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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.

Cheng-Loong Liang,1,2 Shih-Wei Wang,1,3 Han-Jung Chen,1,2 Yu-Duan Tsai,1,2 Jui-Sheng Chen,1,2 Hao-Kuang Wang,1,2 Kuo-Wei Wang2,4 1Department of Neurosurgery, E-DA Hospital, Kaohsiung, Taiwan; 2School of Medicine, I-Shou University, Kaohsiung, Taiwan; 3Department of Rheumatology, E-DA Hospital, Kaohsiung, Taiwan; 4Department of Neurosurgery, E-Da Cancer Hospital, Kaohsiung, TaiwanCorrespondence: Kuo-Wei Wang Email wang11290713@hotmail.com.twBackground: After proper patient selection, anatomically correct pulsed radiofrequency of the lumbar facet joints provide long-term pain relief in a routine clinical setting. In the study, we performed an analysis of clinical and radiological predictive factors and provide the scientific basis for this promising modality.Methods: The study included 198 patients with lower back pain due to lumbar facet joint disease who underwent medial branch block and pulsed radiofrequency during the period 2015– 2019. According to the improvement in pain score, the patients were divided into good and poor outcome groups. Clinical and radiological data were collected and analyzed.Results: The multivariable analysis revealed the predictive factors, including lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and post lumbar fusion procedures.Conclusion: With the results of this study, we demonstrated that the improved outcome after the surgery was related to lumbar lordosis, lower lumbar lordosis, pelvic tilt, the number of facet joints, old compression fracture with/without vertebroplasty, and the lumbar fusion procedures. Old compression fractures and lumbar fusion would change the radiological factors and cause refractory lumbar facet joint pain.Keywords: lumbar facet joint pain, pulsed radiofrequency, lumbar lordosis, lower lumbar lordosis, pelvic tilt angle, lumbar fusion

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.

Using a database that enabled longitudinal follow-up, we assessed the cost, outcome, complications, and readmission rate of ruptured cerebral aneurysms repaired by surgical clipping and endovascular coiling.This study was a retrospective review of data from a series of patients who underwent surgical clipping or endovascular coiling of ruptured cerebral aneurysms between 1996 and 2013. The medical records and hospital cost data were all examined.A total of 7690 and 1380 cases were treated with clipping and coiling, respectively. Patients treated with clipping had more comorbidities and were older. The average total cost for endovascular coiling was $13,974.3, whereas the average total cost for surgical clipping was $16,581.7. Perioperative (30-day) mortality was 10.7% in patients with coiled aneurysms, compared with 12.6% in those with clipped aneurysms (P = 0.045). After 1 year of follow-up, clipping was associated with a significantly longer length of hospital stay (P0.001) and significantly higher total hospital costs (P0.001).In Taiwan, the total hospital costs for the surgical clipping of cerebral aneurysms were higher than for endovascular coiling, and the surgical results were associated with significant complications. We suggest that the indications for coiling might need to be expanded from the current standards dictated by the guidelines in Taiwan.

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.

This population-based study was designed to estimate and compare the risk of Alzheimer’s disease (AD) between patients with primary Sjögren’s syndrome (SS) and non-SS patients during a 10-year follow-up period. This is a retrospective cohort study. Data were obtained from the Taiwan’s National Health Insurance Research Database. We identified 4463 primary SS patients and 22,315 non-SS patients; patients were matched by sex, age, and the year of index use of health care. Each patient was studied to identify the subsequent manifestation of AD. Cox proportional hazard regression was used to study the subsequent manifestation of AD, and Kaplan-Meier survival curves were used to compare survival probability. During the 10-year follow-up period, 7 primary SS and 13 non-SS patients developed AD. During the 10-year follow-up period, the risk of AD was 2.68-fold higher in the primary SS cohort with an overall adjusted hazard ratio (HR) of 2.69 (95% CI 1.07–6.76), after adjusting for demographics and comorbidities. Within the 10-year period, patients with primary SS showed a 2.69-fold increased risk of developing AD. This risk increases with time, and the relative risk of AD is higher in older patients with primary SS.

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.

