced radiation exposure to medical personnel during percutaneous vertebroplasty procedures for VCFs.

Objective. To compare the efficacy of percutaneous vertebroplasty (PV) with conservative therapy for patients with acute vertebral compression fractures. Design. Prospective, nonrandomized, comparison study. Background. The efficacy of PV has not been well established because there have been few comparative studies with conservatively treated control groups. Patients and Methods. Fifty-five consecutive patients (8 men and 47 women, age 47–94) with osteoporosis and symptomatic acute vertebral compression fractures were enrolled. Thirty-two patients received PV, whereas 23 received conservative therapy. Outcome Measures. Changes in pain intensity, physical functioning, and pain medication requirement were evaluated. Results. Both PV and conservative therapy provided pain reduction ( P < 0.001), improvements in physical functioning ( P < 0.001), and decreased medication ( P < 0.001). Reductions in visual analogue pain scores were more significant in the vertebroplasty group at 1 ( P < 0.001) and 4 weeks ( P < 0.001) but not at 12 months. Improvements in physical functioning were significant at 1 ( P < 0.001) and 4 weeks ( P < 0.001). Medication requirements were lower in the vertebroplasty group at all three time points. Conclusions. Pain relief, physical functioning improvement, and medication requirement after vertebroplasty are immediately and significantly better when compared with conservative therapy.

The identification of reliable outcome predictors after traumatic brain injury (TBI) is crucial. The objective of our study was to investigate the role of tau protein as a serum marker of TBI.Thirty-four patients with severe TBI (Glasgow Coma Scale [GCS] score at admissionor= 8) were considered. The tau protein level in the blood samples obtained at the time of admission was measured. The outcome was assessed by using the Glasgow Outcome Scale (GOS) at 6 mo post-injury. Demographic, clinical, and laboratory variables were analyzed to study their effect on the outcome.tau Protein levels were higher in the poor outcome group (436.2 +/- 473.6 pg/mL) than in the good outcome group (51.6 +/- 81.5 pg/mL) (P0.0001). Univariate analyses demonstrated that poor outcome was significantly associated with a poor GCS score (P = 0.001), higher serum tau protein levels (P0.001), abnormal pupil light reflex (P = 0.013), and basal cistern compression on computed tomogram (CT) (P = 0.026). Multivariate analyses revealed that a poor GCS score (P = 0.049) and higher serum tau protein levels (P = 0.043) were independent prognostic factors for poor outcome. The receiver-operating characteristic (ROC) curve demonstrated that a tau protein levelor= 114.5 pg/mL yielded 88% sensitivity and 94% specificity for predicting a poor outcome.These results suggest that in addition to GCS; serum tau protein levels may serve as indicators for the prediction of outcome following severe TBI. However; it should be viewed with caution because of the small sample size and wide standard deviations.

