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Table of Contents    
NI FEATURE: THE FOURTH DIMENSION - COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 3  |  Page : 815-825

A summary of some of the recently published, seminal papers in neurosciences


1 Department of Neurosurgery, Wockhardt Hospital, Mumbai, Maharashtra, India
2 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
4 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
5 Department of Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
6 Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication15-May-2018

Correspondence Address:
Dr. Kuntal K Das
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.232306

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How to cite this article:
Turel MK, Tripathi M, Yadav R, Srijithesh P R, Takkar A, Mehta S, Ahuja CK, Mehrotra A, Das KK. A summary of some of the recently published, seminal papers in neurosciences. Neurol India 2018;66:815-25

How to cite this URL:
Turel MK, Tripathi M, Yadav R, Srijithesh P R, Takkar A, Mehta S, Ahuja CK, Mehrotra A, Das KK. A summary of some of the recently published, seminal papers in neurosciences. Neurol India [serial online] 2018 [cited 2018 Nov 20];66:815-25. Available from: http://www.neurologyindia.com/text.asp?2018/66/3/815/232306




Garancher A, et al . NRL and CRX define Photoreceptor identity and reveal subgroup-Specific Dependencies in Medulloblastoma. Cancer Cell 2018;33:435-49.

Cancer cells often express differentiation programs unrelated to their tissue of origin, although the contribution of these aberrant phenotypes to malignancy is poorly understood. An aggressive subgroup of medulloblastomas (MBs) express a photoreceptor differentiation program normally expressed in the retina. The authors established that two photoreceptor-specific transcription factors, neural retina leucine zipper (NRL) and cone-rod homeobox (CRX) genes, are master regulators of this program and are required for tumor maintenance in this subgroup. Beyond photoreceptor lineage genes, they identified B-cell lymphoma-extra large (BCL-XL) protein (encoded by the BCL2-like 1 gene and a transmembrane molecule in the mitochondria) as a key transcriptional target of NRL. This provides evidence substantiating anti-BCL therapy as a rational treatment opportunity for select MB patients. Their results highlight the utility of studying aberrant differentiation programs in cancer and their potential as selective therapeutic vulnerabilities.

Contributed by Dr. Mazda K. Turel

Link MJ, et al . Quality of Life in Patients with Vestibular Schwannomas Following Gross Total or Less than Gross Total Microsurgical Resection: Should we be Taking the Entire Tumor Out? Neurosurgery 2018;82:541-7.

In many cases, less than gross total resection (GTR) of vestibular schwannomas (VS) is performed to preserve neurological, and especially, facial nerve functions. This study was conducted in 143 patients to analyze the long-term quality of life (QoL) in a cohort of patients who received either GTR (n = 122) or less than GTR (n = 21) for VS less than 3 cm of size. QoL was assessed at a mean of 7.7 years after surgery. Patients who underwent GTR had smaller tumors; otherwise, there were no baseline differences between the groups. Patients who underwent GTR, after multivariable adjustment for baseline features as well as facial nerve and hearing outcomes, reported significantly better Short Form Health Survey-36 (SF-36) physical and mental scores, Patient-Reported Outcomes Measurement Information System (PROMIS-10) physical and mental scores, Penn Acoustic Neuroma Quality of Life (PANQOL) facial, energy, general health scores, and total scores compared to patients receiving less than GTR. This fact is especially significant in the assessment of mental health, indicating there may indeed be a psychological advantage to the patient that translates to overall well-being, to have the entire tumor removed if microsurgical resection is undertaken.

Contributed by Dr. Mazda K. Turel

Prell J, et al. Reduced Risk of Venous Thromboembolism with the Use of Intermittent Pneumatic Compression After Craniotomy: A randomized Controlled Prospective Study. J Neurosurg 2018 Doi: 10.3171/2017.9.JNS17533.

The term “venous thromboembolism” (VTE) subsumes deep venous thrombosis (DVT) and pulmonary embolism. The incidence of DVT after performing a craniotomy was reported to be as high as 50%. The present study aimed to evaluate the intraoperative use of intermittent pneumatic compression (IPC) of the lower extremities for prevention of VTE in 108 patients undergoing elective craniotomy. In the control group, the conventional compression stockings were worn during surgery. In the treatment group, IPC of the calves was used in addition. The presence of DVT was evaluated by Doppler sonography, both pre- and postoperatively. The intraoperative use of IPC led to a significant reduction of VTE, and the risk of VTE was approximately quartered by the use of IPC. The duration of surgery was confirmed to be correlated with VTE incidence; every hour of surgery increased the risk of DVT by a factor of 1.5. The authors concluded that the intraoperative use of IPC significantly lowered the incidence of potentially fatal VTE in patients undergoing a craniotomy. The method of IPC was easy to use and carried no additional risks.

Contributed by Dr. Mazda K. Turel

Jenkinson MD, et al. Intraoperative imaging technology to maximise extent of resection for glioma. Cochrane Database Syst Rev 2018;1:CD012788.

A Cochrane review of the image-guided surgery techniques (iMRI, fluorescence-guided surgery with 5-aminolevulinic acid, and 'neuronavigation') has found some evidence that these methods may result in larger extents of brain tumor excision. The authors identified four randomised controlled trials in patients with high-grade gliomas, but found that available evidence (for extent of resection) was of low- to very low-quality, and that there was insufficient data to determine whether or not any of the evaluated technologies affected the overall survival, the time until disease progression, or the quality of life.

Contributed by Dr. Mazda K. Turel

Saadeh FS, et al. Seizure outcomes of supratentorial brain tumor resection in pediatric patients. Neuro Oncol 2018 doi: 10.1093/neuonc/noy026.

A retrospective study has examined the rate of developing seizures and the risk factors for developing them in children between 0 and 21 years of age, after supratentorial brain tumor resection. Of the 200 patients examined, 67 (34%) patients experienced postoperative seizures; 18 (27%) patients had early seizures, and 49 (73%) patients had late seizures. The findings from these 200 patients identified five risk factors, which the authors state “should be considered in the postoperative management of these patients”: seizures before surgery, age of less than two years, tumor location in the temporal or the thalamic region, and preoperative hyponatremia. The extent of resection did not correlate with seizure development. This fact could be used to guide the postoperative management of patients harbouring a supratentorial tumor and the appropriate usage of anti-epileptic drugs (AEDs).

Contributed by Dr. Mazda K. Turel

Dagan M, et al. Multitarget transcranial direct current stimulation for freezing of gait in Parkinson's disease. Mov Disord 2018 doi: 10.1002/mds.27300.

