Neurology Commons^™

Hyperosmolar Therapy For Raised Intracranial Pressure., Ethan A Benardete

Department of Neurosurgery Faculty Papers

No abstract provided.

Metabolic Syndrome And Migraine., Amit Sachdev, Michael J Marmura

Department of Jefferson Headache Center Papers and Presentations

Migraine and metabolic syndrome are highly prevalent and costly conditions. The two conditions coexist, but it is unclear what relationship may exist between the two processes. Metabolic syndrome involves a number of findings, including insulin resistance, systemic hypertension, obesity, a proinflammatory state, and a prothrombotic state. Only one study addresses migraine in metabolic syndrome, finding significant differences in the presentation of metabolic syndrome in migraineurs. However, controversy exists regarding the contribution of each individual risk factor to migraine pathogenesis and prevalence. It is unclear what treatment implications, if any, exist as a result of the concomitant diagnosis of migraine and …

Validation Of A Novel, Non-Invasive System For Autonomic Profiling In Healthy Volunteers, Agostino Ingraldi, Behzad B. Pavri, Himanshu Patel, Sammy Zakaria, Reginald T. Ho, Arnold J. Greenspon

The Medicine Forum

Noninvasive profiling of the autonomic nervous system has been shown to have prognostic value in patients with myocardial infarction, CHF and diabetes. The ANSAR system (ANX 3.0, Philadelphia, PA) is a new commercially available system that utilizes respiratory rate, HR and BP to assess on-going sympathovagal modulation during various maneuvers known to evoke autonomic perturbations. Instead of using conventional Fast Fourier Transform for frequency domain analysis, a Continuous Wavelet Transform (CWT) is used to generate numerical and graphical data. The system calculates Low Frequency Area (LFA, analogous to LF Power) and Respiratory Frequency Area (RFA, analogous to High Frequency Power.) …

A Case Of Invasive Thymoma, Jon Geddes

The Medicine Forum

A 52 year-old man with a past medical history of an isolated seizure presented to the Veterans Affairs hospital complaining of weakness which was most prominent in the face and upper extremities. About 6 months prior to this admission he developed intermittent episodes of weakness when chewing and swallowing. He would often have to use his hands to close his jaw when eating or talking. He noticed that his voice had developed a nasal quality but he did not have slurred speech. He denied drooling, ptosis, cramping or muscle twitches. He was seen 6 months ago at another VA hospital …

Neurophysiological Impact And Modeling-Independent Elucidation Of Inactivation Pathways In A-Type K+ Channels, J.D. Fineberg, David Ritter, Manuel Covarrubias

Department of Molecular Physiology and Biophysics Faculty Papers

Poster presented at Society for Neuroscience

Abstract:

A-type voltage-gated K⁺ channels auto-regulate their function by undergoing fast inactivation. Independent of molecular mechanisms, this inactivation can proceed after channel opening (open-state inactivation, OSI) or from a closed state prior to opening (closed-state inactivation, CSI). We hypothesize that the specific neurophysiological roles of A-type Kv channels depend on whether they undergo OSI, CSI or both (CSI+OSI). To explore these possibilities, we introduced Markov kinetic schemes of the A-type Kv4 conductance into a computational model of the hippocamcal CA1 neuron assuming either CSI or CSI+OSI and compared the properties of the somatic …

Pulmonary Complications In Patients With Severe Brain Injury., Kiwon Lee, Fred Rincon

Department of Neurology Faculty Papers

Pulmonary complications are prevalent in the critically ill neurological population. Respiratory failure, pneumonia, acute lung injury and the acute respiratory distress syndrome (ALI/ARDS), pulmonary edema, pulmonary contusions and pneumo/hemothorax, and pulmonary embolism are frequently encountered in the setting of severe brain injury. Direct brain injury, depressed level of consciousness and inability to protect the airway, disruption of natural defense barriers, decreased mobility, and secondary neurological insults inherent to severe brain injury are the main cause of pulmonary complications in critically ill neurological patients. Prevention strategies and current and future therapies need to be implemented to avoid and treat the development …

Neurosurgical Applications Of Magnetic Resonance Diffusion Tensor Imaging, Daniel D. Hirsch, Bs, Benjamin M. Zussman, Bs, Adam E. Flanders, Md, Ashwini D. Sharan, Md

