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Background: Handgrip strength (HGS) testing is a highly recommended method for screening for sarcopenia in older adults. However, there is no consensus on the optimal protocol and number of trials for screening sarcopenia in older adults with cognitive impairment., Objective: To investigate the use of the first trial (FT), the mean of three trials (MT), and the highest value (HT) from three trials of the HGS test to screen for sarcopenia in older adults with cognitive impairment. Additionally, to analyze the consistency, agreement, and measurement error in the diagnosis of muscle weakness., Methods: 176 older adults with cognitive impairment were evaluated. The HGS test was repeated three times. Analyses were performed using the Friedman repeated measures test with Wilcoxon post-hoc, intraclass correlation coefficient (ICC), Standard Error of Measurement (SEM), Minimal Detectable Change (MDC95), and Kappa index tests., Results: There was no significant difference between the first trial (FT) and the mean of three trials (MT) (d = 0.17 [95 % CI: -0.08, 0.42]), but both differed significantly from the highest value (HT) (p < 0.001). The ICC indicated a reliability of 0.97 (95 % CI: 0.95, 0.98) across all participants, while the kappa index demonstrated over 80 % agreement. The SEM for the first measure of HGS ranged from 0.59 to 2.12 kgf. The MDC 95 ranged from 1.64 to 5.87 kgf., Conclusion: For HGS testing, there was excellent consistency between the FM and MT. All three testing methods demonstrated excellent agreement in diagnosing muscle weakness. The measurement errors confirm that FT can be reliably used to monitor changes during rehabilitation., Competing Interests: Conflict of interest The authors declare no conflicts of interest., (Copyright © 2024 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: Central cord syndrome (CCS) is expected to become the most common traumatic spinal cord injury, yet its optimal management remains unclear. This study aimed to evaluate variability in nonoperative vs operative treatment for CCS between trauma centers in the American College of Surgeons Trauma Quality Improvement Program, identify patient- and hospital-level factors associated with treatment, and determine the association of treatment with outcomes., Methods: Adults with CCS were identified from the Trauma Quality Improvement Program database (2014-2016). Mixed-effects modeling with a random intercept for trauma centers was used to examine the adjusted association of patient- and hospital-level variables with nonoperative treatment. The random-effects output of the model assessed the risk-adjusted variability in nonoperative treatment across centers. Outlier hospitals were identified, and the median odds ratio was calculated. The adjusted effect of nonoperative treatment on mortality, morbidity, and hospital length of stay (LOS) was examined at the patient and hospital level by mixed-effects regression., Results: Three thousand, nine hundred twenty-eight patients across 255 centers were eligible; of these, 1523 (38.8%) were treated nonoperatively. Older age, noncommercial insurance (odds ratio [OR] 1.26, 95% CI 1.08-1.48, P = .004), absence of fracture (OR 0.58, 95% CI 0.49-0.68, P < .001), severe head injury (OR 1.41, 95% CI 1.09-1.82, P = .008), and comatose presentation (1.82, 95% CI 1.15-2.89, P = .011) were associated with nonoperative treatment. Twenty-eight hospitals were outliers, and the median odds ratio was 2.02. Patients receiving nonoperative treatment had shorter LOS (mean difference -4.65 days). Nonoperative treatment was associated with lesser in-hospital morbidity (OR 0.49, 95% CI 0.37-0.63, P < .001) at the patient level. There was no difference in mortality., Conclusion: Operative decision-making for CCS is influenced by patient factors. There remains substantial variability between trauma centers not explained by case-mix differences. Nonoperative treatment was associated with shorter hospital LOS and lesser inpatient morbidity., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Challenging lesions, difficult to diagnose through non-invasive methods, constitute an important emotional burden for each patient regarding a still uncertain diagnosis (malignant x benign). In addition, from a therapeutic and prognostic point of view, delay in a definitive diagnosis can lead to worse outcomes. One of the main innovative trends currently is the use of molecular and functional methods to diagnosis. Numerous liver-specific contrast agents have been developed and studied in recent years to improve the performance of liver magnetic resonance imaging (MRI). More recently, one of the contrast agents introduced in clinical practice is gadoxetic acid (gadoxetate disodium)., Aim: To demonstrate the value of the hepatobiliary phases using gadoxetic acid in MRI for the characterization of focal liver lesions (FLL) in clinical practice., Methods: Overall, 302 Lesions were studied in 136 patients who underwent MRI exams using gadoxetic acid for the assessment of FLL. Two radiologists independently reviewed the MRI exams using four stages, and categorized them on a 6-point scale, from 0 (lesion not detected) to 5 (definitely malignant). The stages were: stage 1- images without contrast, stage 2- addition of dynamic phases after contrast (analogous to usual extracellular contrasts), stage 3- addition of hepatobiliary phase after 10 min (HBP 10'), stage 4- hepatobiliary phase after 20 min (HBP 20') in addition to stage 2., Results: The interobserver agreement was high (weighted Kappa coefficient: 0.81- 1) at all stages in the characterization of benign and malignant FLL. The diagnostic weighted accuracy (Az) was 0.80 in stage 1 and was increased to 0.90 in stage 2. Addition of the hepatobiliary phase increased Az to 0.98 in stage 3, which was also 0.98 in stage 4., Conclusion: The hepatobiliary sequences improve diagnostic accuracy. With growing potential in the era of precision medicine, the improvement and dissemination of the method among medical specialties can bring benefits in the management of patients with FLL that are difficult to diagnose., Competing Interests: Conflict-of-interest statement: All authors report no relevant conflicts of interest for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Appropriate dietary recommendations represent a key part of secondary prevention in cardiovascular disease (CVD). We evaluated the effectiveness of the implementation of a nutritional program on quality of diet, cardiovascular events, and death in patients with established CVD., Methods: In this open-label, multicenter trial conducted in 35 sites in Brazil, we randomly assigned (1:1) patients aged 45 years or older to receive either the BALANCE Program (experimental group) or conventional nutrition advice (control group). The BALANCE Program included a unique nutritional education strategy to implement recommendations from guidelines, adapted to the use of affordable and regional foods. Adherence to diet was evaluated by the modified Alternative Healthy Eating Index. The primary end point was a composite of all-cause mortality, cardiovascular death, cardiac arrest, myocardial infarction, stroke, myocardial revascularization, amputation, or hospitalization for unstable angina. Secondary end points included biochemical and anthropometric data, and blood pressure levels., Results: From March 5, 2013, to Abril 7, 2015, a total of 2534 eligible patients were randomly assigned to either the BALANCE Program group (n = 1,266) or the control group (n = 1,268) and were followed up for a median of 3.5 years. In total, 235 (9.3%) participants had been lost to follow-up. After 3 years of follow-up, mean modified Alternative Healthy Eating Index (scale 0-70) was only slightly higher in the BALANCE group versus the control group (26.2 ± 8.4 vs 24.7 ± 8.6, P < .01), mainly due to a 0.5-serving/d greater intake of fruits and of vegetables in the BALANCE group. Primary end point events occurred in 236 participants (18.8%) in the BALANCE group and in 207 participants (16.4%) in the control group (hazard ratio, 1.15; 95% CI 0.95-1.38; P = .15). Secondary end points did not differ between groups after follow-up., Conclusions: The BALANCE Program only slightly improved adherence to a healthy diet in patients with established CVD and had no significant effect on the incidence of cardiovascular events or death., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Osseous- associated cervical spondylomyelopathy (OA-CSM) has a high prevalence in Great Danes. In order to understand the progression of osseous changes, we aimed to perform a long-term computed tomographic (CT) follow-up study of Great Dane dogs with and without OA-CSM. Canine CSM is comparable to a common neurologic disease often diagnosed in older people termed cervical spondylotic myelopathy or degenerative cervical myelopathy, which is progressive in nature. The natural history of cervical spondylotic myelopathy in people has been well described, whereas there is scarce information on the natural history of canine OA-CSM. Our first goal was to evaluate if follow-up CT studies showed any changes compared to initial CT studies in Great Dane dogs with a diagnosis of OA-CSM. Our second goal was to establish whether clinically normal Great Danes went on to develop any vertebral changes or clinical signs consistent with OA-CSM. We enrolled Great Danes diagnosed with OA-CSM and clinically normal Great Danes who had previously participated in a prospective study. All dogs had clinical and CT follow-up evaluations., Results: Twelve Great Dane dogs were investigated: six OA-CSM affected and six clinically normal dogs. The median time between CT studies was 28 months (OA-CSM dogs) and 25 months (normal dogs). On follow-up CT, two OA-CSM-affected dogs developed new sites of stenosis, and two clinically normal dogs developed new sites of stenosis (one each). Disc spaces most commonly affected were C4-C5, C5-C6 and C6-C7. New sites of foraminal stenosis were noted in two of the CSM-affected and four of the clinically normal dogs. Morphometric evaluation showed no statistically significant differences between the initial and follow-up CT studies in the OA-CSM affected or normal groups., Conclusion: Our long-term CT follow-up study documented progression of vertebral canal stenosis in four out of twelve dogs. The majority of dogs did not develop new sites of stenosis or show progression of vertebral lesions.

