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Table of Contents    
NI FEATURE: THE FOURTH DIMENSION - COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 242-258

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


1 Department of Neurosurgery, Wockhardt Hospital and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
2 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
5 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
6 Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication7-Mar-2019

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


DOI: 10.4103/0028-3886.253576

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How to cite this article:
Turel MK, Tripathi M, Aggarwal A, Singla N, Ahuja CK, Takkar A, Mehta S, Garg K, Mehrotra A, Das KK. A summary of some of the recently published, seminal papers in neuroscience. Neurol India 2019;67:242-58

How to cite this URL:
Turel MK, Tripathi M, Aggarwal A, Singla N, Ahuja CK, Takkar A, Mehta S, Garg K, Mehrotra A, Das KK. A summary of some of the recently published, seminal papers in neuroscience. Neurol India [serial online] 2019 [cited 2019 Aug 24];67:242-58. Available from: http://www.neurologyindia.com/text.asp?2019/67/1/242/253576




Schepers VPM, et al. Participation restrictions in patients after surgery for cerebral meningioma. J Rehabil Med 2018 doi: 10.2340/16501977-2382.

136 pateints were enrolled in this study to examine restrictions in patients after surgery for cerebral meningioma and to explore possible determinants of participation. The mean time after surgery was 3 years. Overall, patients showed favourable levels of participation. Nevertheless, many patients reported one or more problems of participation. Restrictions were most frequently reported regarding household duties, work or education. Twenty-three patients (32.9% of those who were in work before the meningioma was detected) were not able to resume their jobs after surgery. Dissatisfaction was reported particularly regarding sports or other physical exercises. The presence of cognitive or emotional problems, multiple comorbidities and epilepsy were related to more participation problems. The results of this study can be used to identify patients at risk of developing participation problems and to tailor rehabilitation programs.

Contributed by Dr. Mazda K Turel

Proust F, et al. A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage. Neurochirurgie 2018 doi: 10.1016/j.neuchi. 2018.08.004.

In this study, 351 patients aged 70 years or older with aneurysmal subarachnoid hemorrhage (SAH) underwent endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29%) patients, or conservative treatment for 48 (13%) patients. Forty-one of these were randomized to EV (n = 20) or to MS (n = 21). At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference. Mortality was higher after MS during the first 2 postoperative months, and thereafter, the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both the arms. In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. The authors concluded that EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and quality of life.

Contributed by Dr. Mazda K Turel

Fujita N, et al. Impact of lumbar hypolordosis on the incidence of symptomatic postoperative spinal epidural hematoma after decompression surgery for lumbar spinal canal stenosis. Eur Spine J 2018 doi: 10.1007/s00586-018-5782-y.

This study aimed to identify the risk factors including radiographic parameters for symptomatic postoperative spinal epidural hematoma (PSEH) after posterior decompression surgery for lumbar spinal canal stenosis (LSS). Out of 1007 consecutive patients, they identified 35 cases of symptomatic PSEH, defined by clinical symptoms and MRI findings, and selected 3 or 4 age- and sex-matched control subjects for each PSEH subject (124 controls). Compared to the control group, PSEH patients had a significantly higher preoperative systolic and diastolic blood pressure, and more levels of decompression. PSEH and control subjects had significant differences in lumbar lordosis (PSEH 25°, control 35°), pelvic tilt (25° ±vs. 21°), sacral slope (24° vs. 27° ), and pelvic incidence minus lumbar lordosis (24° vs. 14°). Multivariate analysis revealed two significant risk factors for PSEH: decompression of two or more levels and lumbar lordosis < 25°. They concluded that LSS patients with lumbar hypolordosis or multilevel stenosis should be carefully observed for PSEH after decompression surgery.

Contributed by Dr. Mazda K Turel

Bienkowski MS, et al. Integration of gene expression and brain-wide connectivity reveals the multiscale organization of mouse hippocampal networks. Nat Neurosci 2018 doi: 10.1038/s41593-018-0241-y.

Understanding the organization of the hippocampus is fundamental to the understanding of brain function related to learning, memory, emotions, and diseases such as Alzheimer's disease. Physiological studies in humans and rodents have suggested that there was both structural and functional heterogeneity along the longitudinal axis of the hippocampus. However, the recent discovery of discrete gene expression domains in the mouse hippocampus has provided the opportunity to re-evaluate the hippocampal connectivity. To integrate mouse hippocampal gene expression and connectivity, the authors mapped the distribution of distinct gene expression patterns in mouse hippocampus and subiculum to create the Hippocampus Gene Expression  Atlas More Details (HGEA). Notably, previously unknown subiculum gene expression patterns revealed a hidden laminar organization. Guided by the HGEA, they constructed the most detailed hippocampal connectome available using Mouse Connectome Project (http://www.mouseconnectome.org) tract tracing data. Their results define the hippocampus' multiscale network organization and elucidate each subnetwork's unique brain-wide connectivity patterns.

Contributed by Dr. Mazda K Turel

Cordonnier C, et al. Intracerebral haemorrhage: Current approaches to acute management. Lancet 2018;392:1257-68.

Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatment options. As a heterogeneous disease, certain clinical and imaging features help to identify the cause, prognosis, and their management. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from the peri- haematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. Evidence suggests some beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.

Contributed by Dr. Mazda K Turel

Martens F, et al. Patients at the highest risk for reherniation following lumbar discectomy in a multicenter randomized controlled trial. JB JS Open Access 2018;3:e0037.

The purposes of the present study were to (1) confirm the risk of recurrent lumbar disc herniation in patients with a large annular defect who had undergone limited discectomy; and, to (2) assess the potential risk factors within this population in a prospective, randomized, multicenter controlled trial investigating the efficacy of an annular closure device following standard limited discectomy. All control patients underwent limited discectomy for the treatment of a single-level symptomatic posterior or posterolateral lumbar disc herniation. Only patients presenting with a large annular defect (6 to 10 mm wide by 4 to 6 mm long) were included in the study (n = 278). At 2 years, the incidence of symptomatic recurrent lumbar disc herniation was 25% with the herniation occurring at a mean duration of 264 days after the index procedure. Of the 64 patients with recurrent lumbar disc herniation, 36 underwent a subsequent surgical procedure. Among those with large anular defects (width, ≥6 mm), female subjects ≤50 years of age had the highest risk (up to 10 times higher) of recurrent lumbar disc herniation. It is recommended that an annular repair or closure should be performed after limited discectomies in patients with large annular defects.

Contributed by Dr. Mazda K Turel

In ‘t Veld BA, et al. Maintaining endotracheal tube cuff pressure at 20 mmHg during anterior cervical spine surgery to prevent dysphagia: A double-blind randomized controlled trial. Eur Spine J 2018 doi: 10.1007/s00586-018-5798-3.

This study aims to assess the effect of endotracheal tube (ETT) cuff pressure adjustment on postoperative dysphagia, sore throat and dysphonia. In this randomized controlled trial, 177 patients treated with anterior cervical spine surgery were randomized to adjustment of the ETT cuff pressure to 20 mmHg after placement of the retractor versus no adjustment. Outcomes were evaluated on day one of surgery and 2 months after the operation. The incidence of dysphagia was 76% on day one and 35% 2 months after surgery. Dysphagia in the intervention and control group was present in 78% versus 74% of patients on day one and 28% versus 41% of patients after 2 months. The severity of dysphagia, sore throat and dysphonia were similar in both the groups. The authors concluded that anterior cervical spine surgery was accompanied by a high incidence of postoperative dysphagia, lasting upto at least 2 months from surgery in over a third of our patients. Adjusting ETT cuff pressure to 20 mmHg after retractor placement, as compared to controls, did not lower the risk for both short- and long-term dysphagia.

Contributed by Dr. Mazda K Turel

Malcolm JG, et al. Autologous cranioplasty is associated with increased reoperation rate: A systematic review and meta-analysis. World Neurosurg 2018;116:60-8.

This study examined the association between choice of cranioplasty material and related complications, comparing autologous bone and synthetic implants. One randomized controlled trial and 11 cohort studies were included for a total of 1586 implants (950 bone, 636 synthetic). Autologous implants had significantly more reoperations than did synthetic implants. Reoperations were most often because of resorption (54%) followed by infection (41%). The pooled incidence of resorption in autologous implants was 20%. Among the other outcomes, there was no significant difference for infections or wound-related complications. For the trauma subpopulation, there was no significant difference in the infection rate with either material. Thus, the authors concluded that autologous implants had significantly more reoperations primarily because of the intrinsic risk of resorption (level of evidence 3b).

Contributed by Dr. Mazda K Turel

Chiocca EA, et al. Viral and other therapies for recurrent GBM: Is a 24-month durable response unusual? Neuro Oncol 2018 doi: 10.1093/neuonc/noy170.

A phase 1 trial of an engineered poliovirus for the treatment of rGBM (GBM) has attracted attention due to 8 survivors reaching the 24-month, and 5 reaching the 36-month survival landmarks. Genetically engineered viruses (oncolytic viruses) have been in trials for GBM for almost two decades. These replication-competent (tumor-selective, oncolytic, replication-conditional) viruses or replication-defective viral vectors (gene therapy) deliver cytotoxic payloads to tumors, leading to immunogenic death and intratumoral inflammatory responses. This transforms the tumor microenvironment from immunologically naïve (”cold”) to inflamed (”hot”) state, increasing the immune cell recognition of tumor antigens and the durable responses observed in virotherapy. Several current and past virotherapy trials have reported a “tail” of apparent responders at the 24-month landmark. Other modalities have also reported a “tail” of seemingly long-term survivors. These trials seem to show that these responder 'tails' characterize a defined subset of GBM patients.

Contributed by Dr. Mazda K Turel

Vieira E, et al. Randomised controlled study comparing 2 surgical techniques for decompressive craniectomy: With watertight duraplasty and without watertight duraplasty. J Neurosurg 2018;129:1017-23.

