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Vassilios G. Dimopoulos, Ioannis Z. Kapsalakis and Kostas N. Fountas

✓Differences in skull morphological characteristics among various human populations were first described by Herodotus of Halicarnassus. The Hippocratic treatise On Head Wounds (Περι των εν κεφαλη τρωματων) provided the first detailed description of human skull anatomy. The Hippocratic author presented the first systematic attempt to create a classification system of skull and cranial suture morphology. Detailed descriptions of various human skull types and cranial sutures were provided along with information regarding the macroscopic structure and thickness of different parts of the skull. The significance of skull thickness in patients with head injuries was also presented in the Hippocratic text. The authors discuss the influence of this treatise on the later development of descriptive skull anatomy and on the development of modern neurosurgery.

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Georgia Xiromerisiou, Efthimios Dardiotis, Vaïa Tsimourtou, Persa Maria Kountra, Konstantinos N. Paterakis, Eftychia Z. Kapsalaki, Kostas N. Fountas and Georgios M. Hadjigeorgiou

Over the past few years, considerable progress has been made in understanding the molecular mechanisms of Parkinson disease (PD). Mutations in certain genes are found to cause monogenic forms of the disorder, with autosomal dominant or autosomal recessive inheritance. These genes include alpha-synuclein, parkin, PINK1, DJ-1, LRRK2, and ATP13A2. The monogenic variants are important tools in identifying cellular pathways that shed light on the pathogenesis of this disease. Certain common genetic variants are also likely to modulate the risk of PD. International collaborative studies and meta-analyses have identified common variants as genetic susceptibility risk/protective factors for sporadic PD.

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Kostas N. Fountas, Anastasia Tasiou, Eftychia Z. Kapsalaki, Konstantinos N. Paterakis, Arthur A. Grigorian, Gregory P. Lee and Joe Sam Robinson Jr.

Object

Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. The Creactive protein (CRP) constitutes a highly sensitive inflammatory marker. The association of elevated systemic CRP and coronary vasospasm has been well established. Additionally, elevation of the serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between elevated CRP levels in the serum and CSF and the development of vasospasm in patients with aSAH.

Methods

. A total of 41 adult patients in whom aSAH was diagnosed were included in the study. Their demographics, the admitting Glasgow Coma Scale (GCS) score, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum and CSF CRP measurements were obtained on Days 0, 1, 2, 3, 5, 7, and 9. All patients underwent either surgical or endovascular treatment within 48 hours of their admission. The outcome was evaluated using the Glasgow Outcome Scale and the modified Rankin Scale.

Results

The CRP levels in serum and CSF peaked on the 3rd postadmission day, and the CRP levels in CSF were always higher than the serum levels. Patients with lower admission GCS scores and higher Hunt and Hess and Fisher grades had statistically significantly higher levels of CRP in serum and CSF. Patients with angiographic vasospasm had higher CRP measurements in serum and CSF, in a statistically significant fashion (p < 0.0001). Additionally, patients with higher CRP levels in serum and CSF had less favorable outcome in this cohort.

Conclusions

Patients with aSAH who had high Hunt and Hess and Fisher grades and low GCS scores showed elevated CRP levels in their CSF and serum. Furthermore, patients developing angiographically proven vasospasm demonstrated significantly elevated CRP levels in serum and CSF, and increased CRP measurements were strongly associated with poor clinical outcome in this cohort.

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Angel N. Boev, Kostas N. Fountas, Ioannis Karampelas, Christine Boev, Theofilos G. Machinis, Carlos Feltes, Ike Okosun, Vassilios Dimopoulos and Christopher Troup

Object

The authors describe the prospective use of a new hand-held point-and-shoot pupillometer (NeurOptics) to assess pupil function quantitatively.

Methods

Repetitive measurements were made in 90 pediatric participants ranging in age from 1 to 18 years, providing a total of 100 measurements under ambient light conditions. The participants consisted of 45 patients without known intracranial or ophthalmological pathological conditions as well as 45 volunteers in the outpatient setting. Quantitative pupil measurements were reliably replicated in the study participants. The mean resting pupil aperture was 4.11 mm and the minimal diameter after stimulation was 2.65 mm, resulting in a 36% change in pupil size. The mean constriction velocity was 2.34 mm/second, with a mean dilation velocity of 2.2 mm/second.

