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Table of Contents    
NI FEATURE: THE FOURTH DIMENSION - COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 542-561

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 Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
7 Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication13-May-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: 10.4103/0028-3886.258003

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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, Yadav R, Mehrotra A, Das KK. A summary of some of the recently published, seminal papers in neuroscience. Neurol India 2019;67:542-61

How to cite this URL:
Turel MK, Tripathi M, Aggarwal A, Singla N, Ahuja CK, Takkar A, Mehta S, Garg K, Yadav R, Mehrotra A, Das KK. A summary of some of the recently published, seminal papers in neuroscience. Neurol India [serial online] 2019 [cited 2019 May 24];67:542-61. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/542/258003




Vleggeert-Lankamp CLA, et al. The NECK trial: Effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; A double-blinded randomized controlled trial. Spine J 2018 doi: 10.1016/j.spinee. 2018.12.013.

The authors conducted this study to evaluate if the patients with cervical radiculopathy due to a herniated disc benefitted more from undergoing anterior cervical disc arthroplasty (ACDA), anterior cervical discectomy and fusion (ACDF), or anterior cervical discectomy (ACD) in terms of clinical outcome measured by the neck disability index (NDI). 109 patients with one level herniated disc were randomized to one of the following treatments: ACDA, ACDF with intervertebral cage, ACD without fusion. The NDI declined from 41 to 47 points at baseline to 19 ± 15 in the ACD group, 19 ± 18 in the ACDF group, and 20 ± 22 in the ACDA group after surgery. Visual Analogue Scale arm and neck pain declined to half its baseline value and decreased below the critical value of 40 mm. Quality of life increased in all the three groups. Adjacent segment degeneration parameters were comparable in all the groups. No statistical differences were demonstrated between the treatment groups. The hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or ACD could not be confirmed during a 2-year follow-up time period. The authors concluded that a single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA.

Contributed by Dr. Mazda K. Turel

Park MK, et al. Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion. Spine J 2018;19:437-47.

The authors conducted a prospective study over a 5-year period, performing the transforaminal lumbar interbody fusion (TLIF) in 881 lumbar levels in 784 patients to study the factors responsible for cage migration (CM) and cage retropulsion (CR). CM without subsidence was observed in 20 (2.3%) and CM with subsidence was observed in 36 (4%) patients. Among the CM cases, CR was observed in 17 (17/56, 30%) patients. A difference in the overall fusion rates was identified, with a rate of 97% (801 of 825) for no CM, 55% (11 of 20) for CM without subsidence, 42% (15 of 36) for CM with subsidence, and 17% (3 of 17) for CR at 1.5 years postoperatively. Their results suggest that osteoporosis is a significant risk factor for both CM and CR. In addition, a pear-shaped disc, posterior positioning of the cage, the presence of endplate injury and the use of a single cage correlated with CM with and without subsidence and CR.

Contributed by Dr. Mazda K. Turel

Kallewaard JW, et al. A multicenter randomized controlled trial on the efficacy of intradiscal methylene blue injection for chronic discogenic low back pain: The IMBI study. Pain 2019 doi: 10.1097/j.pain.0000000000001475.

The aim was to study the effects of intradiscal methylene blue (MB) injections compared with placebo on the pain intensity in patients with chronic discogenic low back pain (CD-LBP). In this multicentric, double-blind, randomized, placebo-controlled trial, both groups received lidocaine hydrochloride injections for the pain associated with the procedure. The primary outcomes were treatment success defined as at least 30% reduction in pain intensity and the Patients' Global Impression of Change 6 months after the intervention. They included 84 patients with CD-LBP of which 14 (35%) in the MB plus lidocaine group showed treatment success compared with 11 (26.8%) in the control group who received placebo plus lidocaine (P = 0.4). 27% of all participants treated with MB stated that their overall health improved much or very much vs 25.6% in the placebo group. The authors were unable to confirm that intradiscal MB injections were better in significantly reducing pain in patients with CD-LBP 6 months after treatment compared with the placebo. They observed that over one-quarter of patients receiving only lidocaine injections reported treatment success. Their results do not support the recommendation of using intradiscal MB injections for patients with CD-LBP.

Contributed by Dr. Mazda K. Turel

Dombrowski ME, et al. Prophylactic perioperative dexamethasone decreases the incidence of postoperative C5 palsies after a posterior cervical laminectomy and fusion. Spine J 2019;19:253-60.

The purpose of this study was to assess the safety and efficacy of prophylactic perioperative DEX (dexamethasone) in decreasing the rate of postoperative C5 palsy. A total of 189 consecutive patients were reviewed. The rate of C5 palsy was investigated and compared with the historical control rate of C5 palsy before the institutional implementation of perioperative DEX. Postoperative C5 palsy occurred in 5 of the 138 patients (3.6%). Patients receiving perioperative DEX had a significantly decreased rate of postoperative C5 palsy compared with those who did not (3.6% vs. 9.5%, P = 0.01). Age was the only risk factor which significantly correlated with the development of C5 palsy (73 vs. 61, P = 0.02). Infection, seroma, and wound complication rates were 2.8%, 2.1%, and 1.4%, respectively, in patients receiving prophylactic DEX. All five patients receiving DEX and still developing C5 palsy recovered with no residual deficits at an average of 17 weeks postoperatively.

Contributed by Dr. Mazda K. Turel

Sprave T, et al. Local response and pathologic fractures following stereotactic body radiotherapy versus three-dimensional conformal radiotherapy for spinal metastases - a randomized controlled trial. BMC Cancer. 2018;18:859.

This was a randomized trial analysing bone density following stereotactic body radiotherapy (SBRT) versus conventional three-dimensional conformal radiotherapy (3DCRT) as part of palliative management of painful spinal metastases in 55 patients. Participants were randomly assigned to receive SBRT (single-fraction 24 Gy) or 3DCRT (30 Gy/10 fractions). As compared to baseline, bone density became significantly higher at 3 and 6 months following SBRT by a median of 34% and 72%, respectively (P < 0.01 for both). These figures in the 3DCRT cohort were 33% and 41%, respectively (P < 0.01 for both). There were no statistical differences in bone density between SBRT and 3DCRT at 3 or 6 months. The 3-month incidence of new pathological fractures was 8.7% in the SBRT arm vs. 4.3% in the 3DCRT arm. They concluded that despite high ablative doses in the SBRT arm, the significant increase in bone density after 3 and 6 months was similar to that of 3DCRT.

Contributed by Dr. Mazda K. Turel

Ilyas A, et al. Preoperative embolization of skull base meningiomas: A systematic review. J Clin Neurosci 2019;59:259-64.

The aim of this systematic review was to assess the outcomes of preoperative embolization for skull base meningiomas. The pooled analysis consisted of 15 studies, comprising a total of 403 patients with skull base meningiomas treated with preoperative embolization. The most common locations were the sphenoid wing (34%), petroclival region (31%), and the cavernous sinus (12%). The median tumor size ranged from 5- 8 cm. Based on the pooled data, angiographic absence of tumor blush was achieved in 17% cases. The median estimated blood loss (EBL) ranged from 225 to 580 mL. Simpson grade I-III resection was achieved in 74% of patients. The overall complication, major complication, and mortality rates were 12%, 6%, and 0.2% respectively. They thus concluded that preoperative embolization was a reasonable adjunct to resection in appropriately selected skull base meningiomas.

Contributed by Dr. Mazda K. Turel

Bunda S, et al. CIC protein instability contributes to tumorigenesis in glioblastoma. Nat Commun 2019;10:661.

Capicua (CIC) is a transcriptional repressor that counteracts activation of genes downstream of receptor tyrosine kinase (RTK)/Ras/ERK signalling. It is well-established that tumorigenesis, especially in glioblastoma (GBM), is attributed to a hyperactive RTK/Ras/ERK signalling. While CIC is mutated in other tumors as well, here the authors show that CIC has a tumor suppressive function in GBM through an alternative mechanism. They found that CIC protein levels were negligible in GBM due to a continuous proteasome-mediated degradation, mediated by the E3 ligase PJA1 and show that this occurred through binding of CIC to its DNA target and phosphorylation on residue S173. PJA1 knockdown increased CIC stability and extended survival using in-vivo models of GBM. Deletion of the ERK binding site resulted in stabilization of CIC and increased therapeutic efficacy of ERK inhibition in GBM models. These results provide a rationale to target CIC degradation in Ras/ERK-driven tumors, including GBM, to increase the efficacy of ERK inhibitors.

Contributed by Dr. Mazda K. Turel

D'Angelo F, et al. The molecular landscape of glioma patients with Neurofibromatosis 1. Nat Med 2019;25:176-87.