Pluchea indica (L.) Less. is a perennial plant known for its versatile uses in traditional medicine. Previous findings have shown that the extracts of Pluchea indica possess significant anti-inflammatory, anti-ulcer and anti-tuberculosis activity. The aim of this study was to demonstrate the anticancer activity of the hexane fraction of P. indica root extract (H-PIRE) in human glioblastoma cells using flow cytometric and western blot analysis. The results shoewd that, H-PIRE suppressed the growth of glioblastoma cells in a dose-dependent manner. H-PIRE treatment markedly decreased the population of cells in S and G2/M phases. The significant upregulation of acidic vesicular organelle (AVO) was detected during H-PIRE treatment. The expression levels of microtubule-associated light chain 3-II (LC3-II) protein, phosphorylated JNK and phosphorylated p38 were significantly increased, confirming the occurrence of autophagy during the process. Finally, the combination treatment of H-PIRE and LY294002, a pan PI3K inhibitor, further decreased cell viability, suggesting an additive anticancer effect. Taken together, our results suggest that H-PIRE suppresses the proliferation of glioblastoma cells by inducing cell cycle arrest and autophagy.

We investigated the impact of serum cholesterol levels on 30-day mortality after ischemic stroke in dialysis patients.From the Taiwan Stroke Registry data, we identified 46,770 ischemic stroke cases, including 1101 dialysis patients and 45,669 nondialysis patients from 2006 to 2013.Overall, the 30-day mortality was 1.46-fold greater in the dialysis group than in the nondialysis group (1.75 versus 1.20 per 1000 person-days). The mortality rates were 1.64, .62, 2.82, and 2.23 per 1000 person-days in dialysis patients with serum total cholesterol levels of 120 mg/dL, 120-159 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively. Compared to dialysis patients with serum total cholesterol levels of 120-159 mg/dL, the corresponding adjusted hazard ratios of mortality were 4.20 (95% confidence interval [CI] = 1.01-17.4), 8.06 (95% CI = 2.02-32.2), and 6.89 (95% CI = 1.59-29.8) for those with cholesterol levels of 120 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively.Dialysis patients with serum total cholesterol levels of ≥160 mg/dL or 120 mg/dL on admission are at an elevated hazard of 30-day mortality after ischemic stroke.

During a spinal cord injury (SCI), mechanical trauma rapidly leads to a blood-spinal cord barrier (BSB) disruption, neural cell damage, axonal damage, and demyelination, followed by a cascade of secondary inflammatory reactions. These inflammatory responses spread the damage to the neural cells and impair the recovery of neurological functions. In the present study, we evaluated the efficacy of simvastatin and a simvastatin-ezetimibe combination therapy in managing the endothelial inflammatory response in an SCI rat model. Adult male Sprague-Dawley rats were group-housed and SCI was induced by using the modified weight-drop method. The animals were divided into 4 groups: (1) sham group, laminectomy only (n=6); (2) no-treatment group, SCI without therapy (n=8); (3) simvastatin group (n=8), and (4) ezetimibe and simvastatin combination therapy group (n=8). A high dose (15 mg/kg) of simvastatin was given to the simvastatin group, and 10 mg/kg simvastatin and 10 mg/kg ezetimibe were given to the combination group. Neurological function was assessed using the Basso, Beattie, and Bresnahan locomotor scale score. Intercellular adhesion molecule-1 (ICAM-1) level was used as an SCI biomarker. ICAM-1 level was the highest at 72 hours after SCI in the no-treament group. The treatment groups showed significant reduction in ICAM-1 levels at 72 hours. The treatment groups, especially the combination treatment group, showed better neurological function scores. Simvastatin and simvastatin- ezetimibe all could improve the neurological function and attenuate the endothelial inflammatory response after spinal cord injury in rat.

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.