In light of the scarcity of information about the occurrence and epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (MRCNS) in small ruminants in general, and particularly dairy goats, we launched this limited-scope study. The findings reported here show the detection of MRSA and MRCNS in goat milk and teat skin samples from dairy goat herds in the state of Ohio. A total of 120 milk samples and 120 teat-swab samples were collected from 5 farms. After conventional isolation and phenotypic characterization of the staphylococci colonies, bacterial isolates were tested by PCR assay targeting the genes nuc to identify Staphylococcus aureus and mecA to detect MRSA and MRCNS. The clonal complexes of MRSA isolates was also determined by multiloccus sequence typing. Fifteen (6.2%) positive S. aureus samples were found in this study: 9 from milk and 6 from teat skin samples. Four (2%) MRSA isolates were detected and, using multiloccus sequence typing genotyping, these were designated to clonal complexes CC133 (n = 2; milk samples) and CC5 (n = 2; teat skin). Three (1.25%) coagulase-negative staphylococci isolates from the teat skin also harbored the mecA gene. Although, the MRSA isolated from milk samples is not a typical human-associated lineage, the CC5 clone isolated from teat skin is a common and widespread clonal complex associated with humans, suggesting that this extramammary niche could be a relevant reservoir of methicillin-resistant staphylococci. Furthermore, the fact that 75% of MRSA were recovered from 1 farm showing poor hygiene practices strengthens the hypothesis that good hygiene practices could be useful to prevent persistence and spread of MRSA at a farm level., (Copyright © 2018 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Traumatic subarachnoid hemorrhage is a common radiographic finding associated with traumatic brain injury. The objective of this investigation is to evaluate the association between hospital-level ICU admission practices and clinically important outcomes for patients with isolated traumatic subarachnoid hemorrhage and mild clinical traumatic brain injury., Design: Multicenter observational cohort., Setting: Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program spanning January 2012 to March 2014., Patients: A total of 14,146 subjects, 16 years old and older, admitted to 215 trauma centers with isolated traumatic subarachnoid hemorrhage and Glasgow Coma Scale score 13 or greater. Patients with concurrent intracranial injuries, severe injury to other body regions, or tests positive for alcohol or illicit substances were excluded., Intervention: ICU admission., Measurements and Main Results: The primary outcome was need for neurosurgical intervention, defined as insertion of an intracranial monitor/drain or craniectomy/craniotomy. Secondary outcomes describing the clinical course included hospital discharge disposition, in-hospital mortality, and length of stay. Admission to ICU was common within the cohort (44.6%), yet the need for neurosurgical intervention was rare (0.24%). Variability was high between centers and remained so after adjusting for differences in case-mix and hospital-level characteristics (median odds ratio, 4.1). No significant differences in neurosurgical interventions, mortality, or discharge disposition to home under self-care were observed between groups of the highest and lowest ICU admitting hospitals. However, those in highest admitting group "stayed" in hospital 1.13 (95% CI, 1.07-1.20; p < 0.001) times that of the lowest admitting group., Conclusions: Critical care admission for mild traumatic brain injury patients with isolated traumatic subarachnoid hemorrhage is frequent and highly variable despite low probability of requiring neurosurgical intervention. Reevaluation of hospital-level practices may represent an opportunity for resource optimization when managing patients with mild clinical traumatic brain injury and associated isolated traumatic subarachnoid hemorrhage.