Neurofibromatosis type 1 (NF1) is a common tumor predisposition syndrome in which glioma is one of the prevalent tumors. Gliomagenesis in NF1 results in a heterogeneous spectrum of low- to high-grade neoplasms occurring during the entire lifespan of the affected patients. Here, the authors present the molecular landscape of low- and high-grade gliomas in patients affected by NF1 (NF1-glioma). They found that the predisposing germline mutation of the NF1 gene was frequently converted to homozygosity and the somatic mutational load of NF1-glioma was influenced by the age and grade of the tumor. High-grade tumors harboured genetic alterations of TP53 and CDKN2A, frequent mutations of ATRX associated with alternative lengthening of telomere, and were enriched in genetic alterations of transcription/chromatin regulation and PI3 kinase pathways. Low-grade tumors exhibited fewer mutations that were over-represented in genes of the MAP kinase pathway. Approximately 50% of low-grade NF1-gliomas displayed an immune signature, T lymphocyte infiltrates, and increased neo-antigen load, making them good candidates for immunotherapy.

Contributed by Dr. Mazda K. Turel

Ameratunga M, et al. Anti-angiogenic therapy for high-grade glioma. Cochrane Database Syst Rev 2018;11:CD008218.

In this recent review of randomised control trials, the Cochrane collaborators concluded that the use of anti-angiogenic therapy (e.g., bevacizumab/Avastin) did not significantly improve the overall survival in newly diagnosed patients with glioblastoma. There was insufficient evidence to support the use of anti-angiogenic therapy for people with newly diagnosed glioblastoma at this time. Overall, there was a lack of evidence of a survival advantage for anti-angiogenic therapy over chemotherapy in recurrent glioblastomas. When considering the combination anti-angiogenic therapy with chemotherapy compared with the same chemotherapy alone, there may possibly be a small improvement in overall survival in the combination group. While there was a strong evidence that bevacizumab (an anti-angiogenic drug) prolonged the progression-free survival in newly diagnosed and recurrent glioblastoma, the impact of this on the quality of life and net clinical benefit for patients remained unclear. Not addressed here is whether subsets of patients with glioblastoma may benefit from anti-angiogenic therapies, nor is their utility in other HGG histologies.

Contributed by Dr. Mazda K. Turel

Tewari BP, et al. Perineural nets decrease membrane capacitance of peritumoral fast spiking interneurons in a model of epilepsy. Nat Commun 2018;9:4724.

Brain tumor patients commonly present with epileptic seizures. The authors show that tumor-associated seizures are the consequence of impaired GABAergic inhibition due to an overall loss of peritumoral fast spiking interneurons (FSNs) concomitant with a significantly reduced firing rate of those that remain. The reduced firing is due to the degradation of perineuronal nets (PNNs) that surround FSNs. They also show that PNNs decrease specific membrane capacitance of FSNs permitting them to fire action potentials at supra-physiological frequencies. Tumor-released proteolytic enzymes degrade PNNs, resulting in increased membrane capacitance, reduced firing, and hence decreased GABA release. These studies uncovered a hitherto unknown role of PNNs as an electrostatic insulator that reduces specific membrane capacitance, functionally akin to myelin sheaths around axons, thereby permitting FSNs to exceed physiological firing rates. Disruption of PNNs may similarly account for excitation-inhibition imbalances in other forms of epilepsy, and PNN protection through proteolytic inhibition may provide therapeutic benefits.

Contributed by Dr. Mazda K. Turel

Amirian ES, et al. Aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and glioma risk: Original data from the Glioma International Case-Control Study and a meta-analysis. Cancer Epidemiol Biomarkers Prev 2018 doi: 10.1158/1055-9965.EPI-18-0702.

There have been few studies of sufficient size to address the relationship between glioma risk and the use of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs), and the results have been conflicting. The purpose of this study was to examine the associations between glioma and aspirin/NSAID use, and to aggregate these findings with prior published studies using a meta-analysis. Using data from the Glioma International Case-Control Study (GICC), consisting of 4,533 glioma cases and 4,171 controls recruited between 2010-2013, alongside data from five previous studies, this meta-analysis found that aspirin may be associated with a reduced risk of glioma. A history of daily aspirin use for six months or longer was associated with a 38% lower glioma risk, compared to not having a history of daily aspirin use. Duration-response trends were not observed for NSAID use. These results imply that aspirin use may be associated with decreased glioma risk. Further research examining the association between aspirin use and glioma risk is warranted.

Contributed by Dr. Mazda K. Turel

Hanley DF, et al. Efficacy and safety of minimally invasive surgery with intracerebral haemorrhage evacuation (MISTIE III): A randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 2019 doi: 10.1016/S0140-6736(19)30195-3.

The authors assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage in an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. The trial included patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. The primary outcome was a good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days. 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days. They concluded that for moderate to large intracerebral haemorrhages, MISTIE did not improve the proportion of good response at 1 year of hemorrhage.

Contributed by Dr. Mazda K. Turel and Dr. Sahil Mehta

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;64:395-400.

In this study, 351 patients aged 70 years or older, with aneurysmal subarachnoid hemorrhage (SAH) underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). 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 arms. They concluded that in elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. 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

Barbaro NM, et al. Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial. Epilepsia. 2018;59:1198-1207.

The aim of the study was to compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE) in a randomized controlled design recruiting adults among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission. The mean verbal memory changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between the groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. These data suggest that ATL has an advantage over SRS in terms of the proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.

Contributed by Dr. Mazda K. Turel

Mbabazi-Kabachelor E, et al. Infection risk for Bactiseal Universal Shunts versus Chhabra shunts in Ugandan infants: A randomized controlled trial. J Neurosurg Pediatr 2019. doi: 10.3171/2018.10.PEDS18354.

The authors conducted this larger randomized controlled trial in Ugandan children requiring shunt placement for hydrocephalus to determine whether there was, in fact, any advantage of one shunt over the other. The authors randomly assigned children younger than 16 years of age without evidence of ventriculitis to either Bactiseal Universal Shunt (BUS) or Chhabra shunt implantation in this single-blind randomized controlled trial. The primary outcome was shunt infection, and secondary outcomes included reoperation and death. The minimum follow-up was 6 months. The BUS was implanted in 124 and the Chhabra shunt in 124. Within 6 months of follow-up, there were 14 infections (5.6%): 6 BUS (4.8%) and 8 Chhabra (6.5%; P = 0.58). There were 14 deaths (5.6%; 5 BUS [4.0%] vs 9 Chhabra [7.3%], P = 0.27) and 30 reoperations (12.1%; 15 BUS vs 15 Chhabra, P = 1.00). Among Ugandan infants, BUS implantation did not result in a lower incidence of shunt infection or other complications. Any recommendation for a more costly standard of care in low-resource countries must have contextually relevant, evidence-based support.

Contributed by Dr. Mazda K. Turel

Ghalaenovi H, et al. The effects of amantadine on traumatic brain injury outcome: A double-blind, randomized, controlled, clinical trial. Brain Inj 2018;32:1050-5.

Amantadine, as a dopamine receptor agonist, may stimulate and help in the recovery of the nervous system after traumatic brain injury (TBI). The authors performed this study as a double-blind, randomized, controlled clinical trial including all patients with TBI who scored nine or lower on the Glasgow Coma Scale (GCS). The protocol included administration of the drug (placebo or amantadine) for 6 weeks and patient evaluation using the GCS and FOUR score on the first, third and seventh days after the drug was started. They included 40 patients in the study. As an only important finding, the amantadine group registered an important rise of levels between the first and the seventh day of the study drug being administered. Based on their findings during the first week and the 6-month (since starting drug) follow-ups, prescribing amantadine did not lead to reportable effects on the patients' level of consciousness, memory, disability, cognition, mortality and performance.

Contributed by Dr. Mazda K. Turel

Schwartz LM, et al. Medical marketing in the United States, 1997-2016. JAMA doi: 10.1001/jama.2018.19320.

Medical marketing is an essential component of drug development, introduction, and awareness among physicians as well as patients. In this carefully conducted analysis, the authors have evaluated the expenditure on marketing of the drugs in the US market. Health care is a big flourishing market, and manufacturers to physicians use various promotional activities for increasing the market share of their products and services. Over the last two decades, medical marketing of drugs has increased from $17.7 to $29.9 million. On stratified classification, it was found that the most rapid increase in the expenditure was on direct-to-customer advertising followed by marketing-to-health professionals. Though there are stricter laws and regulations now to limit industry driven pressures and resultant biases in the prescription, the current situation is far from ideal. In the times of dwindling trust between the service providers and the seekers, the findings of this study assume a great importance and calls for serious introspection before it is too late.

