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Objective To assess the predictive value of swab cultures of cryopreserved skull flaps during cranioplasties for surgical site infections (SSIs). Methods A retrospective review was conducted of consecutive patients who underwent delayed cranioplasties with cryopreserved autografts between 2009 and 2017. The results of cultures obtained from swabs and infected surgical sites were assessed. The accuracy, sensitivity, and specificity of swab cultures for SSIs were evaluated. Results The study included 422 patients categorized into two groups, swab and nonswab, depending on whether swab cultures were implemented during cranioplasties. The overall infection rate was 7.58%. No difference was seen in infection rates between groups. There were 18 false-positive and no true-positive swab culture results. All bacteria between swab cultures and SSI cultures were discordant. Meanwhile, there were 19 false-negative swab cultures. The results showed high specificity but low sensitivity for swab cultures to predict SSI occurrence and the pathogens. Conclusions Owing to low accuracy and sensitivity, swab cultures of cryopreserved autografts should not be routinely performed during delayed cranioplasties.

Laparoscopic ventriculoperitoneal shunt surgery has been reported to have several advantages in selected patients. However, the prognostic factors have been understudied specifically for this surgery. We sought to investigate the factors influencing the complications after the laparoscopic ventriculoperitoneal shunt placement.All surgeries in this prospective study were performed by the same team of neurosurgeons and general surgeons. Clinical parameters as well as potential risk factors for postoperative complications were analyzed. The endpoint was overall complications requiring surgical revision within the follow-up period after surgery.Ninety-nine patients (51 male and 48 female) scheduled for laparoscopic-assisted ventriculoperitoneal shunt surgery between 2019 and 2021 were included. Overall shunt complication rate was 9% (9 of 99 cases), and there was 1 patient (1%) who had distal dysfunction among them. Body mass index ≥27 kg/mVentriculoperitoneal shunt surgery provided benefits with little complication rate, whereas patients treated with nonprogrammable shunts and obese patients had less favorable outcome. A positive correlation between the vertical distance from the distal tip to the bottom of peritoneal cavity and pressure adjustments inferred to the advantage of the laparoscopic method.

Application of radiosurgery to the newly diagnosed or post-operative residual perioptic lesions has been proved to improve tumor control. However, risk of vision injury induced by radiosurgery may increase substantially if the radiation dose is too high or tumor is close to the optic apparatus. The purpose of this study was to evaluate the safety and the effectiveness of fractionated stereotactic radiosurgery (FSRS) for perioptic tumors. We retrospectively analyzed 60 consecutive patients with 53 meningiomas and 7 schwannomas treated with FSRS between October 2007 and February 2020. We administered a marginal dose of 6–7 Gy (mean 6.8 Gy) per fraction and delivered 3 fractions in 3 consecutive days. The median tumor volume was 6.31 cm3 (range 0.3–58.23 cm3). The mean minimum lesion-optic distance (MLOD) is 0.85 mm (range 0–3 mm). After mean follow-up period of 69.6 months (range 6.82–156.32 months; median 58.9 months), the tumor control rates at 1, 3, 5, 8 and 13 years were 98.3%, 93.4%, 90.60%, 88.4% and 88.4%, respectively. Four out of the 60 tumors (6.7%) experienced a transient volume increase after FSRS. None of the patients developed visual impairment related to radiation induced optic neuropathy (RION) after FSRS. In conclusion, FSRS offers an alternative treatment option in treating perioptic meningiomas and schwannomas with acceptable tumor control rates and good visual preservation in the present study.

Initial tumor enlargement (or pseudoprogression) instead of true tumor progression is a common phenomenon in patients with acoustic neuromas who are treated with stereotactic radiosurgery (SRS). This phenomenon can affect clinical decision-making and patient management. This study assessed the correlation between initial tumor enlargement and magnetic resonance imaging characteristics in patients with acoustic neuromas who were treated with linear accelerator (LINAC)-based SRS. The long-term tumor control outcomes were also analyzed.In total, 330 patients with sporadic acoustic neuromas who were treated with LINAC SRS between March 2006 and March 2020 were retrospectively evaluated to assess their initial tumor enlargement. The tumors were divided into homogeneously enhanced, heterogeneously enhanced, and cystic types based on the morphological characteristics noted on magnetic resonance images. Tumor control was assessed in 275 patients with a follow-up duration of more than 2 years.Initial enlargement was observed in 137 of 330 (41.5%) tumors as early as 3 months after LINAC SRS. Data analysis revealed that postoperative tumors with a residual volume lower than 2.5 cmInitial enlargement can occur as early as 3 months after SRS. Postoperative residual tumors with a volume lower than 2.5 cm