The authors' objective was to conduct a prospective randomized controlled trial comparing 2 techniques for performing decompressive craniectomy (DC): with watertight duraplasty and without watertight duraplasty (rapid-closure DC). The study population comprised patients ranging in age from 18 to 60 years who were admitted with a clinical indication for unilateral DC. After unilateral DC was completed, watertight duraplasty was performed in the control group, while in the test group, no watertight duraplasty was performed and the exposed parenchyma was covered with surgicel and the remaining dura mater. There were 27 patients in the test group and 28 in the control group. There were no significant differences between the groups regarding age, Glasgow Coma Scale score at the time of surgery, Glasgow Outcome score score, and the number of postoperative follow-up days. There were 9 surgical complications (5 in the control group and 4 in the test group). The authors concluded rapid-closure DC without watertight duraplasty is a safe procedure. It is not associated with a higher incidence of surgical complications (cerebrospinal fluid leak, wound infection, brain abscess, or subgaleal fluid collections), and it decreased surgical time by 31 minutes on an average. There was also a hospital cost reduction of US $420.00 (23.4% reduction) per procedure.

Contributed by Dr. Mazda K Turel

Siddiqi SH, et al. Repetitive transcranial magnetic stimulation with resting state network targeting for treatment-resistant depression in traumatic brain injury: A randomized, controlled, double blinded pilot study. J Neurotrauma 2018 doi: 10.1089/neu. 2018.5889.

Repetitive transcranial magnetic stimulation (rTMS) has demonstrated antidepressant efficacy, but has limited evidence in depression associated with traumatic brain injury (TBI). Here, the authors investigated the use of rTMS targeted with individualized resting-state network mapping (RSNM) of dorsal attention network (DAN) and default mode network (DMN) in subjects with treatment-resistant depression associated with TBI. 14 subjects with treatment-resistant depression and prior concussive or moderate TBI received resting-state fMRI scans. The primary outcome was Montgomery-Asberg Depression Rating Scale (MADRS). The mean MADRS improvement was 56% ± 14% (n = 9) with active treatment and 27% ± 25% (n = 5) with sham treatment. One subject randomized to sham treatment withdrew prior to starting treatment. There were no seizures or other significant adverse events. MADRS improvement was inversely correlated with functional connectivity between the right-sided stimulation site and the subgenual anterior cingulate cortex (sgACC). Active treatment led to an increased sgACC-DMN connectivity and increased sgACC anti-correlation with the left- and right-sided stimulation sites. This pilot study provides evidence that RSNM-targeted rTMS is feasible in TBI patients with depression. Given the dearth of existing evidence-based treatments for depression in this patient population, these preliminarily encouraging results indicate that larger controlled trials are warranted.

Contributed by Dr. Mazda K Turel

Formento E, et al. Electrical spinal cord stimulation must preserve proprioception to enable locomotion in humans with spinal cord injury. Nat Neurosci 2018 doi: 10.1038/s41593-018-0262-6.

Epidural electrical stimulation (EES) of the spinal cord restores locomotion in animal models of spinal cord injury but is less effective in humans. Here, the authors hypothesized that this interspecies discrepancy was due to interference between EES and proprioceptive information in humans. Computational simulations, and preclinical and clinical experiments reveal that EES blocks a significant amount of proprioceptive input in humans, but not in rats. This transient deafferentation prevents modulation of reciprocal inhibitory networks involved in locomotion and reduces or abolishes the conscious perception of leg position. Consequently, continuous EES can only facilitate locomotion within a narrow range of stimulation parameters and is unable to provide meaningful locomotor improvements in humans without rehabilitation. Simulations showed that burst stimulation and spatiotemporal stimulation profiles mitigated the cancellation of proprioceptive information, enabling robust control over motor neuron activity. This giant step in spinal cord injury research demonstrates the importance of stimulation protocols that preserve proprioceptive information to facilitate walking with EES.

Contributed by Dr. Mazda K Turel

Lindback Y, et al. PREPARE: Presurgery physiotherapy for patients with degenerative lumbar spine disorder: A randomized controlled trial. Spine J 2018 doi: 10.1016/j.spinee. 2017.12.009

The aim of this randomized controlled trial (RCT) was to study if presurgery physiotherapy improved function, pain, and health in patients with degenerative lumbar spine disorder scheduled for surgery. A total of 197 patients, 25–80 years of age were consecutively included at a spine clinic. Primary outcome was Oswestry Disability Index (ODI). Patients were randomized to either presurgery physiotherapy or standardized information, with follow-up after the presurgery intervention as well as 3 and 12 months post surgery. The presurgery physiotherapy group had better ODI, visual analog scale (VAS) back pain, EuroQol-5D (EQ-5D), EQ-VAS, Fear Avoidance Belief Questionnaire-Physical Activity (FABQ-PA), Self-Efficacy Scale (SES), and Hospital Anxiety and Depression Scale (HADS) depression scores and activity level compared with the waiting-list group after the presurgery intervention. The improvements were small, but larger than the study-specific minimal clinical important change (MCIC) in VAS back and leg pain, EQ-5D, and FABQ-PA, and almost in line with MCIC in ODI and Physical Component Summary (PCS) in the physiotherapy group. Post-surgery, the only difference between the groups was higher activity level in the physiotherapy group compared with the waiting-list group. The authors thus concluded that presurgery physiotherapy decreased pain, risk of avoidance behavior, and worsening of psychological well-being, and improved the quality of life and physical activity levels before surgery, compared with waiting-list controls.

Contributed by Dr. Mazda K Turel

Fang J, et al. Comparison of equiosmolar hypertonic saline and manniol for brain relaxation during craniotomies: A meta-analysis of randomized controlled trials. Neurosurg Rev 2018;41:945-56

The authors conducted a meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of equiosmolar hypertonic saline (HS) with mannitol on intraoperative brain relaxation in patients undergoing craniotomies. The outcome indicators included brain relaxation, hemodynamic status, fluid volume, and blood chemistry. A total of nine RCTs involving 665 patients were identified and included. There was a greater increase in the odds of good intraoperative brain relaxation in the HS group compared with the mannitol group. In comparison with HS, mannitol slightly reduced the central venous pressure as well as significantly increasing the diuretic effect regardless of the dosage of HS. HS increased the plasma sodium level significantly but reduced the intraoperative fluid intake. However, there were no significant differences in plasma osmolality and mean arterial pressure. These results suggest that there appears to be better brain relaxation without a significant increase in the urine volume in the HS group compared with mannitol in patients requiring craniotomies. High-quality RCTs with larger sample sizes will be required in the future to confirm these conclusions.

Contributed by Dr. Mazda K Turel

Brainard J. What a massive database of retracted papers reveal about science publishing death penalty. Scientific Community 2018. doi: 10.1126/science.aav8384.

A recent trend in publishing research articles has already taken the form of a business. This trend is evident by a sudden upsurge in the number of journals, invitations to publish in mushrooming journals, and invitations to attend overseas ghost conferences etc. This eye-opening article in Science highlights the trend, pattern, and an estimate of the published scientific literature that is retracted by the publishers/authors due to various reasons. The last decade had witnessed nearly a 10-fold increase in the number of the retracted articles in which fraud comprised as high as 60% of the retractions! The whistle blowers have estimated the magnitude of this problem by identifying the sheer number of such retractions and the underlying reasons. Though the number is getting bigger, it seems to be just a tip of the iceberg. Many publishing houses silently withdraw the paper without publicly acknowledging it, the responsible author is not highlighted, or sometimes the exact reason is not mentioned. Some trends are noteworthy: a) Nearly 4 out of 10000 papers are withdrawn. This number is relatively constant but the denominator is gradually increasing. b) A subset of authors is responsible for nearly one-fourth of the total retractions. Their researches can be counted as deliberate misconduct, rather than a mistake. c) Nations with smaller scientific communities appear to have a bigger problem with retractions. d) Retraction does not always mean a misconduct but the stigma associated with a retraction may continue to maintain the corruption. e) International collaboration with many partners may result in tainting the reputation of the lead authors if they are not sure about the scientific conduct and the intent of their co-authors. The countries with the absolute number of maximum retractions are United States of America and China.

Though primarily called a matter of moral misconduct, corruption in the scientific literature has far-fetched effects as evident by infamous incident of serial offender anesthesiologist, Joachim Boldt. It is also a responsibility of the readers to take every new research with a pinch of salt and its own evaluation with a critical eye. Each one of us can be a watchdog by highlighting fallacies/deficiencies in the research. A deliberate bad science is more dangerous than no science.

Contributed by Dr. Manjul Tripathi

Olsson A, et al. Survival of glioma patients in relation to mobile phone use in Denmark, Finland and Sweden. J Neurooncol 2018. doi: 10.1007/s11060-018-03019-5.

In some ways, controversy in the use of mobile phones is similar to cigarette smoking during the times of Second World War and its correlation with sudden increase in the number of lung cancers after two decades. Exposure to radiation has been historically linked to various malignancies including gliomas. Many prospective and retrospective trials such as INTERPHONE have tried to evaluate the association between mobile phone usage and the risk of carcinogenesis. No study finds any association between the two and studies only evaluating the heavy phone users also have faced a selection bias. The study by Olsson et al., tried to investigate the survival among glioma patients in Scandinavian countries in relation to their mobile phone usage at the time of diagnosis, as assessed in the INTERPHONE study. This study had two arms, observational in humans and interventional in rats. No study could prove any risk of reduced survival with mobile phone exposure in patients of glioma. I personally believe that this is a very important issue, which needs judicious evaluation on a long-term basis. Another factor to consider is the authenticity of data on this topic as the results might be biased because of industry driven pressure.

Contributed by Dr. Manjul Tripathi

Leroy HA, et al. Radiosurgery and fractionated radiotherapy for cavernous sinus meningioma: a systematic review and meta-analysis. Acta Neurochir 2018. Doi: 1 0.1007/s11060-018-03019-5.

Among all benign confined cavernous sinus tumors (hemangioma, meningioma [CSM], schwannoma), meningioma is the one which got a unanimous approval to be treated by radiation techniques. The results of surgery are generally poor in terms of functional improvement. This paper is a good review on the outcome of cavernous sinus meningiomas receiving radiation treatment by different radiation techniques (gamma knife radiosurgery [GKRS], fractionated radiotherapy [FRT], linear accelerator radiosurgery etc.). GKRS achieved the best tumor volume shrinkage (nearly twice higher rate than FRT) and improvement in visual acuity (in more than 21% patients). Local progression-free survival was nearly same in all the treatment modalities, and the functional improvement in terms of cranial neuropathy was similar too. Published adverse radiation effects were in the similar range in all three-radiation modalities. With these results, it can be concluded that GKRS is a better radiosurgical tool for CSM with visual problems. On the other hand, hypofractionated schemes with the new ICON model or volume fractionation with the earlier gamma knife models should be preferred for better patient comfort and functional outcome.