The objective of this study was to evaluate the effects of multi-target transcranial direct current stimulation of the primary motor cortex and the left dorsolateral prefrontal cortex on the freezing of gait and related outcomes in Parkinson's disease (PD). Twenty patients with PD and freezing of gait received 20 minutes of transcranial direct current stimulation on 3 separate visits. Performance on the freezing of gait-provoking test, timed up and go, and the Stroop test improved after simultaneous stimulation of the primary motor cortex and left dorsolateral prefrontal cortex, but not after solely the stimulation of the primary motor cortex only with sham stimulation. The authors concluded that transcranial direct current stimulation, designed to simultaneously target the motor and the cognitive regions, apparently induces immediate after-effects in the brain that translate into reduced freezing of gait and improvements in the executive function and mobility.

Contributed by Dr. Mazda K. Turel

Barbaro NM, et al. Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial. Epilepsia 2018 doi: 10.1111/epi.14045.

This randomized, single-blinded, controlled trial compared stereotactic radiosurgery (SRS) against anterior temporal lobectomy (ATL) for patients with pharmaco-resistant unilateral mesial temporal lobe epilepsy (MTLE) in 14 centers in the USA, UK, and India. The treatment was either with SRS at 24 Gy to the 50% isodose targeting mesial structures, or with the standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at a 36-month follow-up visit.

A total of 58 patients (31 in SRS group, 27 in ATL group) were treated. Sixteen (52%) patients undergoing SRS and 21 (78%) patients undergoing ATL achieved seizure remission. The mean VM changes from the baseline for 21 English-speaking, dominant-hemisphere patients did not differ between the groups; consistent worsening occurred in 36% of patients undergoing SRS and in 57% of patients undergoing ATL. The QOL improved with seizure remission.

These data suggest that ATL has an advantage over SRS in terms of the proportion of seizure remission. Both SRS and ATL appear to be effective and reasonably safe as treatment options for MTLE. SRS is an alternative to ATL for patients with medical contraindications or those reluctant to undergo an open surgery.

Contributed by Dr. Mazda K. Turel

Zoia C, et al. Usefulness of corset adoption after single-level lumbar discectomy: A randomized controlled trial. J Neurosurg Spine 2018 doi: 10.3171/2017.8.SPINE17370.

The authors sought to verify whether or not corset adoption could improve the short-term and mid-term outcome scores of patients after a single-level lumbar discectomy. A randomized controlled trial of 54 consecutive patients was performed. The patients were randomly assigned to use or not use a lumbar corset in the upright position. Patients who had already undergone previous interventions for disc herniation or with concomitant canal or foraminal stenosis were excluded. The visual analogue scale, Oswestry disability index, and Roland Morris disability questionnaire were used to compare groups at 1- and 6-month follow-up time points. No significant differences were reported between the 2 groups at either time point for any of the given outcomes, irrespective of the scale used. The authors concluded that corset adoption does not improve the short-term and midterm outcomes of patients after a single-level lumbar discectomy.

Contributed by Dr. Mazda K. Turel

Dijkerman ML, et al. Decompression with or without concomitant fusion in lumbar stenosis due to degenerative spondylolisthesis: A systematic review. Eur Spine J 2018 doi: 10.1007/s00586-017-5436-5.

The primary objective of this systematic review was to compare the outcomes after decompression with and without concomitant instrumented fusion in patients with lumbar stenosis and degenerative spondylolisthesis. PubMed, Embase, CENTRAL, Cochrane, Web of Science, CINAHL and Academic Search Premier were searched. Eleven studies were included in the analysis involving 3119 patients in total. In the majority of these studies, including the two randomized control trials, the clinical outcome in both the patient groups was comparable on most of the clinical outcome measures. Currently, there is not enough evidence that adding instrumented fusion to decompression leads to superior outcomes compared to decompression only, in patients with lumbar stenosis and degenerative spondylolisthesis. The most important clinical outcome measures, including the Oswestry disability index, show comparable results. The least invasive and least costly procedure, decompression alone, is therefore preferred in patients with a low-grade spondylolisthesis with predominant leg pain.

Contributed by Dr. Mazda K. Turel

Hurwitz EL, et al. The Global Spine Care Initiative: A summary of the global burden of low back and neck pain studies. Eur Spine J 2018 doi: 10.1007/s00586-017-5432-9.

This article summarizes the relevant findings related to low back and neck pain from the Global Burden of Disease (GBD) reports for the purpose of informing the Global Spine Care Initiative. In 2015, low back and neck pain were ranked as the fourth leading cause of disability-adjusted life years (DALYs) globally just after ischemic heart disease, cerebrovascular disease, and lower respiratory infections. In 2015, over half a billion people worldwide had low back pain, and more than a third of a billion had neck pain of more than a 3-month duration. Low back and neck pain are the leading causes of years-lived-with-disability in most countries and age groups. The prevalence of low back and neck pain and disability have increased markedly over the past 25 years and will likely increase further as the population ages. Spinal disorders should be prioritized for research funding given the huge and growing global burden. A four part series has currently been published on the global burden of back pain in Lancet on behalf of the Lancet Low Back Pain Series Working Group.

Contributed by Dr. Mazda K. Turel

Asboth L, et al. Cortico-reticulo-spinal circuit reorganization enables functional recovery after severe spinal cord contusion. Nat Neurosci 2018;21:576-88.

Severe spinal cord contusions interrupt nearly all brain projections to lumbar circuits producing leg movement. Failure of these projections to reorganize leads to permanent paralysis. Here, the authors modelled these injuries in rodents. A severe contusion abolished all motor cortex projections below the level of injury. However, the motor cortex immediately regained adaptive control over the paralyzed legs during electrochemical neuromodulation of lumbar circuits. Glutamatergic reticulospinal neurons with residual projections below the level of injury relayed the cortical command downstream. Gravity-assisted rehabilitation enabled by the neuromodulation therapy reinforced these reticulospinal projections, rerouting cortical information through this pathway. This circuit reorganization mediated a motor cortex-dependent recovery of natural walking and swimming without the requirement of neuromodulation. Cortico-reticulo-spinal circuit reorganization may also improve recovery in humans and may serve as a brainstem bypass following spinal cord injury.

Contributed by Dr. Mazda K. Turel

Daly S, et al. Hyperbaric oxygen therapy in the treatment of acute severe traumatic brain injury: A systematic review. J Neurotrauma 2018;35:623-9.

There has been no major advancement in a quarter of a century in the treatment of acute severe traumatic brain injury (TBI). This review summarizes 40 years of clinical and pre-clinical research on the treatment of acute TBI with hyperbaric oxygen therapy (HBO2). Thirty studies that administered HBO2 within 30 days of a TBI were identified from PubMed searches. The pre-clinical studies consistently reported positive treatment effects across a variety of outcome measures with almost no safety concerns, thus providing strong proof-of-concept evidence for treating severe TBI in the acute setting. Of the eight clinical studies reviewed, four were based on the senior author's investigation of HBO2 as a treatment for acute severe TBI. These studies provided evidence that HBO2 significantly improves physiologic measures without causing cerebral or pulmonary toxicity and can potentially improve clinical outcomes. This comprehensive review demonstrates that HBO2 has the potential to be the first line of significant treatment in the acute phase of severe TBI.