Conclusion

Pupil symmetry was impressive in the entire cohort.

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Kostas N. Fountas, Eftychia Z. Kapsalaki, Gregory P. Lee, Theofilos G. Machinis, Arthur A. Grigorian, Joe S. Robinson Jr., Ioannis Vergados and Panagiotis G. Theodosiadis

Object

The association of vitreous and/or subhyaloid hemorrhage with aneurysmal subarachnoid hemorrhage (SAH) has been frequently identified since the original description by Terson in 1900. In this prospective clinical study the authors examined the actual incidence of Terson hemorrhage in patients suffering aneurysmal SAH, they attempted to identify those parameters that could predispose its development, and they evaluated its prognostic significance in the overall patients' outcome.

Methods

A total of 174 patients suffering aneurysmal SAH were included in this study. The admitting Glasgow Coma Scale scores (GCS), World Federation of Neurological Societies (WFNS) scale scores, Hunt and Hess grades, and Fisher grades were recorded. A careful ophthalmological evaluation was performed in all participants. The exact anatomical locations and the largest diameter of the dome of the ruptured aneurysms were also recorded. Surgical clipping or endovascular coiling was used in 165 patients. Clinical outcome was evaluated at discharge from the hospital by using the Glasgow Outcome Scale and the modified Rankin Scale. Periodic ophthalmological evaluations were performed for 2 years.

Results

In this series, the observed incidence of Terson hemorrhage was 12.1%. Statistical analysis of our data demonstrated that patients with low GCS scores and high WFNS scores, Hunt and Hess grades, and Fisher grades had an increased incidence of Terson hemorrhage. The mortality rate for patients with Terson hemorrhage was 28.6%, whereas that for patients without Terson hemorrhage was 2.0%. Moreover, patients with Terson hemorrhage who survived had significantly worse outcomes than those in patients without Terson hemorrhage.

Conclusions

Terson hemorrhage constitutes a common SAH-associated complication. Its incidence is increased in patients with low GCS and high WFNS scores, and high Hunt and Hess and Fisher grades. Its presence is associated with increased mortality and morbidity rates.

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Carlos Feltes, Kostas N. Fountas, Theofilos Machinis, Leonidas G. Nikolakakos, Vassilios Dimopoulos, Rostislav Davydov, Mozaffar Kassam, Kim W. Johnston and Joe Sam Robinson

Object

Painful osteoporotic vertebral compression fractures (VCFs) are a significant cause of disability in the elderly population. Kyphoplasty, a recently developed minimally invasive procedure, has been advocated for the successful management of these fractures in terms of immediate pain relief, and also for restoration of the premorbid level of daily activities. In this retrospective study the authors report on their experience with the early management of VCFs with kyphoplasty.

Methods

A retrospective analysis was conducted in 13 patients (seven women and six men) whose ages ranged from 48 to 87 years (mean age 71.5 ± 11 years [mean ± standard deviation]). The interval between onset of symptoms and surgical intervention ranged from 4 to 9 weeks. Twenty levels (12 thoracic, eight lumbar) were treated in this cohort. Immediate and early postoperative (1-month follow-up visit) visual analog scale (VAS) pain scores, activity levels, and restoration of vertebral body (VB) height were assessed.

The mean preoperative VAS score was 8 ± 1, whereas the immediate and early postoperative scores were 1 ± 1. These findings reflected a resolution of 90 to 100% of preoperative pain. All patients resumed routine activities within hours of the procedure, although improvement in VB height was not accomplished in this cohort. No major complications were encountered in this clinical series.

Conclusions

Kyphoplasty is a safe and effective method for the treatment of osteoporotic VCFs. Failure to restore VB height does not seem to interfere with the excellent pain management and good functional outcome provided by this procedure.

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Aristotelis S. Filippidis, Dimitrios C. Papadopoulos, Eftychia Z. Kapsalaki and Kostas N. Fountas

Object

The aim of this study was to provide a systematic update of the current literature regarding the clinical role of the S100B serum biomarker in the initial evaluation of children who have sustained a mild traumatic brain injury (TBI).