Contributed by Dr. Manjul Tripathi

Schipp D, et al. Consumption of a dark roast coffee blend reduces DNA damage in humans: Results from a 4-week randomised controlled study. Eur J Nutr. 2018. doi: 10.1007s00394-018-1863-2.

This interesting study is a boost for the coffee lovers and it may intensify the war amongst beverages. The authors have attempted to compare the effect of dark roasted coffee with water in protection of DNA damage in humans. In this well designed randomised prospective controlled trial, healthy participants were compared after a month's duration of water versus coffee consumption on their DNA damage. The coffee consumers (500 ml of freshly brewed dark roasted coffee) were found to be 23% safer than water consumers. Hence, the study indicates that a regular consumption of coffee blend may have a beneficial effect on the integrity of human DNA irrespective of the gender. This study also suggested that the DNA protective effect of dark roast coffee existed irrespective of the volume of consumption per day. Naturally, further studies on the chemical composition and biological effects of dark roast versus light/medium roast coffee seem warranted. It would be interesting to note if this beneficial effect was limited to any specific ethnic population or not.

Contributed by Dr. Manjul Tripathi

Cohen J. Q&A: The odd—and sometimes tense—intersection of cops, soldiers, and public health. Science mag. doi: 10.1126/science.aaw7091.

This interview is based on a series published in the recent issue of Lancet on the topic of security and public health. Public health sectors and security services are interconnected in their attempt to resolve local and global health related issues. Involvement of security services in health care delivery is a double edged sword. In some instances, it has shown beneficial effects in the effective control of diseases such as Zika and Ebola virus outbreak control. On the other hand, health care providers may be at the receiving end of the security forces as witnessed in war torn zones of Syria, Afghanistan and Peoples Republic of Congo. This two paper series (Militaries and global health: peace, conflict, and disaster response and Law enforcement and public health: recognition and enhancement of joined-up solutions) explores the relationship between the security forces and the public health sector. Health care and health delivery are two separate areas which actually need security services to ensure an effectual delivery. Such articles are a big help in framing better policies not only for the present but for the future too.

Contributed by Dr. Manjul Tripathi

Lewitt PA, et al. Safety and efficacy of CVT-301 (levodopa inhalation powder) on motor function during off periods in patients with Parkinson's disease: A randomised, double-blind, placebo-controlled phase 3 trial. Lancet Neurol 2019;18:145-54.

Levodopa has truly changed the management of Parkinson's disease ever since it was discovered in 1961. Nevertheless, the oral absorption of Levodopa has a delayed and often unpredictable onset of action. There are high chances of off period effects, which need to be carefully treated and monitored. There are various combinations of levodopa and various routes of delivery like the oral, subcutaneous, inhalational, and direct gastric delivery. In this article, a randomization was done with evaluation of a self-administered inhalation levodopa combination for the management of off period side effects in patients with PD. The authors reported improvement in the Unified Parkinson's Disease Rating Scale (UPDRS) score (at 30 min post-dose) with a significantly greater percentage of patients maintaining the response through 60 min after dosing. Investigators have identified atrial fibrillation and hypotension as possible complications in this cohort. Overall, inhalational levodopa was found to be an effective drug with a good compliance and a comparable efficacy. Long term trials are needed for determining the patient compliance and safety profile.

Contributed by Dr. Manjul Tripathi

Holtzhausen L, et al. Shared decision-making in sports concussion: Rise to the 'OCAsion' to take the heat out of on-field decision making. Br J Sports Med 2019;0:1-3.

Management of a sports concussion is as difficult as the diagnosis itself. It has been stressed several times that concussion is a serious but hugely under-diagnosed condition. The recent injury assessment in 2018 Fédération Internationale de Football Association (FIFA) world cup has witnessed the same conflicts in the management of concussion. The diagnosis of concussion is frequently biased because of the inherent issues of the players' career and the team physicians' interest. To curtail the biases, a concept of 'shared decision making' has been introduced. This plan involves the clinicians' use of Elwyn's three talk model for shared decision-making at an individual level, but also at two extra levels of engagement. The authors have proposed “OCAsion”, i.e., organizational level, coach level, and athlete level engagement in decision making of a suspected concussed patient. It broadly involves 'team talk', 'option talk', and 'decision talk' at each level for an effective management. The ultimate benefit of this approach is to give the team physician a freedom to consult the coach, and the confidence and help in making a less biased opinion for a better safety of the players.

Contributed by Dr. Manjul Tripathi

Boutet A, et al. Focused ultrasound thalamotomy location determines clinical benefits in patients with essential tremor. Brain 2018:141;3405-14.

MR guided focused ultrasound lesioning is an attractive and minimally invasive treatment modality for stereotactic lesioning in patients with various movement and psychiatric disorders. At present, essential tremor (ET) remains the only Food and Drug Association (FDA) approved indication for this procedure. The conventional target for tremor predominant symptomatology, whether in ET or idiopathic Parkinson's disease (IPD), is ventral intermediate (VIM) nucleus of the thalamus. However, VIM is an ill defined target on radiology and it frequently needs intraoperative recordings for confirmation. The lesioning is largely performed on the basis of predefined targets based on the experience gained from stereotactic radio frequency lesioning and gamma knife thalamotomy procedures. In this article, the authors have subdivided the VIM nucleus to correlate the size and location of the lesions with clinical benefit and safety/efficacy profiles. The posterior portion of VIM nucleus has been identified as the most ideal target for lesioning with no side effects. Apart from it, lesions larger than 170 mm3 are associated with a significantly high adverse event profile including motor or sensory deficits. This article adds to our understanding of the treatment conducive zone inside the VIM.

Contributed by Dr. Manjul Tripathi

Stangeland H, et al. Poststroke psychosis: A systematic review. J Neurol Neurosurg Psychiatry 2018;89:879-85.

Post stroke psychosis is an under recognized and a grave condition with an incidence of one in every 20 patients in the European population. Post stroke psychosis is a delayed onset disorder with manifestations occurring after several months the incidence of stroke. The most common psychosis was delusional disorder, followed by schizophrenia-like psychosis and mood disorder with psychotic features. The estimated delusion prevalence was 4.67% and hallucinations 5.05%. In general, post stroke psychosis is associated with a poor long-term survival and functional outcome. Its delayed onset provides a lead time for an early detection and prophylactic implementation of the antipsychotic medications. It would be interesting to note that such a condition is grossly under reported in the Indian population, which significantly stresses the patient care system. Long term studies on the safety and efficacy of antipsychotics in this population are urgently needed.

Contributed by Dr. Manjul Tripathi

Link TW, et al. Middle meningeal artery embolization for chronic subdural hematoma: A series of 60 cases. Neurosurgery 2018. doi: 10.1093/neuros/nyy521.

With increasing life span of the world population, neurosurgeons are bound to see an increasing number of patients with chronic subdural hematoma (cSDH). Though the treatment is seemingly easy, there is a large percentage of patients who develop a recurrence of cSDH (2%-37%). A combination of associated medical co-morbidities and the on-going antiplatelet medications in many of these patients, makes the surgical decision, at times, difficult. It is well known that neovascularity of the subdural membrane and leakiness of these vessels maintain and promote growth of cSDH. To stop this neovascularization, the authors have studied the role of embolization of the middle meningeal artery. They included 49 patients with 60 sides of chronic SDH for MMA embolization. The patients selected were the ones who were symptomatic yet without any mass effect on radiology. The therapy was employed in the following 3 scenarios: cSDH in which no prior surgery had been done, treatment of recurrent cSDH, and prophylaxis to prevent a recurrence after surgery. Using the transfemoral route, embolization was done with poly vinyl alcohol particles. The prophylaxis group was excluded for analysis. 45 (90%) patients were successfully managed with MMA embolization while there was failure of therapy in 4 (8.9%) patients. Since this therapy is minimally invasive, the authors have suggested a superiority of this procedure over surgical therapy, provided there is no need for urgent surgical evacuation.

Contributed by Dr. Ashish Aggarwal

Dangayach NS, et al. Does the obesity paradox predict functional outcome in intracerebral hemorrhage? J Neurosurg. 2017 doi: 10.3171/2017.5.JNS163266.

Spontaneous intracerebral hemorrhage (ICH) continues to be a disease with a high morbidity and mortality. There are some well known predictors of a poor outcome, namely, increasing age, a poor admission Glasgow Coma Scale (GCS) score, a large volume of ICH, the location in the posterior fossa, etc. But, are there any other factors which have a protective effect and hence predict better outcomes? In the present study, the authors have analyzed the effect of obesity on the outcomes after ICH. A total of 286 patients were enrolled. Out of these, the complete data and a 3-month follow up were available for 202 patients. The authors took a cut-off body mass index (BMI) value of 25Kg/2 to categorize an individual as underweight or of normal weight. There were 70 patients in the normal/underweight category and 132 patients in the overweight/obese category. The outcome at 3 months was assessed by the modified Rankin's scale (mRS) score, which was dichotomized as favorable (mRS 0,1,2,3) and unfavorable (mRS 4,5,6) outcomes. The overall mortality in the study group was 41% (n = 82). In the subgroup analysis, overweight/obese individuals had more chances of favorable outcomes. The authors go on to discuss the reasons for this paradox. While the precise reasons remain obscure, the presence of excessive fat was hypothesized to confer these patients a better metabolic reserve to deal with the condition. However, further studies are warranted before reading too much into this conclusion.