Contributed by Dr. Mazda K. Turel

Katayama K, et al. The effect of goreisan on the prevention of chronic subdural hematoma recurrence - multicenter, randomized controlled study. J Neurotrauma 2018 doi: 10.1089/neu. 2017.5407.

The relatively high rate of postoperative recurrence in the treatment of chronic subdural hematoma (CSDH) is a significant problem. Goreisan is an herbal medicine that exhibits a hydragogue effect by inhibiting the expression of aquaporins, and its efficacy in preventing postoperative CSDH recurrence has been suggested by several case trials. This multicenter, prospective, randomized controlled trial was performed in Japan to investigate the preventive effect of goreisan on postoperative CSDH recurrence. Patients with symptomatic CSDH over the age of 60 years undergoing burr hole surgery were enrolled in this study. The patients were randomly allocated to the control group or the goreisan group, in which oral administration of goreisan (7.5 g daily) was continued for 12 weeks. The primary endpoint was the post-operative recurrence rate at 12 weeks, and the secondary endpoint was hematoma volume reduction rates on CT scan at 12 weeks. 188 patients were followed up and analyzed (the control group; n = 88, the goreisan group; n = 92). The recurrence rates considering patients of all ages and patients under 75 years old were relatively low in the goreisan group but without a significant difference. The hematoma volume reduction rates showed no significant difference. Based on the results of the present study, a larger-scale study that includes more cases is necessary in the future to confirm the efficacy of goreisan.

Contributed by Dr. Mazda K. Turel

Martinez-Ramirez D, et. al. Efficacy and safety of deep brain stimulation in Tourette syndrome. JAMA Neurol 2018;75:353-9.

Gilles de la Tourette syndrome, a rare developmental neurological disorder, has remained an enigma for the physicians for years. Broadly, it is considered to be a dysfunction in the cortico-basal ganglia and the thalamocortical networks. As the pathophysiology of the disease still remains poorly defined, the targets for the stimulation surgeries remain ill-defined too. In this perspective, “The International Tourette Syndrome Deep Brain Stimulation Public Database and Registry” analyzed 185 patients of resistant Tourette syndrome and evaluated these patients on a common clinical ground and rating scales. Although the small sample size did not allow any definitive recommendation to be made, nearly similar benefits were observed by targeting the centromedian nucleus of thalamus and the posterior globus pallidus interna. Overall, DBS provided >55% improvement in the tic score, and therefore, remains the most promising treatment modality among all the available options at present. This was accompanied by an overall adverse event rate of 35.4%, principally related to hardware malfunction, dysarthria, and paraesthesia. Thus, the study highlighted the need for a long-term evaluation of these patients based on their individual analysis for making any recommendations regarding the management guidelines for this debilitating disorder of the young population.

Contributed by Dr. Manjul Tripathi, Dr. Srijithesh PR, and Dr. Sahil Mehta

Cohen JD, et al. Detection and localization of surgically resectable cancers with a multi-analyze blood test. Science 2018;359:926-30.

Malignancies remain the leading cause of mortality throughout the world. Statistics reveal an increasing incidence and prevalence of primary and systemic malignancies in all the ethical groups throughout the world. Earlier detection of the cancer is the key to reducing mortality and morbidity. Another goal of cancer management is the detection of cancers before they metastasize to other organs. Eight common solid malignancies can be diagnosed with “liquid biopsy,” i.e. blood tests that detect somatic mutations. The authors described a new blood test called 'Cancer SEEK', which detects tumors at an early stage by poly-based assays and protein biomarkers. Two major problems with similar kind of tests conducted earlier have been a low yield and an inability to identify the anatomical site of primary cancer in the absence of clinically evident disease. Though the results of this study can be considered as a proof of concept at present, a long-term analysis with a dedicated evaluation of sensitivity and specificity is needed for the detection of neoplasia in different stages of the diseases. Such tests might be a burden in the absence of a good positive predictive value, as false positive cases would be unnecessarily scrutinized which would introduce significant financial, ethical, and clinical dilemmas. This is, however, a welcome step, as for many adult cancers, it takes two to three decades for the incipient neoplastic lesions to progress to end-stage disease. Even when metastasis has been initiated but is not yet evident radiologically, cancers can be cured in up to 50% of the cases with systemic therapies.

Contributed by Dr. Manjul Tripathi

Gaínza-Lein M, et. al. Association of time to treatment with short-term outcomes for pediatric patients with refractory convulsive status epilepticus. JAMA Neurol. 2018. doi: 10.1001/jamaneurol.2017.4382.

Irrespective of the age of the patient, refractory convulsive status epileptics (RCSE) remains a neurological emergency. A delay in the management often proves detrimental and may even cause a fatality. In pediatric patients, an untimely management of RCSE is ultimately associated with a higher frequency of death, the use of multiple antiepileptics, a longer convulsion duration, more frequent hypotension, and a poor functional outcome. Findings of this study highlight the need to increase the general public awareness for status epileptics similar to other emergencies like cardiac arrest and stroke. The probable answer to this situation is administration of rescue medication for patients with known seizure disorder and an early administration of first antiepileptic (usually benzodiazepine) in the prehospital setting, usually at home. Family members and parents of at-risk and known epileptic patients should be counselled for a seizure action plan for a faster detection, recognition, and treatment of status epilepticus.

Contributed by Dr. Manjul Tripathi

Martínez-Moreno NE, et al. Stereotactic radiosurgery for tremor: Systematic review. J. Neurosurg. 2018;1-12.

This literature review provides a practice guideline by the International Stereotactic Radiosurgery Society. Thirty four full text articles were analyzed with an evaluation of the outcome and complication profiles for patients with intractable tremors. Broadly, some remarks could be concluded with level four evidence; a. Stereotactic radiosurgery (SRS) can be considered for patients with medically refractory tremors who are not considered for invasive surgery; b. SRS should be considered even if the patient is a candidate for invasive surgery as it seems to have a lower complication profile; and, c. GKRS should be considered with a single 4 mm collimator shot with 130-150 Gy radiation in a single session by targeting the ventral intermediate nucleus, after ensuring a proper localization with stereotactic  Atlas More Detailses and magnetic resonance imaging. This review, however, still fails to provide an answer on whether or not stimulation surgery should be preferred to lesioning surgeries as the current level of evidence does not favor any particular modality.

Contributed by Dr. Manjul Tripathi

Graffeo CS, et al. Hypopituitarism after single-fraction pituitary adenoma radiosurgery: Dosimetric analysis based on patients treated using contemporary techniques. Int J Radiat Oncol Biol Phys. 2018. doi: 10.1016/j.ijrobp.2018.02.169.

