Remote Cerebellar Hemorrhage (Zebra Sign) in Vascular Neurosurgery: Pathophysiological Insights

Hemorrhage in regions remote from the site of initial intracranial operations is rare, but may be fatal. Postoperative cerebellar hemorrhage as a complication of supratentorial surgery, with a radiological appearance known as zebra sign, is an increasingly recognized clinical entity and is associated mainly with vascular neurosurgery or temporal lobe resection. The pathophysiology remains unclear. Three cases of remote cerebellar hematoma occurred after neck clipping of anterior communicating artery aneurysms. All patients had similar clinical findings and underwent pterional craniotomy with the head in accentuated extension. One patient died and the two were discharged without symptoms. Cerebellar hemorrhage probably has a multifactorial origin involving positioning associated with abundant cerebrospinal fluid drainage causing cerebellar sag with resultant vein stretching and bleeding, and use of aspirin or other antiplatelet agents.

Does Trochanteric Transfer Eliminate the Trendelenburg Sign in Adults?

Premature closure of the proximal femoral growth plate results in coxa brevis, which usually is associated with insufficiency of the hip abductors. Distal and lateral transfer of the greater trochanter sometimes is recommended to correct this problem. Most of what is known arises from studies of children and adolescents. We asked whether this procedure in adults with coxa brevis would eliminate hip abductor insufficiency and would improve their hip function based on the Harris hip score (HHS). We prospectively followed 11 patients, aged 19 to 55 years (mean, 40 years) who had distal and lateral trochanteric transfer. All patients had pain and a positive Trendelenburg test before surgery. This test was performed at the latest followup by three observers and the interobserver reliability was determined by the kappa coefficient. The HHS was obtained before surgery and at the latest followup. The minimum followup was 25 months (mean, 52 months; range, 25-77 months). Insufficiency of the hip abductors was eliminated in seven (according to two observers) and eight (according to one observer) of the 11 patients after surgery; the kappa coefficient ranged from 0.79 to 1.0. The mean HHS improved from 64 points preoperatively to 76 points at the final followup. The two patients with preexisting severe osteoarthritis of the hip had the worst final scores and persisted with a positive Trendelenburg test at the final followup. Distal and lateral transfer of the greater trochanter can eliminate insufficiency of the hip abductors and improve joint function in adult patients with coxa brevis and we believe should be considered for patients without severe osteoarthritis of the hip. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

DC-SIGN (CD209) gene promoter polymorphisms in a Brazilian population and their association with human T-cell lymphotropic virus type 1 infection

This study evaluated four polymorphisms located in the DC-SIGN (CD209) gene promoter region (positions -336, -332 -201 and -139) in DNA samples from four Brazilian ethnic groups (Caucasians, Afro-Brazilian, Asians and Amerindians) to establish the population distribution of these single-nucleotide polymorphisms (SNPs) and correlated DC-SIGN polymorphisms and infection in samples from human T-cell lymphotropic virus type 1 (HTLV-1)-infected individuals. To identify CD209 SNPs, 452 bp of the CD209 promoter region were sequenced and the genotype and allelic frequencies were evaluated. This is the first study to show genetic polymorphism in the CD209 gene in distinct Brazilian ethnic groups with the distribution of allelic and genotypic frequency. The results showed that -336A and -139A SNPs were quite common in Asians and that the -201T allele was not observed in Caucasians, Asians or Amerindians. No significant differences were observed between individuals with HTLV-1 disease and asymptomatic patients. However, the -336A variant was more frequent in HTLV-1 -infected patients [HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), 80%; healthy asymptomatic HTLV-1 carriers, 90 %] than in the control group (70 %) [P=0.0197, odds ratio (OR)=2.511, 95 % confidence interval (CI)=1.218-5.179). In addition, the -139A allele was found to be associated with protection against HTLV-1 infection (P=0.0037, OR=0.3758, 95% CI=0.1954-0.7229) when the HTLV-1 -infected patients as a whole were compared with the healthy-control group. These observations suggest that the -139A allele may be associated with HTLV-1 infection, although no significant association was observed among asymptomatic and HAM/TSP patients. In conclusion, the variation observed in SNPs -336 and -139 indicates that this lectin may be of crucial importance in the susceptibility/transmission of HTLV-1 infections.

Postural adjustment as a sign of attention in 7-month-old infants

Adjustments during postural control have been recognized in the process of the integration of movement and cognition. The objective of the present work was to describe postural changes and to verify if there is a correlation between postural adjustment and attention span in 7-month-old infants during 1 min of viewing an animated puppet. Method: Twenty-nine healthy infants (14 males) born from 31 to 39 weeks (median 36) were placed in a prone position and filmed watching a puppet during I min. The analysis of the images allowed us to catalogue the changes in position, the frequency of these changes, and the attention span. The following items were quantified: total number of infant positions, positions with weight transfer, changes in support, axis, decubitus, trunk and cervical movements, timing and pauses in visual attention. Results: Twenty-one infants stayed in the prone position during most of the recording, and eight chose sitting position before starting the session. Two groups were studied according to the main position throughout the filming, one in prone and the other in sitting positions, although they could rolling or crawling. For prone group the attention span was positively correlated with the number of positions with weight transfer (r = 0.53, p = 0.04), negatively correlated with trunk movements (r = -0.63, p = 0.01), and not correlated with birth or current weight. This work suggests that changes in the trunk movements and weight transfer are different traits related to the attention in 7-month-old infants. (C) 2008 Elsevier B.V.. All rights reserved.

Keyhole sign: how specific is it for the diagnosis of posterior urethral valves?

Objectives Posterior urethral valves (PUV) are the most common cause of renal impairment in boys during early childhood. Although antenatal suspicion of this pathology has become quite common in recent years, prenatal diagnosis remains challenging. The aim of this study was to evaluate the predictive value of different ultrasound criteria currently used to diagnose PUV. Methods We reviewed the antenatal and postnatal files of 54 male patients referred to our center from 2000 to 2006 after detection of fetal bilateral hydronephrosis. The following ultrasound criteria were evaluated in relation to the postnatal diagnosis of P U V: amniotic fluid volume, bladder wall thickness, bladder dilatation and the presence of the `keyhole sign`. Results Forty-two fetuses (77.8%) were suspected to have PUV on prenatal examination. Out of these, 29 (69.0%) had PUV confirmed postnatally. The sensitivity and specificity of the antenatal diagnosis of PUV were 94% and 43%, respectively. Increased bladder wall thickness and bladder dilatation were highly associated with the diagnosis of PUV (P < 0.001). However, a thick-walled bladder was observed in 39.1% and a dilated bladder in 47.8% of the infants with a postnatal diagnosis other than PUV. The presence of the keyhole sign was not found to predict a diagnosis of PUV (P = 0.27). Conclusion In this series the use of classical prenatal ultrasound signs to diagnose PUV showed high sensitivity but low specificity. The best diagnostic indicators were increased bladder wall thickness and dilatation of the bladder. The keyhole sign was not found to be a reliable predictor of PUV. Copyright (C) 2009 ISUOG. Published by John Wiley & Sons, Ltd.