JHN Journal

Magnetic Resonance (MR) Diffusion Tensor Imaging (DTI) is a rapidly evolving technology that enables the visualization of neural fiber bundles, or white matter (WM) tracts. There are numerous neurosurgical applications for MR DTI including: (1) Tumor grading and staging; (2) Pre-surgical planning (determination of resectability, determination of surgical approach, identification of WM tracts at risk); (3) Intraoperative navigation (tumor resection that spares WM damage, epilepsy resection that spares WM damage, accurate location of deep brain stimulation structures); (4) Post-operative assessment and monitoring (identification of WM damage, identification of tumor recurrence). Limitations of MR DTI include difficulty tracking small and crossing …

Undergraduate Neurosurgical Learning Opportunities At Jefferson, Leadership Committee Neurosurgery Student Interest Group

JHN Journal

On the evening of November 29, 2011, Jefferson’s Neurosurgery Interest Group (NSIG) hosted fourteen Jefferson Medical College students for a technical course entitled “Foundations in Neurosurgery” taught by Dr. Ashwini Sharan, Associate Professor of Neurosurgery and Director of the Division of Functional Neurosurgery, and Dr. Joshua Heller, Assistant Professor of Neurosurgery at Thomas Jefferson University Hospital. Additional instructors included Jefferson neurosurgery residents Rohan Chitale (PGY5), Chengyuan Wu (PGY4), and Karl Balsara (PGY2). Stryker MedED provided equipment, models, and instructors Ryan Dugan and Devin Opdendyk (Figure 1).

Complications Of Decompressive Craniectomy, Sandra Ho, Bs, Yinn C. Ooi, Md, Muhamad A. Sheikh, Mbbs, Mitchell Maltenfort, Phd, Jack Jallo, Md, Phd

JHN Journal

Introduction:

Persistent elevation of intracranial pressure (ICP), if untreated, may lead to brain ischemia or lack of brain oxygen and even brain death.1-6,10 When standard treatments for elevated ICP are exhausted without any signs of improvement, decompressive craniectomy can be an effective alternative solution.7,19 Decompressive craniectomies (DC) have been used as a method of controlling intracranial pressure in patients with cerebral edema secondary to cerebral ischemia, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), among others. 8-10 Several studies over the years have demonstrated the efficacy of this procedure.7-9,11,35,36 However, consensus is still lacking in the utility of DC as …

Fractionated Stereotactic Radiosurgery Alone For The Treatment Of A Papillary Craniopharygioma, Tyler J. Kenning, Md, James J. Evans, Md

JHN Journal

The use of radiation treatment (RT) is usually reserved for residual or recurrent craniopharyngiomas, and the role of RT alone and not as an adjunctive therapy to surgery has not been clearly defined. The authors describe a case of a 50-year-old man presenting with a large suprasellar craniopharyngioma with extension into the third ventricle, producing acute hydrocephalus. A ventriculoperitoneal shunt was performed concurrently with an endoscopic biopsy. Treatment with fractionated stereotactic radiosurgery (FSR) resulted in near resolution of the lesion with no evidence of recurrence over six years. A review of RT for the treatment of craniopharyngiomas without surgical resection …

B-Vitamin Deficiency In Patients Treated With Antiepileptic Drugs., Scott Mintzer, Christopher T Skidmore, Michael R Sperling

Department of Neurology Faculty Papers

Enzyme-inducing antiepileptic drugs (AEDs) produce many alterations in metabolism, including vitamin levels. Whether they produce clinically relevant deficiency of B vitamins has rarely been assessed. We obtained B-vitamin levels in patients who were being converted from an inducing AED (phenytoin or carbamazepine) to a non-inducing AED (levetiracetam, lamotrigine, or topiramate), with measurements both before and ≥ 6 weeks after the switch. A group of normal subjects underwent the same studies. Neither folate nor B12 deficiency was seen in any patient. Vitamin B6 deficiency was found in 16/33 patients (48%) taking inducers, compared to 1/11 controls (9%; p=0.031). After switch to …