Dear editor We read with great interest the article by Liang et al “Repeated vertebral augmentation for new vertebral compression fractures of postvertebral augmentation patients: a nationwide cohort study”.1 In their study, the authors investigated the factors possibly associated with new vertebral compression fractures in patients who previously had vertebral augmentation procedures. They reported that osteoporosis (OP) was not observed as a risk factor for repeat vertebral augmentation. Among multiple chronic diseases, hypertension (HT) was reported as one factor associated with new vertebral fractures. Among the medications used to treat or prevent OP, they reported calcium/vitamin D, bisphosphonates, and calcitonin were associated with not having repeat vertebral augmentation. However, steroids, paracetamol, and nonsteroidal anti-inflammatory drugs were associated with having repeat vertebral augmentation. We would like to comment on their article. The authors described OP as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak bone mass as measured by dual-energy X-ray absorptiometry. However, the National Osteoporosis Foundation reported the diagnosis of OP as low BMD measurements or the occurrence of adulthood hip or vertebral fracture in the absence of major trauma.2 Vertebral compression fractures would be the only indicator of OP in patients with normal BMD scores. This might have led to underdiagnosis of OP. Furthermore, both vertebral degenerative changes and fractures may cause misinterpretation of BMD scores as normal when there is significant OP. We suggest that using “low BMD score” would be better than “OP” as nonassociated with new vertebral compression fracture. In line with our comments, Table 2 shows that 34,500 patients have a diagnosis of OP; however, as indicated in Table 3, 57,568 patients are undergoing treatment for OP. This inconsistency could mean that the rate of OP is more than determined in this study. It may also mean that multiple OP medications were used concomitantly by some of the patients. This point should be clarified. The authors reported that the HT and diabetes mellitus were associated with repeat vertebral augmentation. However, it is not discussed how HT may be related to repeat vertebral augmentation. In the elderly, one of the important factors underlying falls may be overtreatment of HT leading to hypotension and/or orthostatic hypotension and consequent falls.3,4 Consideration of patients with low blood pressure levels or clinically significant orthostatism on antihypertensive medications would help the authors to interpret this association. Another factor that would be associated with having repeat vertebral augmentation is “falls” which could not be estimated in this study database. It would be useful to search “vertigo” or “syncope” as a predisposing risk factor for falling.5 Although it is rarely diagnosed on clinical grounds, sarcopenia is prevalent in elderly people (between 3% and 52%).6 Sarcopenia is commonly seen in patients with dementia, cerebrovascular accidents, and diabetes, and is a strong risk factor for both OP and falls.2,7 We suggest that sarcopenia which is not included in the discussion, should be considered as an important factor underlying the increased risk of vertebral augmentation in these patients. Finally, regarding the association between the use of analgesics and repeat vertebral augmentation, the authors discussed that the increase in fracture risk in these patients may stem from changes in postural balance or dizziness (a side effect of nonsteroidal anti-inflammatory drugs). In this regard, dizziness is not a known adverse event associated with paracetamol. Therefore, we suggest that there may be an indirect association between analgesics, in particular paracetamol, and repeat vertebral augmentation: patients having more severe fractures and more severe pain might have used these agents more frequently. It is also possible that subjects having pain more commonly visited their physician and pain could be a common indication for repeat vertebral augmentation procedures. We suggest that the findings of the present study should be interpreted in view of aforementioned considerations.

Cheng-Loong Liang,1 Hao-Kwan Wang,1 Fei-Kai Syu,2 Kuo-Wei Wang,1 Kang Lu,1 Po-Chou Liliang1 1Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan; 2Department of Pharmacy, China Medical University Hospital, Taichung City, Taiwan Purpose: Postvertebral augmentation vertebral compression fractures are common; repeated vertebral augmentation is usually performed for prompt pain relief. This study aimed to evaluate the incidence and risk factors of repeat vertebral augmentation.Methods: We performed a retrospective, nationwide, population-based longitudinal observation study, using the National Health Insurance Research Database (NHIRD) of Taiwan. All patients who received vertebral augmentation for vertebral compression fractures were evaluated. The collected data included patient characteristics (demographics, comorbidities, and medication exposure) and repeat vertebral augmentation. Kaplan–Meier and stratified Cox proportional hazard regressions were performed for analyses.Results: The overall incidence of repeat vertebral augmentation was 11.3% during the follow-up until 2010. Patients with the following characteristics were at greater risk for repeat vertebral augmentation: female sex (AOR=1.24; 95% confidence interval [CI]: 1.10–2.36), advanced age (AOR=1.60; 95% CI: 1.32–2.08), diabetes mellitus (AOR=4.31; 95% CI: 4.05–5.88), cerebrovascular disease (AOR=4.09; 95% CI: 3.44–5.76), dementia (AOR=1.97; 95% CI: 1.69–2.33), blindness or low vision (AOR=3.72; 95% CI: 2.32–3.95), hypertension (AOR=2.58; 95% CI: 2.35–3.47), and hyperlipidemia (AOR=2.09; 95% CI: 1.67–2.22). Patients taking calcium/ vitamin D (AOR=2.98; 95% CI: 1.83–3.93), bisphosphonates (AOR=2.11; 95% CI: 1.26–2.61), or calcitonin (AOR=4.59; 95% CI: 3.40–5.77) were less likely to undergo repeat vertebral augmentation; however, those taking steroids (AOR=7.28; 95% CI: 6.32–8.08), acetaminophen (AOR=3.54; 95% CI: 2.75–4.83), or nonsteroidal anti-inflammatory drugs (NSAIDs) (AOR=6.14; 95% CI: 5.08–7.41) were more likely to undergo repeat vertebral augmentation.Conclusion: We conclude that the incidence of repeat vertebral augmentation is rather high. An understanding of risk factors predicting repeat vertebral augmentation provides valuable basis to improve health care for geriatric populations. Keywords: vertebroplasty, kyphoplasty, comorbidity, bisphosphonate, old ageTwo Letters to the Editor have been recieved and publishedÄ°lhan et alWilson et al&nbsp