Background Cases of acute sphenoid sinusitis complicated by septic cavernous sinus (CS) thrombosis and internal carotid artery (ICA) stenosis are rarely reported. Different causative pathogens have been reported for this condition. We present two extremely rare and special cases with diverse clinical presentations and outcomes. Case 1 involved a female patient with less extensive sinusitis, but critical ICA occlusion. Case 2 involved a male patient with extensive pansinusitis, meningitis, cerebritis, and vasculitis due to fungal infection, but less stenosis of the ICA lumen. Both patients underwent surgical debridement and received broad-spectrum antibiotics. Additional anti-fungal medication was also administered in Case 2. However, outcomes differed considerably between cases. Discussion Case 1 recovered with minimal neurological deficits and had Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores of 5 and 2, respectively; however, the Case 2 had GOS and mRS scores of 3 and 4, respectively. Although rare, septic CS thrombosis with ICA stenosis can lead to unexpected and severe neurological sequelae. Fungal infection can result in catastrophic complications and poorer prognosis. Conclusion In addition to early detection, aggressive surgical debridement and adequate antimicrobial treatment are crucial to satisfactory outcomes in patients with septic CS thrombosis complicated with ICA stenosis.

Background The aim of this study was to assess the relationship between the atlantodental interval (ADI) on dynamic flexion/extension cervical radiographs and functional outcomes of posterior spinal fixation by the Harms technique for atlantoaxial subluxation (AAS).Dynamic flexion/extension on cervical radiographs is a standard assessment for evaluation of C1/2 instability in AAS patients. Most studies focused on postoperative ADI and functional outcome, including pain and fusion rate; only few studies compared dynamic ADI change pre- to post-operatively. Material and methods Retrospectively, we reviewed the medical records of 16 patients who underwent posterior spinal fixation in our center from 2018 to 2019. We used dynamic cervical flexion/extension radiographs to assess the pre- to postoperative change at 12 months in ADI of flexion (ADIf), ADI of extension (ADIe), ADI between flexion/extension (ADIΔ), C1/2 fusion rate and functional outcomes measured by the modified Japanese Orthopaedic Association scale (mJOA scale). Postoperative CT at 3∼12 months assessed screw positioning on the Gertzbein and Robbins classification. Results In the 16 patients included in this study, ADIf, ADIe and ADIΔ were significantly reduced, from respectively 8.0mm, 5.0mm and 3.0mm preoperatively to 4.6mm, 3.8mm and 0.8mm at 12 months' follow-up. The fusion rate was 81% and the mJOA score recovery rate was 34.9±14.7%. Although the screw malposition rate was higher than in other studies in C1(10%) and C2(20%), there were no new neurologic deficits or worsening of symptoms at follow-up. Conclusions The ADIΔ showed significant reduction, showing that the Harms technique of posterior spinal fixation can effective in maintaining the stability of the atlantoaxial joint and improving functional outcome.

Most mild traumatic brain injuries (TBIs) can be treated conservatively. However, some patients deteriorate during observation. Therefore, we tried to evaluate the characteristics of deterioration and requirement for further management in mild TBI patients. From 1/1/2017 to 12/31/2017, patients with mild TBI and positive results on CT scans of the brain were retrospectively studied. Patients with and without neurological deteriorations were compared. The characteristics of mild TBI patients with further neurological deterioration or the requirement for interventions were delineated. One hundred ninety-two patients were enrolled. Twenty-three (12.0%) had neurological deteriorations. The proportions of deterioration occurring within 24 h, 48 h and 72 h were 23.5, 41.2 and 58%, respectively. Deteriorated patients were significantly older than those without neurological deteriorations (69.7 vs. 60.2; p = 0.020). More associated extracranial injuries were observed in deteriorated patients [injury severity score (ISS): 20.2 vs. 15.9; p = 0.005). Significantly higher proportions of intraventricular hemorrhage (8.7 vs. 1.2%; p = 0.018) and multiple lesions (78.3 vs. 53.8%; p = 0.027) were observed on the CT scans of patients with neurological deteriorations. Subset analysis showed that deteriorated patients who required neurosurgical interventions (N = 7) had significantly more initial GCS defects (13 or 14) (71.4 vs. 12.5%; p = 0.005) and more initial decreased muscle power of extremities (85.7 vs. 18.8%; p = 0.002). More attention should be given to mild TBI patients with older age, GCS defects, decreased muscle power of the extremities, multiple lesions on CT scans and other systemic injuries (high ISS). Most deteriorations occur within 72 h after trauma.