Contributed by Dr. Ashish Aggarwal

Luedi MM, et al. Dexamethasone-mediated oncogenicity in vitro and in an animal model of glioblastoma. J Neurosurg. 2018 doi: 10.3171/2017.7.JNS17668.

Glioblastoma (GBM) continues to have a dismal prognosis despite recent advances in therapy. There are two molecular variants of GBM – the mesenchymal type and the proneural type. The mesenchymal type is more aggressive and controlled by the transcription factor, CCAAT enhancer binding protein beta (CEBPB). One major factor contributing to morbidity in GBM is the associated brain edema. This edema is generally treated with dexamethasone. But the beneficial effect of dexamethasone has long remained questionable. The authors conducted this study with the following query-to see whether dexamethasone induced invasion, proliferation and neoangiogenesis in GBM. The authors obtained gene expression levels of 155 patients of the mesenchymal type of GBM and 99 patients of the proneural type of GBM. They, then, demonstrated that dexamethasone actually induced invasion, proliferation and angiogenesis in both the subtype derived cell lines. This effect was demonstrable both in the in vitro and in vivo mice model. The implications of the findings of this study are immense and call for further studies.

Contributed by Dr. Ashish Aggarwal

Knerlich-Lukoschus F, et al. Prophylactic antibiotics in pediatric neurological surgery. Childs Nerv Syst. 2018. doi: 10.1007/s00381-018-3864-0.

Surgical site infections remains a feared complication of any surgical procedure which can undo the efforts put forth by the surgical team and can even endanger the lives of the patients. The American College of Surgeons—National Surgical Quality Improvement Program conducted an analysis and found an overall postoperative infection rate of 5.3% after neurosurgical procedures in adult patients. However, a similar data is not available for pediatric population. Surgical antibiotic prophylaxis (SAP) is a method to give an antibiotic shortly before the incision with an aim to avoid proliferation of micro-organisms. The literature currently considers a single dose of cefazolin (30mg/Kg) injected within 60 min of the incision and repeated in 4 hours to be adequate. Third generation cephalosporins do not confer any additional benefit. Clindamycin and vancomycin should be reserved for specific situations. For shunt related prophylaxis, large cohort studies are not available in the pediatric population. In this perspective, the authors have talked about the widely prevalent individualised, often arbitrary use and at times, misuse of SAP and have called for a need to develop evidence based SAP guidelines and recommendations.

Contributed by Dr. Ashish Aggarwal

Ernst G, et al. Subcutaneous bone flap storage after emergency craniectomy: Cost-effectiveness and rate of resorption. J Neurosurg. 2018.doi: 10.3171/2017.6.JNS17943.

Decompressive craniectomy remains one of the life saving measures in cases of refractory intracranial hypertension. During the procedure, few options exist as far as the storage of the removed bone flap is concerned. Some neurosurgical centres cryopreserve the bone, while many center, particularly in the developing world, have a preference for a subcutaneous pocket in the anterior abdominal wall. There are stated benefits and pitfalls of both the techniques. The authors in the present study preserved the bone flaps in the subcutaneous flap and compared their results with the literature. Initially, 193 patients were enrolled; however, cranioplasty was done in 108 patients. Resorption was categorized into 4 categories–early mild, early late, late mild, late severe. The authors found an overall resorption rate of 10%, which was comparable to the cryopreserved bone flap. Subcutaneously preserved bone had added benefits in terms of cost and infrastructure requirement. This study, therefore, comes as a big boost for the neurosurgeons working in resource constrained set ups around the world.

Contributed by Dr. Ashish Aggarwal

Lu VM, et al. Clinical outcomes following early versus late pharmacologic thromboprophylaxis in patients with traumatic intracranial hemorrhage: A systematic review and meta-analysis. Neurosurg Rev. 2018. doi: 10.1007/s10143-018-1045-y.

The problem of traumatic brain injury (TBI) has attained epidemic proportions. It remains a disease with a high mortality and morbidity. An important cause of delayed morbidity and mortality following TBI is deep vein thrombosis and its most dreaded complication – venous thromboembolism (VTE). The reported incidence of DVT in untreated patients is around 25%. In the presence of a hematoma inside the cranial cavity, neurosurgeons are scared to start heparin for pharmacologic thrombo-prophylaxis (PTP) in these situations. Studies show that PTP initiated within 72 hours of ICH stabilization (as revealed by the CT scan) does not increase the risk of progression of hematoma. A big question is when to start the PTP? In this systematic review and meta analysis, the authors have collected data on the progression of ICH and incidence of VTE following PTP. The authors then explored if early PTP (within 72 hours of hospital admission) led to an increased risk of ICH progression. The following outcome results were seen in the early versus late PTP groups—the incidence of VTE was 5.2% versus 9.2%, the incidence of DVT was 4.5% versus 9.0% and the incidence of PE was 1.3% versus 2.4% respectively. Despite the obvious advantages of PTP, the overall mortality, however, did not show any difference.

Contributed by Dr. Ashish Aggarwal

Gessler F, et al. Surgery for glioblastoma in light of molecular markers: Impact of resection and MGMT promoter methylation in newly diagnosed IDH-1 wild-type glioblastomas. Neurosurgery 2019;84:190-7.

The authors have investigated the impact of molecular markers on the prognosis of GBM. They took only those tumours which did not show IDH 1 mutations to exclude its impact on the prognosis. A total of 175 IDH 1 negative GBM patients were taken and their MGMT (O6-methylguanine-DNA methyltransferase) promoter methylation status and extent of resection (EOR) were noted. 84 tumours displayed MGMT promoter methylation and 91 were negative. 104 patients had gross total resection of tumour. Analysis of MGMT methylation status demonstrated that patients with a methylated MGMT promoter displayed significantly longer progession free survival (PFS) and overall survival (OS). Similarly, a gross total resection resulted in better PFS and OS. Age was another factor which influenced the outcome; the patients with age less than 60 years had a favourable outcome. They have concluded that in primary GBM (IDH 1 negative), the EOR and MGMT promoter methylation status are the two most important factors for prolonging PFS and OS.

Contributed by Dr. Navneet Singla

Chan AK, et al. Chlorhexidine showers are associated with a reduction in surgical site infection following spine surgery: An analysis of 4266 consecutive surgeries. Neurosurgery 2018;0:1-10.

In this study, the authors have analyzed the efficacy of chlorhexidine shower in reducing the surgical site infection following spine surgery. A total of 4266 patients were analyzed, out of which 1725 were before adopting CHG shower protocol and 2541 were after implementing the shower protocol. The patients are instructed to have at least 3 showers before surgery; two night before, one night before and on the morning of surgery. 15 patients developed surgical site infection: 12 in the pre-CHG group and 3 in CHG group. On the subgroup analysis, SSI following non-fusion spinal surgeries were significantly lower in the CHG group. Infections were less in fusion procedures also but not to a statistically significant level. This may be because of the prolonged nature of fusion surgeries that the effectiveness of chlorhexidine had vanished. In spinal region wise subgroup analysis, only lumbar non-fusion surgeries showed a benefit. There was no increase in the resistant organisms in the CHG group. The authors have concluded it to be largest study showing the efficacy of pre-operative chlorhexidine shower in reducing SSI.

Contributed by Dr. Navneet Singla

Mampre D, et al. Extending the resection beyond the contrast-enhancement for glioblastoma: Feasibility, efficacy, and outcomes. Br J Neurosurg 2018;32:528-35.

In this retrospective study, the authors have tried to identify if GBM resection beyond the contrast enhancing (CE) part in MRI had any survival or recurrence-free advantage. 245 patients were taken and their pre- and post-operative MRI were analysed to calculate the CE and FLAIR volumes of tumour. Gross total resection was achieved in 84 (34%) and subtotal excision in 161 (66%) patients. In 11 (5%) patients, supra-total resection was achieved. The mean pre- and post-operative CE volume was 31.9 cc and 1.9 cc, respectively, and that in FLAIR was 78.3 and 59.7cc respectively. In multivariate analyses, the postoperative CE tumour volume was significantly associated with both recurrence and survival advantage but the FLAIR volume was not. The median survival and recurrence rates were the same following gross total and supra-total excision. The authors have concluded that it was the CE part of the tumor rather than peritumoral edema that should be removed surgically in order to enhance survival.