Owing to the diversity in cause and damage, there is no standard surgical treatment method for a complicated penetrating craniofacial injury. The treatment of a complicated penetrating head injury caused by a steel bar is presented here. A 66-year-old woman fell onto a steel bar at a construction site and it penetrated the mandible, entered the sinus and orbital cavities, and reached the base of the frontal bone. A multi-disciplinary team including a neurosurgeon, otolaryngologist, and plastic surgeon was involved in removing the steel bar. The patient survived without sequelae except for blindness in the right eye. Despite the lack of standardized surgical treatment for a complicated penetrating craniofacial injury, aggressive treatment by a multidisciplinary team can result in good outcomes. Language: en

Summary Background Seizures are important neurological complications of bacterial meningitis, but no information about its epidemiology and the outcomes of seizures after community-acquired bacterial meningitis (CABM) in an adult population have been reported. Aims To determine the frequency, clinical relevance, subtypes of seizures during the acute phase of bacterial meningitis, and the long-term outcomes of seizure complicating adult CABM. Methods In this 12-year retrospective study, 117 adult patients were identified with culture-proven CABM. A comparison was made between the clinical data of the patients with and without seizures during hospitalization. Results Thirty-one patients had seizures during CABM, accounting for 27% (31/117) of the episodes. The time interval between the onset of bacterial meningitis and the seizures was 1–21 days (mean, 4 days). Furthermore, 80% (25/31) of the episodes occurred within 24h of presentation. Ten patients who had seizures progressed to status epilepticus. At follow-up after completing treatment, 10 patients completely recovered and were seizure-free, 19 died of meningitis during the acute stage and the other two progressed to chronic epilepsy. Conclusion A log-rank test demonstrated that the long-term outcome of adult CABM with acute seizures produced worse outcomes than for those who had no seizures, though no difference was noted between focal and generalized seizures. None of our patients without seizures in the acute phase of bacterial meningitis developed late seizures during the follow-up periods. Poor outcome in this study may attribute to neurological complications such as seizure, hydrocephalus, infection itself, or a combination of complications.

Background The predictive factors, clinical relevance, and outcomes of hydrocephalus complicating adult bacterial meningitis were studied. Methods In this 16-year retrospective study, 136 adult patients were identified with culture-proven bacterial meningitis. A comparison was made between the clinical and cerebrospinal fluid data of patients with and without hydrocephalus on admission. Results Twenty-eight patients had hydrocephalus secondary to bacterial meningitis, accounting for 21% (28/136) of the episodes. Of the 28 patients, the initial computed tomographic scans and/or magnetic resonance imaging studies revealed hydrocephalus in 27 patients, and delayed hydrocephalus developed despite commencement of antimicrobial therapy in the remaining patient. The interval from initial symptoms to external ventricular drainage was 3.9 ± 4.6 days (range, 1-14 days). Among them, 7 patients underwent external ventricular drainage for hydrocephalus during the acute phase of bacterial meningitis. At follow-up of at least 6 months or more, 14 patients survived and 14 died, with an overall mortality rate of 50%. Conclusion In this study, disturbed consciousness and a higher mean age at the time of admission are risk factors for developing hydrocephalus during the acute phase of bacterial meningitis. Poor outcomes are also found in this specific group of patients, and these may be attributed to the infection itself, hydrocephalus, or both. Because of fulminated clinical courses and high fatality rates, surgical intervention may be suitable only for those who have progressive hydrocephalus and are neurologically stable. In spite the high fatality rate, adequate treatment of neurologic complications and aggressive antimicrobial therapy are essential in improving therapeutic outcomes.

In this study, 116 patients, at least 1 month of age but younger than 5 years, were identified with culture-proven bacterial meningitis. A comparison was made between the clinical data of the patients with and without seizures during hospitalization. Seizures during acute bacterial meningitis accounted for 47% (55/116) of the episodes. Time interval between the onset of bacterial meningitis and that of seizures was 1 to 20 days (mean, 4 days). Twelve of these 55 patients had one or more afebrile seizures after completing the treatment. At follow-up of at least 1 year after completing treatment, 26 patients had good outcomes, whereas the other 29 patients had poor outcomes. A strong correlation between the findings of abnormalities through neuroimaging and the occurrence of seizures during hospitalization was observed. The long-term outcomes of patients with infantile and childhood bacterial meningitis, who had seizures during the acute phase of bacterial meningitis, were worse than the outcomes of those who did not have such seizures. No child developed late seizures unless there were acute seizures. Factors associated with seizures during acute bacterial meningitis include disturbed consciousness on admission, abnormal neuroimaging findings, and low glucose and high concentration of total proteins in cerebrospinal fluid.