Anatomical Relationships Of The Anterior Blood Vessels To The Lower Lumbar Intervertebral Discs: Analysis Based On Magnetic Resonance Imaging Of Patients In The Prone Position., Alexander R Vaccaro, Christopher K Kepler, Jeffrey A Rihn, Hidekazu Suzuki, John K Ratliff, James S Harrop, William B Morrison, Worawat Limthongkul, Todd J Albert

Rothman Institute Papers

BACKGROUND: Intra-abdominal vascular injuries are rare during posterior lumbar spinal surgery, but they can result in major morbidity or mortality when they do occur. We are aware of no prior studies that have used prone patient positioning during magnetic resonance imaging for the purpose of characterizing the retroperitoneal iliac vasculature with respect to the intervertebral disc. The purpose of this study was to define the vascular anatomy adjacent to the lower lumbar spine with use of supine and prone magnetic resonance imaging.

METHODS: A prospective observational study included thirty patients without spinal abnormality who underwent supine and prone magnetic resonance …

Nociceptive Neuropeptide Increases And Periorbital Allodynia In A Model Of Traumatic Brain Injury., Melanie B. Elliott, Michael L. Oshinsky, Peter S. Amenta, Olatilewa Awe, Jack I. Jallo

Department of Neurosurgery Faculty Papers

OBJECTIVE: This study tests the hypothesis that injury to the somatosensory cortex is associated with periorbital allodynia and increases in nociceptive neuropeptides in the brainstem in a mouse model of controlled cortical impact (CCI) injury.

METHODS: Male C57BL/6 mice received either CCI or craniotomy-only followed by weekly periorbital von Frey (mechanical) sensory testing for up to 28 days post-injury. Mice receiving an incision only and naïve mice were included as control groups. Changes in calcitonin gene-related peptide (CGRP) and substance P (SP) within the brainstem were determined using enzyme-linked immunosorbent assay and immunohistochemistry, respectively. Activation of ionized calcium-binding adaptor molecule-1-labeled …

Egr-1 Induces Darpp-32 Expression In Striatal Medium Spiny Neurons Via A Conserved Intragenic Element., Serene Keilani, Samira Chandwani, Georgia Dolios, Alexey Bogush, Heike Beck, Antonis K Hatzopoulos, Gadiparthi N Rao, Elizabeth A Thomas, Rong Wang, Michelle E Ehrlich

Farber Institute for Neuroscience Faculty Papers

DARPP-32 (dopamine and adenosine 3', 5'-cyclic monophosphate cAMP-regulated phosphoprotein, 32 kDa) is a striatal-enriched protein that mediates signaling by dopamine and other first messengers in the medium spiny neurons. The transcriptional mechanisms that regulate striatal DARPP-32 expression remain enigmatic and are a subject of much interest in the efforts to induce a striatal phenotype in stem cells. We report the identification and characterization of a conserved region, also known as H10, in intron IV of the gene that codes for DARPP-32 (Ppp1r1b). This DNA sequence forms multiunit complexes with nuclear proteins from adult and embryonic striata of mice and rats. …

Management Of Sexual Disorders In Spinal Cord Injured Patients., Vafa Rahimi-Movaghar, Alexander R Vaccaro

Department of Neurosurgery Faculty Papers

Spinal cord injured (SCI) patients have sexual disorders including erectile dysfunction (ED), impotence, priapism, ejaculatory dysfunction and infertility. Treatments for erectile dysfunction include four steps. Step 1 involves smoking cessation, weight loss, and increasing physical activity. Step 2 is phosphodiesterase type 5 inhibitors (PDE5I) such as Sildenafil (Viagra), intracavernous injections of Papaverine or prostaglandins, and vacuum constriction devices. Step 3 is a penile prosthesis, and Step 4 is sacral neuromodulation (SNM). Priapism can be resolved spontaneously if there is no ischemia found on blood gas measurement or by Phenylephrine. For anejaculatory dysfunction, massage, vibrator, electrical stimulation and direct surgical biopsy …

Rituximab Induces Sustained Reduction Of Pathogenic B Cells In Patients With Peripheral Nervous System Autoimmunity., Michael A Maurer, Goran Rakocevic, Carol S Leung, Isaak Quast, Martin Lukačišin, Norbert Goebels, Christian Münz, Hedda Wardemann, Marinos Dalakas, Jan D Lünemann