Gene delivery is an indispensable technique for various biomedical applications such as gene therapy, stem cell engineering and gene editing. Recently, magnetic nanoparticles (MNPs) have received increasing attention for their use in promoting gene delivery efficiency. Under magnetic attraction, gene delivery efficiency using viral or nonviral gene carriers could be universally enhanced. Besides, magnetic nanoparticles could be utilized in magnetic resonance imaging or magnetic hyperthermia therapy, providing extra theranostic opportunities. In this review, recent research integrating MNPs with a viral or nonviral gene vector is summarized from both technical and application perspectives. Applications of MNPs in cutting-edge research technologies, such as biomimetic cell membrane nano-gene carriers, exosome-based gene delivery, cell-based drug delivery systems or CRISPR/Cas9 gene editing, are also discussed.

With the improvement of internet technology in health applications, the utilization of internet and social media as new survey methodologies and recruitment source for research participants have been encouraged, yet evidence of the feasibility in people living with HIV (PLHIV) study is still lacking. We conducted a cross-sectional survey to determine whether there are differences among PLHIV recruited from social media networks and health-care systems using an HIV stigma and discrimination questionnaire. The result revealed that PLHIV recruited from social media networks were younger, more sexually active, and had higher educational status and awareness of the country's HIV rights protection laws than those recruited from hospitals. By contrast, participants recruited from hospitals were more diverse regarding key population compositions, had lived with HIV for a longer duration, had a higher prevalence of concomitant physical disabilities than those recruited from social media networks, and fit Taiwan PLHIV characteristics described by 2016 census from Taiwan Centres for Disease Control. We conclude that sampling bias exists when utilizing social media networks for PLHIV studies.

There is conflicting results on whether prior antiplatelet therapy (APT) is associated with poor outcome in spontaneous intracerebral haemorrhage (ICH) patients. To determine whether prior APT is associated with spontaneous ICH, and whether there is a difference between the different types of APT, including cyclooxygenase inhibitor (COX-I), adenosine diphosphate receptor inhibitor (ADP-I) and phosphodiesterase inhibitor (PDE-I). A retrospective study of patients with ICH diagnosed between 2001 and 2013 in the National Health Insurance Research Database. Baseline unbalance between APT and non-APT groups was solved by multivariable adjustment (primary analysis) and propensity score matching (sensitivity analysis). Patients with prior APT had a higher rate of in-hospital death (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.09-1.23) compared to non-APT group. Compared to non-APT group, there was a greater rate of in-hospital death with spontaneous ICH with ADP-I (OR, 1.49; 95% CI, 1.24-1.79) and COX-I (OR, 1.17; 95% CI, 1.09-1.25). PDE-I exhibited no difference in in-hospital death with spontaneous ICH (OR, 1.03; 95% CI, 0.91-1.16) compared to non-APT group. Remarkably, the in-hospital mortality rate was significantly higher in the ADP-I group than in the PDE-I group (hazard ratio, 1.45; 95% CI, 1.17-1.80). In this study, ADP-I and COX-1, but not PDE-I, are the most likely contributors to the association of APT with poor outcome with spontaneous ICH patients. These findings suggest that the complexity of the different mechanism of actions of prior APT can alter the outcome in spontaneous ICH.

Objective The impact of antithrombotic agents on patients with primary intracerebral hemorrhage (ICH) remains controversial, especially patients who require emergent craniotomy. This study was undertaken to evaluate clinical outcomes in operated patients with ICH with and without previous antithrombotic agents. Methods This is a retrospective cohort study. Between January 2001 and December 2013, all patients with ICH who received emergent craniotomy and who were present in Taiwan's National Health Insurance Research Database were screened and divided into those with previous antiplatelet therapy, anticoagulant therapy, and nonantithrombotic therapy according to their health care claims data within 3 months of index admission. The primary end points included in-hospital mortality and complications and short-term outcome. Results Of 18,872 eligible patients, 16,251 (87.1%) did not receive any antithrombotic therapy, 2267 patients had antiplatelet therapy, and 354 patients had anticoagulation therapy. After propensity score matching, significantly more blood transfusions and craniectomies were identified in the patients with previous antithrombotic treatment compared with those undergoing nonantithrombotic therapy. Compared with the nonantithrombotic treatment cohort, patients under previous anticoagulant treatment had significantly higher in-hospital mortality (odds ratio, 2.12; 95% confidence interval, 1.45–3.10). Furthermore, during the 6-month follow-up period, previous anticoagulant therapy was independently associated with a greater risk of all-cause mortality (P = 0.001). The in-hospital and 6-month all-cause mortality of patients with previous antiplatelet treatment was not significantly different from patients with nonantithrombotic treatment. Conclusions These findings suggested an increased risk of in-hospital mortality and poor short-term outcome among operated patients with ICH with previous antithrombotic therapy, particularly anticoagulant therapy, but not with antiplatelet therapy.