The potential of a bacterial exopolysaccharide named FucoPol, produced by the bacterium Enterobacter A47, as encapsulation matrix was explored. Spherical capsules with a smooth surface were produced by spray drying. The obtained microcapsules had average diameters ranging from 0.5 to 26.7μm and presented thin walls (thickness from 222 to 1094nm). The capsules were loaded with two bioactive compounds: gallic acid (GA) and oregano essential oil (OEO). Both bioactive materials were encapsulated in FucoPol particles, retaining their antioxidant activity after the drying process. Release studies showed that GA release in simulated gastric and intestinal fluids was faster than that of OEO, envisaging that the latter had established stronger interactions with the polymer matrix. These results suggest that FucoPol has a good potential for use as encapsulating material of bioactive compounds for application in several areas, including food, cosmetic or pharmaceutical products., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background Context: Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy., Purpose: This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy., Design/setting: This is a retrospective review of a prospectively collected cohort., Patient Sample: We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN., Outcome Measures: Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes)., Methods: We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes., Results: Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy., Conclusions: Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Staphylococcus aureus is the most common contagious mastitis pathogen affecting cows worldwide. Practices to control this organism have been advocated for decades, and identification of risk factors in individual herds is crucial in prevention and control of Staph. aureus. The objectives of this paper were to estimate prevalence of Staph. aureus in Ohio dairies and to determine a potential association of herd characteristics and management practices with isolation of Staph. aureus in bulk tank milk. A questionnaire about herd characteristics, milking procedures, udder health, mastitis control, and biosecurity practices was mailed to 780 dairy producers; the response rate for the survey was 49%. Staphylococcus aureus prevalence was 48, 64, and 69% when 1, 2, or 3 samples of bulk tank milk from each herd were considered, respectively. Herds practicing prestrip, pre- and postmilking teat dip, and using a single towel per cow as part of the milking routine as well as herds where owners were involved in milking were at significantly reduced odds for detection of Staph. aureus in their bulk tank milk., (Copyright © 2016 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Four common Portuguese rice varieties--Thaibonnet, Gladio, Albatros, and Eurosis--were tested for their relative susceptibility to Sitophilus zeamais Motschulsky, a common pest of stored rice in Portugal and in tropical countries. Physical (moisture content, hardness, length, and width) and chemical (by attenuated total reflection-Fourier transform infrared spectroscopy) properties of rice kernels were measured. Insect bioassays measured median developmental time, Dobie's index of susceptibility, percentage of damaged grains and weight loss, and progeny developed. This was done for paddy, brown rice, and polished rice for each variety. There were small, but significant, differences in insect resistance among the varieties. However, it was different for paddy and polished rice. In paddy, these differences were correlated with hull damage, and Eurosis was the most susceptible variety. In polished rice, resistance was correlated with hardness, and Thaibonnet was the most susceptible variety. In general, paddy rice was more resistant to insect attack, followed by polished rice and then brown rice. Paddy kernels selected with undamaged hull were completely resistant to attack. Implications for IPM and breeding for resistant varieties are discussed., (© The Authors 2015. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