Contributed by Dr. Manjul Tripathi

Mollayeva T, et al. Traumatic brain injury: Sex, gender and intersecting vulnerabilities. Nat Rev 2018. Doi: 10.1038/s41582-018-0091-y

It is a known fact that outcomes following traumatic brain injury (TBI) have several confounding variables including age, sex, and gender. This review article evaluates the gender-based crime on all aspects of vulnerability of injury, age, presentation of injury, response to treatment, and the outcome. This detailed overview of gender based TBI is a good account of unique interactions between various social, economic, cultural, behavioral, and biological conditions affecting the vulnerability of a patient. The role of sex hormones in affecting the outcome is still not decided. There are fundamental differences in TBI among males, females, and gender diverse population and it is time to decide for some groundbreaking research to answer these questions. Even with all the advances in the last century, the outcome following TBI is still dismal and it remains our responsibility to evaluate the factors for primordial and primary prevention of TBI.

Contributed by Dr. Manjul Tripathi

Fayed ZY, et al. Combined unilateral posteroventral pallidotomy and ventral intermediate nucleus thalamotomy in tremor-dominant Parkinson's disease versus posteroventral pallidotomy alone: A prospective comparative study. Stereotact Funct Neurosurg 2018;96:264–9.

The outcome in functional neurosurgery is dependent on the judicious patient selection. The surgeon's job is to hit the bull's eye and the margin of error is very small. For the last one decade, subthalamic nucleus is the most preferred target for Parkinson's disease (PD). However, there are other targets as well such as globus pallidus interns (Gpi) and ventromedial nucleus of thalamus (VIM). The optimal target among all these is chosen on the basis of predominant symptomatology of the triad (rigidity, tremor, bradykinesia). Gpi is preferred for dystonia predominant and levodopa induced dyskinesia patients. VIM is not the most conventional target and is chosen in patients with tremor predominant symptomatology. In this article, Fayed et al., have presented a remarkable report with combined lesioning of pallidotomy and thalamotomy in patients with tremor predominant PD and compared the results with pallidotomy alone group. Patients with combined pallidotomy and thalamotomy had greater improvement in tremor control with equal improvement in dystonia with lesser requirement of drugs. This is a novel approach with the same profile of side effects and long-term studies are warranted for its validation.

Contributed by Dr. Manjul Tripathi

Foreman KJ, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: Reference and alternative scenarios for 2016–40 for 195 countries and territories. Lancet 2018. Doi: 10.1016/S0140-6736 (18) 31694-5.

Despite various planning commissions of various national and international agencies, health predictor models are still not able to forecast the difficulties in robust ways. This detailed study has developed predictions for life expectancy; years of life lost, and all-cause and cause specific mortality for 250 causes of death world over. This study has forecast the different health drivers and their role in predicting the health scenarios of the future (2040) with geographical distribution of the disease burden. Though with the current health policies, the disease burden and health scenarios would probably remain the same, yet life expectancy is predicted to increase by 4.4 years for both males and females. In low and middle-income countries, communicable diseases would continue to remain the main causes of morbidity and mortality. At the same time, non-communicable disorders would also rise more than the current pace and demand serious efforts in modifying the life style and other risk factors. Another, serious risk would remain a predictable rise in the cases of HIV/AIDS if the countries lose momentum against the HIV epidemic. A sedentary life style, antibiotic resistance, and lack of enthusiasm among policy makers and goverment agencies may adversely affect the projected best health scenarios. Governments and health agencies gearing up for the coming days can use this model and prediction.

Contributed by Dr. Manjul Tripathi

Moran CG, et al. Changing the system - major trauma patients and their outcomes in the NHS (England) 2008–17. E Clin Med 2018;08. doi: https://doi.org/10.1016/j.eclinm.2018.07.001

This detailed epidemiological article should be discussed for improving health care system for patients with traumatic brain injury (TBI). The key determinant in outcome in TBI is not the surgical efficiency but prevention of head injury, on site resuscitation, time interval between injury and hospital admission, and post surgical nursing care. Establishment of a dedicated trauma system in England has now proven its worth. It helped on all the fronts including a robust and 'true' data collection, clinical care and custom tailored approaches in managing problems pertinent to specific geographical areas. A commentary by DJ Lockey on the same topic beautifully summaries the findings and prospects of long term care. Lancet should be applauded for publishing two relevant articles on TBI in the same issue, in which one provides an account of TBI in last decade (Foreman KJ, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016–40 for 195 countries and territories. Lancet 2018) while another predicts the future on the similar lines as George Orwell did for the world in 1949 with the dystopian novel “1984”.

Contributed by Dr. Manjul Tripathi

Killinger BA, et al. The vermiform appendix impacts the risk of developing Parkinson's disease. Sci Transl Med 2018;10:465.

Parkinson's disease (PD) is primarily thought to be a disease causing loss of dopaminergic neurons resulting in motor symptoms. New research is recognizing non CNS sites of disease affliction and a common such site is the gastro intestinal (GI) tract. An important pathological characteristic of PD is aggregation of synuclein, which has been found in the enteric neurons as well. These very same synuclein aggregates are thought to ascend to the brain via vagus nerves and cause PD. In response to environmental toxins or micro-organisms, the GI tract can accumulate aberrant synuclein via activation of the immune system. Appendix, which was originally thought to be a vestigial organ, is now being recognized as having a role in immunity. This may make appendix prone to accumulation of synuclein and thus theoretically increase the risk of PD. The authors in the present study investigated if the removal of the appendix reduce the risk for PD. For this, they examined the health records of 1,698,000 individuals and followed them for upto 52 years. Of these, 551,647 had appendectomy. Each of these was matched (age, sex and location) to two control individuals without an appendectomy. In follow up, 2252 patients had PD. The authors found that the incidence of PD was lower in the appendectomy group compared to controls. The overall risk of developing PD was significantly decreased by 19.3% in appendectomized individuals compared to the general population. Also, PD was found in fewer percentage of patients and also later in life in those who had appendectomy as compared to controls.

Contributed by Dr. Ashish Aggarwal

Fujiki Y, et al. Serum glucose/potassium ratio as a clinical risk factor for aneurysmal subarachnoid hemorrhage. J Neurosurg 2018;129:870.875

Despite improvement in treatment, the prognosis of ruptured intracranial aneurysm remains poor. Several clinical grading systems and biomarkers have been developed to predict prognosis. The authors studied 565 patients of aneurysmal SAH and have analyzed the relationship between serum glucose/potassium ratio and prognosis. All patients were graded clinically on the basis of Hunt and Kosnik (H-K) or World Federation of Neurological Surgeons grading systems. Laboratory data was acquired at admission. All patients underwent clipping of the aneurysm. Glucose/potassium ratio was significantly elevated in patients with poor clinical grades. The outcome was assessed using Glasgow outcome scale at discharge and at 3 months. 355 patients had a good outcome and 210 patients had a poor outcome. Glucose/potassium ratio was 42.3 in patients with a good outcome, while it was 57.9 in those with a poor outcome. This was statistically significant. The authors concluded that in future, this glucose/potassium ratio may aid in decision making in cases of severe SAH.

Contributed by Dr. Ashish Aggarwal

Wilker EH, et al. Ambient pollutants and spontaneous intracerebral hemorrhage in Greater Boston. Stroke 2018;49:2764-6.

Ambient air pollution has become a major cause of concern in recent years both for the general public and medical community. There is an ever increasing list of detrimental effects of air pollution on different organs. The authors studied levels of four different pollutants in the days preceding the incidence of ICH. 577 patients with ICH (deep and lobar) were studied for air pollutants namely--PM 2.5 (particulate matter 2.5 microns or less), black carbon, nitrogen dioxide and ozone. Multivariate analysis revealed no association between ICH and PM2.5, black carbon, or nitrogen dioxide. Ozone had an association with lobar ICH. The authors surmise that ozone may have a deleterious effect on already fragile vessels because of cerebral amyloid angiopathy. The authors suggest the need for further large studies to assess the effects of ozone on brain.

Contributed by Dr. Ashish Aggarwal

Walker CT, et al. Human amniotic membrane for the prevention of intradural spinal cord adhesions: Retrospective review of its novel use in a case series of 14 patients. Neurosurgery 2018;83:989-96.

Re-tetheering of spinal cord to the dura at the site of surgical scar is a difficult-to-treat condition and the reported incidence in a 5-year period is 13% in adults to 57% in children. Majority of these patients report a worsening of symptoms. The available therapies largely fail to adequately address this issue. In fact, a repeat surgery may exacerbate the condition. The authors, in the present study, have used human amniotic membrane (HAM) to prevent spinal cord adhesions. The HAM graft was prepared in such a way that both sides had nonadhesive epithelial layer. After microsurgical detethering, this graft was placed in the subarachnoid layer between the point of adhesion and dura and stitched using interrupted sutures. In this first of its kind study, the authors published a series of 14 patients in whom this technique was used. Only one patient had retethering (caudal to graft) in the post-operative period which required a redo surgery. No adverse effects attributable to the graft placement were reported. The authors cite some limitations in their study, namely the non-randomized nature of the study and a short follow up. However, the series has been presented as a proof of concept study requiring further work for determining the efficacy and safety of the technique.

Contributed by Dr. Ashish Aggarwal

Nasi D, et al. Risk factors for post-traumatic hydrocephalus following decompressive craniectomy. Acta Neurochir 2018;160:1691–8.

Post traumatic hydrocephalus (PTH) develops in a significant number of patients who undergo decompressive craniectomy (DC) for traumatic brain injury (TBI). It may be the result of converting the closed box of cranial cavity into an open box after DC. 190 patients included in this study underwent DC for TBI and were followed up for development of PTH. At 30 days of DC, 130 patients were alive, out of which 37 (28.4%) developed PTH. 34 patients underwent a ventricloperitoenal shunt for the treatment of PTH. On univariate analysis, a younger age, presence of subarachnoid haemorrhage (SAH), bifrontal decompression, presence of inter-hemispheric hygroma, and delayed cranial reconstruction were found to be risk factors for PTH but on multivariate analysis only hygroma and delayed cranioplasty were significantly associated with the need for a VP shunt. Development of PTH in 130 alive patients 30 days after the DC resulted in a significantly poor outcome.