OBJECTMultilevel long-segment lumbar fusion poses a high risk for future development of adjacent-segment degeneration (ASD). Creating a dynamic transition zone with an interspinous process device (IPD) proximal to the fusion has recently been applied as a method to reduce the occurrence of ASD. The authors report their experience with the Device for Intervertebral Assisted Motion (DIAM) implanted proximal to multilevel posterior lumbar interbody fusion (PLIF) in reducing the development of proximal ASD.METHODSThis retrospective study reviewed 91 cases involving patients who underwent 2-level (L4–S1), 3-level (L3–S1), or 4-level (L2–S1) PLIF. In Group A (42 cases), the patients received PLIF only, while in Group B (49 cases), an interspinous process device, a DIAM implant, was put at the adjacent level proximal to the PLIF construct. Bone resection at the uppermost segment of the PLIF was equally limited in the 2 groups, with preservation of the upper portion of the spinous process/lamina and the attached supraspinous ligament. Outcome measures included a visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI) for functional impairment. Anteroposterior and lateral flexion/extension radiographs were used to evaluate the fusion status, presence and patterns of ASD, and mobility of the DIAM-implanted segment.RESULTSSolid interbody fusion without implant failure was observed in all cases. Radiographic ASD occurred in 20 (48%) of Group A cases and 3 (6%) of Group B cases (p < 0.001). Among the patients in whom ASD was identified, 9 in Group A and 3 in Group B were symptomatic; of these patients, 3 in Group A and 1 in Group B underwent a second surgery for severe symptomatic ASD. At 24 months after surgery, Group A patients fared worse than Group B, showing higher mean VAS and ODI scores due to symptoms related to ASD. At the final follow-up evaluations, as reoperations had been performed to treat symptomatic ASD in some patients, significant differences no longer existed between the 2 groups. In Group B, flexion/extension mobility at the DIAM-implanted segment was maintained in 35 patients and restricted or lost in 14 patients, 5 of whom had already lost segmental flexion/extension mobility before surgery. No patient in Group B developed ASD at the segment proximal to the DIAM implant.CONCLUSIONSProviding a dynamic transition zone with a DIAM implant placed immediately proximal to a multilevel PLIF construct was associated with a significant reduction in the occurrence of radiographic ASD, compared with PLIF alone. Given the relatively old age and more advanced degeneration in patients undergoing multilevel PLIF, this strategy appears to be effective in lowering the risk of clinical ASD and a second surgery subsequent to PLIF.

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.

summary The severe drought events worldwide have increased the awareness of serious impacts to various social and economic sectors. It is a challenge to make efficient water resources management that optimizes economic and social well-beings under great uncertainty of hydro-meteorology. Artificial intelligence techniques possess an outstanding ability to handle non-linear complex systems. This study proposes a systematical water allocation scheme, which integrates system analysis with artificial intelligence techniques, for decision makers to mitigate drought threats. We first derive evaluation diagrams through a large number of interactive evaluations based on long-term hydrological data to provide a clear perspective of all possible drought conditions and their corresponding water shortages, and then configure neural-fuzzy networks to learning the associations between events and outcomes for estimating water deficiency levels under various hydrological conditions. The adaptive neuro-fuzzy inference system (ANFIS) is adopted to construct the mechanism between designed inputs (water discount rate and the exceedence probabilities of hydrological conditions) and simulated outputs (water deficiency levels). The water allocation in the Shihmen Reservoir watershed of northern Taiwan is used as a case study. The results suggest that the drought thresholds of reservoir storage in the beginning of the first paddy crops can be recommended as: Q50, Q60, Q70 and Q90 for precautionary, preliminary, moderate and severe drought conditions, respectively. The inference system further indicates reservoir storage is identified as the most influential variable that significantly affects water shortage. We demonstrate the proposed water allocation scheme significantly avails water managers of reliably recommending drought thresholds and determining a suitable discount rate on irrigation water supply. This study has direct bearing on more intelligent and effectual water allocation management, which is expected to substantially benefit water managers.

Glioblastoma multiforme (GBM) is a highly malignant brain tumor with limited therapeutic options, and high recurrence and mortality rates. In this study, the anti-tumorigenic properties of luteolin on GBM were examined in vitro. Luteolin was isolated from the whole plant of Glossogyne tenuifolia and the chemical structure was determined by its spectroscopic data. The inhibitory effect of luteolin on the proliferation of GBM 8401 and U87 human glioblastoma cells and the apoptotic effect of this compound on GBM 8401 cells were investigated. Luteolin inhibited the growth of GBM 8401 and U87 cells in a dose- and time-dependent manner. It significantly induced S and G2/M phase cell cycle arrest and apoptotic cell death by decreasing the expression of cyclin-dependent kinase (CDK1), cyclin B1, and anti-apoptotic proteins (Bcl-2, Mcl-1). In addition, luteolin increased the expression of pro-apoptotic proteins (Bid, Bak, Bax, Bad) and activated caspase-3, with a concomitant increased in the levels of cleaved poly-ADP-ribose polymerase (PARP). Moreover, luteolin reduced the cell migration of GBM 8401 cells. Combination treatment of luteolin with 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), an anticancer drug used in clinical GBM treatment, enhanced significantly the cytotoxic effect of BCNU in GBM 8401 cells. These results suggest that luteolin may be a potential candidate for GBM adjuvant therapy.