To evaluate p16(INK) (4a) immunoexpression in CIN1 lesions looking for differences between cases that progress to CIN2/3 maintain CIN1 diagnosis, or spontaneously regress. Seventy-four CIN1 biopsies were studied. In the follow-up, a second biopsy was performed and 28.7% showed no lesion (regression), 37.9% maintained CIN1, and 33.4% progressed to CIN2/3. Immunostaining for p16(INK) (4a) was performed in the first biopsy and it was considered positive when there was strong and diffuse staining of the basal and parabasal layers. Pearson's chi-square was used to compare the groups (p ≤ 0.05). The age of the patients was similar. There was no significant difference in p16(INK) (4a) immunoexpression in the groups, however, statistical analyses showed a significant association when only the progression and regression groups were compared (p = 0.042). Considering p16(INK) (4a) positivity and the progression to CIN2/3, the sensitivity, specificity, positive, and negative predictive values in our cohort were 45%, 75%, 47%, and 94%, respectively. We emphasize that CIN1 with p16(INK) (4a) staining was associated with lesion progression, but the sensitivity was not high. However, the negative predictive value was more reliable (94%) and p16(INK) (4a) may represent a useful biomarker that can identify CIN1 lesions that need particular attention, complementing morphology., (© 2014 APMIS. Published by John Wiley & Sons Ltd.)