Gamma knife radiosurgery is, at present, the most favored stereotactic radiation technique for residual or recurrent pituitary adenomas as an adjuvant radiation therapy. However, it also leads to its own share of complications, which are frequently avoidable with a better dosimetry plan. Post-radiation hypopituitarism is a dose and time dependent phenomenon. This article by a leading group has highlighted a few important conclusions: a. A mean radiation dose of 11 Gy is the deciding factor for long-term hormonal deficiencies, hence attempts should be made to reduce the radiation dose delivered to the normal pituitary gland to <11Gy; b. The tumor coverage and dosimetry should not be compromised for the long-term hormonal control; c. All patients need protocol based clinico-radiological follow up to identify subclinical hormonal deficiencies before they become overt; and, d. The exact radiation tolerance of the pituitary stalk and the mammillary bodies still remains ill-defined but radiation spillage of <7 Gy to the pituitary stalk should be practiced. All these effects are desirable but may be impossible to achieve in the post-operative cases where normal pituitary gland cannot be identified from the post-operative fat packing and inflammatory changes. The male sex, a small pituitary gland, and a higher mean pituitary dose were independent predictors for the poor long-term outcome.

Contributed by Dr. Manjul Tripathi

Capper D, et al. DNA methylation-based classification of central nervous system tumors. Nature. 2018. doi: 10.1038/nature26000.

With each refinement in the World Health Organisation (WHO) classification of central nervous system (CNS) tumors, new entities with further sub-classifications are being added principally on the basis of histological and molecular classification schemes. Though more accurate than the earlier schemes, the latest WHO classification (2016) still remains elusive with respect to the categorization of borderline and challenging cases. These cases have significant inter-observer variability among the pathologists and often result in a change in the histological grading and diagnosis on retrospective evaluation. At present, a pathologist is forced to classify a tumor into a pertinent group even in the ambiguous cases. In order to make this procedure more objective and facilitate the pathological diagnosis, deoxyribose nucleic acid (DNA) methylation profiling is proposed to be a more robust method, which is reproducible when the sample is either small or of poor quality. This modification has enabled a change in the diagnosis in nearly 12% of the patients. This objective machine- based learning provides a high level of standardization to reduce the substantial inter-observer variability commonly noticed in CNS tumor registries. As things stand today, DNA methylation should not replace but substantiate the current molecular-histological diagnostic algorithm for establishing a more accurate diagnosis, an easy exchange of information among care providers, and a better patient care.

Contributed by Dr. Mazda K. Turel and Dr. Manjul Tripathi

Sorrells SF, et al. Human hippocampal neurogenesis drops sharply in children to undetectable levels in adults. Nature 2018. doi: 10.1038/nature25975.

The presence of a pool of progenitor cells in the hippocampus of primates leads to the addition of a large number of new neurons to the existing pool. This has been shown by many studies. However, this study by Sorrells et al., found that the number of increases in progenitors and new neurons in the human dentate gyrus reduced significantly in the first few years of life. The authors could find only a few isolated young neurons by 7 and 13 years of age. The authors could not find young neurons in the hippocampus of any of the adults with epilepsy or in healthy controls. The authors thus concluded that neurogenesis is very rare in human beings after the first few years of life and this is contrary to the phenomenon in other species where it remains preserved.

Contributed by Dr. Ravi Yadav

Archer DB, et al. A widespread visually-sensitive functional network relates to symptoms in essential tremor. Brain 2018;141:472-85.

Essential tremor is the commonest movement disorder characterized by predominantly upper limb postural tremors. Although their exact etiology is still not known, it is believed that the tremor originates in one or many of the neural oscillators in the cerebellum-thalamo-motor cortical projections. In this study, Archer et al., directly manipulated the visual feedback to explore its role in improving or worsening of essential tremor based on the functional MRI findings. They found that an increase in the visual feedback increased the frequency of tremors and this was shown by the abnormal increase in blood oxygen level dependent (BOLD) signals in the regions that included the cerebellum-thalamocortical projection as well as parietal and visual areas. Thus, the novel findings of this study are that a diffuse functional network relates to the tremor severity in essential tremors that can be identified by functional imaging and is associated with tremor severity. These observations point towards an enhanced tremor severity by a higher visual feedback. The authors suggest that this finding may have implications in developing patient-friendly computational devices that do not increase tremors by a visual feedback.

Contributed by Dr. Ravi Yadav

Fridriksson J, et al. Anatomy of aphasia revisited. Brain 2018;17. doi: 10.1093/brain/awx363.

Aphasia has been the core clinical symptom in patients with stroke of the dominant cerebral hemisphere. The classic model of teaching in the past century has been the Wernicke-Leichtheim model. The evidence to support the hypothesis given by Hickok and Poeppel, which suggests the 'dual stream' model to explain the aphasias, is the basic foundation of this paper. The authors prove the presence of a dorsal stream and a ventral stream of connections based on the data using lesions to show the neuroanatomical correlates of the dorsal and ventral streams that support speech and language processing. With the help of their data, they have demonstrated that the dorsal stream lesions are associated with motor speech impairment and the ventral stream lesions are associated with impaired speech comprehension. The authors argue in favor of this hypothesis as a better method for explanation of similar syndromes of aphasia arising out of lesions along these circuits. The authors also suggest that tests for aphasia based on these streams should be developed for a more accurate assessment.

Contributed by Dr. Ravi Yadav

Lhommée E, et al. EARLYSTIM study group. Behavioural outcomes of subthalamic stimulation and medical therapy versus medical therapy alone for Parkinson's disease with early motor complications (EARLYSTIM trial): Secondary analysis of an open-label randomised trial. Lancet Neurol 2018;17:223-31.

Bilateral subthalamic nucleus deep brain stimulation (STN DBS) is the standard therapy for patients with advanced Parkinson's disease. This interesting paper reports the two years follow up data of the previously published EARLYSTIM study and assesses changes in the behavior of patients with Parkinson's disease on a combined treatment with subthalamic stimulation and medical therapy in comparison to the medical therapy alone. This was a parallel, open-label study conducted at 17 different centers in Europe. The recruited patients with Parkinson's disease who had developed early motor complications were randomized to either medical therapy alone or bilateral subthalamic stimulation plus medical therapy. The results showed that patients in the STN DBS group had lesser number of neuropsychiatric complications as compared to the medical therapy group alone. The requirement of antipsychotic drugs also was significantly more in the medical therapy group. The authors thus concluded that STN DBS was able to reduce the rates of behavioral complications in patients with Parkinson's disease.

Contributed by Dr. Ravi Yadav

Thompson AJ, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018;17:162-73.