Background Cranioplasty is a relatively simple and straightforward intervention; however, it is associated with a high incidence of postoperative seizures. Postcranioplasty seizures, especially early seizures, are common and associated with poor outcomes and longer hospital stays. Protocols for preventing and managing early seizures have not been well established. Methods The medical records of 595 patients who underwent cranioplasty were retrospectively reviewed. Of these patients, 259 had preexisting seizures and 336 had no seizures before cranioplasty. Prophylactic antiepileptic drugs (AEDs) were administered to patients who had no seizures before cranioplasty for 1 week, whereas an advanced AED regimen was administered to patients with preexisting seizures. Subsequently, clinical characteristics, occurrence of recurrent seizures, early seizures, and postoperative complications were analyzed. Results Our previous study showed positive results for prophylaxis in new-onset early seizures. In the patients with preexisting seizures, 46.7% of the patients (121/259) experienced recurrent seizures after cranioplasty and 17.4% of the patients (45/259) experienced early recurrent seizures within 1 week of their operation. In the group who received the advanced AEDs, early recurrent seizures were significantly reduced to 8.7% compared with the regular group (20.5%; P = 0.027). Younger age and preoperative hydrocephalus engendered a higher risk of recurrent seizures. The number of previous craniotomies was observed to have a trend of increasing early recurrent seizures. Conclusions Cranioplasty is associated with a high incidence of postoperative seizures. Our management protocol for postcranioplasty seizures includes seizure prophylaxis and advanced use of AEDs, which can reduce the occurrence of early seizures.

Introduction: The purpose of this study is to determine the success and complication rates of linear accelerator (LINAC)-based radiosurgery (X-knife) for indirect carotid-cavernous fistulas (CCFs). Materials and Methods: This retrospective study was performed at the Department of Radiosurgery, Chang Gung Memorial Hospital, Taiwan, and reviewed data from May 2006 to May 2018. Thirteen patients with CCF who were treated with stereotactic radiosurgery were included, and side, volume, pathological type, origin, location, postoperative regression, and recurrence rate were evaluated with postradiotherapy. Patients were either followed up with contrast magnetic resonance imaging or angiography. Radiosurgery was considered successful if the patients' clinical symptoms improved with radiological remission or if there was a reduction in CCF flow in angiography. Results: Of the 11 patients, three (27.3%) received transarterial embolization (TAE) before radiosurgery. Successful radiological outcomes were seen in 10 (90.9%) patients, and the remaining one patient (9.1%) had stationary disease with no reduction in CCF flow. Ten patients (90.9%) had improved clinical symptoms; however, one patient (9.1%) was complicated with iatrogenic blindness after TAE treatment. No acute or subacute transient postradiation changes, optic nerve injuries, or brainstem radionecrosis were noted in any of the patients. Conclusions: In this study, LINAC-based radiosurgery for CCF was found to be an effective, safe, and successful treatment alternative to TAE treatment in patients with indirect CCF. The risk of postradiotherapy complications was low, and obliteration and regression rates were high.

Background Dual antiplatelet therapy is widely used for stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs) to prevent thromboembolic events (TEs). Compared to clopidogrel associated with aspirin, knowledge of the safety and efficacy of ticagrelor is lacking in large studies to date. Methods A retrospective cohort study was conducted from January 2016 to December 2018 with at least one year of follow-up in a single institution and systemic review. Results Altogether, 153 patients with UIA receiving SACE were separated into two groups: 113 patients receiving clopidogrel plus aspirin and 40 patients receiving ticagrelor plus aspirin. Acute in-stent thrombotic events were noted in two patients in the clopidogrel group (1.77%) and none in the ticagrelor group (0%). Additionally, one patient (0.88%) in the clopidogrel group had an early ischemic stroke (Conclusion Compared to the clopidogrel based regimen, ticagrelor can also reduce TEs without increasing bleeding tendency for SACE of UIAs. Ticagrelor combined with low-dose aspirin is a safe and effective alternative option for SACE.