Contributed by Dr. Navneet Singla

Budohoski KP, et al. Predictors of early progression of surgically treated atypical meningiomas. Acta Neurochir 2018;160:1813–22.

Atypical meningiomas represent a heterogenous group with their behaviours ranging from very benign to extremely aggressive. Uniform guidelines of their management are not available. 220 patients diagnosed as having an atypical meningioma (WHO grade 2) on histology were inducted into the study. Gross total excision was achieved in 143 patients. Adjuvant radiotherapy (RT) was given in 57 (26%) patients. Subtotal resection, parasagittal location, peritumoural oedema and a mitotic index >7/10 high power field were significantly associated with an early recurrence. Adjuvant radiotherapy resulted in lower rates of early recurrence within 2 years. Brain invasion was not found to be associated with early recurrence but uniformity of including brain sample in the histological tissue could not be ascertained. The authors recommended that identification of clinical, biological and molecular predictors of recurrence were required to stratify the management decisions.

Contributed by Dr. Navneet Singla

Al-Afif S, et al. Intracranial foreign material granulomas after cranial surgery. Acta Neurochir 2018. Doi: 10.1007/s00701-018-3663-0

Various synthetic materials are used in neurosurgical procedures viz. hemostatic agents for haemostasis, artificial bone material for skull defects, teflon for microvascular decompression, aneurysmal wrapping, dural closure etc., can result in foreign body reaction and formation of foreign body (FB) granulomas. These granulomas may present with mass effect months to years after surgery. Authors have collected 12 such cases who presented with mass effect and were operated with histopathological confirmation of FB granulomas over a 13-year period. All patients presented with enhancing masses within a median period of 13 months from first surgery. Total excision was achieved in all cases. FB granuloma was due to oxidized cellulose polymer in 6 cases, suture in 3 cases, gelatine foam, bone wax and methylmethacrylate in one case each. These all materials are intentionally left materials, unlike general surgical procedures in which non-absorbable materials are left unintentionally resulting in FBG and then litigation. Prognosis of FBG is excellent provided a high index of suspicion is maintained, and in the presence of mass effect, an early surgery has been instituted.

Contributed by Dr. Navneet Singla

Wagner FB, et al. Targeted neurotechnology restores walking in humans with spinal cord injury. Nature 2018;563:65-71.

Spinal cord injury (SCI) has been believed to be incurable from centuries but Wagner et al., have given hope to such patients using advanced neurotechnology and rehabilitation. Three patients were able to walk with assistance using 'Epidural Electrical Stimulation (EES)' by implanting a targeted real time pulse generator. This real time spatio-temporal stimulation delivered to the spinal cord enabled co-ordinated hip, knee and ankle movements and restored stepping. Selective EES trains were delivered coinciding with the intended movement. This stimulation to the targeted individual posterior roots engaged motor neurons of proprioceptive circuits at the appropriate time. With the help of gravity-assisted locomotor device, residual neural pathways got reorganized by EES stimulation and controlled walking could start despite chronic paralysis. These neurotechnologies based upon spatio-temporal EES are more effective than continuous EES, and may be due to modulation of cortical excitability by recruiting propriceptive pathways. The authors proposed that this therapy may be even more efficacious early after spinal cord injury due to the presence of neuronal plasticity, and also because the atrophy of neuromuscular tissues has not yet occurred, as is seen in chronic SCI. The field of SCI is poised to take a giant leap forward with this invention.

Contributed by Dr. Navneet Singla

Nguyen HS, et al. Management and survival trends for adult patients with malignant gliomas in the setting of multiple primary tumors: A population based analysis. J Neurooncol 2018. doi: 10.1007/s11060-018-03028-4.

Concurrent malignancies in the setting of intracranial glioma may have a negative impact on the patient outcome. Literature in this respect is very scarce. The authors extracted demographics and clinical data from the SEER-18 [Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI)] registry for adult patients with malignant gliomas (MG). The cases were classified as:

Group (A) - One primary only or first primary of multiple primaries, and

Group (B) - second primary or subsequent primary tumor.

Multiple groupings (oral cavity, digestive system, respiratory system, skin, breast, genital systems, urinary system, lymphoma) exhibited lower glioma-related observed survival compared to Group A. Association with “leukemia” appears to confer longer glioma-related survival while a history of “breast” or “digestive system” malignancies confer a shorter glioma-related survival. It was concluded that patients with newly diagnosed MG with extra-central nervous system primary tumors appear to have worse glioma-related observed survival compared to those with malignant glioma as the only primary or the first of multiple primary tumors.

Contributed by Dr. Chirag K Ahuja

Mehan WA, et al. Does including neck CTA in work-up of suspected intracranial hemorrhage add value? Emerg Radiol 2018 doi: 10.1007/s10140-018-1654-3.

Neck computed tomographic angiography (CTA) can be performed in conjunction with head CTA in patients of acute intracranial haemorrhage (ICH), despite relatively low appropriateness (ACR Appropriateness Criteria 2-6). Whether it is clinically justified or offers just an additional radiation burden to the patient is debatable. This article reviews 220 head and neck CTAs performed for ICH or headache over a 24-month. The images were seen by experts for planning catheter angiography. The findings helpful for performing catheter angiography were observed on neck CTA in 22% patients and included anatomical arch variants such as a bovine arch, a direct vertebral artery arch origin, and an aberrant subclavian artery. However, findings that might substantially prolong angiography for more than 10 min, if remaining unknown, occurred in 5% patients. Incidental findings prompting additional imaging or significant clinical action occurred in 20% patients. It was thus realized that although CTA neck can provide helpful information for planning catheter angiography, it rarely uncovers findings that would significantly prolong the procedure, if remaining undetected.

Contributed by Dr. Chirag K Ahuja

Matsuo S, et al. Time-of-flight MRA signal intensity predicts the cerebral hemodynamic status after superficial temporal artery to middle cerebral artery anastomosis. J Clin Neurosci 2018 doi: 10.1016/j.jocn. 2018.10.116.

The arterial signal intensities on magnetic resonance angiography (MRA) seem to correlate with the relevant hemisphere's hemodynamics in patients with cerebrovascular diseases. This article evaluates whether superficial temporal artery (STA) signal intensities (SI) on MRA were useful to evaluate the postoperative cerebral hemodynamics of patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) steno-occlusive disease who underwent unilateral STA-MCA anastomosis. 21 consecutive patients who underwent MRA and superficial temporal artery duplex ultrasonography (STDU) at 3 months and 1 year postoperatively were enrolled. Bilateral region of interests (ROIs) on time-of-flight (TOF)-MRA source images were placed on the STA just before its bifurcation. The STA-SI ratio (ratio of the SI on the operated STA to that of the contralateral STA) was calculated. The STA diameter and flow velocities on STDU significantly correlated with the STA-SI ratio at 1 year postoperatively. The end-diastolic flow velocity ratio significantly correlated with the STA-SI ratio at 1 year postoperatively. The STA-SI ratio, thus, formed an important parameter for predicting the extent of postoperative collateral bypass flow, and it might help to predict the postoperative cerebrovascular reserve.

Contributed by Dr. Chirag K Ahuja

Yu LB, et al. Management of residual and recurrent aneurysms after clipping or coiling: Clinical characteristics, treatments and follow-up outcomes. World Neurosurg 2018 doi: 10.1016/j.wneu. 2018.10.160.

Recurrent intracranial aneurysms (RAs) pose a significant challenge to the treating neurointerventionist. The present study aims to explore a potential optimal management strategy of RAs. 117 patients with recurrent intracranial aneurysms treated at a single center, were enrolled. 13.7% and 86.3% of these had initially undergone microsurgical clipping and endovascular coiling, respectively. These RAs were treated with coil embolisation (75/117), microsurgical clipping (32/117) and conservative treatment (10/117). Clipping was complete in all patients (32/32); aneurysm remnants were seen in 33% (25/75) patients of coiling. However, operative complication in form of cerebral infarction was more common in the clipping group (12.5%) vs the coiling group (1.3%). The follow up showed favourable outcomes in all groups. The follow-up rates of recurrence were significantly higher in the coiling group compared with the clipping group (26% vs 0%) with, however, no major consequence.

Contributed by Dr. Chirag K Ahuja

Hou K, et al. Current status of endovascular treatment for dural arteriovenous fistulas in the superior sagittal sinus region: A systematic review of the literature. World Neurosurg 2018 doi: 10.1016/j. wneu. 2018.10.145.

Dural arteriovenous fistulas (DAVFs) occurring in the superior sagittal sinus (SSS) region are difficult to completely cure. The present review addresses this issue with a pool of 33 studies from the medical literature. Out of the 42 patients who were explored, 12 (28.6%) patients presented with intracranial hemorrhage, and 9 (21.4%) patients presented with cognitive impairment. Of these, 31/42 (73.8%) patients were treated via transarterial route and 11/42 (26.2%) were treated via transvenous route. Complete angiographic cure was achieved in 87.8% patients. 9.5% (4/42) patients reported procedural complications. More than half (22/37) of the patients were discharged with a modified Ranking Scale (mRS) score of 0, and 12/37 patients had an improved neurological state. Endovascular treatment, thus, proves to be an effective treatment for SSS region DAVFs.

Contributed by Dr. Chirag K Ahuja

Barboza MA, et al. A practical score for prediction of outcome after cerebral venous thrombosis. Front Neurol 2018;22:882.

Cerebral venous thrombosis (CVT) is a common disease, the present therapy of which is aimed at sinus recanalization by anticoagulation. However, the prognosis may be extremely variable. The authors aimed to develop a CVT grading scale (CVT-GS) to aid in the short-term clinical decision-making. 467 consecutive patients with CVT who were hospitalized were enrolled. Factors associated with 30-day mortality were selected and a scale was devised. After the scale was configured, the prognostic performance was tested for prediction of short-term death or moderately impaired-to-death [modified Rankin scale (mRS) >2]. CVT-GS was categorized as mild, moderate or severe for the prediction of 30-day fatality rate and a probability of mRS > 2. The CVT-GS was composed of parenchymal lesion size > 6 cm (3 points), bilateral Babinski signs (3 points), male sex (2 points), parenchymal hemorrhage (2 points), and level of consciousness (coma: 3 points, stupor: 2, somnolence: 1, and alert: 0)- total points 13. CVT was categorized as mild (0-2 points), moderate (3-7 points), or severe (8-13 points). The CVT-GS could predict the 30-day mortality and mRS >2 with significant accuracy. CVT-GS can, thus, serve as a clinical biomarker for prediction of outcome after CVT.