Event-related desynchronization/synchronization (ERD/ERS) is a technique to quantify subject's nonphase-locked neural activities underlying specific frequency bands, reactive to external/internal stimulus. However, conventional ERD/ERS studies usually utilize fixed frequency band determined from one or few channels to filter whole-head EEG/MEG data, which may inevitably include task-unrelated signals and result in underestimation of reactive oscillatory activities in multichannel studies. In this study, we adopted multivariate empirical mode decomposition (MEMD) to extract beta-related oscillatory activities in performing self-paced right and left index-finger lifting tasks. The MEMD extracts common modes from all channels in same-index intrinsic mode functions (IMFs) which allows the temporal-frequency features among different channels can be compared in each subband. The beta-band oscillatory activities were further bandpass filtered within trial-specific beta bands determined from sensorimotor-related channels (C3 and C4), and then rectified using amplitude modulation method to detect trial-by-trial beta rebound (BR) values in ERS time courses. The validity of the MEMD approach in BR values extraction has been demonstrated in multichannel EEG study which showed larger BR values than conventional ERS technique. The MEMD-based method enables the trial-by-trial extraction of sensorimotor oscillatory activities which might allow the exploration of subtle brain dynamics in future studies.

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.

C2 vertebroplasty is more challenging than transpedicular percutaneous vertebroplasty in the thoracic and lumbar spine.We report an anterior ascending approach for C2 percutaneous vertebroplasty to avoid potential injury to vital structures surrounding the C2 vertebra.A technique note with 5 consecutive cases.Neurosurgery department of a university hospital.Fluoroscopically guided manual compression was applied using 3 fingers at the C5 level between the muscle and trachea. The larynx and trachea were displaced medially and the carotid artery laterally. The anterior cervical spine was palpated, and a 15-gauge 4-inch bone marrow biopsy needle was introduced through an anterior ascending approach. When the tip touched the intervertebral disc between C2 and C3, the needle was pushed through the disc until it penetrated into the C2 vertebral body. After confirming adequate needle insertion, vertebroplasty was performed.Pain relief was achieved in 4/5 (80%) patients. One patient possibly did not benefit from percutaneous vertebroplasty, and asymptomatic cement extravasation was detected in 2 patients.Sample size; impossibility of placebo control.An anterior ascending approach for C2 percutaneous vertebroplasty is a valuable alternative for relieving pain caused by metastatic spinal tumors. This approach is familiar to surgeons performing anterior cervical discectomies, percutaneous nucleoplasty, or odontoid screw placement surgeries.Vertebroplasty, pain, axis, cement leak, metastases, palliative medicine, spine, fracture.

SummaryBackgroundThe efficacy of PRF for lumbar facet joint pain is not well established because comparative studies with other modes of management are sparse.AimThe purpose of this study was to compare the efficacy of conventional radiofrequency (CRF) and pulsed radiofrequency (PRF) denervation in the treatment of lumbar facet joint pain.MethodsLumbar facet joint pain was confirmed in 40 patients undergoing double medial branch blocks. Among them, 16 patients received CRF for pain management and 18 patients were offered PRF. Outcome was assessed before treatment and 3 months and 6 months after treatment. Changes in pain intensity were evaluated using a visual analog scale (VAS). Physical functioning was evaluated using a Revised Oswestry Disability Index (ODI).ResultsIn the CRF group, the VAS scores after treatment were significantly lower than before treatment at 3 months (p

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.

Genetic algorithms (GAs) are well known optimization methods. However, complicated systems with high dimensional variables, such as long-term reservoir operation, usually prevent the methods from reaching optimal solutions. This study proposes a multi-tier interactive genetic algorithm (MIGA) which decomposes a complicated system (long series) into several small-scale sub-systems (sub-series) with GA applied to each sub-system and the multi-tier (key) information mutually interacts among individual sub-systems to find the optimal solution of long-term reservoir operation. To retain the integrity of the original system, over the multi-tier architecture, an operation strategy is designed to concatenate the primary tier and the allocation tiers by providing key information from the primary tier to the allocation tiers when initializing populations in each sub-system. The Shihmen Reservoir in Taiwan is used as a case study. For comparison, three long-term operation results of a sole GA search and a simulation based on the reservoir rule curves are compared with that of MIGA. The results demonstrate that MIGA is far more efficient than the sole GA and can successfully and efficiently increase the possibility of achieving an optimal solution. The improvement rate of fitness values increases more than 25%, and the computation time dramatically decreases 80% in a 20-year long-term operation case. The MIGA with the flexibility of decomposition strategies proposed in this study can be effectively and suitably used in long-term reservoir operation or systems with similar conditions.

