Thursday, April 17, 2014

Survival and Neurocognitive Outcomes After Cranial or Craniospinal Irradiation Plus Total-Body Irradiation Before Stem Cell Transplantation in Pediatric Leukemia Patients With Central Nervous System Involvement

Survival and Neurocognitive Outcomes After Cranial or Craniospinal Irradiation Plus Total-Body Irradiation Before Stem Cell Transplantation in Pediatric Leukemia Patients With Central Nervous System Involvement
International Journal of Radiation Oncology * Biology * Physics

Purpose: To evaluate survival and neurocognitive outcomes in pediatric acute lymphoblastic leukemia (ALL) patients with central nervous system (CNS) involvement treated according to an institutional protocol with stem cell transplantation (SCT) and a component of craniospinal irradiation (CSI) in addition to total-body irradiation (TBI) as preparative regimen.Methods and Materials: Forty-one pediatric ALL patients underwent SCT with TBI and received additional cranial irradiation or CSI because of CNS leukemic involvement. Prospective neurocognitive testing was performed before and after SCT in a subset of patients. Cox regression models were used to determine associations of patient and disease characteristics and treatment methods with outcomes.Results: All patients received a cranial radiation boost; median total cranial dose was 24 Gy. Eighteen patients (44%) received a spinal boost; median total spinal dose for these patients was 18 Gy. Five-year disease-free survival (DFS) for all patients was 67%. Those receiving CSI had a trend toward superior DFS compared with those receiving a cranial boost alone (hazard ratio 3.23, P=.14). Patients with isolated CNS disease before SCT had a trend toward superior DFS (hazard ratio 3.64, P=.11, 5-year DFS 74%) compared with those with combined CNS and bone marrow disease (5-year DFS 59%). Neurocognitive testing revealed a mean post-SCT overall intelligence quotient of 103.7 at 4.4 years. Relative deficiencies in processing speed and/or working memory were noted in 6 of 16 tested patients (38%). Pre- and post-SCT neurocognitive testing revealed no significant change in intelligence quotient (mean increase +4.7 points). At a mean of 12.5 years after transplant, 11 of 13 long-term survivors (85%) had completed at least some coursework at a 2- or 4-year college.Conclusion: The addition of CSI to TBI before SCT in pediatric ALL with CNS involvement is effective and well-tolerated. Craniospinal irradiation plus TBI is worthy of further protocol investigation in children with CNS leukemia.

Original Article: http://www.redjournal.org/article/S0360-3016(14)00184-9/abstract?rss=yes

Occipital Headaches and Neuroimaging in Children (P4.324)

Occipital Headaches and Neuroimaging in Children (P4.324)
Neurology recent issues

OBJECTIVE:To determine the implications of occipital headache in children and clarify when imaging is indicated.BACKGROUND:Occipital headache in children is considered a warning sign of intracranial pathology. The new ICHD-3 beta criteria for migraine state, "Occipital headache in children is rare and calls for diagnostic caution." Support for this comes from studies in emergency departments rather than neurologists' offices.DESIGN/METHODS:We performed a retrospective chart review cohort study of all patients referred to a child neurology clinic for headache in 2009. Patients were stratified by headache location: solely occipital, occipital plus other area(s) of head pain, or no occipital involvement. We assessed location as a predictor of 1) whether neuroimaging was ordered, and 2) whether intracranial pathology was found. Analyses were performed using logistic regression, Chi-Square, and Fisher's exact tests.RESULTS:A total of 356 patients were included. Median age was 12.1 years (27 months to 18 years), and 56.5% were female. Headaches were solely occipital in 6.4% and occipital-plus in 13.2%. Patients with occipital head pain were more likely to undergo neuroimaging than those without occipital involvement (solely occipital: 91%, RR 4.9, 95% CI 1.2-20.6; occipital-plus: 85%, RR 2.7, 95% CI 1.2-5.8; no occipital pain: 65%, ref.). Occipital pain alone or with other locations was not significantly associated with radiographic evidence of elevated intracranial pressure, tumor, benign cyst, or sinusitis. Occipital pain was associated with Chiari I malformation (solely occipital: RR 4, 95% CI 1.2-13.5; occipital-plus: RR 3.3, 95% CI 1.5-6.9).CONCLUSIONS:Children with occipital headache are more likely to undergo neuroimaging. In our study, occipital pain was associated with Chiari I malformation but not with more serious intracranial pathology. Detecting a Chiari I malformation is useful only if the clinical presentation is consistent with tonsillar compression; otherwise, it may be an incidental finding in a child with migraine. Without a worrying history and with a normal examination, neuroimaging can be deferred in most pediatric patients when occipital pain is present.