The objective of this study was to assess the role of teat skin colonization in Staphylococcus aureus intramammary infections (IMI) by evaluating genetic relatedness of Staph. aureus isolates from milk and teat skin of dairy cows using pulsed-field gel electrophoresis and characterizing the isolates based on the carriage of virulence genes. Cows in 4 known Staph. aureus-positive herds were sampled and Staph. aureus was detected in 43 quarters of 20 cows, with 10 quarters positive in both milk and skin (20 isolates), 18 positive only in milk, and 15 only on teat skin. Quarters with teat skin colonized with Staph. aureus were 4.5 times more likely to be diagnosed with Staph. aureus IMI than quarters not colonized on teat skin. Three main clusters were identified by pulsed-field gel electrophoresis using a cutoff of 80% similarity. All 3 clusters included both milk and skin isolates. The majority of isolates (72%) belonged to one predominant cluster (B), with 60% of isolates in the cluster originating from milk and 40% from teat skin. Genotypic variability was observed within 10 pairs (formed by isolates originating from milk and teat skin of the same quarter), where isolates in 5 out of the 10 pairs belonged to the same cluster. Forty-two virulence factors were screened using PCR. Some virulence factors were carried more frequently by teat skin isolates than by milk isolates or isolates from quarters with high somatic cell counts. Isolates in the predominant cluster B carried virulence factors clfA and clfB significantly more often than isolates in the minor clusters, which may have assisted them in becoming predominant in the herds. The present findings suggest that teat skin colonization with Staph. aureus can be an important factor involved in Staph. aureus IMI., (Copyright © 2014 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Unexplained post-procedural events such as cerebral edema, inflammation, aseptic meningitis and hydrocephalus have been reported following unruptured cerebral aneurysm coiling. However, understanding of the etiology for these occurrences is limited due to their rare occurrence. A multicenter registry was developed to investigate further the occurrence of these events., Method: This registry consisted of a retrospective analysis of unruptured aneurysms treated with hydrocoil that evolved to develop focal cerebral edema, inflammation, aseptic meningitis, or ventricular enlargement/hydrocephalus following uncomplicated coil embolization. Data points included pre, intra, and postoperative imaging, patient demographics, aneurysm demographics, procedural details such as coils used, medications administered, and intraprocedural complications, and all post-procedure follow-up including clinical status of the patients and all adverse events., Results: Twenty-five patients (26 aneurysm coiling procedures) were found at 12 centers over an 8-year period. The mean aneurysm size was 13.7 mm. The average time from treatment to onset of symptoms was 8.5 months (2 weeks to 30 months, median 6 months). Delayed hydrocephalus was the most common clinical presentation. Six of the 25 patients were asymptomatic and did not require treatment., Conclusion: Patients undergoing endovascular coiling may be at risk of developing delayed complications, which may or may not be symptomatic. This risk appeared low and was restricted mostly to larger aneurysms. These events can be difficult to detect due to delayed presentation.