Background Spinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS. Methods This retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture. Results Of the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; P = 0.006). Patients with SCI had more instances of subluxation or dislocation (48.3% vs. 8.9%; P P = 0.003) than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004). Conclusions Patients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3–C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates.

Altered cognition or hemiparesis can occur in neurocritical but conscious patients, and recognizing pain is challenging. This study aimed to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) in this specific group.This prospective study included ventilated, conscious patients who had certain neurologic deficits. CPOT scores were assessed before and after nociceptive (turning the patient) and non-nociceptive (measuring body temperature) procedures. The patients' self-reported pain was also recorded using a numerical rating scale (NRS).Sixty-three patients were enrolled. The intraclass correlation coefficient was r = 0.975-1.000 (p0.001) for turning the patient. Discriminant validation indicated that CPOT scores were significantly higher after turning the patient compared with measuring body temperature (p = 0.025). CPOT scores were positively correlated with NRS when turning the patient (r = 0.724, p0.001). After turning, the mean increase in CPOT score was lower in the patients with hemiparesis than in those without hemiparesis (p = 0.079), however it was significantly higher in the patients with cognitive dysfunction compared to those without cognitive dysfunction (p = 0.022).The CPOT is an appropriate instrument to assess pain in conscious patients, particularly those with cognitive dysfunction. The influence of hemiparesis on the CPOT is noteworthy.

Traumatic intraventricular hemorrhage (tIVH) is associated with increased mortality and disability in traumatic brain injury (TBI). However, the significance of tIVH itself remains unclear. Our goal is to assess whether tIVH affects in-hospital mortality and short-term functional outcomes. We retrospectively reviewed the records of 5048 patients with TBI during a 5-year period, and 149 tIVH patients were analyzed. Confounding was reduced using the inverse probability of treatment weighting (IPTW) based on propensity score. The association between IVH and outcomes was investigated using logistic regression in the IPTW-adjusted cohort. In our study, after adjustment for analysis, the in-hospital mortality rate (11.4% vs. 9.2%) and the poor functional outcome rate (37.9% vs.10.6%) were significantly higher in the tIVH group than in the non-tIVH group. Factors independently associated with outcomes were age ≥ 65 years, Glasgow Coma Scale (GCS) severity score, and the Graeb score. The Traumatic Graeb Score, a novel scoring system for predicting functional outcomes associated with tIVH, comprised the sum of the following components: GCS scores of 3 to 4 (=2 points), 5 to 12 (=1 point), 13 to 15 (=0 points); age ≥ 65 years, yes (=1 point), no (=0 points); Graeb score (0–12 points). A Traumatic Graeb Score ≥ 4 is an optimal cutoff value for poor short-term functional outcomes.

Background Psychiatric disorders and ocular neurovascular diseases may share a similar pathophysiological route of vascular structures or neurological changes. The aim of this study is to investigate the association between ocular neurovascular diseases and the risk of major psychiatric disorders. Methods This was a retrospective case–control, population-based study including patients aged ≥20 and were diagnosed between 1997 and 2013. Ocular neurovascular diseases diagnosed between 1997 and 2006 and newly diagnosed psychiatric disorders including bipolar disorder (BD), major depressive disorder (MDD), and schizophrenia between 2007 and 2013 were registered. Patients were propensity-score matched with control groups without psychiatric disorders in each cohort based on selected covariates. Results A total of one million sampled patients in the database were categorized based on their diagnoses; 2243 (37.4% men) were categorized into the BD group, 10,110 (35.2% men) into the MDD group, and 1623 (43.1% men) into the schizophrenia group. In the BD group, all glaucoma (OR 1.49, [1.18–1.89]), open-angle glaucoma (OR 2.08, [1.34–3.24]), and closed-angle glaucoma (OR 2.12, [1.36–3.33]) showed statistical significance of risk. In the MDD group, age-related macular degeneration (OR 1.33, [1.13–1.57]), all glaucoma (OR 1.24, [1.11–1.37]), open-angle glaucoma (OR 1.47, [1.21–1.80]), and dry eye syndrome (OR 1.22, [1.13–1.31]) were associated with a significantly higher risk. In the schizophrenia group, only all glaucoma (OR 1.47, [1.02–2.11]), glaucoma suspect (OR 1.88, [1.01–3.49]), and open-angle glaucoma (OR 2.19, [1.13–4.26]) showed statistical significance. Conclusions In this population-based study, ocular neurovascular diseases, especially glaucoma, were associated with increased risks of BD, MDD, and schizophrenia.