This interesting review article expands the well-established McDonald's Multiple Sclerosis (MS) diagnostic criteria, incorporating newer insights into this condition gathered since the last modification in the year 2010. The core additions to the criteria are the inclusion of clinical or MRI evidence of dissemination in space, oligoclonal bands in the cerebrospinal fluid (CSF) and the inclusion of cortical lesions. These factors can also be used to consider dissemination in space. Thus, this updated criterion provides some clarity in the diagnosis of MS for the clinicians. Whether or not a better diagnostic crtieria will ultimately result in better treatment outcomes remains to be seen.

Contributed by Dr. Ravi Yadav

Schenkman M, et al. Effect of high-intensity treadmill exercise on motor symptoms in patients with de novo Parkinson disease: A phase 2 randomized clinical trial. JAMA Neurol 2018;75:219-26.

The paper reports the results of a phase 2 randomized clinical trial investigating the effect of treadmill exercise performed at two different intensities (high and moderate) on de-novo early Parkinson disease patients (Hoehn and Yahn scale 1 or 2), called Study in Parkinson Disease of Exercise (SPARX). The exercise regime comprised treadmill exercise at least three days per week and involved a high-intensity exercise (aimed to achieve 80%-85% maximum heart rate) and a moderate intensity exercise (targeting 60%-65% of maximum heart rate). The main outcome parameters were safety, feasibility and adherence to the exercise regimen and the 6-month change in the United Parkinson's Disease Rating Scale (UPDRS) motor score. One hundred and twenty eight participants were randomized into three groups. Both the exercise groups met the target of the proposed exercise schedule. The mean change in the UPDRS motor score in the high-intensity group was 0.3 (95% confidence internval (CI), -1.7 to 2.3), while the change was nearly 10 times more than in the usual care group (3.2, 95% CI, 1.4-5.1). There was no significant difference between the medium-intensity group and the usual care group. Adverse effects were physical pain and injury related to the exercise. Falls were not disproportionately more in the exercise groups. Given the phase 2 nature of the study, the authors recommended a larger efficacy trial.

Contributed by Dr. Srijithesh PR

Albers GW, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018;378:708-18.

This paper reports the results of DEFUSE 3 (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial. It hypothesized that patients who had perfusion mismatch were likely to benefit from endovascular therapy administered between 6 to 16 hours of the onset of stroke or after the time last seen well. The ischemic core and penumbral volumes were calculated using an automated image post-processing software. Eligible patients were those who had occlusion of an intracranial carotid artery or a proximal middle cerebral artery on CT or MR angiography. One hundred and eight two patients were randomized at 38 centres between the endovascular therapy and the standard medical therapy groups based on the presence of predefined perfusion mismatch. The study was terminated early after an interim analysis demonstrated clear efficacy of the endovascular therapy group. The endovascular therapy group had a better outcome with an adjusted odds ratio of 3.36 (95% confidence interval (CI), 1.99-5.77). There was a 28% absolute difference in the functional independence at 90 days in the endovascular therapy group. The results of this study correlated well with another similar trial published recently (DAWN trial). These two trials and certain other trials have used the perfusion mismatch criteria for patient selection and thus have been able to demonstrate a larger effect size for functional independence than those obtained using alternative methods of patient selection.

Contributed by Dr. Srijithesh PR

Skljarevski V, et al. Effect of different doses of galcanezumab vs placebo for episodic migraine prevention: A randomized clinical trial. JAMA Neurol 2018;75:187-93.

Calcitonin gene-related peptide (CGRP) is an important mediator involved in migraine. Monoclonal antibodies against CGRP or CGRP receptors are novel 'designer molecules' developed for prophylaxis against an acute attack of migraine. In this paper, a phase 2b study of a humanized monoclonal antibody, galcanezumab, the authors have used four different doses for the prophylaxis of episodic migraine. The study protocol involved subcutaneous injections of galcanezumab at doses of 5, 50, 120, or 300 mg, or a placebo given monthly during a 3-month treatment period. Four hundred and ten patients were randomized. Out of all the dosing patterns, galcanezumab in a dose of 120mg significantly reduced the primary end point of migraine headache days compared with the placebo. Although side effects were reported in 5% of the patients, there were no serious adverse effects.

This study is at best a proof-of-concept result. The duration of this study was not enough to capture the expected spectrum of side effects of antibodies to CGRP. CGPR has an important role as a vasodilatory agent and is distributed in the enteric nervous system. The cardiovascular and gastrointestinal side effects need to be observed in the future studies, which must include an appropriate sample size of patients who are followed up for a much longer duration. The harm-benefit assessment would also warrant a head-to-head trial with the established migraine prophylactic agents.

Contributed by Dr. Srijithesh PR

Sato T, et al. Mogamulizumab (Anti- CCR4) in HTLV-1- associated myelopathy. N Engl J Med 2018;378:529-38.

Human T- lymphotropic virus type 1 (HTLV-1) causes HTLV-1 associated myelopathy, commonly known as tropical spastic paraparesis and T cell leukaemia lymphoma. Their pathology involves affection of the CCR4+ cells, leading to functional changes and chronic inflammation in the spinal cord. The authors in this open label dose escalation phase 1- 2a trial studied the role of mogamulizumab, a humanized monoclonal antibody against CCR4 in glucocorticoid refractory tropical spastic paraparesis. 21 patients were enrolled and received mogamulizumab at a dose of 0.003 mg/kg infusion every 8 weeks. There was a dose dependent reduction in the proviral load of peripheral blood mononuclear cells and cerebrospinal fluid inflammatory markers. Clinically, there was a reduction in spasticity and in motor deficits. Skin rash was the main side effect of this treatment. Therefore, it was concluded that there was a need for further studies to clarify the effectiveness of this drug in tropical spastic paraparesis.

Contributed by Dr. Srijithesh PR and Dr. Sahil Mehta

McManus RJ, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): An unmasked randomized controlled trial. Lancet 2018;391:949-59.

Studies evaluating self-monitored titration of antihypertensive medications give contradictory findings and the precise place of tele-monitoring over self-monitoring alone is unclear. The TASMINH4 trial was a parallel randomized controlled trial of 1182 hypertensive participants older than 35 years of age. The study was aimed to assess the efficacy of self-monitored blood pressure, with or without tele-monitoring, for antihypertensive titration in patients in primary care, compared with the usual care. Patients were randomly assigned (1:1:1) to self-monitoring of blood pressure (self montoring group), to self-monitoring of blood pressure with tele-monitoring (tele-monitoring group), or to usual care (clinic blood pressure monitoring; usual care group). After 12 months, the systolic blood pressure measurements were lower in both the intervention groups compared with the usual care group. No difference between the self-monitoring and tele-monitoring groups was, however, recorded. It was concluded that self-monitoring, with or without tele-monitoring, leads to a significantly lower blood pressure than the titration guided one that is based on clinic readings. Self-monitoring of blood pressure could become a cornerstone of hypertension management for most general practitioners; and, the use of self-monitoring techniques will go a long way in avoiding various cardiological and neurological complications.