Purpose: Vertebral compression fractures (VCFs) are increasingly observed after spine stereotactic body radiation therapy (SBRT). The aim of this study was to determine the risk of VCF after spine SBRT and identify clinical and dosimetric factors predictive for VCF. The analysis incorporated the recently described Spinal Instability Neoplastic Score (SINS) criteria., Methods and Materials: The primary endpoint of this study was the development of a de novo VCF (ie, new endplate fracture or collapse deformity) or fracture progression based on an existing fracture at the site of treatment after SBRT. We retrospectively scored 167 spinal segments in 90 patients treated with spine SBRT according to each of the 6 SINS criteria. We also evaluated the presence of paraspinal extension, prior radiation, various dosimetric parameters including dose per fraction (≥20 Gy vs <20 Gy), age, and histology., Results: The median follow-up was 7.4 months. We identified 19 fractures (11%): 12 de novo fractures (63%) and 7 cases of fracture progression (37%). The mean time to fracture after SBRT was 3.3 months (range, 0.5-21.6 months). The 1-year fracture-free probability was 87.3%. Multivariate analysis confirmed that alignment (P=.0003), lytic lesions (P=.007), lung (P=.03) and hepatocellular (P<.0001) primary histologies, and dose per fraction of 20 Gy or greater (P=.004) were significant predictors of VCF., Conclusions: The presence of kyphotic/scoliotic deformity and the presence of lytic tumor were the only predictive factors of VCF based on the original 6 SINS criteria. We also report that patients with lung and hepatocellular tumors and treatment with SBRT of 20 Gy or greater in a single fraction are at a higher risk of VCF., (Published by Elsevier Inc.)

Background and Purpose: Venous malformations are the most common of all vascular anomalies, 40% of which are found in the head and neck. We discuss results of percutaneous sclerotherapy using bleomycin for facial VMs by using subjective clinical assessment and objective changes on MR imaging., Materials and Methods: Thirty-seven patients with facial VMs were treated by percutaneous sclerotherapy with bleomycin. Of these, 31 patients with 32 lesions had pre- and posttreatment MR imaging. Each lesion received between 1 and 9 sclerotherapy sessions (average, 3.5). MR findings and clinical results of treatment were retrospectively reviewed. Clinical results were based on the physician's physical examination and interview of the patient; these were classified as worse, unchanged, or better. Objective results on MR imaging were classified as worse, no change, minor improvement (<50% decrease in size), marked improvement (>or=50% decrease), or cure. Objective and subjective results were compared., Results: Twenty-one lesions showed objective improvement on MR imaging. Of these, 10 showed minor decrease in size and 11 showed marked decrease. Eleven lesions showed no change on MR imaging. No VMs were worse or completely cured. Subjectively, 29 patients and 30 clinicians thought that lesions improved. Four of 32 (12.5%) patients suffered minor transient complications., Conclusions: Percutaneous sclerotherapy by using bleomycin is a safe technique to objectively decrease size and subjectively alleviate symptoms of facial VMs. Subjective clinical improvement is not always associated with visual size reduction on MR imaging. Minimal size reduction or partial fibrosis of the lesion may be enough to achieve subjective clinical improvement.

Objective: Dural arteriovenous fistulae (DAVF) of the hypoglossal canal region are rare lesions. We describe three cases of DAVF of the hypoglossal canal presenting with ocular symptoms and discuss the endovascular management options., Methods: Three consecutive patients with DAVF of the hypoglossal canal region presented with proptosis, chemosis and disturbances of extra-ocular mobility. Each patient was treated using a different endovascular approach, based on variations of the vascular access., Results: The cases and treatments are reviewed, with a literature review on the subject. Endovascular treatment, transvenous or trans-arterial was curative in all cases., Conclusion: DAVF of the hypoglossal canal region can present with ocular manifestations very similar to DAVF of the cavernous sinus or carotid-cavernous fistulas. Endovascular treatment is usually feasible and effective, but an understanding of the vascular anatomy and pathophysiology of the disease are of utmost importance when planning the approach.

Object: The purpose of this study was to evaluate the authors' initial experience with the integration of high-resolution rotational and biplanar angiography during neurovascular operative procedures., Methods: Eight patients with intracerebral arteriovenous malformations (AVMs) and aneurysms underwent surgical treatment of their lesions in a combined endovascular surgical suite. After initial head positioning, preoperative biplane and rotational angiography was performed. Resection of the AVM or clipping of the aneurysm was then performed. Further biplane and rotational 3D angiograms were obtained intraoperatively to confirm satisfactory treatment., Results: One small residual AVM identified intraoperatively necessitated further resection. One aneurysm was clipped during endovascular inflation of an intracarotid balloon for temporary proximal control. The completeness of treatment was confirmed on intraoperative 3D rotational angiography in all cases, and there were no procedure-related complications., Conclusions: Intraoperative rotational angiography performed in an integrated biplane angiography/surgery suite is a safe and useful adjunct to surgery and may enable combining endovascular and surgical procedures for the treatment of complex vascular lesions.