Contributed by Dr. Navneet Singla

Hilf N, et al. Actively personalized vaccination trial for newly diagnosed glioblastoma. Nature 2019;565:240-5.

Immunotherapy protocols have traditionally not worked well in GBMs due to a low mutational load. The authors have proposed a new mode of immunotherapy with exploitation of the full repertoire of tumour antigens- both unmutated antigens and neoepitopes. The Glioma Actively Personalized Vaccine Consortium (GAPVAC), GAPVAC-101 phase 1 trial was conducted using vaccinations with both types of antigens in newly diagnosed GBM patients. 15 patients with (human leukocyte antigen) HLA-A*02:01 or HLA-A*24:02 were taken in the study and treated with APVAC1 (vaccine derived from the premanufactured library of unmutated antigens) followed by APVAC2 (Vaccine targeted against neoepitopes). All patients received standard radiotherapy and temozolamide without any change. There was a sustained response of central memory CD8+ T cells induced by APVAC1 and CD4+ T cell response of T helper 1 type against the predicted neoepitopes induced by APVAC2. The median progression-free and overall survival was 14.2 and 29 months, respectively. This novel mode of immunotherapy has shown a great promise in GBM management.

Contributed by Dr. Navneet Singla

Oltulu I, et al. Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach. Neurosurg. Review 2018. doi: 10.1007/s10143-018-01064-2.

Thoracic disc herniations (TDH) are uncommon and rarely symptomatic but at times necessitate a surgical intervention. A number of surgical approaches have been described for TDH such as transpleural, trans-sternal, costotransversectomy, lateral extracavitary, transpedicular and thoracoscopic approaches. In this series, the authors present the results of their minimal invasive lateral transthoracic approach (LTTA) and extreme lateral interbody fusion (XLIF). Fifty-nine patients with 69 thoracic disk herniations were operated (51 single-level, six two-level, and two three-level). The most common level operated was T7-T8. 41 patients had a central disc herniation while 10 had a paracentral disc herniation and 18 had both central and paracentral TDH. 32 patients had a calcified disc. At an average follow-up of 60.8 months, 39 of the 43 patients with myelopathy improved and the mean preoperative visual analog scale (VAS) of 7.7 improved to 4.3. The mean short form (SF)-36 physical component summary (PCS) and mental component summary (MCS) also showed significant improvement. The mean preoperative ODI (Oswestry Disability Index) score of 51.1 improved to 39.3. There was no neurological deterioration and dural tear was the most common (8.5%) complication. The authors stated that this technique not only minimized the manipulation of the thecal sac and decreased the risk for neurological injury but also was associated with significantly less pulmonary complications than those seen with the traditional open procedures.

Contributed by Dr. Navneet Singla

Li J. et al., Weak direct current (DC) electric fields as a therapy for spinal cord injuries: Review and advancement of the oscillating field stimulator (OFS). Neurosurg. Review 2018. doi: 10.1007/s10143-018-01068-y.

The existence of DC electric fields and their occurrence in cellular processes has been well established. It is also established that the current in human body is carried through ions and not electrons. In vitro studies have shown that neurons when exposed to DC electric fields (EFs) as low as 10 mV/mm can cause axonal growth cones towards the cathode. EFs enhance the rate of neurite outgrowth and branching. The phenomenon of simultaneous EF-induced cathodal attraction and reduction in axon dieback provides the foundation for its use in treating spinal cord injury (SCI). For an ideal sensory and motor recovery, the injured spinal axons must extend both cranially and caudally across the lesion to synapse with functional, healthy neurons. This two-way projection poses an interesting problem since DC electric field–induced axonal growth tends to be biased towards the cathode. So the concept of oscillatory field stimulator (OFS) has come up in which electrode polarity is switched every 15-minutes. This reversal of polarity encourages bidirectional axon growth across the damaged cord region and neutralizes the electrochemical by-products that accumulate at the electrodes. In this study, the OFS devices were implanted into ten human patients with complete acute SCI. Interestingly, the 1-year motor score improved by 6.3 points from the baseline, light touch up by improved by 6.3 points from the baseline, light touch improved by 23.9 points from the baseline, pin prick sensory score increased by 19 points and somatosensory evoked potentials (SSEPs) remained improved throughout the study period. The visual analog scale (VAS) score improved from 8 to a mean of 2 and no reported cases of neuropathic pain were noted. The surgical procedure was well tolerated, with only one patient developing surgical site infection. New miniaturized wireless semiconductor technologies, better OFS design and incorporating modern microelectronics can improve functionality in the future.

Contributed by Dr. Navneet Singla

Rogers DM, et al. The central vein: FLAIR signal abnormalities associated with developmental venous anomalies in patients with multiple sclerosis. Am J Neuroradiol. 2018;39:2007-13.

Developmental venous anomalies (DVAs) may have surrounding white matter FLAIR hyperintensities, attributable to demyelination. This study aimed at quantifying the prevalence of white matter signal abnormalities associated with DVAs in patients with multiple sclerosis compared with controls. Retrospective evaluation of the magnetic resonance (MR) data was performed in a blinded fashion by neuroradiologists and the prevalence of FLAIR hyperintense signal abnormalities adjacent to the DVA in patients with MS was compared with controls (patients with DVAs without MS). The incidence of FLAIR signal abnormality was significantly higher in patients of DVAs with MS as compared to that of DVAs in the control group. They suggested that the underlying demyelinating pathologic process of MS may be the cause of this propensity in patients with MS and postulated that impaired venous drainage in the territory of DVA may predispose to the development of these lesions.

Contributed by Dr. Chirag K. Ahuja

Yeh RW, et al. PARACHUTE Investigators. Parachute use to prevent death and major trauma when jumping from aircraft: Randomized controlled trial. BMJ 2018;363:5094.

The authors have been successful in creating a flutter among the readers through this insanely humorous piece of publication wherein they have tried to determine whether using a parachute prevents death or major traumatic injury when jumping from an aircraft. The intervention involved jumping from an aircraft (airplane or helicopter) with the end points being death or major traumatic injury (defined by an Injury Severity Score over 15) upon impact with the ground measured immediately after landing. A total of 23 participants were randomized into two groups- one with a parachute and the other with an empty back-pack during jump. They concluded that parachute use did not significantly reduce death or major injury. The only catch, and hence limitation, of the study was that the trial was only able to enrol participants on a small stationary aircraft on the ground (mean height - 0.6 m), suggesting cautious extrapolation to high altitude jumps. They have aptly concluded that when beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enrol individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.

Contributed by Dr. Chirag K. Ahuja

Yao R, et al. Surgical site infection in spine surgery: Who is at risk? Global Spine J 2018;8:5S-30.

Surgical site infection (SSI) after spinal surgeries is a widely prevalent problem. This study attempts at reviewing the various risk factors and categorizing them into the patient and surgical subgroups with the eventual aim of identifying and modifying them to reduce the occurrence of SSI. The authors analysed the published literature on the risk factors causing SSI in adult spine surgery for their interpretation. Overall, 94 studies were included, of which the majority were cohort studies (72) followed by case-controlled studies (12). The notable patient-associated risk factors were diabetes mellitus, obesity, subcutaneous fat thickness, multiple medical comorbidities, current status of smoking and malnutrition. The various surgical factors contributing to an increased risk were preoperative radiation/postoperative blood transfusion, combined anterior/posterior approach, surgical invasiveness or levels of instrumentation. The study thus identified important modifiable and non-modifiable risk factors that should be recognized in the preoperative surgical planning and discussed with patients/relatives preoperatively.

Contributed by Dr. Chirag K. Ahuja

Suh CH, et al. MRI findings in tumefactive demyelinating lesions: A systematic review and meta-analysis. Am J Neuroradiol 2018;39:1643-9.

Tumefactive demyelination, as the name states, mimics glioma many-a-times, leading to an unwanted surgical intervention or inappropriate management. The present study evaluates the MR imaging findings of tumefactive demyelinating lesions (TDLs) and determines its accuracy in discriminating these lesions from gliomas. The authors performed a systematic search of Ovid MEDLINE and EMBASE and selected 19 original articles with 476 patients describing MRI findings in patients with TDLs. The pooled incidence of open ring or incomplete rim enhancement was 35%, and closed ring or complete rim enhancement was 18% (P = 0.0281). The pooled incidences of a T2 hypointense rim, absent or mild mass effect, and absent or mild perilesional edema were 48%, 67%, and 57%, respectively. TDLs showed a high apparent diffusion coefficient, peripheral restricted diffusion, and a low cerebral blood volume. The pooled sensitivity and specificity of MR imaging for differentiating TDLs from primary brain tumors were 89% and 94%, respectively. Thus, the conventional MR imaging findings may help to differentiate TDLs from primary brain tumors with a reasonable diagnostic accuracy.