Background Effective ART is crucial for combating the HIV pandemic. Clinically, plasma viral load monitoring to achieve virological suppression is the guide for an optimal ART. The presence of low-level viraemia (LLV) below the definition level of virological failure is a risk factor for ART failure. However, there is no treatment consensus over LLV yet, mainly due to the limitation of standard HIV-RNA genotyping and the resultant insufficient understanding of LLV characteristics. Objectives To better profile drug resistance mutations (DRMs) and the associated factors in cases experiencing LLV. Methods A prospective observational study was conducted from 2017 to 2019. HIV-DNA was used as an alternative to HIV-RNA for HIV genotyping coupled with deep sequencing for ART-naive and ART-failure cases, as well as those with LLV. Results Eighty-one ART-naive, 18 ART-failure and 16 LLV cases received HIV genotyping in the study. Three-quarters (12/16) of cases experiencing LLV harboured DRMs. Cases with LLV had higher prevalence of DRMs to NNRTIs than the ART-naive group (69% versus 20%, P Conclusions HIV DRM profiles in LLV cases were significantly different to those in ART-naive and ART-failure cases. Approaches to consolidate ART compliance and early exploration of potential ART resistance may be needed for cases experiencing LLV episodes.

Severe neurological complications following infective endocarditis remain a major problem with high mortality rate. The long-term neurological consequences following infective endocarditis remain uncertain. Otherwise, neurosurgeries could be performed after these complications; however, few clinical series have reported the results. Therefore, we utilized a large, nationwide database to unveil the long-term mortality and neurosurgical outcome following infective endocarditis. We included patients with a first-time discharge diagnosis of infective endocarditis between January 2001 and December 2013 during hospitalization. Patients were further divided into subgroups consisting of neurological complications under neurosurgical treatment and complications under non-neurosurgical treatment. Long-term result of symptomatic neurological complications after infective endocarditis and all-cause mortality after different kinds of neurosurgeries were analyzed. There were 16,495 patients with infective endocarditis included in this study. Symptomatic neurological complications occurred in 1,035 (6.27%) patients, of which 279 (26.96%) accepted neurosurgical procedures. Annual incidence of neurological complications gradually increased from 3.6% to 7.4% (P P = 0.012, increased from 20% initially to nearly 50% over the 5-year follow-up). However, neurosurgery had no effect on the long-term mortality rate (50.9% vs. 47.6%, P = 0.451). Incidence of neurological complications post-infective endocarditis is increasing, and patients with these complications have higher mortality rates than patients without. Neurosurgery in these populations was not associated with higher long-term mortality. Therefore, it should not be ruled out as an option for those with neurological complications.

Cervical laminectomy is an effective treatment for multilevel cervical compressive myelopathy. Symptomatic spinal cord compression (SSCC) by paraspinal musculature (PSM) following cervical laminectomy is rarely reported. The aim of this study was to evaluate the frequency and pathogenesis of this complication after cervical laminectomy. Between 2007 and 2016, the medical records of 1309 cervical laminectomy patients were reviewed. From these 1309 records, seven patients (five men and two women; average age, 64.12 years; range 48–78 years) with SSCC by PSM following cervical laminectomy were identified. The incidence and possible risk factors of this rare condition were evaluated. The frequency of SSCC by PSM following cervical laminectomy was 0.53%. Presenting symptoms included paralyses and paresthesias, depending on the level and severity of cervical spinal cord compression. The initial onset of neurologic deterioration varied from 12 h to 21 days after operation. Most patients recovered well after surgical management with an average Barthel index of 74.3 at 6 months after surgery. In comparison with 63 controls, this rare complication was associated with preoperative cervical kyphosis, prior antiplatelet therapy, and posterior decompression with prone position. SSCC by PSM is a rare but devastating complication following cervical laminectomy, especially in those patients with preoperative kyphosis, prior antiplatelet treatment, and decompression with prone position. MRI is an ideal tool to identify this complication. Rapid cervical cord decompression and avoidance of recurrent compressive events can achieve a good clinical outcome. These slides can be retrieved under Electronic Supplementary Material.