Contributed by Dr. Aastha Takkar

Ozgur OK, et al. Validity and acceptance of color vision testing on smartphones. J Neuroophthalmol 2018;38:13-6.

Smartphones have become an essential tool for most of the professionals. Though they have been used widely, their clinical validity has not been explored that well. Ishihara color plates (ICP) are the most commonly used color vision test (CVT) tools as of now. In this interesting prospective case control study of 206 patients, the authors assessed the validity of smartphone color vision testing (CVT) by comparing the results using the Eye Handbook (EHB) CVT application vs standard Ishihara color plates (ICP). CVT was performed with both ICP and EHB under standardized background illuminance. In healthy controls and in patients with ocular pathology, there was an agreement of the CVT results when smartphone CVT (EHB) was compared with the standard Ishihara color plates. Overall, the majority preferred smartphone color vision testing to standard Ishihara color plate testing. These findings demonstrate that further research may help in better understanding and improving the validity of smartphone color vision testing.

Contributed by Dr. Aastha Takkar

Morrow SA, et al. Effect of treating acute optic neuritis with bioequivalent oral vs intravenous corticosteroids. A randomized clinical trial. JAMA Neurol doi: 10.1001/jamaneurol.2018.0024.

The current standard of treatment for optic neuritis is intravenous (IV) administration of corticosteroids. While oral corticosteroids have been used widely, it is uncertain whether bioequivalent doses of corticosteroids administered orally will be more cost-efficient and convenient for these patients. This single blinded randomized clinical trial of 55 patients was carried out to determine whether or not recovery of vision following treatment of acute optic neuritis with a high-dose IV corticosteroid was superior to that with a bioequivalent dose of an oral corticosteroid. Patients between 18 and 64 years of age presenting within 14 days of acute optic neuritis, without any recovery at the time of randomization and without any previous history of optic neuritis in the same eye, were screened. Participants were randomized 1:1 to the IV methylprednisolone sodium succinate (1000-mg) or the oral prednisone (1250-mg) groups. At 1 and 6 months, no statistically significant recovery of P100 latency was noted in the IV group over the oral group. Similar non-significant finding was found for the usual and low contrast 'best corrected visual acuity' also. This study suggests that bioequivalent doses of oral corticosteroids may be used as an alternative to IV corticosteroids to treat acute optic neuritis.

Contributed by Dr. Aastha Takkar

Ballard C, et al. Evaluation of the safety, tolerability, and efficacy of pimavanserin versus placebo in patients with Alzheimer's disease psychosis: A phase 2, randomised, placebo- controlled, double- blind study. Lancet Neurol 2018;17:213-22.

Pimavanserin, a selective 5-hydroxytryptamine 2A (5HT2A) receptor inverse agonist is The Food and Drug Administation (FDA) approved medication for Parkinson's disease related psychosis. However, no drug is approved for psychosis occurring in Alzheimer's disease. This phase 2 randomized trial enrolled 180 patients aged >50 years of possible or probable Alzheimer's disease with psychosis. Equal number of patients received pimavanserin (17 mg two tablets daily) and a placebo. There was a significant improvement in psychosis at week 6 in the pimavanserin group as measured by the neuropsychiatry inventory. However, the improvement was not persistent at 12 weeks. Pimavanserin was well tolerated with no effect on cognition.

Contributed by Dr. Sahil Mehta

Galovic M, et al. Prediction of late seizures after ischaemic stroke with a novel prognostic model (the SeLECT score): A multivariable prediction model development and validation study. Lancet Neurol 2018;17:143-52.

Stroke is a major cause of acquired epilepsy in adults and can be divided into early (<7 days) or late (>7 days) post stroke epilepsy. A single episode of late seizure occurring after a structural lesion has a 60% risk of recurrence within the next 10 years. In this multivariable prediction model involving 1200 participants, 5 variables were studied. This included severity of stroke involvement, large artery atherosclerosis, early seizures, cortical involvement and middle cerebral artery involvement. The highest value (9 points) in this model predicted a 63% risk of late seizures occurring within 1 year and 83% within 5 years. The model had a high (0.77) concordance rate among the validation cohorts. This model is freely available as a smartphone app and can be personalized to predict the risk of seizures in an individual patient and can guide the use of anti-epileptogenic treatment in future trials.

Contributed by Dr. Sahil Mehta and Dr. Chirag K. Ahuja

Creamer M, et al. Intrathecal baclofen therapy versus conventional medical management for severe post stroke spasticity: Results from a multicentre, randomized, controlled, open- label trial (SISTERS). J Neurol Neurosurg Psychiatry 2018. doi: 10.1136/jnnp-2017-317021.

Post stroke spasticity occurs in 17-43% of stroke survivors within the first year and can adversely affect the quality of life by causing pain, deformities, stiffness and reduced range of motion. Intrathecal baclofen therapy is indicated for use in chronic spasticity of cerebral or spinal cord origin. In this multicentre trial, 60 patients with post stroke spasticity in at least ≥2 extremities with an Ashworth score ≥3 in at least 2 muscle groups in the lower limbs were enrolled and followed up till 6 months. The authors found a significant clinical improvement in the intrathecal baclofen group compared to the conventional medical management group. However, there was a higher incidence of adverse events, as expected, in the surgery group. This study provides a strong evidence for considering intrathecal baclofen therapy for severe post stroke spasticity.

Contributed by Dr. Sahil Mehta

Velly L, et al. Use of brain diffusion tensor imaging for the prediction of long-term neurological outcomes in patients after cardiac arrest: A multicentre, international, prospective, observational, cohort study. Lancet Neurol 2018;17:317-26.

The rates of revival following cardiac arrest have increased over the last few decades. However, the prediction of neurological outcome has remained a major challenge. Quantitative whole-brain white matter fractional anisotropy (WWM-FA), a measure of brain connectivity using diffusion tensor imaging, has been used by authors to predict long-term neurological outcomes. This is a prospective study (part of the MRI-COMA study) done across 14 centres in Europe. WWM-FA values in patients sustaining a cardiac arrest and in normal patients at 7 and 28 days were compared with the standard criteria, for assessment of unfavorable neurological outcomes. 185 patients were enrolled with 150 of them having an interpretable multimodal MRI data available. 22% patients had a favorable neurological outcome at 6 months. The prognostic accuracy was significantly higher with the normalized WWM-FA value than with the standard criteria for an unfavorable outcome for other MRI sequences. It was seen that in patients who were unconscious 7 days after their cardiac arrest, the normalized WWM-FA value, measured by diffusion tensor imaging, could be used to accurately predict neurological outcomes at 6 months.

Contributed by Dr. Chirag K. Ahuja

Eagles ME, et al. Incorporating a modified Graeb score to the modified Fisher scale for improved risk prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Neurosurgery 2018;82:299-305.