Contributed by Dr. Chirag K Ahuja

Ziff OJ, et al. Statins and the risk of intracerebral haemorrhage in patients with stroke: Systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2018 doi: 10.1136/jnnp-2018-318483.

Statins, that once were labelled wonder-drugs, currently face the question of being overhyped. Whether or not they increase the risk of intracerebral haemorrhage (ICH) in patients with a previous stroke remains uncertain. To address this question, the authors have performed a systematic literature review and meta-analysis involving observational and randomised studies comparing statin therapy with control (placebo or no treatment) in patients with a previous ICH or ischemic stroke (IS). The risk ratios (RR) for the primary outcome (ICH) and secondary outcomes (IS, any stroke, mortality and function) were pooled using random effects meta-analysis according to the stroke subtype. 317291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled RR for recurrent ICH; on the contrary, they were associated with significant reduction in mortality and poor functional outcome. In patients with previous IS, statins were associated with a non-significant increase in ICH but a significantly lower risk of recurrent IS, mortality and a poor functional outcome. The study concluded that the advantages of statins far outweighed their adverse effects and that statins did not increase the risk of hemorrhage when used after a stroke.

Contributed by Dr. Chirag K Ahuja

Ikeguchi R, et al. CSF and clinical data are useful in differentiating CNS inflammatory demyelinating disease from CNS lymphoma. Mult Scler 2018;24:1212-23.

Central nervous system (CNS) inflammatory demyelinating diseases (IDD) often masquerade as lymphomas. The diagnostic uncertainty of lymphoma often keeps clinicians challenged. The authors in this interesting study measured cerebrospinal fluid (CSF) cell counts; concentrations of proteins, glucose, interleukin (IL)-6, IL-10, soluble IL-2 receptor (sIL-2R), and myelin basic protein; and, the IgG index in 64 patients with multiple sclerosis (MS), 35 patients of neuromyelitis optica (NMO), 17 patients of tumefactive demyelination (TDL), 12 patients of CNS lymphoma and 10 patients of glioma (n = 10) to evaluate whether CSF analysis could differentiate CNS IDDs from CNS lymphoma and glioma. It was noted that median CSF IL-10 and sIL-2R levels were higher in CNS lymphoma patients than in MS, NMOSD, or TDL patients. Logistic regression revealed that CSF sIL-2R levels predicted the presence of CNS lymphoma. It was concluded that CSF sIL-2R levels could be used to differentiate CNS lymphoma from CNS IDDs. Further studies may identify other applications of CSF as a diagnostic biomarker.

Contributed by Dr. Aastha Takkar

Robertson K, et al. Effect of gabapentin vs pregabalin on pain intensity in adults with chronic sciatica. A randomized clinical trial. JAMA Neurol 2018. doi: 10.1001/jamaneurol. 2018.3077.

Chronic sciatica (CS) is a common cause of significant morbidity. Optimal pharmacologic treatment is still unclear. While gabapentin (GBP) and pregabalin (PGB) are both currently used to treat CS, equipoise exists. A preplanned interim analysis of a randomized, double-blind, double-dummy crossover trial of PGB vs GBP for management of CS at half the estimated final sample size was performed in a single-center, tertiary referral public hospital. The study was aimed to assess the efficacy of GBP vs PGB head-to-head for the treatment of CS. 20 patients with unilateral CS was enrolled. The trial clinician determined imaging corroborating a root-level lesion concordant with symptoms and/or signs and participants were randomly assigned. The participants received GBP (400mg to 800mg 3 times a day) then PGB (150mg to 300mg twice daily) or vice versa, each taken for 8 weeks. Crossover followed a 1-week washout. The primary outcome was pain intensity at baseline and 8 weeks. Secondary outcomes included disability and severity/frequency of adverse events. Gabapentin was found to be superior to PGB, with fewer and less severe adverse events. Head to head, GBP showed superior visual analogue pain intensity scale reduction irrespective of the sequence order; however, the disability index reduction was unchanged. Adverse events for PGB were more frequent especially when PGB was taken first. It was concluded that both pregabalin and GBP were significantly efficacious. However, GBP was superior with fewer and less severe adverse events.

Contributed by Dr. Aastha Takkar

Naddaf E, et al. Muscle biopsy and electromyography correlation. Front Neurol 2018;9:839.

In myopathies, the correlation of individual electromyographic and histopathologic findings is poorly explored. The authors in this study, identified 100 patients who had a muscle biopsy and electromyography performed on identical muscles. Fibrillation potentials correlated with atrophic, necrotic, and regenerating fibers, fibers harboring vacuoles, fiber splitting, fibers reacting for non-specific esterase, fibers with congophilic inclusions, inflammation (endoymysial and perimysial), and increased endomysial connective tissue. Short-duration motor unit potentials correlated with atrophic, necrotic, and regenerating fibers, increased endomysial connective tissue, and perimysial inflammation. Long-duration motor unit potentials correlated with fiber-type grouping. Increased phases of motor unit potentials correlated with atrophic fibers, increased endomysial connective tissue, and fibers reacting for non-specific esterase; while increased turns correlated with atrophic and regenerating fibers, increased endomysial connective tissue and target formations. Rapid recruitment correlated with regenerating fibers, perimysial inflammation, and increased endomysial connective tissue. The study tries to provide an objective evidence of the correlation between clinical, electromyographic, and histopathologic findings.

Contributed by Dr. Aastha Takkar

Nanc M, et al. Could platelet indices and neutrophil to lymphocyte ratio be new biomarkers for differentiation of arteritic anterior ischemic neuropathy from non-arteritic type? Neuroophthalmology 2018;42:287-94.

This clinical retrospective comparative study was performed with the aim to assess the possible relationship between arteritic anterior ischemic optic neuropathy (AAION) and non-arteritic anterior ischemic optic neuropathy (NAAION) with blood platelet parameters and NLR (neutrophil-to-lymphocyte ratio). The medical records of 12 patients with AAION, 33 patients with NAION, and 35 healthy subjects were examined. Mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) values showed marked elevation in the AAION and NAION groups compared with the control group. The mean neutrophil to lymphocyte ratio (NLR) was significantly higher only in the AAION group compared to the NAION and control groups suggesting that platelet function played an important role in AIONs and NLR might be used to differentiate AAION from NAION.

Contributed by Dr. Aastha Takkar

Herzog AG, et al. Association of unintended pregnancy with spontaneous fetal loss in women with epilepsy- Findings of the Epilepsy Birth Control Registry. JAMA Neurol. 2018. doi: 10.1001/jamaneurol. 2018.3089.

Unintended pregnancy in women with epilepsy is associated with the increased risk of spontaneous fetal loss (SFL). The Epilepsy Birth Control Registry conducted this web-based, retrospective survey between 2010 and 2014 to assess whether planned pregnancy is a determinant of SFL in women with epilepsy. The demographic data; epilepsy; antiepileptic drug (AED) and contraceptive--related data; and, reproductive data from 1144 women with epilepsy were collected in the community from women between the ages of 18 and 47 years. The primary outcome was the risk ratio for SFL in unplanned vs planned pregnancies. The secondary outcome was the identification of some potentially modifiable variables (maternal age, pregnancy spacing, and AED category) of SFL vs live birth. Of a total of 794 pregnancies, 530 were unplanned pregnancies and 264 planned pregnancies. The risk for SFL in 653 unaborted pregnancies in women with epilepsy was greater for unplanned than planned pregnancies. Inter-pregnancy interval and maternal age, but not AED category, were also associated. The risk was greater when inter-pregnancy interval was less than 1 year relative to the younger-than-18-years cohort. The risks were lower for the intermediate older cohort aged 18 to 27 years but was not significantly different for the small number of participants in the 38-to-47-years cohort. No individual AED category's SFL frequency differed significantly from the other AED category. The Epilepsy Birth Control Registry retrospective survey finding that unplanned pregnancy in women with epilepsy may double the risk for SFL warrants prospective investigation with outcome verification.

Contributed by Dr. Aastha Takkar

Grunseich C, et al. Safety, tolerability, and preliminary efficacy of an IGF-1 mimetic in patients with spinal and bulbar muscular atrophy: A randomised, placebo-controlled trial. Lancet Neurol 2018. doi: 10.1016/S1474-4422 (18) 30320-X

The authors in this randomised, placebo control trial assessed the safety, tolerability, and preliminary efficacy of BVS857, an insulin-like growth factor-1 (IGF-1) mimetic, in ambulatory, adult, genetically confirmed patients of spinal and bulbar muscular atrophy who had symptomatic weakness. Patients were randomly assigned (2:1) to study drug (n = 18) or placebo (9) by a number scheme. After a safety and tolerability assessment, BVS857 was administered once a week (0·06 mg/kg intravenously) for 12 weeks. Primary outcome measures were safety, tolerability, and the effects of BVS857 on thigh muscle volume (TMV) measured by MRI. BVS857 was found to be safe with no serious adverse events and no significant differences were found in adverse events between the BVS857 and placebo groups. A significant difference in change in TMV was observed in the BVS857 group versus the placebo group. There were no differences between groups in measures of muscle strength and function. The intervention was associated with a high incidence of immunogenicity and did not improve muscle strength or function. Further studies are needed to assess the efficacy of activating the IGF-1 pathway in this disease.

Contributed by Dr. Aastha Takkar

Ludolph A, et al. Safety and efficacy of rasagiline as an add-on therapy to riluzole in patients with amyotrophic lateral sclerosis: A randomised, double-blind, parallel-group, placebo-controlled, phase 2 trial. Lancet Neurol 2018;17:681-8.

The neuroprotective potential of rasagiline in Parkinson's disease has been well recognised. The authors in this randomised, placebo control, parallel group, double blind trial assessed whether or not rasagiline 1 mg/day can prolong the survival in patients with amyotrophic lateral sclerosis also receiving riluzole. Of the 273 patients screened for eligibility, patients were randomly assigned (1:1) to receive either rasagiline (n = 127) or a placebo (n = 125) in addition to riluzole (100 mg/day), after stratification for the site of onset (bulbar or spinal) and study centre. The patients were followed up 2, 6, 12, and 18 months after randomisation. The primary endpoint was survival time, defined as the time-to-death or time-to-study cut-off-date.