Variants of the external osteoplastic flap procedure or endoscopy have been used to approach the frontal sinus mucocele. The authors introduce a modified external approach for radical resection of the mucocele. Using the bicoronal skin incision, the skin flap exposed the right upper orbital rim. The outer table craniotomy was then performed to expose the frontal sinus cavity while carefully preserving the inner table, with radical removal of the mucocele mucosa. The sinus cavity was irrigated with hyper-oxide solution to ensure adequate destruction of possible residual mucosa. The fascia of the frontalis muscle was split, with one part placed into the mucocele cavity to plug the nasofrontal duct. The advantages of the procedures for mucocele removal include clear visualization of the frontal sinus for radical resection of the mucosa, preservation of the inner table avoiding dura manipulation, prevention of central nervous system infection, possibly lower rates of recurrence, prevention of mucosal ingrowth by plugging of the nasofrontal ducts with fascia, and favorable cosmetic outcome. The disadvantages are more intensive surgery comparable to the endoscopic approaches and execution difficulties when the frontal mucocele is small. Additional clinical studies are needed to evaluate the efficiency and safety of this procedure.

This 16-year (1986-2001) retrospective study enrolled 80 infantile patients (aged, 30-365 days old) with culture-proven bacterial meningitis. The most prevalent pathogens were Salmonellaspecies, Streptococcus (S.) agalactiae, Escherichia (E.) coli, and Haemophilus (H.) influenzae, accounting for about 59% of the episodes. Meningitis caused by Salmonella species, E. coli and H. influenzae occurs more often in the older infants, while that caused by S. agalactiae occurs more often in young infants. Our study revealed a decrease in the proportion of Salmonella meningitis from 27% in the first 8 years to 9% in the second 8 years with E. coli replacing Salmonella species as the leading pathogen of this disease during the second period. Overall mortality rate for both periods of time was 11%. However, if we take those with undesirable poor outcomes into account, 43% of patients could be considered treatment failures. The study also reveals a high prevalence of neurological complications when this disease is caused by H. influenzae, S. pneumoniae, and Salmonella species. Stepwise logistic regression analysis revealed that only initial changing levels of consciousness (P = 0.006) were independently associated with treatment failure. The most frequent neurological complications associated with this disease included subdural empyema, hydrocephalus, cerebral infarctions, and seizures. Because therapeutic regimens may require attention to the eradication of bacterial pathogen but also the neurological complications, early diagnosis and choice of appropriate antibiotics are essential to increasing the possibility of survival.

To determine the clinical features, prognostic factors, and therapeutic results of Guillain-Barre syndrome (GBS) in order to improve the therapeutic strategy for this disease. We retrospectively reviewed the electrodiagnostic study and medical records of patients with GBS admitted to Chang Gung Memorial Hospital, Kaohsiung, between January 1986 and December 2000. Outcomes and prognosis were followed-up after 1 year. Ninety-six patients were enrolled in this study. According to the clinical and electrophysiological findings, 77 patients were acute inflammatory demyelinating polyradiculoneuropathy, seven were Miller Fisher syndrome, and six were axonal forms, and six were unclassified. At a follow-up of 1 year, 61 patients (64%) recovered, 30 (31%) had residua and five (5%) died. Amongst these 30 had residua, including unassisted gait in 19, assisted gait in four, and wheel/bed bound in seven. According to the statistical analysis, disabilities at the nadir (P < 0.0001) and at admission (P = 0.014) were significant prognostic factors. Variables used for the stepwise logistic regression, and the results revealed that after analysis for all the above variables, only disability at the nadir (P < 0.0001) was independently associated with the treatment failure rate. Our study revealed 27% of cases in need of respiratory support during hospitalization, and 5% of hospital-treated patients die from the complications. Furthermore, 31% had residua at a follow-up of 1 year or more. If prognostic factors are considered, disability at the nadir during hospitalization demonstrates consistently poor therapeutic outcomes. Therefore, early diagnosis, choice of appropriate treatment, and preventing complications during acute stages are essential to maximize the potential for survival.