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.

Objective: The presence of cortical venous reflux is recognized as an indicator of increased risk of intracranial hemorrhage and neurological deficits in cranial dural arteriovenous fistulas. Its disconnection is well accepted as a treatment for fistulas with direct cortical reflux (Borden type III), but the role of disconnection of the cortical venous reflux in the management of fistulas that involve the venous sinus and cortical venous reflux (Borden type II) is still a matter of debate. We analyze the experience of the Toronto Brain Vascular Malformation Study Group in the management of these lesions by simple cortical venous reflux disconnection and its impact in the future risk of bleeding., Methods: From June 1984 to August 2004, 347 patients with dural arteriovenous fistulas, either cranial or spinal, were evaluated by the group. Fifty-three patients had a Borden type II dural arteriovenous fistulas. Twenty-five patients were submitted to simple surgical disconnection of the dural arteriovenous fistulas, two were lost for follow-up. There were 15 females and 8 males, with mean age at diagnosis of 53.9 years. Follow-up time was 112.6 patient-years, from 2 months to 11 years, mean 4.9 years. Endovascular treatment was attempted in all patients, but no disconnection was possible. Twelve patients had their fistulas completely occluded by endovascular means, but are not analyzed here. There were four complications from the 93 endovascular procedures, and 3 from the 27 surgical procedures. Two patients required a repeated surgical procedure. No episode of intracranial hemorrhage or worsening neurological deficit was seen after disconnection of the cortical venous reflux in 4.9 years of follow-up., Conclusion: Simple surgical disconnection of the cortical venous reflux maybe an option in the management of patients with Borden type II dural arteriovenous fistulas. This procedure is a much smaller surgical undertaking and is associated with fewer complications than attempts to resect or pack the whole fistula, especially if located in the skull base.

Study Design: Case report., Objective: To report a case of very delayed repeated meningitis after surgical treatment of scoliosis., Summary of Background Data: Delayed infection after spine surgery is a well-reported phenomenon, presenting usually with local wound symptoms and back pain. The occurrence of meningitis after spinal instrumentation is reported but not common. Delayed repeated episodes of meningitis after surgical treatment of scoliosis have never been reported., Case Report: We report a case of a 44-year-old gentleman, submitted to surgical treatment of scoliosis years ago, who presented with repeated episodes of meningitis due to the formation of an abnormal communication between an infected cyst in the bone cavity where the rods were located and the intradural space in the lumbar spine. Computerized tomography and magnetic resonance imaging revealed the presence of a bone cyst with thickened layering, and surgical exploration revealed the communication between this cystic cavity and the intradural space. After surgical closure of the dural space and cleaning of the cyst, the patient responded well to antibiotic therapy and was free of new episodes of meningitis up to the last follow-up, 1 year after the surgical treatment. Clinical diagnosis of delayed postoperative infection in spine surgery may be difficult if no wound signs are present. Clinical symptoms vary and may include increased back pain, wound redness, swelling and drainage, elevated erythrocyte sedimentation rate and white blood count, fever, and malaise., Conclusions: Delayed meningitis can be a late complication of spinal instrumentation for scoliosis. A high index of suspicion is necessary.

The association between the formation of intracranial aneurysms and situations of increased blood flow in certain areas of the brain is well accepted today. It has been seen in association with arteriovenous malformations of the brain, carotid occlusion, and Moyamoya disease. The occurrence of aneurysms in small arteries of the skull base, with the exception of the intracavernous carotid artery, however, is rare. We report a case of a 55-year-old woman who presented with an intracerebral hemorrhage caused by a ruptured anterior ethmoidal artery aneurysm. To the best of our knowledge, this is only the second case of documented intracranial bleeding from such a lesion.