Methods

Searches in MEDLINE were defined with the keywords “mild TBI children S100,” “mild TBI pediatric S100,” and “children S100 brain injury.” From the pool of obtained studies, those that had the inclusion criteria of mild TBI only or mixed types of TBI but including detailed information about groups of children with mild TBI were used.

Results

Few studies were identified and fewer included more than 100 cases. The prospective studies showed that the S100B biomarker levels could be influenced by patient age and the time frame between head injury and blood sampling. Moreover, extracranial sources of S100B or additional injuries could influence the measured levels of this biomarker. A normal value of S100B in children with mild TBI could rule out injury-associated abnormalities on CT scans in the majority of reported cases.

Conclusions

The vulnerability of S100B serum levels to the influences of patient age, blood sampling time, and extracranial S100B release limits the biomarker's role in the initial evaluation of children with mild TBI. The application of S100B in pediatric mild TBI cases has an elusive role, although it could help in selected cases to avoid unnecessary head CT scans.

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Kostas N. Fountas, Ioannis Tsougos, Efstathios D. Gotsis, Stylianos Giannakodimos, Joseph R. Smith and Eftychia Z. Kapsalaki

Object

The purpose of this prospective study was to compare the results of proton MR spectroscopy (MRS) in temporal poles in patients with unilateral mesial temporal sclerosis (MTS) with the histopathological findings of the resected temporal poles.

Methods

A total of 23 patients (14 male and 9 female) with a mean age of 25.2 years (range 17–45 years) were included in this study, which was conducted over a 4-year period. All patients suffered medically refractory epilepsy due to unilateral, MRI-proven MTS, with no other imaging abnormalities. All participants underwent preoperative single-voxel proton MRS using a 3-T MRI unit. The hippocampi and temporal poles were examined bilaterally. The concentrations of N-acetyl-aspartate (NAA), choline (Cho), and creatine (Cr) were measured, and the NAA/Cho, NAA/Cr, and NAA/Cho+Cr ratios were calculated. All patients underwent anterior temporal lobectomy and ipsilateral amygdalohippocampectomy, and surgical specimens from the temporal poles were sent for histopathological examination. Comparisons of the spectroscopic and histopathological results of the resected temporal poles were performed. The modified Engel classification system was used for evaluating seizure outcome in the cohort.

Results

The preoperative spectroscopic profiles of the sclerotic hippocampi were abnormal in all patients, and the contralateral hippocampus showed altered spectroscopic findings in 12 patients (52.2%). Spectroscopy of the temporal poles demonstrated severely decreased concentrations of NAA, markedly increased concentrations of Cho, and increased concentrations of Cr in the temporal pole ipsilateral to the MTS in 15 patients (65.2%). Similarly, the NAA/Cho, NAA/Cr, and NAA/Cho+Cr ratios were severely decreased in the temporal pole ipsilateral to the MTS in 16 patients (69.6%). Histopathological examination of the resected temporal poles demonstrated ischemic changes in 5 patients (21.7%), gliotic changes in 4 (17.4%), demyelinating changes in 3 (13.0%), and microdysplastic changes in 1 patient (4.3%). Comparisons of the spectroscopic and histopathological findings showed that the sensitivity of proton MRS was 100%, its specificity was 80%, its positive predictive value was 87%, and its negative predictive value was 100%. The mean follow-up time in this study was 3.4 years. At the end of the 2nd postoperative year, 17 patients (73.9%) were in Engel Class I, 5 (21.7%) were in Class II, and 1 (4.3%) was in Class III.

Conclusions

Proton MRS detected altered ipsilateral temporal pole metabolism in patients with unilateral MTS. These metabolic changes were associated with permanent histological abnormalities of the temporal pole. This finding demonstrates that MTS may be a more diffuse histological process, and exact preoperative knowledge of its temporal extent becomes of paramount importance in the selection of the best surgical approach in these patients. Further validation of the observations is necessary for defining the role of temporal pole proton MRS in cases of temporal lobe epilepsy.