Sixty patients with Guillain-Barre syndrome (GBS), aged 16-83 years, have been identified over a period of 7 years. Of 60 patients, 30 received the double filtration plasmapheresis (DFP), 4 received intravenous immunoglobulin, and the other 26 received supportive care only. Therapeutic outcomes at 1 year were determined using a modified Barthel index. At a follow-up of 1 year or longer, 31 patients (52%) had recovered, 24 (40%) had residua, and 5 (8%) had died. According to the statistical analysis, disability at the nadir and electrophysiological signs significantly influenced the long-term outcomes. Complications associated with DFP procedures included physiologic change, technique-related complications, and vascular access-related complications. None of our patients had fatal complications related to DFP treatment. Contrary to the established belief that the disease has a favorable outcome, several hospital-treated patients may still die or present residua even several months after the onset of symptoms. Because disability at the nadir influences the outcomes, early diagnosis and choice of appropriate treatment, which might include DFP, to prevent further neurological deficits, are essential to maximize the potential for survival.

Background Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals. Methods We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group. Results Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86). Conclusions The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

Traumatic brain injury (TBI) leads to important and deleterious neuroinflammation, as evidenced by indicators such as edema, cytokine production, induction of nitric oxide synthase, and leukocyte infiltration. After TBI, cerebral vascular endothelial cells play a crucial role in the pathogenesis of inflammation. In our previous study, we proved that simvastatin could attenuate cerebral vascular endothelial inflammatory response in a rat traumatic brain injury. This purpose of this study was to determine whether simvastatin combined with an antioxidant could produce the same effect or greater and to examine affected surrogate biomarkers for the neuroinflammation after traumatic brain injury in rat. In our study, cortical contusions were induced, and the effect of acute and continuous treatment of simvastatin and vitamin C on behavior and inflammation in adult rats following experimental TBI was evaluated. The results demonstrated that simvastatin combined with an antioxidant could provide neuroprotection and it may be attributed to a dampening of cerebral vascular endothelial inflammatory response.

White matter hyperintensities (WMHs) of presumed vascular origin are common in ageing population, especially in patients with acute cerebral infarction and the volume has been reported to be associated with mental impairment and the risk of hemorrhage from antithrombotic agents. WMHs delineation can be computerized to minimize human bias. However, the presence of cerebral infarcts greatly degrades the accuracy of WMHs detection and thus limits the application of computerized delineation to patients with acute cerebral infarction. We propose a computer-assisted segmentation method to depict WMHs in the presence of cerebral infarcts in combined T1-weighted, fluid attenuation inversion recovery, and diffusion-weighted magnetic resonance imaging (MRI). The proposed method detects WMHs by empirical threshold and atlas information, with subtraction of white matter voxels affected by acute infarction. The method was derived using MRI from 25 hemispheres with WMHs only and 13 hemispheres with both WMHs and cerebral infarcts. Similarity index (SI) and correlation were utilized to assess the agreement between the new automated method and a gold standard visually guided semi-automated method done by an expert rater. The proposed WMHs segmentation approach produced average SI, sensitivity and specificity of 83.142±11.742, 84.154±16.086 and 99.988±0.029% with WMHs only and of 68.826±14.036, 74.381±18.473 and 99.956±0.054% with both WMHs and cerebral infarcts in the derivation cohort. The performance of the proposed method with an external validation cohort was also highly consistent with that of the experienced rater.

Determination of the volumes of acute cerebral infarct in the magnetic resonance imaging harbors prognostic values. However, semiautomatic method of segmentation is time-consuming and with high interrater variability. Using diffusion weighted imaging and apparent diffusion coefficient map from patients with acute infarction in 10 days, we aimed to develop a fully automatic algorithm to measure infarct volume. It includes an unsupervised classification with fuzzy C-means clustering determination of the histographic distribution, defining self-adjusted intensity thresholds. The proposed method attained high agreement with the semiautomatic method, with similarity index 89.9 ± 6.5%, in detecting cerebral infarct lesions from 22 acute stroke patients. We demonstrated the accuracy of the proposed computer-assisted prompt segmentation method, which appeared promising to replace the laborious, time-consuming, and operator-dependent semiautomatic segmentation.