Department of Neurology Faculty Papers

The B cell-depleting IgG1 monoclonal antibody rituximab can persistently suppress disease progression in some patients with autoimmune diseases. However, the mechanism underlying these long-term beneficial effects has remained unclear. Here, we evaluated Ig gene usage in patients with anti-myelin-associated glycoprotein (anti-MAG) neuropathy, an autoimmune disease of the peripheral nervous system that is mediated by IgM autoantibodies binding to MAG antigen. Patients with anti-MAG neuropathy showed substantial clonal expansions of blood IgM memory B cells that recognized MAG antigen. The group of patients showing no clinical improvement after rituximab therapy were distinguished from clinical responders by a higher load of clonal …

The Appropriateness Of Long-Term Opioids To Treat Chronic Back Pain, Thomas Watanabe, Michael Salino, Adam Schreiber

Department of Rehabilitation Medicine Faculty Papers

Point/Counterpoint Case Scenario: A 55-year old man presents to a pain clinic upon referral from his primary care physician. His symptom is axial low back pain. His pain started approximately 1 year earlier without a specific inciting event. He denies radiation of pain into the lower extremities. There is no bowel or bladder involvement. There is no directional preference. He reports pain "all the time," with minimal specific exacerbating or relieving factors. There is no medical-legal involvement. His medical history is significant for hypertension, hypercholesterolemia, obesity, and sleep apnea. He is a divorced father of 2 adult children. He is …

Old Remedies For Epilepsy: Avicenna's Medicine., A A Asadi-Pooya, A R Nikseresht, E Yaghoubi

Department of Neurology Faculty Papers

BACKGROUND: The history of epilepsy and its treatments dates back to at least 4 millennia. Avicenna, c. 980 AD in Bukhara, Khorasan-1037 in Hamedan was a Persian-speaking Iranian physician, who has many recommendations and suggested various therapies for epilepsy in his book, The Canon of Medicine.

METHODS: We first reviewed the most important ancient treatments for epilepsy mentioned by Avicenna and considered those as the key words for our next step. Then, we made a literature search (medline and scopus) with those key words to find out new scientific findings in modern medicine about the Avicenna's suggestions.

RESULTS: Among the …

Early Versus Delayed Decompression For Traumatic Cervical Spinal Cord Injury: Results Of The Surgical Timing In Acute Spinal Cord Injury Study (Stascis), Michael G. Fehlings, Alexander Vaccaro, Jefferson R. Wilson, Anoushka Singh, David W. Cadotte, James S. Harrop, Bizhan Aarabi, Christopher Shaffrey, Marcel Dvorak, Charles Fisher, Paul Arnold, Eric M. Massicotte, Stephen Lewis, Raja Rampersaud

Department of Neurosurgery Faculty Papers

Background: There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (,24 hours after injury) versus late ($24 hours after injury) decompressive surgery after traumatic cervical SCI.

Methods: We performed a multicenter, international, prospective cohort study (Surgical Timing in Acute Spinal Cord Injury Study: STASCIS) in adults aged 16–80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was …

Utilization Of Ct Scans And Mris In An Insured Population With Migraine, Neil I. Goldfarb, Valerie Pracilio, Mph, Daisy Ng-Mak, Phd, Joe Couto, Pharmd, Mba, Cary Sennett, Md, Phd, Mary Hopkins, Rn, Jon Bumbaugh, Stephen Silberstein, Md

College of Population Health Lectures, Presentations, Workshops

Background:

• Neuroimaging is a diagnostic tool that may be used to rule out a serious condition when a patient presents with head pain. It is not typically warranted for patients who have a normal neurologic exam, and may be over utilized despite established practice parameters set by the American Academy of Neurology.

•A decision to use neuroimaging should consider the type of headache and presence of any clinical features that suggest a serious condition.

Over-utilization of neuroimaging has cost and safety implications.