Contributed by Dr. Chirag K. Ahuja

Trelles M, et al. Natural history of endoscopic third ventriculostomy in adults: Serial evaluation with high-resolution CISS. Am J Neuroradiol 2018;39:2231-6.

The long-term patency of endoscopic third ventriculostomy (ETV), a well-accepted treatment choice for non communicating hydrocephalus, is often difficult to assess. The evaluation of the characteristics of the third ventricle floor defect may define its patency rates and patient related clinical outcomes. The authors evaluated 98 MR imaging studies done in 34 ETV patients over a duration of 5 years and measured the defect area. The average change in the defect area throughout the studied period was 0.02 mm2/day with a higher increase in size noted in the first 3 postsurgical months. Use of the NICO Myriad device was correlated with a larger final defect size. They concluded that high-resolution MR imaging might prove useful in the postoperative evaluation of ETV and should thus be performed for its assessment on a routine basis.

Contributed by Dr. Chirag K. Ahuja

Suh CH, et al. The diagnostic value of diffusion-weighted imaging in differentiating metastatic lymph nodes of head and neck squamous cell carcinoma: A systematic review and meta-analysis. Am J Neuroradiol 2018;39:1889-95.

Head and neck squamous cell carcinomas warrant an accurate lymph node staging for proper treatment planning. The article explores the diagnostic performance of diffusion weighted imaging (DWI) for differentiating metastatic cervical lymph nodes from benign cervical lymph nodes in such patients and to identify an optimal cut-off value for apparant diffusion coefficent (ADC). A computerized literature search was performed to identify the relevant original articles on DWI in head and neck cancers. Nine studies with 337 patients were included. In all studies, ADC values derived from metastatic lymph nodes were significantly lower than ADC values derived from the benign lymph nodes. The median ADC cut-off value was 0.965 × 10-3 mm2/s. The pooled sensitivity and specificity for the diagnostic performance of DWI in differentiating metastatic lymph nodes from benign lymph nodes were 90% and 88% respectively. DWI thus demonstrated a high diagnostic performance in differentiating metastatic lymph nodes from benign lymph nodes in these patients.

Contributed by Dr. Chirag K. Ahuja

Suh CH, et al. Diffusion-weighted imaging and diffusion tensor imaging for differentiating high-grade glioma from solitary brain metastasis: A systematic review and meta-analysis. Am J Neuroradiol 2018;39:1208-14.

Differentiating high-grade glioma from solitary brain metastasis is very important from a management perspective but is still intriguing. The authors have evaluated the diagnostic performance of diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI) for differentiating the two, based on a literature search of Ovid MEDLINE and EMBASE until 2017. Fourteen studies with 1143 patients were included. The individual sensitivities and specificities of the 14 included studies showed a wide variation, ranging from 46.2% to 96.0% for sensitivity and 40.0% to 100.0% for specificity. The pooled sensitivity and specificity of both DWI and DTI from all these studies was also calculated, being 79.8% and 80.9%, respectively. Thus, DWI and DTI as sole parameters for differentiation of high-grade glioma from solitary brain metastasis showed only a moderate diagnostic performance in the meta-analysis. We recommend a multiparametric MR evaluation in this problem, which yields a much better diagnostic accuracy.

Contributed by Dr. Chirag K. Ahuja

Cobo-Calvo, et al. Usefulness of MOG-antibody titres at first episode to predict the future clinical course in adults. J Neurol. 2019. doi: 10.1007/s00415-018-9160-9.

This interesting retrospective study included 79 myelin oligodendrocyte glycoprotein antibody (MOG-Ab) positive adult patients to analyze whether the titres of MOG-Ab at onset varied according to the clinical phenotype and whether they had an impact on the disease prognosis. Patients with varied visual and motor disabilities were included. MOG-Ab were tested by a cell-based assay. MOG-Ab titres were found to be higher in Caucasians and in patients with a more severe disease. MOG-Ab titres were not associated with any risk of relapses or with the final clinical outcome. It was concluded that the titres did not predict the future disease course despite a clear association with higher MOG-Ab titres.

Contributed by Dr. Aastha Takkar

D'Ovido F, et al. Association between alcohol exposure and the risk of amyotrophic lateral sclerosis in the Euro-MOTOR study. J Neurol Neurosurg Psychiatry. 2019;90:11-9.

Antioxidants have been proposed to benefit many neurodegenerative diseases but with rather inconsistent scientific association. The aim of Euro-MOTOR, an international population-based case–control study was to assess the role of alcohol, and red wine in particular, in developing amyotrophic lateral sclerosis (ALS). This was a case–control study where patients with ALS (n = 1557) and controls (n = 2922) matched for gender, age and area of residency, were recruited in a population-based design. Exposure to alcohol was not found to be significantly associated with the risk of developing ALS. With regard to the red wine consumption, only a single region the double-fold increased risk remained significant. With a few exceptions, no significant association was found between alcohol consumption and ALS. The study of the association between alcohol and ALS requires a thorough exploration, especially considering the varying alcohol concentrations in different types of alcoholic beverages.

Contributed by Dr. Aastha Takkar

Ziff OJ, et al. Statins and the risk of intracerebral haemorrhage in patients with stroke: Systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2019;90:75-83.

This systematic literature review and meta analysis tried to address the evidence for statin therapy on intracranial hemorrhage (ICH) and other clinical outcomes in patients with previous ischemic stroke (IS) or ICH. Forty-three studies with a combined total of 317 291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled relative risk for recurrent ICH; however, statins were associated with significant reductions in the mortality and poor functional outcome. In patients with previous IS, statins were associated with a non-significant increase in ICH, but significantly lower risks of recurrent IS, any stroke, mortality, and poor functional outcome. Irrespective of the stroke subtype, there were non-significant trends towards future ICH with statins. This risk, however, was overshadowed by substantial improvement in mortality and functional outcome among patients who used statin.

Contributed by Dr. Aastha Takkar

Lech M, et al. Human Computer Interface for tracking eye movements improves assessment and diagnosis of patients with acquired brain injuries. Front. Neurol. 2019. doi: 10.3389/fneur.2019.00006

Smooth pursuit eye movements occurring in response to moving stimuli may be used as one of the early surrogate signs to differentiate the minimally conscious state from the vegetative state. The commonly used Glasgow Coma Scale (GSC) is limited to a standard neurological examination and is likely to misinterpret these clinical states. Based upon these hypotheses, the authors developed an interface for gaze tracking to enhance the assessment of consciousness in 10 patients with acquired brain injuries. 9 out of 10 patients were considered unaware and had a GCS of ≤8. The human computer interface (HCI) revealed that 6 of them were conscious enough to complete at least one of the gaze tracking tasks. 1 out of these 6 patients was originally diagnosed as having persistent vegetative state and one to be in coma. The authors hence provide a novel tool to assess patients suffering from disorders of consciousness.

Contributed by Dr. Aastha Takkar

Stack SW, et al. Childbearing and maternity leave in residency: Determinants and well-being outcomes. Postgrad Med J. 2018. doi: 10.1136/postgradmedj-2018-135960.

This interesting survey based assessment was done to characterize determinants of resident maternity leave and its effect on maternal and infant well-being. It also tried to identify factors that influence the decision to delay childbearing among residents who are not parenting. Female residents at a large academic medical centre were contacted on their experiences with maternity leave and impact of factors on the length of the leave. Forty-four percent (214/481) of the residents responded to the survey. 23% of the residents were parents, and of them 12% took maternity leave during training. The most common self-reported determinant of leave was financial. Residents with >8 weeks of leave were less likely to have postpartum depression or burnout and more likely to breastfeed longer, perceive support from colleagues and programme directors, and be satisfied with resident parenthood. Among 104 non-parents who were married or partnered, 81% were delaying childbearing, citing busy work schedules, concern for burdening colleagues and finances. This study has provided insight towards multiple aspects of resident wellbeing and the need of clearer policies.

Contributed by Dr. Aastha Takkar

Alghamdi A, et al. Neuro-ophthalmological manifestations of Behçet's disease. Br J Ophthalmol 2019;103:83-7.