A retrospective analysis of 66 adults with severe head injury admitted to the neurosurgical intensive care unit (ICU) who required tracheostomy.The purpose of this cohort study was to examine the impact of the tracheostomy timing in patients with severe head injury.Patients were included in this study if they were admitted to the neurosurgical ICU because of severe head injury and if tracheostomy was performed. The patients were classified into 2 groups: early tracheostomy (ET) and late tracheostomy (LT). The timing of tracheostomy was considered early if it was performed by day 10 of mechanical ventilation and late if it was performed after day 10. We compared the duration of mechanical ventilation, length of stay (LOS) at ICU, hospital LOS, incidence of pneumonia, duration of antibiotics use, and mortality between the ET and LT groups.Of the 2481 patients with severe head injury admitted to the neurosurgical ICU, 66 (2.7%) required tracheostomy; 16 of whom were in the ET group and 50 were in the LT group. The ICU LOS was significantly shorter in the ET group (p0.001). The incidence of nosocomial pneumonia was lower in the ET group (p=0.04) and the duration of antibiotic use was significantly shorter in the ET group (p0.001). The patients in the ET group had a lower incidence of pneumonia caused by gram-negative microorganisms (p=0.001).ET in patients with severe head injury might contribute to a shorter duration of ICU LOS, lower incidence of gram-negative microorganism-related nosocomial pneumonia, and shorter duration of antibiotic use.

Although serum tau protein levels increase following TBI, the time course is unknown. The aim of the present study was to determine whether serum tau protein levels increased in both a severity-dependent and time-dependent manner in an experimental model of rat traumatic brain injury (TBI).A total of 24 Sprague-Dawley rats were subjected to varying grades of TBI using a contusion injury model on the right parietal cortex. Enzyme-linked Immunoabsorbent Assay (ELISA) analysis for serum was performed at 15 min pre-injury, 1, 6, 24, 48, and 168 h post-injury. Immunoblotting for serum tau protein, neurological evaluation and histological observation were also performed.Tau protein levels rapidly increased after 1 h in both mild and severe TBI groups (p0.001), and declined after 6 h. In the sham-operated group, tau protein levels did not change significantly after TBI. Tau protein levels were severity-dependent at 1 and 6 h after TBI. The levels were higher in the severe TBI group than in the mild TBI group at 1 h (p0.001) and 6 h (p0.001).Serum tau protein levels were severity-dependent and time-dependent at 1 and 6 h after TBI. However, the serum tau protein may not be a useful marker 24 h after TBI.

Study design Case report. Objective To report a rare case of anterior spinal cord syndrome caused by a cement embolism in the anterior spinal artery after vertebroplasty. Summary of background data Vertebroplasty is commonly performed for the management of pain associated with benign compression fractures, multiple myelomas, lymphomas, vertebral metastatic lesions, and hemangiomas. Here, we describe a severe complication associated with this procedure; a similar complication has not been reported previously. Methods A 63-year-old woman suffered from persistent severe back pain that radiated to both sides of the chest wall 1 week before medical consultation. Magnetic resonance imaging analysis of the thoracolumbar spine revealed a pathologic fracture in the body of the T9 and T10 vertebrae, with retropulsion into the spinal canal and compression of the spinal cord at the T10 level. We performed decompressive laminectomy of the T9-10 vertebrae with tumor biopsy and vertebroplasty. Results Immediately after the operation, the patient experienced paraplegia and loss of sensitivity to pain/temperature; however, deep pressure sensation and 2-point discrimination below the umbilicus (T10 level) were preserved. Computed tomography scans showed the presence of PMMA in T9 and T10, with opacification of the paravertebral vessels, the left intercostal artery at the T10 level, and a segment of the anterior spinal artery at the T10-11 level. Conclusion We present the first report describing a case of anterior spinal cord syndrome caused by a cement embolism in the anterior spinal artery after vertebroplasty. The severity of this complication warrants that surgeons should inform patients of the same while obtaining their consent for vertebroplasty.

Background The aim of this study is to assess the efficacy of pulsed RF lesioning of cervical medial branches in patients with whiplash-related chronic cervical zygapophysial joint pain in whom other conservative treatments failed. Methods Cervical zygapophysial joint pain was confirmed in 14 patients undergoing double diagnostic blocks. These patients underwent pulsed RF lesioning of the cervical medial branches. Pulsed RF procedures were performed in 2 cycles of 180 seconds after localization under fluoroscopy guide. Results Twelve (85.7%) patients had substantial pain relief at 1 month. Eleven (78.3%) patients still had more than 60% pain relief at 6 months. Only 5 (35.7%) patients recurred within 12 months. At 12-month follow-up, 9 (64.3%) patients had significant pain improvement. Medication requirements decreased in 13 (92.8%) patients at 1 month, 12 (85.7%) patients at 6 months, and 10 (71.4%) patients at 12 months. Conclusions Pulsed RF of cervical medial branches is a potential treatment for patients with chronic whiplash-related cervical zygapophysial joint pain that failed other conservative treatments. This treatment provides long-lasting pain relief and reduces pain medication requirements.