Aneurysmal subarachnoid hemorrhage (SAH) may cause delayed cerebral ischemia (DCI), a potentially devastating complication. Estimation of the extent of SAH in the early CT as per the modified Fischer scale (mFS) reasonably predicts its occurrence. In this study, another scoring system [modified Graeb score (mGS)] was evaluated by the authors in an attempt to improve the prognostic accuracy of DCI. Clazosentan to Overcome Neurological Ischemia and Infarction Occurring after Subarachnoid Hemorrhage (CONSCIOUS-1) trial cohort was used for this analysis. IVH volume was quantified with the mGS. The relation of the mGS to the eventual development of DCI was evaluated. It was found that the mFS and the mGS had similar correlation with DCI. A combined new scale that included both the scoring systems significantly improved the area under the curve (AUC) analysis compared to the mFS.

Contributed by Dr. Chirag K. Ahuja

Roark C, et al. ABC/2 method does not accurately predict cerebral arteriovenous malformation volume. Neurosurgery 2018:82;220-5.

The formula ABC/2 is commonly used by physicians to calculate volumes for various intracranial lesions including AVMs. It is particularly used during nidal volume calculation for stereotactic radiosurgery (SRS). Whether or not the volume derived from this formula closely corresponds to the actual volume is the question at hand. This is because the treatment response is based on the dose of radiation, which in turn, is dependent on the calculated volume. To address this issue, the authors retrospectively reviewed their data over 10 years. They recorded the maximum nidal diameters in orthogonal planes on digital subtraction angiogram images to determine the volume using the ABC/2 formula. Data on the nidal target volume was extracted from the operative records of SRS. Both the volumes were then compared. The median volume was 4.96 cm 3 with SRS planning methods and 6.07 cm3 with the ABC/2 methodology in the 90 AVMs identified. There was a significant difference between the SRS volume and the ABC/2 volume (P = 0.002). This study, therefore, demonstrates that the ABC/2 method grossly overestimates cerebral AVM volume when compared to the volumetric analysis from the SRS planning software.

Contributed by Dr. Chirag K. Ahuja

Boulouis G, et al. Outcome of intracerebral haemorrhage related to non-vitamin K antagonists oral anticoagulants versus vitamin K antagonists: A comprehensive systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2018;89:263-70.

Anticoagulation with vitamin K antagonists (VKA) has been shown to cause intracerebral haemorrhage (ICH) in some patients. Whether or not this can be prevented/reduced by other similar drugs is the aim of this paper. Non-vitamin K antagonists oral anticoagulants (NOAC) associated ICH is largely unknown. The authors performed a comprehensive systematic review and meta-analysis to compare the baseline ICH volume, the amount of hematoma expansion and the clinical outcomes occurring in patients who develop a NOAC-ICH versus those who develop a VKA-ICH. They performed a PubMed search, including conference abstracts, for observational studies comparing baseline characteristics and outcomes in patients with NOAC-ICH versus VKA-ICH in accordance with the PRISMA and the MOOSE guidelines. The main outcome measures were mortality and unfavorable functional outcomes (modified Rankin scale: 4–6) at discharge and at 3 months, as well as the ICH volumes and the haematoma expansion rates between the two groups. 393 NOAC-ICH and 3482 VKA-ICH were pooled in for this meta-analysis. The authors found no difference in the mean ICH-volume and the rates of hematoma expansion between the two groups. Also, there was no difference in the all-cause mortality within these groups. Thus, no set of drugs was proven to be better than the other. The quest for a safe drug, as far as ICH is concerned, still remains unfulfilled.

Contributed by Dr. Chirag K. Ahuja

Meng Y, et al. Risk factors for surgical site infection after intracranial electroencephalography monitoring for epilepsy in the pediatric population. J Neurosurg: Ped DOI: 10.3171/2018.1.PEDS17476.

This was a retrospective single center study of 199 patients who underwent an intracranial electroencephalography monitoring for epilepsy. The idea was to focus on the resultant surgical site infection (SSI) within a period of 21 days to 51 days. Univariate analysis of the 8 patients developing this complication demonstrated 4 factors related to SSI: number of people present in the operating room during the electrode insertion, the length of insertion surgery (P = 0.04), the history of a previous operation at the same surgical site (P = 0.04), and the number of depth electrodes inserted (P = 0.01). Multivariate analysis revealed that both the number of people present during the implant operation (OR 0.08, 95% CI 0.01–0.70) and the number of depth electrodes inserted (OR 3.52, 95% CI 1.44–8.59) independently contributed to SSI. The authors concluded that the number of people present during the implant operation, as well as the number of depth electrodes could lead to breach in sterility and thus result in an increased risk of infection.

Contributed by Dr. Anant Mehrotra

Massimi L, et al. Postoperative epileptic seizures in children: Is the brain incision a risk factor? Neurosurgery 2018;82:465-72.

The authors conducted a retrospective study on one-hundred and forty three consecutive patients operated for supratentorial lesions to determine whether or not brain incision increased the risk of postoperative seizures (PS) and postoperative epilepsy (PE). The children were divided into two groups, namely, group A (n = 68) who required brain corticotomy primarily for hemispheric lesions, and group B (75) treated through extracortical approaches mainly for suprasellar and optic tumors. Children who had pre-operative seizures were excluded from the study. No significant differences were found between group A and B as far as incidence of PSs (11.7% vs 14.5%) and PE (4.5% vs 6.5%), timing, and type of seizures were concerned after a mean follow-up of 6.8 years. None of the factors analysed, including the size of corticotomy in group A (<3 cm 2 vs >3 cm 2) had any impact on the epileptogenesis. The authors concluded that surgical cortical trauma does not represent a risk factor for the development of post-operative seizures.

Contributed by Dr. Anant Mehrotra

Mocco J, et al. Aneurysm morphology and prediction of rupture: An International Study of Unruptured Intracranial Aneurysms Analysis. Neurosurgery 2018;82:491-6.

The authors used the prospective International Study of Unruptured Intracranial Aneurysms cohort to identify the morphological characteristics that could predict the propensity of unruptured intracranial aneurysms to rupture in the future. For this purpose, the authors compared the data of 57 patients with ruptured aneurysms with that of 198 patients with unruptured aneurysms. The perpendicular height of the aneurysm (P = 0.008) and the size ratio (ratio of maximum diameter to the parent vessel diameter; P = 0.01) were predictors of aneurysm rupture on univariate analysis. Other parameters like aspect ratio, daughter sacs, multiple lobes, aneurysm angle, neck diameter, parent vessel diameter, and calculated aneurysm volume were not statistically significant predictors of rupture. On multivariate analysis, the perpendicular height of the aneurysm was the only significant predictor of rupture (chi-square test 7.1, P value. 008).

Contributed by Dr. Anant Mehrotra

Tye E Y, et al. Circumferential fusion: A comparative analysis between anterior lumbar interbody fusion with posterior pedicle screw fixation and transforaminal lumbar interbody fusion for L5–S1 isthmic spondylolisthesis. Spine J 2018;18:464-71.

