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Taichung, Taiwan

Orija I.B.,Atlanta Medical Center | Weil R.J.,Neurological Institute | Hamrahian A.H.,Cleveland Clinic
Best Practice and Research: Clinical Endocrinology and Metabolism | Year: 2012

Pituitary incidentalomas (PIs) are commonly encountered in clinical practice. While most are microincidentalomas (<1 cm) and not functional, in some cases their identification may lead to discovery of unrecognized abnormalities such as pituitary hormonal deficiencies, excess hormone secretion or visual field defects. Although the majority are pituitary adenomas, the potential list of differential diagnosis is extensive. A limited biochemical work up for asymptomatic patients with microincidentalomas, to include measurement of prolactin and IGF-1, is reasonable, with further studies to be tailored based on the clinical picture. All patients with macroincidentalomas (≥1 cm) should be evaluated for hypopituitarism and undergo visual field testing if the sellar mass abuts or compresses the optic chiasm. Most PIs can be followed, closely without surgery over time, but some may require surgical removal, especially if they are found to be macroincidentalomas at presentation, encroaching on or abutting the optic chiasm, or are found to be functional, excluding prolactinomas. Recovery of pituitary function may be seen in some patients with mass effect following resection of a sellar mass. The association of headache and pituitary incidentalomas remains a diagnostic challenge. There are no randomized controlled studies to guide the follow up approach when surgery is not indicated; most of the follow up algorithms in the literature are based on personal experience. Most retrospective series on natural history indicate that microincidentalomas tend not to grow; without a need for long-term follow up unless the patient becomes symptomatic. Macroincidentalomas, on the other hand, have a propensity to grow and need a more aggressive follow up approach to minimize morbidity. © 2011 Elsevier Ltd. All rights reserved.

Rajagopalan V.,Cleveland Clinic | Pioro E.P.,Neurological Institute | Pioro E.P.,Cleveland Clinic
Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration | Year: 2014

Voxel based morphometry (VBM) allows objective and automated detection of structural changes in brains of patients with amyotrophic lateral sclerosis (ALS). We investigated whether VBM could identify cortical atrophy from T1-weighted images obtained during routine 1.5T studies of ALS patients with various clinically defined phenotypes. For this purpose T1-weighted brain MRI was obtained at 1.5T during routine clinical study in neurologic disease controls (n = 15) and ALS patients (n = 88) categorized into four subgroups based on their clinical phenotypes: predominant upper motor neuron (UMN) dysfunction with or without corticospinal tract (CST) hyperintensity (ALS-CST+/-), combined UMN and prominent lower motor neuron (LMN) dysfunction (classic ALS), and frontotemporal dementia (ALS-FTD). VBM analysis of gray matter (GM) was carried out using FSL. Results demonstrated that clinically obtained brain MRI at 1.5T revealed significantly reduced GM volume in brains of only ALS-FTD patients and not of those with predominant UMN dysfunction or classic ALS, compared to neurologic disease controls. In conclusion, GM volume loss in motor and extramotor regions of only ALS patients with FTD and not of ALS patients without FTD suggests distinct sites of predominant pathology and possibly of disease onset. Brain volumetric measures supplemented by histopathological correlations and other neuroimaging techniques, such as diffusion tensor imaging, may provide insight into ALS pathophysiology. © 2014 Informa Healthcare.

Elkind M.S.V.,Neurological Institute
CONTINUUM Lifelong Learning in Neurology | Year: 2011

Purpose of Review: This article presents current knowledge on stroke epidemiology. It covers recent data on the global burden of stroke, disparities, silent stroke, traditional and novel risk factors, and stroke triggers as well as the clinical implications of these findings. Recent Findings: Stroke is the third leading cause of death and the leading cause of chronic disability in the United States, and the burden of stroke worldwide is even greater. Large international and US case-control and prospective cohort studies have demonstrated disparities in stroke mortality and incidence. They have also shed light on the relative importance of several well-established, modifiable risk factors for ischemic stroke, such as hypertension, atrial fibrillation, other cardiac diseases, hyperlipidemia, diabetes, cigarette smoking, physical inactivity, alcohol consumption, abdominal obesity, diet, and TIA. Research on other putative stroke risk factors (including inflammation, infection, renal disease, depression, stress, and others) is ongoing. Identifying stroke triggers may be another way to minimize stroke incidence if high-risk time windows can be determined. Summary: Stroke is a major global health burden. While many of the risk factors for stroke are well known and have been studied for decades, recent studies continue to shed light on the distribution and severity of these problems. © 2011, American Academy of Neurology. All rights reserved.