ObjectThe authors conducted a study to assess the eye lens dosimetry in trigeminal neuralgia (TN) treatment when using the Leksell Gamma Knife model C.MethodsPhantom studies were used to measure the maximal dose reaching the eye lens with and without eye shielding. Six consecutive patients with TN were evaluated for Gamma Knife surgery (GKS). The maximum prescribed dose of 80 Gy was delivered with a single shot using the 4-mm collimator helmet. High-sensitivity thermoluminescence dosimeter chips (TLDCs) were used to measure the dosimetry.In vitro, the Leksell GammaPlan (LGP) system predicted the mean maximal doses of 1.08 ± 0.08 and 0.15 ± 0.01 Gy (mean ± standard deviation) to the lens ipsilateral to the treated trigeminal nerve without and with eye shielding, respectively. The TLDCs-measured dosimetry indicated the mean maximal doses of 1.12 ± 0.09 and 0.17 ± 0.01 Gy without and with eye shielding, respectively. The maximal doses to the lens contralateral to the nerve were similar.In vivo, the LGP predicted the mean maximal doses to the lens ipsilateral to the treated nerve as 1.1 ± 0.07 and 0.16 ± 0.02 Gy, respectively, without and with eye shielding. The dosimetry measured by TLDCs indicated the mean maximal dose to the lens ipsilateral to the treated nerve as 0.17 ± 0.02 Gy with eye shielding. The mean maximal doses to the lens contralateral to the nerve were similar. Using the 110 and 125˚ gamma angles, the LGP predicted the mean maximal doses of 0.32 ± 0.04 and 0.12 ± 0.04 Gy to the lens without and with eye shielding, respectively.Conclusions Patients with TN undergoing GKS without eye shielding may develop cataracts due to the high radiation dose to the eye lenses. The authors suggest the routine use of bilateral eye shielding for the patients.

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

To analyze the prognostic factors and therapeutic outcome of adult patients with isolated symptomatic stenosis of the middle cerebral artery (MCA). Forty-nine patients were retrospectively verified with isolated symptomatic stenosis of the MCA through both magnetic resonance angiogram and transcranial color-coded duplex sonography. Therapeutic outcome at 1 year or more was determined using a modified Barthel index (BI). For the purpose of analysis, the patients were divided into two groups: a good outcome group (BI > or = 12) and a poor outcome group (BI < 12 or recurrent stroke). The association between different therapeutic regimens and the percent free of recurrent stroke after the first event of cerebral infarction was assessed with Kaplan-Meier plots compared by a log-rank test. These patients accounted for 2.8% of all patients with the first event of cerebral infarction during the same period. At follow-up of 1 year or more, 63% had good outcomes whilst the other 37% had poor outcomes. Overall, 26.5% suffered from recurrent strokes during the follow-up period. According to the statistical analysis, the stepwise logistic regression revealed that only the National Institutes of Health Stroke Scale (NIHSS) at the time of admission was independently associated with a poor outcome. Furthermore, Kaplan-Meier analysis showed a significantly higher percentage of patients free of recurrent stroke events amongst those who were treated with warfarin. The NIHSS at the time of admission was a predictor of outcome amongst our patients, and stenosis of the MCA implies the danger of recurrent cerebral events. Our study also demonstrates the efficacy of oral anticoagulants in the secondary prevention in this specific group of patients. Therefore, we look forward to more prospective multicenter investigations in evaluating the efficiency of therapy in the future.