Neurocutaneous melanosis (NCM) is characterized by diffuse or focal proliferation of melanin-producing cells over the skin or leptomeninges. Even without malignant transformation, the prognosis is poor after symptomatic progression of NCM, resulting from either mass effect in central nervous system or hydrocephalus. We reported a 26-year-old female patient with rapid deterioration after the onset of NCM. Despite no solid tumor formation, elevated cerebrospinal fluid protein content, which complicated shunting procedure, associated with hydrocephalus played the key role in clinical deterioration. Adult onset of NCM with Dandy–Walker malformation was never reported in our literature review. Diagnosis and treatment for such disease entity are discussed.

Microglia are activated after spinal cord injury (SCI), but their phagocytic mechanisms and link to neuroprotection remain incompletely characterized. Docosahexaenoic acid (DHA) has been shown to have significant neuroprotective effects after hemisection and compression SCI and can directly affect microglia in these injury models. In rodent contusion SCI, we demonstrate that DHA (500 nmol/kg) administered acutely post-injury confers neuroprotection and enhances locomotor recovery, and also exerts a complex modulation of the microglial response to injury. In rodents, at 7 days after SCI, the level of phagocytosed myelin within Iba1-positive or P2Y12-positive cells was significantly lower after DHA treatment, and this occurred in parallel with an increase in intracellular miR-124 expression. Furthermore, intraspinal administration of a miR-124 inhibitor significantly reduced the DHA-induced decrease in myelin phagocytosis in mice at 7 days post-SCI. In rat spinal primary microglia cultures, DHA reduced the phagocytic response to myelin, which was associated with an increase in miR-124, but not miR-155. A similar response was observed in a microglia cell line (BV2) treated with DHA, and the effect was blocked by a miR-124 inhibitor. Furthermore, the phagocytic response of BV2 cells to stressed neurones was also reduced in the presence of DHA. In peripheral monocyte-derived macrophages, the expression of the M1, but not the M0 or M2 phenotype, was reduced by DHA, but the phagocytic activation was not altered. These findings show that DHA induces neuroprotection in contusion injury. Furthermore, the improved outcome is via a miR-124-dependent reduction in the phagocytic response of microglia., US Department of Defence CDMRP/SCIRP award (W81XWH-10-1-1040 to P.K.Y., T.B. and A.M.T.); The Barts and London Charity (to P.K.Y. and A.M.T.); Rod Flower Vacation Scholarship (to A.L.B.); International Spinal Research Trust (to J.H. and P.G.P.); Ray W. Poppleton Endowment (to P.G.P.); Chang Gung Memorial Hospital, Taiwan (CMRPG3A1051–1054 to Z.-H.L.). M.A.B. is funded by the Spanish Ministry of Economy and Competitivity (Programa Ramón y Cajal: RYC-2017-21804).

Cranioplasty is a technically simple procedure intended to repair defects of the skull to provide protection after craniectomy, improve functional outcomes, and restore cosmesis. Several materials have been used for the restoration of skull defects, including autologous bone grafts (AGs), polymethyl methacrylate (PMMA) flaps, and titanium mesh (T-mesh). However, the long-term results of cranioplasty after use of these materials are controversial.Medical records of 596 patients who underwent cranioplasty at our medical center between 2009 and 2015 with at least 2.5 years of follow-up were retrospectively reviewed. Patients were classified into 3 groups according to the materials used: AG, three-dimensional PMMA, and T-mesh. Demographic and clinical characteristics and postoperative complications were analyzed.Cranioplasty with AG had the highest bone flap depression rate (4.9%; P = 0.02) and was associated with a 26% long-term bone flap resorption. Younger age was a risk factor for bone flap resorption. T-mesh had a higher risk of postoperative skin erosion and bone exposure (17%; P = 0.004). Patients with diabetes, previous craniotomy, or hydrocephalus showed a higher risk of postoperative skin erosion. PMMA was associated with the highest rate of postoperative infection (14.4%3 months, 28.1%3 months; P0.05), and previous craniotomy may increase the infection risk after cranioplasty with PMMA.Complications after cranioplasty are high, and the various types of cranioplasty materials used are associated with different complications. Surgeons need to be aware of these potential complications and should choose the appropriate material for each individual patient.