Objective. The present study was performed to ascertain whether sacroiliac joint (SIJ) pain represents a potential source of pain in patients who have undergone lumbar or lumbosacral fusions. Design. Prospective cohort study. Patients and Methods. Between June 2007 and June 2009, 130 patients who underwent lumbar or lumbosacral fusions were evaluated for SIJ pain. Fifty-two patients for whom positive findings were obtained on at least three of the provocating tests for SIJ pain were selected to receive dual diagnostic blocks. Outcome Measures. A positive response was defined as characteristic pain reduction of 75% for 1–4 hours following the SIJ blocks. Predictive factors for a positive response to the SIJ blocks were also investigated. Results. Among the 52 patients, 21 were considered to have SIJ pain on the basis of two positive responses to diagnostic blocks. Univariate analysis revealed that the predictive factors related to positive responses were unilateral pain ( P = 0.002), more than three positive responses to provocating maneuvers ( P = 0.02), and postoperative pain with characteristics different from those of preoperative pain ( P = 0.04). Conclusions. SIJ pain is a potential source of pain after lumbar and lumbosacral fusion surgeries. Provocating SIJ maneuvers represent reliable tests for SIJ pain. The characteristics of postoperative SIJ pain frequently differ from those of preoperative pain.

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.

To derive an optimal strategy for reservoir operations to assist the decision-making process, we propose a methodology that incorporates the constrained genetic algorithm (CGA) where the ecological base flow requirements are considered as constraints to water release of reservoir operation when optimizing the 10-day reservoir storage. Furthermore, a number of penalty functions designed for different types of constraints are integrated into reservoir operational objectives to form the fitness function. To validate the applicability of this proposed methodology for reservoir operations, the Shih-Men Reservoir and its downstream water demands are used as a case study. By implementing the proposed CGA in optimizing the operational performance of the Shih-Men Reservoir for the last 20 years, we find this method provides much better performance in terms of a small generalized shortage index (GSI) for human water demands and greater ecological base flows for most of the years than historical operations do. We demonstrate the CGA approach can significantly improve the efficiency and effectiveness of water supply capability to both human and ecological base flow requirements and thus optimize reservoir operations for multiple water users. The CGA can be a powerful tool in searching for the optimal strategy for multi-use reservoir operations in water resources management.

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.

Background Auditory steady-state response (ASSR) induced by repetitive auditory stimulus is commonly used for audiometric testing. ASSR can be measured using electro-encephalography (EEG) and magnetoencephalography (MEG), referred to as steady-state auditory evoked potential (SSAEP) and steady-state auditory evoked field (SSAEF), respectively. However, the signal level of SSAEP and SSAEF are weak so that signal processing technique is required to increase its signal-to-noise ratio. In this study, a complementary ensemble empirical mode decomposition (CEEMD)-based approach is proposed in MEG study and the extraction of SSAEF has been demonstrated in normal subjects and tinnitus patients. Methods The CEEMD utilizes noise assisted data analysis (NADA) approach by adding positive and negative noise to decompose MEG signals into complementary intrinsic mode functions (IMF). Ten subjects (five normal and five tinnitus patients) were studied. The auditory stimulus was designed as 1 kHz carrier frequency with 37 Hz modulation frequency. Two channels in the vicinities of right and left temporal areas were chosen as channel-of-interests (COI) and decomposed into IMFs. The spatial distribution of each IMF was correlated with a pair of left- and right-hemisphere spatial templates, designed from each subject’s N100m responses in pure-tone auditory stimulation. IMFs with spatial distributions highly correlated with spatial templates were identified using K-means and those SSAEF-related IMFs were used to reconstruct noise-suppressed SSAEFs. Results The current strengths estimated from CEEMD processed SSAEF showed neural activities greater or comparable to those processed by conventional filtering method. Both the normal and tinnitus groups showed the phenomenon of right-hemisphere dominance. The mean current strengths of auditory-induced neural activities in tinnitus group were larger than the normal group. Conclusions The present study proposes an effective method for SSAEF extraction. The enhanced SSAEF in tinnitus group echoes the decreased inhibition in tinnitus’s central auditory structures as reported in previous studies.

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.