Posterior fossa ischemia is not a very frequent situation. It is responsible for about 25% of all ischemic strokes, and the vast majority of the cases are related to atherosclerotic stenosis of the vertebral and/or basilar arteries. Acute ischemia can also occur in the setting of vertebral artery dissection, traumatic or spontaneous. Recently, blunt trauma has been increasingly recognized as a cause for craniocervical artery injury. The management options for both traumatic and atherosclerotic lesions of the posterior fossa are still under debate. We present a case of a delayed onset of hemodynamic ischemic symptoms due to bilateral vertebral artery occlusion probably related to remote trauma to the head and neck in a 55-year-old-man treated successfully with extracranial to intracranial bypass.

The embolization of missiles to the intracranial circulation is a rare event. We describe here a case of a man shot by a shotgun, presenting with a posterior fossa stroke and occlusion of the superior cerebellar artery by a metallic pellet. To our knowledge, this is the third case of posterior fossa circulation pellet emboli.

Aneurysmal subarachnoid hemorrhage (SAH) carries a grim prognosis, with high mortality and morbidity rates. The mortality rate in the first 30 days postrupture is estimated to be in the range of 40 to 50%, and almost half of the survivors will be left with a neurological deficit. Unlike patients with aneurysmal SAH, those with unruptured intracranial aneurysms usually experience no neurological deficit, and their treatment is prophylactic, aiming to reduce the risk of future bleeding and its consequences. The risk of rupture therefore assumes special importance when making decisions regarding which patient or aneurysm to treat. In previous reports the risk of bleeding for unruptured aneurysms has been stated as approximately 2% per year. The retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) reported very low annual bleeding rates (0.05-1%) and high surgical morbidity and mortality rates (8-18%), prompting discussion in which the benefits of prophylactic treatment in the majority of these lesions were questioned. Prospective data from the second part of the ISUIA recently included rupture rates ranging from 0 to 10% per year. The aim of this paper was to review the evidence that is currently available for neurosurgeons to use when making decisions regarding patients who would benefit from treatment of an unruptured intracranial aneurysm.

Extradural hematoma (EDH) is a frequent lesion, with an incidence varying from 0.2 to 6% in patients admitted to hospital due to traumatic head injury. The higher incidence is found in patients with more severe injuries. The association of EDH with subperiosteal intraorbital hematomas is rarely reported, and we were not able to find in the literature any report of traumatic bilateral intraorbital hematomas and EDH. We report this case of a 32 year-old man with bilateral intraorbital (subperiosteal) hematoma associated with unilateral EDH. The lesions were treated surgically, but unfortunately with an unfavorable outcome.

Hemangioblastomas of the spinal cord are rare lesions, and those located at the cauda equina are even rarer. Most commonly these tumors are present in patients with von Hippel-Lindau (VHL) syndrome. We describe here the case of a 48 years old woman with a pure radicular hemangioblastoma, not associated with VHL, presenting with radicular pain, diagnosed with magnetic ressonance imaging (MRI) and submitted to total resection with a very good outcome. To our knownledge, this is the second report to describe the MRI aspect of histologically proved hemangioblastoma of the cauda equina in a patient without clinical criteria for VHL.

Meningiomas represent aproximatelly 30% of all intracranial tumors in autopsy studies. With an incidence of 2.3 per 100000, they are considered commom tumors in clinical practice. Twenty percent of the all intracranial tumors diagnosed in vivo are meningiomas. Most of these lesions are benign and the prognosis is intimatelly related to acessibility and ressectability of the lesion. Malignant meningiomas are rare lesions, representing between 1 to 11% of all meningiomas, varying with the definition of pathological criteria for malignancy used, and are categorized in atypical or malignant. Only recently rhabdoid transformation of meningiomas have been reported. We present a case of an extremelly aggressive rhabdoid meningioma in a 56 year-old woman. The tumor was surgically removed twice, with a lethal outcome due to local recurrence, despite maximum radiation and quimiotherapy, six months after the initial presentation.