The United States Headache Consortium, a panel of experts on migraine, set the guidelines for diagnosis and …

Association Between Triptanuse And Cardiac Contraindications In An Insured Migraine Population, Daisy Ng-Mak, Phd, Valerie P. Pracilio, Mph, Stephen Silberstein, Md, Joseph Couto, Pharmd, Mba, Cary Sennett, Md, Phd, Mary Hopkins, Rn, Jon Bumbaugh, Neil I. Goldfarb

College of Population Health Lectures, Presentations, Workshops

Background

Safety concerns exist when using triptansto treat patients with cardiac contraindications.

–Triptans cause vasoconstriction, a safety concern for migraineurswith cardiovascular (CV) disease or other cardiac risk factors.

–All triptans contain contraindications in their package inserts to avoid use in patients with cardiac conditions.

•Previous research indicates that clinicians are less likely to prescribe triptansin patients with CV disease or CV risk factors.

Limited research has examined the proportion of migraine patients with cardiovascular disease or those individuals who were concurrently treated with triptans.

Surgical Outcome In Pet-Positive, Mri-Negative Patients With Temporal Lobe Epilepsy, Carla Lopinto-Khoury, Michael R. Sperling, Christopher Skidmore, Maromi Nei, James Evans, Ashwini Sharan, Scott Mintzer

Department of Neurology Faculty Papers

PURPOSE:

Fluorodeoxyglucose positron emission computed tomography (FDG-PET) hypometabolism is important for surgical planning in patients with temporal lobe epilepsy (TLE), but its significance remains unclear in patients who do not have evidence of mesial temporal sclerosis (MTS) on magnetic resonance imaging (MRI). We examined surgical outcomes in a group of PET-positive, MRI-negative patients and compared them with those of patients with MTS.

METHODS:

We queried the Thomas Jefferson University Surgical Epilepsy Database for patients who underwent anterior temporal lobectomy (ATL) from 1991 to 2009 and who had unilateral temporal PET hypometabolism without an epileptogenic lesion on MRI (PET+/MRI-). We compared …

Manifestations Of Rheumatoid Arthritis: Epidural Pannus And Atlantoaxial Subluxation Resulting In Basilar Invagination., Adam L Schreiber, Do, Ma

Department of Rehabilitation Medicine Faculty Papers

Presented in part at the AAPMR 71st Annual Assembly Meeting, Seattle, WA, November 4-7, 2010.

Atlantoaxial instability results from cartilaginous destruction, periarticular erosions, and ligament and tendon attenuation. Instability affects 19%-70% of patients, and basilar invagination from vertical odontoid subluxation through the foramen magnum occurs in 38% of patients. This phenomenon occurs twice as often in women than men, whose age at diagnosis typically ranges from 30-50 years. Along with bony compression, the pannus further decreases the space available for the cord by 3mmor more in approximately 66% of patients (Figures 1-7). The earliest and most common symptom of cervical …

Mir-128 Inhibits Tumor Growth And Angiogenesis By Targeting P70s6k1., Zhu-Mei Shi, Jing Wang, Zhiping Yan, Yong-Ping You, Chong-Yong Li, Xu Qian, Yu Yin, Peng Zhao, Ying-Ying Wang, Xie-Feng Wang, Ming-Na Li, Ling-Zhi Liu, Ning Liu, Bing-Hua Jiang

Kimmel Cancer Center Faculty Papers

MicroRNAs are a class of small noncoding RNAs that function as critical gene regulators through targeting mRNAs for translational repression or degradation. In this study, we showed that miR-128 expression levels were decreased in glioma, and identified p70S6K1 as a novel direct target of miR-128. Overexpression of miR-128 suppressed p70S6K1 and its downstream signaling molecules such as HIF-1 and VEGF expression, and attenuated cell proliferation, tumor growth and angiogenesis. Forced expression of p70S6K1 can partly rescue the inhibitory effect of miR-128 in the cells. Taken together, these findings will shed light to the role and mechanism of miR-128 in regulating …

Macrophage Imbalance (M1 Vs. M2) And Upregulation Of Mast Cells In Wall Of Ruptured Human Cerebral Aneurysms: Preliminary Results., David Hasan, Nohra Chalouhi, Pascal Jabbour, Tomoki Hashimoto

Department of Neurosurgery Faculty Papers

BACKGROUND: M1 and M2 cells are two major subsets of human macrophages that exert opposite effects on the inflammatory response. This study aims to investigate the role of macrophage M1/M2 imbalance and mast cells in the progression of human cerebral aneurysms to rupture.