No major difference was noted between the groups in the primary outcome of survival, although post-hoc analysis suggested that rasagiline might modify the disease progression in patients with an initial slope of Amyotrophic Lateral Sclerosis Functional Rating Scale Revised greater than 0·5 points per month at baseline. Rasagiline was otherwise well tolerated, and most adverse events were attributed to amyotrophic lateral sclerosis disease progression rather than treatment.

Contributed by Dr. Aastha Takkar

Girard TD, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med. 2018. doi: 10.1056/NEJMoa1808217.

Delirium is the most common manifestation of acute brain dysfunction in critically ill patients and leads to a higher mortality, longer hospital stays, higher costs and long-term cognitive impairment. The authors in this multicentre randomized trial compared the effect of haloperidol and ziprasidone with a placebo on the duration of delirium in patients admitted to the intensive care unit (ICU) with respiratory failure or shock. Delirium was diagnosed using confusion assessment method (CAM-ICU). Majority of the patients had hypoactive delirium. There was no benefit of using haloperidol (max. dose 20mg/day) or ziprasidone (max. dose 40 mg/day) in decreasing the days the patient was alive without delirium. Prolongation of QTc(QT interval corrected to heart rate) was more common with the ziprasidone group.

Contributed by Dr. Sahil Mehta

Hu J, et al. Effects of vitamin D3 supplementation on cognition and blood lipids: A 12- month randomised, double- blind, placebo-controlled trial. J Neurol Neurosurg Psychiatry 2018. doi: 10.1136/ jnnp-2018-318594.

The annual conversion rates for mild cognitive impairment to dementia ranges from 10-15%. The role of vitamin D in cognition is being increasingly recognized besides bone health. It increases acetylcholine by increasing choline acetyltransferase activity. The authors in this randomized double blind placebo controlled trial found that supplementation of vitamin D in a dose of 400 U/day for 12 months in patients with mild cognitive impairment significantly improved their cognitive function. Also, there was a significant decrease in the total cholesterol levels compared to the placebo group. Total cholesterol levels had an inverse relation with full intelligent quotient. Further long term studies are needed to prove or disapprove this association.

Contributed by Dr. Sahil Mehta and Dr Kuntal K Das

Chitnis T, et al. Trial of fingolimod versus interferon beta- 1a in pediatric multiple sclerosis. N Engl J Med 2018;379:1017-27.

Pediatric multiple sclerosis (MS) is defined as MS occurring before age 18 years and accounts for 3-5% of total MS population. Fingolimod is an oral sphingosine-1- phosphate receptor modulator and is approved for adult MS. In this randomized, multicentre trial, the authors compared fingolimod with interferon beta 1a. The mean age of the children was 15.3 years with 62% female patients. They were followed up for two years. The fingolimod group had significantly reduced annualized relapse rates and MRI disease activity. However, there were more adverse effects in the fingolimod group in the form of infections and seizures. This trial led to the Food and Drug Association (FDA) USA approval of fingolimod for treating relapsing MS in children aged 10 year and older.

Contributed by Dr. Sahil Mehta

Zeydan B, et al. Association of bilateral salpingo-oophorectomy before menopause onset with medial temporal lobe neurodegeneration. JAMA Neurol 2018. doi: 10.1001/jamaneurol. 2018.3057.

Women who undergo surgical menopause (bilateral salpingo-oophorectomy) before natural menopause have higher chances of developing dementia. Pre-menopausal estrogen deficiency is thought to be the primary cause for development of dementia in this subgroup. The authors in this population-based case control study found the association between surgical menopause and medial temporal lobe degeneration. They found that women with bilateral salpingo-oophorectomy had smaller amygdala volumes, thinner parahippocampal and entorhinal cortices, and lower entorhinal white matter fractional anisotropy values. However, treatment with estrogen for 10 years after bilateral salpingo-oophorectomy did not prevent the occurrence of structural changes in the temporal lobes. Future research into the type of estrogen treatment, route of administration, dosing and influence of other hormones is needed in this regard.

Contributed by Dr. Sahil Mehta\

Tian DC, et al. Fingolimod enhances the efficacy of delayed alteplase administration in acute ischemic stroke by promoting anterograde reperfusion and retrograde collateral flow. Ann Neurol 2018. doi: 10.1002/ana. 25352.

Fingolimod is a well-known disease modifying drug in multiple sclerosis. In addition to its immunomodulatory effects, it also attenuates microvascular thrombus formation and limits the expansion of infarct volume, as seen in various studies and stroke models. 50% of the patients with recanalization have an unfavourable outcome. This futile recanalization hampers collateral circulation and cause infarct growth. In this prospective open label trial conducted at three Chinese centres, patients within 4.5-6 hrs of symptom onset with large vessel occlusion were randomly assigned to alteplase or alteplase plus fingolimod group. There was an early clinical improvement at 24 hours and favourable shift of the modified Rankin score (mRS) at day 90 in the fingolimod plus alteplase group. Also, fingolimod significantly improved the anterograde reperfusion of downstream territory and prevented the failure of retrograde perfusion from collateral circulation. Future large phase III trials are needed to confirm these findings.

Contributed by Dr. Sahil Mehta

Wu YT, et al. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol 2018;84:601-10.

Carpal tunnel syndrome (CTS) is the most common cause of peripheral neuropathy. Treatment includes non-surgical (analgesics, splints, corticosteroid injection) and surgical methods. The authors in this randomized trial compared the efficacy of perineural injection of corticosteroids versus 5% dextrose in mild-to-moderate CTS. It is hypothesized that 5% dextrose reduces neurogenic inflammation. The authors found that there was no difference in the steroid versus dextrose group in the first three months in terms of visual analog scale and Boston carpal tunnel syndrome questionnaire. However, the effect of dextrose persisted through the 4th to 6th month with significant reduction in pain and disability. Additional studies are needed to confirm the findings of this study.

Contributed by Dr. Sahil Mehta

Sun Y, et al. Generalized polyspike train: An EEG biomarker of drug- resistant idiopathic generalized epilepsy. Neurology 2018. doi: 10.1212/WNL.0000000000006472.

Approximately one-third of patients with idiopathic generalized epilepsy (IGE) continue to have seizures. The authors in this case control study identified clinical and EEG biomarkers of drug resistance in idiopathic generalized epilepsy. The authors found that a specific EEG pattern called as 'generalized polyspike train' defined as burst of more than 5 spikes lasting less than a second in sleep may be used as a biomarker for drug resistance in patients with IGE. Other two patterns namely generalized paroxysmal fast activity (GPFA) and generalized low voltage fast activity (GLVFA) were seen only in drug resistant patients though the findings were not statistically significant. All patients with GPFA had absence seizures. The network between the cortex and subcortical structures is more active in drug resistant patients when compared to the drug responsive ones.

Contributed by Dr. Sahil Mehta

Rao A, et al. Diffusion tensor imaging in a large longitudinal series of patients with cervical spondylotic myelopathy correlated with long term functional outcome. Neurosurgery 2018;83:753-60.

Fractional anisotropy (FA) of the high cervical cord has been shown to correlate with upper limb functions in traumatic cervical cord injury. However, any such correlation is not known to occur in cervical spondylotic myelopathy (CSM). The authors aimed to determine the usefulness of FA as a biomarker for severity of CSM and as a prognostic biomarker for improvement after surgery. FA values of the whole cord cross-section at the level of maximal compression and upper cervical cord (C1-2) were calculated from diffusion tensor imaging (DTI) scans preoperatively. Modified Japanese Orthopedic Association (mJOA) scale was used to study the functional status of the patients. DTI at C4-7 was obtained in controls. In their 47 patients, they found that FA values at the level of maximal compression correlated positively with preoperative mJOA score. Preoperative FA correlated inversely with recovery throughout the postoperative period. This was statistically significant at 12 months post-surgery. The patients with preoperative FA < 0.55 had a statistically significant difference in outcome compared to patients with FA > 0.55. The authors concluded that FA is a valid biomarker for the severity of CSM and can predict postoperative improvement as well.

Contributed by Dr. Kanwaljeet Garg

Krag M, et al. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med 2018. doi: 10.1056/NEJMoa1714919.

It is considered mandatory to give some sort of gastrointestinal stress ulceration prophylaxis to the patients admitted in intensive care unit (ICU), without much evidence base. The authors aimed to evaluate the effects of and adverse events associated with the prophylactic use of the proton-pump inhibitor (PPI), pantoprazole, in adult patients in the ICU who were at risk for gastrointestinal bleeding.

This study was conducted at multiple centres in Europe and was a parallel group, blinded trial. More than 3000 adult patients (n = 3298) who were admitted in ICU due to any acute condition and were at risk of gastrointestinal bleeding [including shock, use of anticoagulant agents, renal-replacement therapy, mechanical ventilation (expected to last > 24 hours), any history of liver disease, or any history of or ongoing coagulopathy] were randomized to the pantoprazole group (40 mg OD intravenous) or the placebo group.

There was no statistically significant difference in the 90-day mortality in both the groups (primary outcome). There was no statistically significant risk of clinically important event (clinically important gastrointestinal bleeding, pneumonia,  Clostridium difficile Scientific Name Search ection, or myocardial ischemia) in the groups. The number of patients with infections or serious adverse reactions and the percentage of days alive without life support within 90 days were similar in the two groups. The authors concluded that there was no difference in mortality at 90 days and the number of clinically important events in the pantoprazole and placebo groups.

Contributed by Dr. Kanwaljeet Garg

Mallela AN, et al. Topical vancomycin reduces surgical-site infections after craniotomy: A prospective, controlled study. Neurosurgery 2018;83:761-7.

Surgical-site infections (SSIs) are an important cause of morbidity and mortality after any kind of surgery. The risk of SSI is less following cranial surgeries due to the rich vascularity of the scalp, but the risk is not zero. Vancomycin has been successfully shown to reduce the risk of SSI in spine surgery. This prospective study aimed to check the efficacy of topical vancomycin applied in the subgaleal space before closure. Three hundred fifty-five patients were studied prospectively in this cohort study; 205 patients received 1 g of topical vancomycin powder in the subgaleal space while 150 matched control patients did not. The risk of SSI was significantly less in the vancomycin group as compared to the standard care group (0.49% [1/205] vs 6% [9/150], P = 0.002). The cost analysis revealed that using vancomycin resulted in saving money by avoiding revision surgeries. The authors concluded that topical vancomycin was a safe, effective, and cost-saving measure to prevent SSIs following craniotomy.