Disclosure: Dr. Bear has nothing to disclose. Dr. Gelfand has received personal compensation in an editorial capacity for Journal Watch Neurology. Dr. Goadsby has received personal compensation for activities with Allergan, Inc., Colucid, MAP Pharmaceuticals, Merck Sharp & Dohme Limited, eNeura, ATI, Boston Scientific Corporation, Eli Lilly & Company, Medtronic, Inc., Bristol-Myers Squibb Company, Amgen Inc., Arteaus, AlderBio, Pfizer Inc., Zogeniz, Nevrocorp, Ipmax, DrReddy, and Zosano. Dr. Goadsby has received research support from Amgen Inc., Merck Sharp & Dohme Limited, and Allergan, Inc. Dr. Bass has nothing to disclose.



Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/P4.324?rss=1

Wednesday, April 16, 2014

Utility of CT Perfusion (CTP) Imaging in Seizures: A Retrospective Analysis and Literature Review (P3.005)

Utility of CT Perfusion (CTP) Imaging in Seizures: A Retrospective Analysis and Literature Review (P3.005)
Neurology recent issues

Objective: To elucidate specific patterns in CTP that can delineate seizure from stroke. Background: CT Perfusion (CTP) has fast become the imaging modality of choice in acute stroke. It can also shed light on stroke mimics (seizures, PRES). Many peculiar CTP changes in relation to seizures have been reported in the literature. Our study sought to delineate the specificities on CTP that can aid in the above objective. Methods: We retrospectively identified patients who presented to our center as stroke alerts but received a discharge diagnosis of seizure between 2008 and 20011. We excluded patients who did not get a CTP or EEG. We compared the patient's CTP with their EEG and MRI. Results: 91% of patients who presented with seizure, had an abnormal CTP. Of these 66% had typical CTP changes suggestive of seizure i.e. ipsilateral increased perfusion, or contralateral increased Time To Peak (TTP), or unilateral increased Cerebral Blood Flow (CBF) and decreased TTP. A minority showed globally increased CBF with EEG showing status epilepticus. The Pattern of perfusion abnormality commonly encountered in seizures was cortical ribboning, sparing the basal ganglia, and not respecting vascular territories. Large vessel CT Angiography (CTA) changes were absent. Conclusions: CTP is a valuable test to help differentiate strokes and seizures. CTP abnormalities are common in patients presenting to the ED with seizures. Particular attention to the patterns of CTP changes increases the specificity of this test. CTP imaging is now routinely available and has a shorter acquisition time than studies such as MRI or EEG making it uniquely useful for seizures. In addition, CTP may aid in targeting certain areas for biopsy in suspected pathologies like tumors and may prevent unnecessary thrombolysis. Given that cerebral blood flow mechanics is a dynamic phenomenon, the timing of CT perfusion is critical. We propose that there is likely a continuum of CTP changes in seizure: increased flow ictally, decreased flow post-ictally, and normalizing subsequently.

Disclosure: Dr. Khaku has nothing to disclose. Dr. Hedna has nothing to disclose. Dr. Waters has nothing to disclose.



Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/P3.005?rss=1

Implementation of Active Learning into the Pre-Clinical Neurology Undergraduate Medical Curriculum (P1.321)

Implementation of Active Learning into the Pre-Clinical Neurology Undergraduate Medical Curriculum (P1.321)
Neurology recent issues

ObjectiveTo report our experience transitioning a pre-clinical neurology medical school curriculum from a lecture-based to an active learning-based format.BackgroundActive learning is an educational model which accentuates student engagement and collaboration. While active learning has been the basis of clinical training, the focus of preclinical medical education has traditionally centered on group lectures. Neurologist educators have been urged to shift emphasis on teaching towards problem-based learning. We describe our experience implementing a transition to an active learning model.Design/methodsBetween 2010-2011 and 2011-2012, the preclinical neurology curriculum converted from traditional lectures to an active learning format. The neurology curriculum was divided into eleven four-hour blocks. Each block focused on a particular subtopic of neurology. Each block was preceded by a reading assignment and class time including group-response activity testing in which teams of 4-5 students worked collaboratively to answer case-based questions. This was followed by class discussion and a one hour traditional pathology lecture.ResultsOur preclinical neurology curriculum transitioned from traditional lecture to an active learning model. The student course pass rate did not decrease after the transition. USMLE step I neuroscience performance did not change significantly after the transition, but overall mean scores on the USMLE step I increased. Over 75% of the 35 students responding to an anonymous poll reported gaining more from the active learning format compared to traditional lectures. 60% of students felt a comfort level with active learning needed 2-3 weeks to occur.ConclusionsActive learning replaced traditional lecture-based learning for our US medical school preclinical neurology course. This transition occurred without a decrease in student pass rate or USMLE Step I scores, and was met with positive reviews from medical students.

Disclosure: Dr. Pula has nothing to disclose. Dr. Nixon has nothing to disclose. Dr. Aiyer has nothing to disclose. Dr. Kattah has received personal compensation for activities with Pfizer, Inc. as a consultant.



Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/P1.321?rss=1

NCSE in Neuro and Medical ICU Patients on Continous EEG Monitoring (P1.271)

NCSE in Neuro and Medical ICU Patients on Continous EEG Monitoring (P1.271)
Neurology recent issues

OBJECTIVE:Determine Incidence and Clinical outcome of Non Convulsive Status Epilepticus(NCSE) in Neuro and Medical ICU patients.BACKGROUND:NCSE is under recognized in critically ill patients and associated with significant morbidity and mortality.It often is only diagnosed with continous EEG monitoring.DESIGN/METHODS:Retrospective chart review study.Instituional IRB approval obtained.The EEG registry at University of Minnesota Medical Center was used to identify adult patients who underwent continuous EEG monitoring for at least 2 days in a Neuro or Medical ICU setting between 2005 and 2013. Exclusion criteria: Normal EEGEnd point:Discharge from hospital or death.Modified Rankin scale was used as a clinical outcome measure.SPSS was used for statistical analysisRESULTS:23.9%(21/88)were diagnosed with NCSE during continous EEG monitoring(19 of these 21 patients were in coma or stupor).Only 5 of these 21 patients had a known diagnosis of Epilepsy.Most common etiology in patients with NCSE was structural or traumatic brain injuries,(brain tumor,shunt malfunction,vascular malformation,subdural hematomas,traumatic SAH etc) followed by vascular and metabolic etiologies(9,4 and 4 patients respectively) only 1 patient had convulsive status epilepticus preceding NCSE.Patients diagnosed with NCSE did not have a worse clinical outcome per modified rankin scale(MRS)(p value 0.666),whereas patients in a state of stupor/coma(per clinical exam)did have a worse clinical outcome(p value < 0.005).CONCLUSIONS:NCSE was diagnosed in nearly one of four critically ill patients who underwent continous EEG most of whom did not have a prior diagnosis of Epilepsy.Most common etiology in the NCSE group was structural or traumatic brain injuries followed by vacular and metabolic etiologies.It was not clear that diagnosing NCSE changed clinical outcome in these patients.More studies including multicenter trials are needed to focus on Non convulsive status in critically ill patients.Study Supported by:Department of Neurology,University of Minnesota

Disclosure: Dr. Tom has nothing to disclose. Dr. Fiol-Elias has nothing to disclose.



Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/P1.271?rss=1

Progression-free survival as a surrogate endpoint for overall survival in glioblastoma: a literature-based meta-analysis from 91 trials

Progression-free survival as a surrogate endpoint for overall survival in glioblastoma: a literature-based meta-analysis from 91 trials
Neuro-Oncology - current issue



Original Article: http://neuro-oncology.oxfordjournals.org/cgi/content/short/16/5/696?rss=1

[Review] End-of-life decisions in patients with severe acute brain injury

[Review] End-of-life decisions in patients with severe acute brain injury
The Lancet Neurology

Most in-hospital deaths of patients with stroke, traumatic brain injury, or postanoxic encephalopathy after cardiac arrest occur after a decision to withhold or withdraw life-sustaining treatments. Decisions on treatment restrictions in these patients are generally complex and are based only in part on evidence from published work. Prognostic models to be used in this decision-making process should have a strong discriminative power. However, for most causes of acute brain injury, prognostic models are not sufficiently accurate to serve as the sole basis of decisions to limit treatment.

Original Article: http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(14)70030-4/abstract?rss=yes

Monday, April 14, 2014

Neuro-oncology Telemedicine Follow-up Visits (I8-1.004)

Neuro-oncology Telemedicine Follow-up Visits (I8-1.004)
Neurology recent issues

OBJECTIVE: To determine whether neuro-oncology follow-up visits can be performed remotely using a videoconferencing system with high levels of safety and patient satisfaction.BACKGROUND: The Neuro-oncology Program at the Kaiser Permanente-Los Angeles Medical center serves the majority of Kaiser HMO patients with primary brain tumors in the Southern California region. We hypothesized that utilization of a videoconferencing system for follow-up visits would lead to high levels of patient satisfaction due to reduced travel time.DESIGN/METHODS: We installed a videoconferencing system (Cisco TelePresence EX90, Cisco Systems, San Jose, CA) in our office in Los Angeles and in a medical office building in Anaheim, CA at a distance of 35 miles. Established neuro-oncology patients from Orange County chose between in-person and remote visits. Patients were seated in an examination room and the neuro-oncologist alerted by text page. A focused history and physical examination was performed, followed by desktop sharing of clinical and laboratory data using an electronic medical record (Epic Systems Corporation, Verona, WI) and of neuroimages (Philips iSite PACS, Andover, MA). Patients completed an anonymous online 16 question satisfaction survey.RESULTS: Thirty-eight unique follow-up patients were evaluated by a single neuro-oncologist (R.G.). Sixty-nine patient visits were performed. Sixty-four visits included evaluation of neuroimaging and 23 visits included evaluation of response to ongoing chemotherapy. During 5 visits chemotherapy was started; during 5 other visits chemotherapy treatment was changed. Patients reported a high level of satisfaction with the visits (average 9.8, on a 1-10 scale). The average estimated travel time saved was 150 minutes per visit. Four surveys reported technical problems and 1 indicated a preference for an in-person visit. No adverse events could be attributed to use of the telemedicine system.CONCLUSIONS: These data suggest that neuro-oncology can be practiced safely and effectively using a telemedicine system, with high levels of patient satisfaction.

Disclosure: Dr. Green has nothing to disclose. Dr. Woyshner has nothing to disclose. Dr. Hauser Dehaven has nothing to disclose.



Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/I8-1.004?rss=1

Tuesday, April 8, 2014

Surgical outcomes in spinal cord ependymomas and the importance of extent of resection in children and young adults

Surgical outcomes in spinal cord ependymomas and the importance of extent of resection in children and young adults
Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 13, Issue 4, Page 393-399, April 2014.
Object Ependymomas are a common type of CNS tumor in children, although only 13% originate from the spinal cord. Aside from location and extent of resection, the factors that affect outcome are not well understood. Methods The authors performed a search of an institutional neuropathology database to identify all patients with spinal cord ependymomas treated over the past 20 years. Data on patient age, sex, clinical presentation, symptom duration, tumor location, extent of resection, use of radiation therapy, surgical complications, presence of tumor recurrence, duration of follow-up, and residual symptoms were collected. Pediatric patients were defined as those 21 years of age or younger at diagnosis. The extent of resection was defined by the findings of the postoperative MR images. Results A total of 24 pediatric patients with spinal cord ependymomas were identified with the following pathological subtypes: 14 classic (Grade II), 8 myxopapillary (Grade I), and 2 anaplastic (Grade III) ependymomas. Both anaplastic ependymomas originated in the intracranial compartment and spread to the spinal cord at recurrence. The mean follow-up duration for patients with classic and myxopapillary ependymomas was 63 and 45 months, respectively. Seven patients with classic ependymomas underwent gross-total resection (GTR), while 4 received subtotal resection (STR), 2 received STR as well as radiation therapy, and 1 received radiation therapy alone. All but 1 patient with myxopapillary ependymomas underwent GTR. Three recurrences were identified in the Grade II group at 45, 48, and 228 months. A single recurrence was identified in the Grade I group at 71 months. The mean progression-free survival (PFS) was 58 months in the Grade II group and 45 months in the Grade I group. Conclusions Extent of resection is an important prognostic factor in all pediatric spinal cord ependymomas, particularly Grade II ependymomas. These data suggest that achieving GTR is more difficult in the upper spinal cord, making tumor location another important factor. Although classified as Grade I lesions, myxopapillary ependymomas had similar outcomes when compared with classic (Grade II) ependymomas, particularly with respect to PFS. Long-term complications or new neurological deficits were rare. Among patients with long-term follow-up, those who underwent GTR had a recurrence rate of 20% compared with 40% among those with STR or biopsy only, suggesting that extent of resection is perhaps a more important prognostic factor than histological grade in predicting PFS, which has been suggested by other data in the literature. Given the relative paucity of these lesions, collaborative multiinstitutional studies are needed, and such efforts should also focus on molecular and genetic analysis to refine the current classification system.

Original Article: http://thejns.org/doi/abs/10.3171/2013.12.PEDS13383?ai=3f6&mi=3ba5z2&af=R

Rolezinho na Neuro (PARTE 2) #rolezinho #livros #neuro

Rolezinho na Neuro (PARTE 2) #rolezinho #livros #neuro
Neurosurgery Blog

Olá Pessoal,

O Rolezinho na Neuro (parte 1) foi um sucesso. Enviamos mais de 20 livros para todo o Brasil sem  NENHUM CUSTO para quem recebeu.

Continuaremos agora com Rolezinho na Neuro (parte 2).

Para participar basta enviar um e-mail para neurocirurgiabr@gmail.com e contar por que você quer o livro. Infelizmente não tenho livro para todos mas irei tentar enviar mais 20 livros que escrevi. Segue abaixo os links dos livros.

OBS: Favor no email dizer qual livro você quer.

1044060_10152299962507577_418148290_n

Onde encontro os livros:
Após um tumor cerebralhttp://goo.gl/MJiTb2
Escrito em letra de médicohttp://goo.gl/Yuy5nV
Thoughts from the Hospitalhttp://goo.gl/goHz1O

Nas principais Livrarias:
Amazon: http://goo.gl/HIcf0B
Google Play: http://goo.gl/obwWHG
iBook: http://goo.gl/ThqLG1
Cultura: http://goo.gl/bvgJ5e
Saraiva: http://goo.gl/Wjw8Hi

 

 

The post Rolezinho na Neuro (PARTE 2) #rolezinho #livros #neuro appeared first on NEUROSURGERY BLOG.



Original Article: http://neurocirurgiabr.com/rolezinho-na-neuro-parte-2-rolezinho-livros-neuro/?utm_source=rss&utm_medium=rss&utm_campaign=rolezinho-na-neuro-parte-2-rolezinho-livros-neuro