Literature is limited with regards to the neuro-ophthalmological manifestations of Behcet's disease (BD). This retrospective study on 217 patients of neuro Behcet's Disease (NBD) suggested that 13.3% of the patients presented with neuro-ophthalmological manifestations. The neuro-ophthalmological manifestations were the first presentation of BD in 45% of patients and developed later in the course of the disease in rest of the patients. They were parenchymal (PM) in 45% and non-parenchymal (NPM) involvement in 55% of the patients. PM manifestations included papillitis, retrobulbar optic neuritis and third cranial nerve palsy. NPM included papilloedema related to cerebral venous thrombosis. 93.1% of patients had visual alterations at presentation. All patients were treated with corticosteroids and 79% of the patients received immunosuppressive agents. After treatment, the visual outcome improved or stabilized in 66.7% of patients while it worsened in the remaining one-third of the patients. This study shows that the neuroophthalmological presentations in BD could be potentially severe and disabling.

Contributed by Dr. Aastha Takkar

Girard TD, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med 2018;379:2506-16.

The choice of antipsychotic medications in patients with delirium in the intensive care unit (ICU) has been controversial. In this randomized, double-blind, placebo-controlled trial, 566 patients with acute respiratory failure or shock and delirium received intravenous boluses of haloperidol (n = 192), ziprasidone (n = 190) or a placebo (n = 184). The use of haloperidol or ziprasidone, as compared with the placebo, had no significant effect on the primary end point (number of days alive without delirium or coma during the 14-day intervention period). There were no significant between-group differences between 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to intensive care unit and hospital discharge, as well as the frequency of development of extrapyramidal symptoms.

Contributed by Dr. Aastha Takkar

Rutten S, et al. Bright light therapy for depression in Parkinson disease: A randomized controlled trial. Neurology 2019;12:1145-56.

Non-motor symptoms such as depression and sleep disturbances are common in patients with Parkinson's disease (PD) and contribute significantly to the increased morbidity and impaired quality of life in PD. Light therapy improves mood and sleep by the activation of the suprachiasmatic nucleus and regularization of the circadian rhythm. The authors in this single centre randomized controlled trial compared the influence of bright light (10,000 lux) to a controlled light (200 lux) in patients with PD and major depressive disorder over a 3-month period. There was no significant difference in the Hamilton depression rating scale score between the two groups. However, there was improvement in the subjective sleep quality in the intervention group. Further trials with larger sample size are required to further elucidate the role of light therapy in depression associated with PD.

Contributed by Dr. Sahil Mehta

Verschuur CVM, et al. Randomized delayed-start trial of levodopa in Parkinson's disease. N Engl J Med 2019;380:315-24.

Levodopa is the most potent and the gold standard drug in the management of Parkinson's disease (PD). The authors in this multicentre randomized placebo controlled trial primarily intended to observe if levodopa had any disease modifying activity when started early on in PD. One group received levodopa (100 mg three times daily) while the other group received a placebo till 40 weeks and then both the groups received levodopa (100 mg thrice daily) for the next 40 weeks. There was no significant difference at the end of 80 weeks indirectly suggesting that levodopa has no disease modifying effect. Moreover, there was no difference in the rates of motor fluctuations and dyskinesias between the two groups. This study suggests that levodopa has no disease modifying effect in the course of Parkinson's disease

Contributed by Dr. Sahil Mehta

Josephson CB, et al. Prediction tools for psychiatric adverse effects after levetiracetam prescription. JAMA Neurol 2019. doi: 10.1001/j amaneurol. 2018.4561.

Levetiracetam is the most commonly used antiepileptic now a days. However, psychiatric adverse effects are not uncommon with this drug. The authors in this retrospective cohort study derived tools to predict the risk of psychiatric adverse effects after levetiracetam use. Female gender, pre-exposure social deprivation, depression, anxiety and recreational drug use were at higher risks of developing psychiatric side effects. The algorithms proposed in this paper can be used in clinical practice to guide the ever increasing number of prescriptions of levetiracetam.

Contributed by Dr. Sahil Mehta

Denis HL, et al. Platelet abnormalities in Huntington's disease. J Neurol Neurosurg Psychiatry 2019;90:272-83.

Huntington's disease (HD) is an autosomal dominant CAG repeat degenerative disorder. It is caused by a mutation of the huntingtin gene leading to production of mutant huntingtin proteins. A number of earlier studies have shown a state of increased vascular permeability in patients with this disease, both within and outside the central nervous system. Moreover, there are other documented changes in HD like membrane alterations in red blood cells, white blood cells and altered release of immunomodulatory cytokines. In this particular study, the authors assessed the functional status of platelets in these patients and compared the results with controls. The methods applied were enzyme linked immunosorbent assay, western blot and ribose nucleic acid sequencing. The study showed a number of platelet dysfunctions like the release of angiogenic factors, angiogenesis and vascular homeostasis. Therefore, this study has provided further insights and a fodder for future studies in this inexorably progressive degenerative disease.

Contributed by Dr. Sahil Mehta

Whone A, et al. Randomized trial of intermittent intraputamenal glial cell line-derived neurotrophic factor in Parkinson's disease. Brain 2019;142:512-25.

Glial cell-line derived neurotrophic factor (GDNF) has shown robust neurorestorative and neuroprotective effects in animal models of Parkinson's disease. The authors of this first such randomized trial in humans compared the benefits of fixed dose GDNF infusions into the putamen using convection enhanced delivery through a skull mounted port versus a placebo. This study included 41 patients of moderate stage Parkinson's disease (UPDRS III 25-45 and Hoehn and Yahr scale 2-3). At 40 weeks, there was no significant decrease in the UPDRS score between the GDNF and placebo group. However, the 3,4-dihydroxy-6-18F-fluoro-l-phenylalanine (FDOPA) positron emission tomography (PET) study did show an increased uptake in the putamen in the active group compared to placebo. Further clinical trials focusing on an optimum dose of GDNF, duration of treatment and other factors are needed before refuting the clinical benefit of this novel therapy in Parkinson's disease.

Contributed by Dr. Sahil Mehta

Dubey D, et al. Clinical, radiologic, and prognostic features of myelitis associated with myelin oligodendrocyte glycoprotein autoantibody. JAMA Neurol 2018. doi: 10.1001/jamaneurol.2018.4053.

The authors of this retrospective observational study compared the clinical and radiological features between aquaporin 4 myelitis, myelin oligodendrocyte glycoprotein (MOG) myelitis and multiple sclerosis (MS) myelitis. The clinical phenotype of acute flaccid myelitis and concurrent acute disseminated encephalomyelitis (ADEM) may favour MOG-IgG myelitis. Radiological appearance of longitudinally extensive myelitis occurred with similar frequency between MOG and aquaporin 4 myelitis. However, multiple spinal cord lesions, conus involvement, H sign on axial T2 images confined to grey matter and lack of enhancement favoured MOG myelitis over aquaporin 4 or multiple sclerosis myelitis. Wheel chair dependence at nadir of myelitis was similar in aquaporin 4 or MOG myelitis but recovery was better in MOG myelitis.

Contributed by Dr. Sahil Mehta and Dr. Ravi Yadav

Brott TG, et al. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: A pre-planned pooled analysis of individual patient data. Lancet Neurol 2019;18:348-56.

Various randomised controlled trials have shown a higher risk of periprocedural stroke, death and subsequent ipsilateral stroke after 2-3 years of carotid artery stenting as compared to endarterectomy. Pooled patient data from four major trials (EVA-3S, SPACE, ICSS and CREST) was studied for periprocedural (up to 120 days) and post procedural events. The median follow up was between 2 to 6.9 years. Risk of stroke or death was more with carotid artery stenting group in the periprocedural period. However, after the periprocedural period of 120 days, risk of ipsilateral stroke was similar between the two groups. Improvements in the periprocedural safety in the stenting group can improve outcomes in the future.

Contributed by Dr. Sahil Mehta

Lu VM, et al. Comparison of operative outcomes of eloquent glioma resection performed under awake versus general anesthesia: A systematic review and meta-analysis. Clin Neurol Neurosurg 2018;169:121-7.

Surgical resection of an eloquent glioma can be achieved under general anesthesia (GA) or under awake anesthesia (AA). The appeal of AA is that it facilitates intraoperative identification and avoidance of eloquent areas, which has the potential to minimize functional compromise. The authors included 9 comparative studies in this meta-analysis to compare the operative outcomes of eloquent area glioma resection performed under GA compared to AA to assist in optimizing the decision algorithm between the two approaches. Resection of glioma involving eloquent areas achieved under AA was comparable in terms of operative (including extent of resection and probability to achieve gross total resection) and functional outcomes (complications like neurological deficits) to that of GA. AA did demonstrate a significantly lower incidence of postoperative nausea and vomiting and shorter length of stay when compared to the GA group. The authors felt that further prospective studies were required to study overall as well as the disease free survival. It will assist in appreciating the long-term clinical benefit of these two techniques and assist in developing a management algorithm.