Contributed by Dr. Kanwaljeet Garg

Pourtaheri S, et al. Vertebral augmentation is superior to nonoperative care at reducing lower back pan for symptomatic osteoporotic compression fractures: A meta-analysis. Clin Spine Surg 2018;31:339-44.

The role of vertebral augmentation (VA) for vertebral compression fractures (VCFs) has been debated after a randomized controlled trial published in the New England Journal of Medicine concluded that vertebroplasty (VP) for osteoporotic VCFs provided no clinical benefit over sham surgery. However, there were many flaws in this study, like many of the VCFs in the study were chronic and/or healed. This study was a systematic review and meta-analysis and the goal of this study was to (i) assess the clinical outcomes with and without VA for osteoporotic VCFs with versus without correlating signs and symptoms; and (ii) acute (symptoms <3 months duration) and subacute VCFs (3–6 month duration) versus chronic VCFs (>6 month).

Thirteen studies with 1467 patients with a minimum of 6-month follow-up were included in the review. The VCFs were divided into symptomatic VCF (SVFs) and asymptomatic VCFs seen only on radiographic examination (RVFs). The authors found that following VA, pain reduction was significantly better for SVFs while there was no difference in RVFs. The pain benefit in SVFs was seen in both acute/subacute SVFs and chronic SVFs. There was no difference in outcomes between VA and nonoperative care for chronic RVF. The authors concluded that VA is better than nonoperative management in reducing lower back pain for symptomatic osteoporotic VCFs while there was no benefit in chronic VCFs that lacked clinical correlation.

Contributed by Dr. Kanwaljeet Garg

Ozawa H, et al. Spinal cord swelling after surgery in cervical spondylotic myelopathy: Relationship with intramedullary Gd-DTPA enhancement on MRI. Clin Spine Surg 2018;31:E363-E367.

Cervical spondylotic myelopathy (CSM) patients may develop spinal cord swelling after spinal canal decompression. The prognosis of CSM patients regarding the development of cord swelling and neurological outcome is difficult to predict. The authors aimed to study the prevalence and clinical relevance of postoperative spinal cord swelling and its relationship with intramedullary Gd-DTPA enhancement on preoperative MRI in patients with CSM in this prospective multicentric study.

A total of 683 consecutive patients who underwent laminoplasty for CSM were included in the study. MRI with contrast apart from T1 and T2 sequences were done before surgery. Based on the presence or absence of contrast enhancement, the patients were divided into two groups. Patients in both the groups underwent postoperative MRI at 1 month and 1 year after surgery. More than one-fourth of the patients who showed intramedullary cord enhancement developed spinal cord swelling following decompression, and this figure was significantly greater than the patients who did not show cord enhancement (26% vs 4%, P = 0.0038). Spinal cord swelling persisted in 3 out of 13 (23%) patients in the enhancement group, while it disappeared in all the patients who did not show enhancement. On multiple regression analysis, intramedullary Gd-DTPA enhancement rather than the spinal cord swelling showed a significant influence in terms of recovery of the Japanese Orthopedic Association score.

The authors concluded that CSM patients who develop spinal cord swelling following decompression should be evaluated according to the presence or absence of intramedullary Gd-DTPA enhancement on MRI. Spinal cord swelling associated with intramedullary Gd-DTPA enhancement was indicative of a poor prognosis.

Contributed by Dr. Kanwaljeet Garg

Koshimizu H, et al. The impact of sarcopenia on cervical spine sagittal alignment after cervical laminoplasty. Clin Spine Surg 2018;31:342-6.

Sarcopenia is a progressive generalized loss of skeletal muscle mass and strength associated with aging. Sarcopenia is shown to be associated with spinal malalignment as per some reports. However, the effect of sarcopenia on the cervical spinal mal-alignment is not very clear from the current literature. Cervical spinal alignment has been reported to be associated with poor outcome after cervical laminoplasty. The authors aimed to evaluate the effect of sarcopenia on the cervical spinal sagittal alignment after cervical laminoplasty in this prospective follow up study. Patients who underwent cervical laminoplasty at the authors' institute were included in the study (n = 171). Sarcopenia was assessed using appendicular skeletal muscle mass index, obtained from arm and leg muscle mass using dual-energy x-ray absorptiometry. Forty-eight patients were found to have sarcopenia using the reference values.

Preoperative, postoperative, and 1-year follow-up C2–C7 sagittal vertical axis (SVA) was greater in the sarcopenia group (poor outcome). Preoperative, postoperative, and 1-year follow-up SF-36 scores were higher in the nonsarcopenia group (better outcome). Preoperative, postoperative, and 1-year follow-up JOA scores were higher in the nonsarcopenia group (better outcome). All these differences were statistically significant. The C2–C7 SVA and JOA scores were negatively correlated at 1-year follow-up. The C2–C7 SVA and SF-36 scores were not correlated at a 1-year follow-up. The authors concluded that C2–C7 SVA was greater and postoperative outcome was worse after the cervical laminoplasty in the sarcopenia group than in the nonsarcopenia group.

Contributed by Dr. Kanwaljeet Garg

Wang D, et al. Seizure outcome after surgical resection of insular glioma. Neurosurgery 2018;83:709-718.

Seizures are the most common presenting complaint of patients with an insular glioma. It has been shown by many studies that greater extent of resection leads to better seizure outcomes but not many studies have documented seizure control rates after resection of insular gliomas.

One-hundred nine patients were included in the study. Sixty-eight percent patients were seizure free 1 year after surgery, while only 39% of patients were seizure free at the final follow up [median - 48 months (range 8-232)]. The median time to seizure recurrence was 46 months (95% CI 31-65 months). The extent of resection was found to be a significant predictor of seizure freedom on multiregression analysis. Seizure recurrence was seen to occur 3 months before tumour recurrence in those patients who had seizure recurrence and tumour progression. Repeat tumour excision led to seizure control for an additional period in these patients, with 36% of patients with recurrent seizures becoming seizure free after reoperation.

The authors concluded that greater seizure freedom occurs with increasing extent of resection. Seizure recurrence is associated with tumour progression, and repeat operation can provide additional seizure control.

Contributed by Dr. Kanwaljeet Garg

Bus S, et al. Accuracy of microelectrode trajectory adjustments during DBS assessed by intraoperative CT. Stereotact Funct Neurosurg 2018;96:231-8.

Microelectrode recording (MER) is done during deep brain stimulation (DBS) to target the optimal electrophysiological target. Sometimes, the result of single-track MER or stimulation is suboptimal, and the only option is to the change the trajectory. However, it is difficult to ascertain the accuracy of these revised trajectories. Intraoperative computed tomography (ICT) can be used to verify the adjustments of revised trajectory. The authors aimed to determine the accuracy of the microelectrode (ME) movements with the help of ICT. The authors studied the accuracy of three types of adjustments: those within the default “+” configuration of the ME holder, those involving rotation of the default “+” to the “X” configuration, and those involving head stage adjustments. The authors found the median (interquartile range) absolute x, y and radial coordinate errors were 0.29 (0.52) mm, 0.38 (0.44) mm and 0.59 (0.64) mm respectively, with the error exceeding 1 mm in many cases. They found that the errors were largest after rotating the multielectrode holder to its “X”- shaped setup. The authors concluded that it is possible to make trajectory adjustments accurately.

Contributed by Dr. Kanwaljeet Garg

Xiong Y, et al. Comparison of 6-year follow up result of hybrid surgery and anterior cervical discectomy and fusion for the treatment of contiguous two segment cervical degenerative disc diseases. Spine (Phila Pa 1976). 2018;43:1418-25.

The authors aimed to compare the outcomes of hybrid surgery (HS, one level disc replacement and other level anterior cervical discectomy and fusion) and anterior cervical discectomy and fusion (ACDF) for the treatment of contiguous 2-segment cervical degenerative disc diseases in this retrospective study. Forty-two patients symptomatic for contiguous 2-level cervical degenerative disc diseases were included in this study, 20 patients in the hybrid group and 22 in the ACDF group. There was significant improvement in the Japanese Orthopedics Association score, neck disability index and visual analog scale score in both the groups as compared to the preoperative status. However, there was no significant difference between these two groups. The range of motion (ROM) of the superior adjacent segment was significantly larger in the ACDF group than in the HS group. The C2-C7 ROM was more in the HS group than in the ACDF group. The complications like sagittal wedge deformity, heterotopic ossification and anterior migration of the disc prosthesis were found in the HS group. No symptomatic adjacent segment degeneration occurred in any of the groups.

The authors concluded that HS has results similar to 2 level ACDF and is an acceptable option in the management of contiguous 2-segment cervical degenerative disc diseases.

Contributed by Dr. Kanwaljeet Garg

Kaiser R, et al. Time factor and disc herniation size: Are they really predictive for outcome of urinary dysfunction in patients with cauda equina syndrome? Neurosurgery 2018;83:1193-200

Seventy one patients operated for cauda equine syndrome were prospectively identified between 2010 and 2013. 52 cases who had preoperative lower urinary tract involvement due to neurogenic cause were included in the study. The “Prolapse: Canal ratio” (PCR) was calculated as a proportion of cross-sectional area of disc prolapse on total cross-sectional area of the spinal canal. The median of preoperative duration of neurogenic lower urinary tract dysfunction (NLUTD) was 72 h (range 48-132h) and the period from the first assessment to surgery 10.5 h (range: 7 to 18.5 h). Urinary incontinence was seen in 46.2% of patients, 38.4% had painless retention and 15.4% had painful retention. In 38.5% of cases, urinary symptoms persisted for more than 20 months postoperatively. There was no correlation between the duration of preoperative NLUTD and urinary dysfunction persistence (P = 0.921). The outcome was not significantly influenced by a delayed surgery beyond 48 h of presentation (P = 0.135). Preoperative incontinence persisted in 58% and painless retention in 30% of cases. The mean protein-creatinine ratio (PCR) was 0.6 ± 0.18. There was no correlation between PCR and outcome (P = 0.537) even after adjusting for the duration of preoperative NLUTD (P = 0.7264).