The authors conducted a retrospective cohort study, which included 66 patients undergoing either transformaninal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) for L5-S1 isthmic spondylolisthesis, to ascertain the clinical, radiographic, and expenditure differences between the two procedures. Quality of life (QoL) outcome scores, radiographic data, and data involving the cost incurred were collected. The patients were followed up for a minimum of 1-year. The QOL outcome scores included the EuroQol-5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Sagittal balance parameters evaluated in this study were: pelvic incidence, pelvic tilt, sacral slope, segmental lordosis, total lordosis, degree of slip, disc height, and L1-axis S1 distance (LASD). In-hospital charges, hospital length of stay (LOS), and post-admission costs accrued over 1 year constituted the expenditure related data. Despite similar statistically significant improvements in the PDQ and EQ-D score at a 1-year follow-up, the ALIFPS group showed a significantly greater improvement in the EQ-5D scores at 1 year (0.1 [0,0.2] vs. 0.2 [0.1, 0.4], P= 0.02). Furthermore, only the ALIFPS cohort showed a significant improvement in segmental lordosis. The ALIFPS cohort also showed a significantly greater improvement in the disc height than the TLIF one (3.5 (2, 5.5) versus 6.7 (4.1, 10), P= 0.01). No significant differences were found in the direct costs between the two procedures. The authors concluded that ALIFPS could provide better clinical outcomes as compared with TLIF without any additional increase in the cost involved.

Contributed by Dr. Anant Mehrotra

Malcolm JG, et al. Early cranioplasty is associated with greater neurological improvement: A systematic review and meta-analysis. Neurosurgery 2018;82:278-88.

This paper tries to analyze the impact of timing of cranioplasty following decompressive craniectomy (DC) in order to be able to make recommendations for the same. All the prominent databases dealing with articles written in English were thoroughly investigated by the authors. They set 90 days (3 months) as the time limit to define early versus late cranioplasty after the primary procedure. They pooled in data from 528 patients available in these papers to compare the neurological conditions pre- and post cranioplasty to determine the overall effect as well as the difference between the early and the late cranioplasty groups. Although the authors did not find any differences between the preoperative status of the early and the late cranioplasty groups, the postoperative outcomes were found heavily tilted in favor of early cranioplasty.

Contributed by: Dr. Kuntal K. Das and Dr. Anant Mehrotra

Zorana J, et al. Long-term exposure to ambient air pollution and incidence of brain tumor: The European Study of Cohorts for Air Pollution Effects (ESCAPE). Neuro-Oncology 2018;20:420-32.

Environmental pollution is a recognized evil of modern civilization. This paper will only add to this rising uproar against pollution. The investigators of this study chose 12 cohorts from 6 different European countries and determined their annual mean pollution exposure which included: particulate matter (PM) ≤2.5, ≤10, and 2.5–10 μm in diameter (PM2.5, PM10, and PMcoarse), PM2.5 absorbance, nitrogen oxides (NO2 and NOx) and elemental composition of PM. At the same time, they estimated the cohort-specific associations of air pollutant concentrations and traffic intensity with total, malignant, and nonmalignant brain tumors, utilizing certain statistical tools. They noted the development of malignant tumors in 466 out of 2,82,194 patients over 12 years. Out of all the pollution parameters, the authors found a positive, albeit statistically insignificant, association of PM2.5 absorbance with malignant brain tumors. There were no such association found with the non-malignant brain tumors.

Contributed by: Dr. Kuntal K. Das

Shan X, et al. Clinical characteristics associated with postoperative seizure control in adult low-grade gliomas: A systematic review and meta-analysis Neuro-Oncology 2018;20:324-31.

Seizure is the commonest mode of presentation in adult, supratentorial, low-grade gliomas. Apart from the oncological concerns, control of epilepsy remains a major goal of surgery in these lesions. The control of epilepsy has been hailed as the primary reason for the improvement in quality of life of these patients following resective surgery. This study aimed to systematically analyze the existing literature to find out the factors predicting seizure freedom after supratentorial low-grade gliomas excision. After reviewing 23 studies with a combined study population of 2641 patients, the authors found that patients aged 45 years or more, patients presenting with generalized seizures, seizures of less than a year of duration and patients with gross total tumor excision did have a better seizure freedom postoperatively.

Contributed by: Dr. Kuntal K. Das

Gutman G, et al. Surgical treatment of cervical radiculopathy: Meta-analysis of randomized controlled trials. Spine 2018;43:E365-E372.

Radiculopathy secondary to degenerative cervical spondylosis represents one of the commonest clinical conditions encountered by spinal surgeons. When the condition is symptomatic and refractory to conservative measures, a surgical intervention becomes mandatory. Anterior cervical discectomy with fusion (ACDF) has remained the gold standard of treatment. Recently, cervical disc replacement (CDR) and minimally invasive posterior cervical foraminotomy (MI-PCF) have become popular as motion preserving alternatives to the traditional ACDF. However, these 3 procedures have never been compared against each other. This meta-analysis analysed 4 randomized controlled trials published till date which dealt with this subject. They found that all the three procedures resulted in clinically satisfactory outcomes in patients with a single-level, single-side cervical radiculopathy, without any sufficient evidence to show the superiority of one procedure over another in terms of effectiveness and long-term symptom relief. However, they noted that CDR was least likely to require secondary procedures (P = 0.0178) while MI-CPF had the lowest percentage of adverse events (P < 0.0001).

Contributed by: Dr. Kuntal K. Das

Adler DH, et al. Characterizing the human hippocampus in aging and Alzheimer's disease using a computational atlas derived from ex vivo MRI and histology. PNAS 2018 doi: 10.1073/pnas. 1801093115.

This study was an interesting attempt to unravel the three-dimensional (3D) organization, anatomical variability, and morbid changes in the human hippocampus with aging and the presence of dementia states. The authors used high-resolution ex vivo MRI scans of 31 human hippocampal specimens derived from autopsy. The specimens included cerebral hemispheres from Alzheimer's disease (AD), no-Alzheimer's dementia patients and subjects without dementia. They derived a 3D probabilistic atlas capturing the average anatomy and anatomic variability of the hippocampal subfields from these specimens. Based on the cryoarchitechture obtained from 9 specimens, labelling of the hippocampal subfields was carried out on the atlas. They found that patients with AD had a disproportionate involvement of the cornu ammonis (CA) 1 subfield and stratum radiatum lacunosum moleculare, with a lesser involvement of the dentate gyrus and CA2/3 subfields. On the other hand, an association with age was found for the dentate gyrus and, to a lesser extent, for CA1. These finding might open up possibilities of an in vivo investigation of similar findings in the future.

Contributed by: Dr. Kuntal K. Das






 

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