Dobson R.,Queen Mary, University of London | Rudick R.A.,Neurological Institute | Turner B.,Royal London Hospital | Schmierer K.,Queen Mary, University of London | Giovannoni G.,Queen Mary, University of London
Neurology | Year: 2014

Objective: Interferon-β (IFN-b) has been shown to reduce relapse rates in multiple sclerosis; however, the clinical response appears to vary among individuals. Can early MRI be used to identify those patients who have a poor response to treatment? Methods: A systematic review of studies examining differential treatment response and clinical endpoints in groups defined as responders or nonresponders to IFN-b was performed. Metaanalytic techniques were used to combine study results where appropriate. Results: Patients with MRI evidence of poor response to IFN-b treatment as defined by either $2 new hyperintense T2 lesions or new gadolinium-enhancing lesions had significantly increased risk of both future relapses and progression as defined by the Expanded Disability Status Scale. There appeared to be an increased risk of poor outcomes 16 years after treatment initiation in those with an initial poor response to treatment. Previous evidence has shown this not to be the case in placebo arms of clinical trials. Conclusions: For those patients starting IFN-b, early MRI, within ± to 24 months after starting treatment, has the potential to provide important information when counseling patients about the likelihood of future treatment failure. This can inform treatment decisions before clinical relapses or disease progression.© 2014 American Academy of Neurology.

Mroz T.E.,Neurological Institute | Wang J.C.,University of California at Los Angeles | Hashimoto R.,Spectrum Research Inc. | Norvell D.C.,Spectrum Research Inc.
Spine | Year: 2010

Study Design. Systematic review. Objective. The objectives of this systematic review were to identify the character and rates of complications in patients after the use of BMP in spine fusion surgery and to determine whether there is a dose-response relationship of BMP with complications. Summary of Background Data. BMP is used on-label for ALIF with LT-CAGE and off-label for various spine fusion applications in the cervical, thoracic, and lumbar spines because of its effectiveness in promoting arthrodesis. Multiple studies published over the past several years have highlighted complications associated with BMP in a variety of clinical fusion scenarios. There are no systematic reviews on this topic, and thus, the complication profile of off-label use or physician directed use of BMP in spinal fusion surgery is not well characterized. Some of the reported complications are unique to BMP, which underscores the need for this thorough literature review. Methods. A systematic review of the English language literature was performed for articles published between 1990 and June 2009. Electronic databases and reference lists of key articles were searched to identify articles examining the use of BMP in spine surgery. Two independent reviewers assessed the level of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria and disagreements were resolved by consensus. Results. Two hundred forty-' articles that assessed outcomes after BMP use in spinal surgery were identified from the literature; of these, 31 articles were selected for inclusion. We determined that multiple complications are associated after the use of rhBMP-2 in both cervical and lumbar spine fusion surgery. There is a mean incidence of 44%, 25%, and 27% of resorption, subsidence, and interbody cage migration reported for lumbar spine interbody fusion surgery although reoperation or long-term detrimental effect was rare. Cervical studies report a mean 5.8% of postoperative soft tissue problems, including dysphagia, when rhBMP-2 is used for ventral cervical fusion. It was determined that the strength of evidence of the peer-reviewed literature that report on types of complications is high for the lumbar and low for the cervical spine, respectively, and that the current strength of evidence on rates of complications with BMP is moderate and low, respectively. Conclusion. The complication profile of BMP-2 for ALIF with LT-CAGE is well characterized. Because of the lack of substantive data, the same is not true for other types of lumbar fusions, or for cervical or thoracic fusion applications. BMP has been associated with a variety of unique complications in the ventral cervical and lumbar spines. The published data on BMP fail to precisely profile this product's use in fusion surgery; hence, it should be used only after a careful consideration of the relevant data. Well-designed and executed studies are necessary to completely define the incidence of various complications relative to type of BMP, type and region of fusion, surgical technique, dose, and carrier, and importantly, to define the natural history and management of associated complications. © 2010, Lippincott Williams & Wilkins.

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