Contributed by Dr. Anant Mehrotra

Sadigh G, et al. Radiological management of angiographically negative, spontaneous intracranial subarachnoid hemorrhage: A multicenter study of utilization and diagnostic yield. Neurosurgery https://doi.org/10.1093/neuros/nyy225

The authors conducted a retrospective multi-center study in which 752 patients of non-traumatic angio-negative subarachnoid haemorrhage were included. Patients with intraparenchymal, subdural, or epidural hematomas in addition to SAH were excluded. The factors studied were the utilization rate, diagnostic yield, and median time from admission for the following imaging tests: initial computed tomography angiography (CTA) and digital subtraction angiography (DSA), brain and cervical spine magnetic resonance imaging (MRI), and any repeat DSA or CTA performed either during the initial admission or at long-term follow-up. In 89% of cases, CTA was performed, and in all the cases, a DSA was performed. 75% of patients underwent brain MRI (positive in 0.7% of cases) and 61% underwent cervical spine MRI (positive in 0.2% of cases). Repeat, same-admission follow-up DSA and CTA were performed in 48% and 51% of patients and were positive in 3.3% and 1% of cases, respectively. Delayed follow-up DSA and CTA after discharge were performed in 26% and 7% of patients and were positive in 2% and 3.7% of the cases, respectively, all with negative prior imaging studies. The authors concluded that brain and cervical spine MRI have low diagnostic yield while repeat CTA and DSA have slightly better yield but are less utilized.

Contributed by Dr. Anant Mehrotra

Wilson, et al. Utilizing pre-procedural CT scans to identify patients at risk for suboptimal external ventricular drain placement with the freehand insertion technique. J Neurosurg 2018 DOI: 10.3171/2018.1.JNS172839

The authors retrospectively analysed 189 consecutive adult patients who underwent EVD placement by a freehand technique. The primary outcome measures included features associated with suboptimal positioning (Kakarla grade 1 vs Kakarla grades 2 and 3). The secondary outcome measures were features associated with unsatisfactory positioning (Kakarla grades 1 and 2 vs Kakarla grade 3). Suboptimal position was seen in 51 EVDs (27%). 15 (8%) EVDs were placed into the eloquent cortex or non-target CSF places. The admitting diagnosis, head height-to-width ratio in the axial plane, and the side of predominant pathology were found to be significantly associated with suboptimal placement (P = 0.02, 0.012, and 0.02, respectively). A decreased height-to-width ratio was also associated with placement into only eloquent cortex and/or non-target CSF spaces (P = 0.003). The authors concluded that freehand technique is associated with significant suboptimal positioning of EVDs including into the eloquent cortex. Using baseline clinical and radiographic features, one can predict the likelihood of inaccurate EVD placement.

Contributed by Dr. Anant Mehrotra

Hseish MK, et al. The influence of spinopelvic parameters on adjacent-segment degeneration after short spinal fusion for degenerative spondylolisthesis. J Neurosurg: Spine doi: 10.3171/2018.2.SPINE171160

The authors retrospectively analysed the results of 3 0 patients (9 males and 21 females; mean age: 64 years) operated for short lumbar and lumbosacral fusion surgeries between August 2003 and July 2010 who had adjacent segment disease (ASD). Thirty matched patients (21 women and 9 men, mean age 63 years) without ASD comprised the control group, according to the following matching criteria: same diagnosis on admission, similar pathologic level (≤1 level difference), similar sex, and age. The average follow-up was 6.8 years (range 5–8 years). The spinopelvic parameters had no significant influence on ASD after short spinal fusion. The authors concluded that neither the spinopelvic parameters nor a mismatch of pelvic incidence (PI) and lumbar lordosis (LL) were significant factors responsible for ASD after a short spinal fusion due to single-level degenerative spondylolisthesis.

Contributed by Dr. Anant Mehrotra

Sato S, et al. Safe stereotactic biopsy for basal ganglia lesions: Avoiding injury to the basal perforating arteries. Stereotact Funct Neurosurg 2018;96:244-8.

The risk of operative site hematoma and its complications are one of the major concerns in stereotactic procedures around the basal ganglia. Hemorrhage generally occurs from the lenticulostriate perforators of the middle cerebral artery. In order to specifically avoid this dreaded complication, the authors proposed a new target planning method incorporating three-dimensional time-of-flight magnetic resonance angiography in the workstation. This new treatment planning was compared with the conventional T1 contrast image based planning to determine the difference. The authors were not only able to visualize the perforators but also eliminated the hemorrhagic complication entirely (0 out of 10 patients in the new planning vis a vis 6 hemorrhages out of 14 patients using the conventional trajectory planning). It is only a matter of time before the findings of this study prompt trajectory planning being done on preoperative MR angiograms.

Contributed by Dr. Kuntal K Das

Mata-Mbemba D Traumatic midline subarachnoid hemorrhage on initial computed tomography as a marker of severe diffuse axonal injury. J Neurosurg 2018 doi: 10.3171/2017.6. JNS17466.

This interesting study explored the midline (interhemispheric or perimesencephalic) traumatic subarachnoid hemorrhage (tSAH) on initial CT and its implications with respect to the presence of diffuse axonal injury (DAI). The hypothesis was based on the similar mechanisms underlying these two manifestations of head trauma. To test this, the authors examined 270 consecutive head injury patients with initial CT within 24 hours and brain MRI within 30 days. They utilized a set of 6 radiological features, including intraventricular hemorrhage (IVH) and tSAH, as markers of DAI and subsequently graded the severity of DAI. Out of the 77 (28.5%) patients with DAI in this study, tSAH and IVH were independently associated with DAI (P < 0.05). Of the tSAH locations, midline tSAH was independently associated with both overall DAI and DAI stages 2 or 3 (severe DAI; P < 0.05). The midline tSAH on the initial CT scan had a sensitivity of 60.8%, a specificity of 81.7%, and positive and negative predictive values of 43.7% and 89.9%, respectively, for severe DAI. When adjusted for admission Glasgow Coma Score, the midline tSAH independently predicted a poor GOSE (Glasgow Outcome Scale–Extended) score at both hospital discharge and after 6 months. The authors thus proposed that the midline tSAH be considered as a predictor of DAI.

Contributed by Dr. Kuntal K Das

Suh CH, et al. 2-Hydroxyglutarate MR spectroscopy for prediction of isocitrate dehydrogenase mutant glioma: A systemic review and meta-analysis using individual patient data. Neuro-Oncology 2018;20:1573-83

Ever since the molecular signatures of gliomas have been described, the field of neuro-oncology has been rejuvenated. Isocitrate dehydrogenase (IDH) mutation is an early event in gliomagenesis and has not only a diagnostic importance but a prognostic significance as well. This systemic review and meta-analysis looked into all published literature on the non-invasive means of assessing IDH mutation, i.e., magnetic resonance spectroscopy (MRS) for determining the presence of 2-hydroxyglutarate (2HG). They also aimed to find an optimal cutoff value for 2HG from studies providing individual patient data. The pooled sensitivity and specificity for the diagnostic performance of 2HG MRS for prediction of IDH mutant glioma were 95% (95% confidence interval [CI], 85–98%) and 91% (95% CI, 83–96%), respectively. In the meta-regression, echo time (TE) was associated with study heterogeneity. Among the studies using point-resolved spectroscopy (PRESS), a long TE (97 ms) resulted in higher sensitivity (92%) and specificity (97%) than a short TE (30–35 ms; sensitivity of 90%, specificity of 88%; P < 0.01). The optimal 2HG cutoff value of 2HG using individual patient data was 1.76 mM. They concluded that 2HG MRS had an excellent specificity for prediction of IDH mutant glioma, with TE being associated with heterogeneity in the sensitivity.

Contributed by Dr. Kuntal K Das

Lee CC et al., Stereotactic radiosurgery for benign (World Health Organization grade I) cavernous sinus meningiomas—International Stereotactic Radiosurgery Society (ISRS) practice guideline: A systematic review. Neurosurgery 2018;83:1128–42.

This paper systematically reviewed the available literature on the stereotactic radiosurgical (SRS) treatment of cavernous sinus meningioma, a tumor that is widely viewed as best treated with this modality. It was an attempt, on the part of the International Stereotactic Radiosurgery Society to provide a practice guideline. After having screened 569 abstracts, a total of 49 full-text articles were included in the analysis. All studies were retrospective. The 5-year progression-free survival (PFS) rates were ranging from 86% to 99%, and the 10-yearr PFS rates were ranging from 69% to 97%. The post-SRS neurological preservation rate ranged from 80% to 100%. The authors observed that SRS could offer a favorable benefit to risk profile for patients with CS meningioma, particularly if the lesions were small. They also recommended that adjuvant or salvage SRS for residual or recurrent tumor can be utilized depending on factors such as tumor volume and proximity to adjacent critical organs at risk.

Contributed by Dr. Kuntal K Das

Fam MD, et al. Symptomatic hemorrhagic complications in clot lysis: Evaluation of accelerated resolution of intraventricular hemorrhage phase III clinical trial (CLEAR III): A post-hoc root-cause analysis. Neurosurgery 2018;83:1260–8.

Intraventricular thrombolysis has recently come up as a treatment alternative for intraventricular hemorrhage. The procedure has been validated in a large randomized controlled trial named “Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-IVH) program”. This paper was a post-hoc root analysis of the recently completed CLEAR III trial to analyze the factors associated with symptomatic bleeding following IVH with and without thrombolysis. Reviewing the clinico-radiologic details of the patients having symptomatic bleeding events within the first year of randomization of the CLEAR III trial, the authors found that 4% subjects developed a secondary symptomatic intracranial hemorrhage. Symptomatic rebleeding events occurred during the dosing protocol (n = 9, 67% alteplase), early after the protocol (n = 5, 40% alteplase), and late (n = 6, 0% alteplase). Catheter-related hemorrhages were the most common (n = 7, 35%) followed by expansion or new intraventricular (n = 6, 30%) and intracerebral (n = 5, 25%) hemorrhages. Symptomatic hemorrhages during therapy were partially attributable to alteplase. Thus, the authors concluded that IVT could marginally increase the overall risk of symptomatic hemorrhagic during the treatment phase.

Contributed by Dr. Kuntal K Das






 

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