Objective To analyze predictive factors and long-term recovery in patients with Guillain-Barre syndrome (GBS) who are in need of mechanical ventilation. Methods In this 15-year retrospective study, 77 adult patients were identified with GBS. A comparison was made between the clinical data from patients who required mechanical ventilation and those who did not. Furthermore, the therapeutic outcomes of those 25 patients in need of mechanical ventilation during hospitalization at 1 year were determined using a modified Barthel index. A score below 12 was defined as a poor outcome, whereas a score of 12 or more was good. Results The study revealed 32% of patients (25/77) in need of respiratory support during hospitalization. At a follow-up of 1 year among the 25 ventilated patients, 7 patients (28%) had normal or minor signs and symptoms, 6 had unassisted gait, 3 had assisted gait, 6 were wheelchair- or bed-bound, and 3 died. The cause of death was septicemia with septic shock in all 3 cases. Factors that predict respiratory failure in the study GBS patients were disability grade on admission and areflexia. Those ventilated patients who had low maximal inspiratory pressure (PI max ) ( 2 O) and maximal expiratory pressure (PE max ) ( 2 O) values at the time of intubation and the presence of complications after mechanical ventilation inevitably had worse outcomes than those who had not. Conclusion If low values of PI max and PE max at intubation were detected, aggressive respiratory management, which might include tracheostomy to allow more efficient bronchial clearing, and prevention of complications caused by prolonged course of mechanical ventilation are essential to maximize the potential for survival.

The clinical data of 62 adult patients who suffered post-neurosurgical nosocomial bacterial meningitis, retrospectively collected over a 16-year period, were studied. Cases were divided into two groups based on the date of presentation, the first period being 1986-1993 and the second 1994-2001. Fever and progressive consciousness disturbance were the most consistent clinical features - signs that may also be attributed to other postoperative neurosurgical problems. The common pathogens included Staphylococcus aureus, coagulase negative Staphylococcus, Pseudomonas aeruginosa, Escherichia coli, and Acinetobacter baumannii. An increase in polymicrobial infections and multi-antibiotic resistance during the second period was identified. In the first half of the study, mortality was 22%, and in the second half 36%. Adult post-neurosurgical nosocomial bacterial meningitis has become an important clinical problem. The choice of appropriate empirical antibiotics is challenging and must be guided by an awareness of the relative frequency of various pathogens and the increasing incidence of resistant strains. Although high mortality rates may, in part, be related to the primary brain pathology, early diagnosis and the timely use of antibiotics based on antimicrobial susceptibility testing are essential for survival.

The clinical features of 22 adult patients with Streptococcus pneumoniae meningitis, retrospectively collected over a 16-year period, were reviewed. Otopharyngeal infection, haematogenous spread and cranial neurosurgery continue to be the predominant routes of infection. Most patients acquired the infection in the community, and predisposing underlying conditions are common. The proportion of S. pneumoniae meningitis compared to all microorganisms causing meningitis in adults declined dramatically from 17% in the first 8 study years to 4% in the last 8 study years. However, all penicillin-resistant S. pneumoniae strains were found in the second half of the study period, accounting for 25% of these episodes. The overall mortality rates for the first and second halves of the study period were 43% and 63%, respectively. Third-generation cephalosporins were the antibiotics of choice for the treatment of S. pneumoniae meningitis in this study, however, the emergence of resistant strains may create a therapeutic challenge in the future. To avoid treatment failure, early diagnosis, careful monitoring of the clinical course and the choice of appropriate antibiotics according to the in vitro antimicrobial susceptibilities, are necessary.

LUMBAR puncture is usually contraindicated in patients with increased intracranial pressure or space-occupying lesions because lumbar cerebrospinal fluid (CSF) drainage can increase the pressure gradient between the supratentorial and infratentorial compartments and thus result in rapid herniation. 1,2 Some authors have also suggested that epidural anesthesia is dangerous in patients with space-occupying lesions not only because of the risks associated with accidental dural puncture, but also because epidural drug and fluid injection can increase intracranial pressure. 3,4 We present a case of a pregnant woman with an occult brain tumor who received an epidural anesthetic for relief of labor pain, which was complicated by an inadvertent lumbar puncture. Several hours after delivery, she had fatal transtentorial brain herniation.

Chronic subdural hematoma is a subdural hematoma that is older than 3 weeks. Chronic subdural hematoma is predominantly a disease of the elderly and is rare in children. Its common manifestations are altered mental state and focal neurological deficits. We report here a rare case of chronic subdural hematoma in a 9-year-old child due to repeated minor dodgeball head injuries. Although such a case has never been reported in sport, the risk still exists. No altered mental state or focal neurological deficits were observed; the child presented with intermittent severe headache with nausea and vomiting. There was also no evidence of child abuse; however, the history of repeated minor head injuries during playing was significant.