OBJECTIVECranioplasty is a relatively simple and less invasive intervention, but it is associated with a high incidence of postoperative seizures. The incidence of, and the risk factors for, such seizures and the effect of prophylactic antiepileptic drugs (AEDs) have not been well studied. The authors’ aim was to evaluate the risk factors that predispose patients to postcranioplasty seizures and to examine the role of seizure prophylaxis in cranioplasty.METHODSThe records of patients who had undergone cranioplasty at the authors’ medical center between 2009 and 2014 with at last 2 years of follow-up were retrospectively reviewed. Demographic and clinical characteristics, the occurrence of postoperative seizures, and postoperative complications were analyzed.RESULTSAmong the 583 patients eligible for inclusion in the study, 247 had preexisting seizures or used AEDs before the cranioplasty and 336 had no seizures prior to cranioplasty. Of these 336 patients, 89 (26.5%) had new-onset seizures following cranioplasty. Prophylactic AEDs were administered to 56 patients for 1 week after cranioplasty. No early seizures occurred in these patients, and this finding was statistically significant (p = 0.012). Liver cirrhosis, intraoperative blood loss, and shunt-dependent hydrocephalus were risk factors for postcranioplasty seizures in the multivariable analysis.CONCLUSIONSCranioplasty is associated with a high incidence of postoperative seizures. The prophylactic use of AEDs can reduce the occurrence of early seizures.

Purpose Seizures in rare atypical and malignant meningiomas were significantly under-studied. Our aim was to examine the rates, predictors, and seizure control in these meningiomas, and to analyze associations between clinical characteristics and seizure free survival (SFS) following surgical resection in an Asian population. Methods We retrospectively analyzed 102 patients with atypical or malignant meningiomas. Seizures occurring before and after the operation were reviewed. We compared demographic data and clinical characteristics including anti-epileptic drug (AED) treatment to extract potential risk factors for seizures. Results Preoperative and postoperative early seizures occurred in 15 (14.7%) and 13 (12.7%) patients, respectively. All preoperative seizures occurred with tumors located at the convexity or parasagittal area (P = .001) and were influenced by peritumor edema (P = .027). Preoperative seizures were predictive of early seizures occurrence postoperatively (P = .016). Twenty-one patients (20.6%) had late seizures postoperatively. SFS was influenced by preoperative seizures, tumor location, AED use, and tumor relapse (P = .003, .001, .013, and .046, respectively). Among 15 patients with preoperative seizures, malignant meningiomas were associated with shorter SFS than atypical meningiomas (P = .001). Fifty one of 87 patients without preoperative seizures had prophylactic AEDs, and none had early seizures (P = .001). Gross total resection (GTR) of tumors induced more new-onset seizure than subtotal resection (P = .045). Conclusion Convexity and parasagittal area tumors as well as peritumor edema induce seizures. Preoperative seizures and tumor relapse predict seizures postoperatively. AEDs treatment improves SFS, and prophylactic AEDs eliminate early seizures after surgery. GTR has negative impact to seizure control.

Background Acute hepatitis A is a fecal-oral transmitted disease related to inadequate sanitary conditions. In addition to its traditional classification, several outbreaks in the men who have sex with men (MSM) population have resulted in acute hepatitis A being recognized as a sexually transmitted disease. However, few studies have clarified the clinical manifestations in these outbreaks involving the MSM population. Methods Beginning in June 2015, there was an outbreak of acute hepatitis A involving the MSM population in Northern Taiwan. We conducted a 15-year retrospective study by recruiting 207 patients with the diagnosis of acute hepatitis A that included the pre-outbreak (January 2001 to May 2015) and outbreak (June 2015 to August 2016) periods in a tertiary medical center in Northern Taiwan. Using risk factors, comorbidities, presenting symptoms, laboratory test results and imaging data, we aimed to evaluate the clinical significance of acute hepatitis A in the MSM population, where human immunodeficiency virus (HIV) coinfection is common. Results There was a higher prevalence of reported MSM (p

OBJECTIVEBurr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown.METHODSA nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed.RESULTSThe in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC.CONCLUSIONSEven for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.

Traditional camera can’t take photos with large depth of field (DOF) because of the lens limits. The region out of DOF often gets blurred due to narrow width of depth. Focal stack photography take a set of (three and above) pictures viewing the same scene with different focus point and fusion the pictures as one using computational algorithms in order to have all-in-focus photos. Some state-of-art focal stack algorithms seek the best-in-focus point among these stack photos and collect them into a new all-in-focus image. This method is derived from the assumption that at least one photo in the stack has the clear vision of the point of the scene. But what if none of these points are in focus because unfortunately focus point falls out of the object of the scene? Focal stack images not only provide us several pictures independently but also partial information about how the object is imaging at a certain depth. With this information, we seek a space called ‘image volume’ to search the best in-focus depth beyond the two dimensional images to avoid the failure mentioned above. We work through the whole scene space and find the accurate depth of every point in the scene. We experiment some pictures with focal stack example and show better results than traditional methods.