METHODS: Ten patients with cerebral aneurysms (five ruptured and five unruptured) underwent microsurgical clipping. During the procedure, a segment of the aneurysm dome was resected and immunostained with monoclonal antibodies for M1 cells (anti-HLA DR), M2 cells (anti-CD 163), and mast cells (anti-tryptase clone AA). A segment of the superficial temporal artery (STA) was also removed and …

Conversion From Enzyme-Inducing Antiepileptic Drugs To Topiramate: Effects On Lipids And C-Reactive Protein., Scott Mintzer, Christopher T Skidmore, Sara J Rankin, Inna Chervoneva, Edward Pequinot, David M Capuzzi, Michael R Sperling

Department of Neurology Faculty Papers

PURPOSE: We previously demonstrated that converting patients from the enzyme-inducers phenytoin or carbamazepine to the non-inducers levetiracetam or lamotrigine reduces serum lipids and C-reactive protein (CRP). We sought to determine if the same changes would occur when patients were switched to topiramate, which has shown some evidence of enzyme induction at high doses. We also examined the effects of drug switch on low-density lipoprotein (LDL) particle concentration.

METHODS: We converted 13 patients from phenytoin or carbamazepine monotherapy to topiramate monotherapy (most at doses of 100-150 mg/day). Fasting lipids, including LDL particle concentration, and CRP were obtained before and ≥6 weeks …

Mis Posterior Cervical Spine Surgery: Five-Level Fusion Through A Novel Cervical Tube, Ashwini Sharan Md, Mitchell A. Hardenbrook, Md, John K. Ratliff Md, James Harrop, Md

JHN Journal

Minimally invasive surgical (MIS) techniques to the spine have focused mainly on the lumbar region. Many reports exist on the ability to decompress the neural structures in the lumbar and thoracic spine both via an anterior and posterior approach. Familiarity with these techniques now allows one or two level interbody and pedicle fusions, and treatment of trauma through MIS approaches. Controversy exists as to the efficacy of these techniques because direct studies comparing MIS approaches with open techniques are lacking. However, proponents of these techniques site smaller incision, less muscle retraction, less blood loss, shorter length of stay and better …

Functional Recovery Of Untreated Human Immunodeficiency Virus-Associated Guillain-Barré Syndrome: A Case Report, Adam L. Schreiber, John W. Norbury Iii, Eduardo A. De Sousa

Department of Rehabilitation Medicine Faculty Papers

HIV-associated Guillain-Barré Syndrome is a well-documented phenomenon, typically occurring at seroconversion. GBS may result in functional impairment treated with a combination of medications, plasmapheresis, and rehabilitation. The quantified functional recovery of HIV-associated GBS with or without HIV treatment is not well-described. Utilizing serial FIM scoring, we describe a patient’s recovery from HIV-associated GBS after treatment with IVIg and acute inpatient rehabilitation without HIV treatment.

What Are The Implications Of Accountable Care Organizations For Physical Medicine And Rehabilitation Practices?, John L. Melvin, Greg Worsowicz

Department of Rehabilitation Medicine Faculty Papers

The goal of delivering quality health care at a lower overall cost through accountable care organizations (ACO) as described as part of the Patient Protection and Affordable Care Act of 2010 (ACA) has gained momentum among payers, providers, and the public. The concept includes developing an organization that provides incentives for quality care while lowering the overall cost of the care. If the goals are met, then both providers and payers would be able to share in the financial savings produced by the lower health care costs achieved while improving the quality of care delivered. The Centers for Medicare and …

The Prevalence Of Cervico-Arterial Dissection In Sub-Arachnoid Hemorrhage In The United States, Ali Seifi, Md, Fred Rincon, Md, Msc, Mitchell Maltenfort, Phd, Pascal Jabbour, Md, Rodney Bell, Md, Michael Moussouttas, Md

Department of Neurology Faculty Papers

Objectives: In this study, we sought to determine the prevalence of cervico-arterial dissection in aubarachnoid hemorrhage (SAH) using a large administrative database.