Contributed by Dr. Kanwaljeet Garg

Lamba N, et al. Fertility after transsphenoidal surgery in patients with prolactinomas: A meta-analysis. Clin Neurol Neurosurg 2019;176:53-60

Prolactinomas in women can often result in infertility. This meta-analysis aimed to evaluate the effectiveness of transsphenoidal surgery (TSS) in restoring fertility in women with prolactinomas. Fourteen studies were included in this meta-analysis. The mean difference between the pre- and post-operative prolactin level was 186.9. The pooled prevalence of pre-operative amenorrhea was 96% as compared to 40% in the post-operative period and the difference was statistically significant. The pooled prevalence of pre-operative galactorrhea was 84% as compared to 29% in the postoperative period (P < 0.01). Univariate meta-regression did not show age, continent, publication year, study design, quality, duration, or timing did not have any significant effect on any of these 3 variables (all P > 0.05). The authors concluded that transsphenoidal surgery improved fertility measures in women with pituitary prolactinomas.

Contributed by Dr. Kanwaljeet Garg

Sussman ES, et al. Contralateral acute vascular occlusion following revascularization surgery for moyamoya disease. J Neurosurg. 2018;14:1-7.

Revascularization surgery is the only known effective treatment for patients with symptomatic moyamoya disease (MMD). Acute perioperative occlusion of the contralateral internal carotid artery (ICA) with contralateral stroke is a highly under-reported complication after revascularization surgery. This study was a retrospective review of a single surgeon's 1446 bypass procedures performed in 905 patients over 25 years. Thirty-four (2.4%) patients developed symptomatic contralateral hemispheric infarcts in the postoperative period. Digital subtraction angiography (DSA) revealed new occlusion of the contralateral ICA in one-fourth of these patients. All of these patients had undergone direct STA to MCA (M4) bypass. The collateral supply originated exclusively from the intracranial circulation in 4/8 (50%) patients, and from both the intracranial and extracranial circulation in the rest. Seven (88%) of 8 patients improved symptomatically during the acute postoperative period with induced hypertension. At the 3-year follow-up, 4/7 patients were below their baseline modified Rankin Scale score or dead, while the rest 3 improved to their baseline level. The authors concluded that acute occlusion of the ICA highlights the importance of hemodynamic interrelationships between the two hemispheres. Induced hypertension during the acute period may provide adequate cerebral blood flow via developing collateral vessels, and good outcomes may be achieved with aggressive supportive management and expedited contralateral revascularization.

Contributed by Dr. Kanwaljeet Garg

Nzwalo H, et al. Fine particulate air pollution and occurrence of spontaneous intracerebral hemorrhage in an area of low air pollution. Clin Neurol Neurosurg 2019;176:67-72.

This study aimed to study the association of ambient particulate matter ≤ 2.5 μm diameter (PM2.5) with the occurrence of spontaneous intracerebral hemorrhage (SICH) in an area of low air pollution in southern Portugal. The authors included 358 patients and compared PM2.5 levels from 3 days before the SICH event (Lag 1, 2, 3) with one control period (Lag 15–17) using a case-crossover analysis. The mean values of PM2.5 were higher on the case days compared to the control period. For each 10 μg/l increase, the likelihood of SICH increased by 5.7%. Strength of the association was higher in patients younger than 70 years; without neurological disability prior to SICH; and with non-lobar type of hematoma. A circadian and circannual pattern was present with an increased strength of the association when SICH occurred in the morning time, in the fall and in the winter. The association was also potentiated at lower temperature values. The authors concluded that short-term increases of PM2.5 could be associated with the occurrence of SICH in a region of low ambient pollution.

Contributed by Dr. Kanwaljeet Garg

Ene CI, et al. Patterns of failure after stereotactic radiosurgery for recurrent high-grade glioma: A single institution experience of 10 years. Neurosurgery 2018. doi: 10.1093/neuros/nyy520.

Stereotactic radiosurgery (SRS) is frequently used as a salvage therapy for small nodular recurrent high-grade gliomas (HGG). However, the effect of SRS in HGG in debated in view of their infiltrative nature. The authors aimed to investigate the manner in which the demographic or the clinical factors influenced the pattern of failure following SRS for recurrent high-grade gliomas. This retrospective study included 47 patients (WHO grade III and IV). Most patients (85%) with recurrent HGG developed “in-field” treatment failure following SRS. Higher SRS doses were associated with statistically significant longer time to failure (hazards ratio = 0.80 per 1 Gy increase). There was a statistically significant increase in the distant versus in-field failure among older patients and this effect was independent of the usage of bevacizumab. The results suggested that higher SRS doses delivered to a larger area as fractioned or unfractioned regimen may prolong the time to failure, especially in the older population. The authors concluded that the most of recurrences occured 'in field' except in elderly in whom 'distant' recurrences were more common.

Contributed by Dr. Kanwaljeet Garg

Champeaux C, et al. Malignant meningioma: An international multicentre retrospective study. Neurosurgery 2018 doi: 10.1093/neuros/nyy610.

Malignant meningiomas (MM) are rare and associated with an unfavourable prognosis. Unlike most reports of MM that tend to represent small cohorts, this study reports clinical data of 178 patients treated for a MM at 6 international institutions in Europe. About two-fifths of patients (n = 76) had a prior history of grade I or grade II meningioma. The patients underwent a total of 380 surgical resections, and 72.5% of patients received radiotherapy. The median follow-up was 4.5 years. Nearly three-fifths of the patients (n = 111, 63.4%) were dead by the time of last follow up and only 23 patients (13.7%) were alive without any residual tumour on the most recent scan. The median overall survival was 2.9 years, and overall survival rates at 1, 5, and 10 years, respectively, were: 77.7%, 40%, and 27.9%. In the multivariate analysis, age at MM surgery < 65 years, previous benign or atypical meningioma surgery, completeness of resection, and adjuvant radiotherapy were established as independent prognostic factors for survival. This large series reiterates the poor prognosis associated with MM. The authors concluded that patients under 65 years of age with primary MM may live longer after complete resection and postoperative radiotherapy.

Contributed by Dr. Kanwaljeet Garg

Machino M, et al. MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome. Clin Neurol Neurosurg 2019. doi.org/10.1016/j.clineuro.2018.12.010.

Patients with cervical spinal cord injury without radiographic abnormality (SCIWORA) usually have increased signal intensity (ISI) on T2 weighted magnetic resonance imaging (MRI). This study aimed to evaluate the clinical effectiveness of grading of MRI-based ISI in adults SCIWORA. One-hundred consecutive SCIWORA patients who had undergone expansive laminoplasty were included. All patients underwent MRI in the acute phase, and ISI was classified into three groups based on sagittal T2- weighted MRI: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). Preoperative MRI showed Grade 0 in 8 patients, Grade 1 in 49 patients, and Grade 2 in 43 patients. The pre- and postoperative Japanese Orthopedic Association (JOA) scores decreased significantly with an increasing ISI grade. The recovery rate of JOA score decreased as the ISI grade increased. The ISI grade showed a correlation with the pre- and postoperative ASIA impairment scale. ISI Grade 2 on MRI was observed in severely paralyzed cases. The authors concluded that MRI-based ISI classification did correlate with preoperative symptom severity in adult patients with SCIWORA and could turn out to be a good predictor of surgical outcome.

Contributed by Dr. Kanwaljeet Garg

Haws BE, et al. Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: Results of a prospective, randomized, single-blind trial. J Neurosurg Spine. 2018. doi: 10.3171/2018.7.SPINE18584.

This prospective, randomized, single-blinded study aimed to characterize the effect of local intraoperative depomedrol application on the perioperative and postoperative outcomes following a single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Ninety-three patients were randomized into depomedrol (DEPO) and no depomedrol (NODEPO) cohorts. DEPO patients received 1 ml depomedrol (80 mg) applied directly to the surgical site by using a Gelfoam carrier prior to the surgical closure. There were no differences in acute postoperative pain or total narcotics consumption in either of the groups and all the patient-reported outcomes at all the points. The only difference was the requirement of fewer hourly narcotics on postoperative day 0 in the DEPO group. The authors concluded that surgical and clinical outcomes following MIS TLIF may not be impacted by intraoperative application of depomedrol.

Contributed by Dr. Kanwaljeet Garg

Goenka S, et al. Effect of early treatment with zoledronic acid on prevention of bone loss in patients with acute spinal cord injury: A randomized controlled trial. Spinal Cord 2018;56:1207-11.

This randomized controlled trial aimed to determine the effect of zoledronic acid on bone loss in people with acute spinal cord injury (SCI). Sixty patients with acute SCI were randomized to receive either standard treatment alone or standard treatment with zoledronic acid within 3 months after injury. Significant differences in the areal bone mineral density (aBMD) were found between the standard treatment alone and standard treatment plus zoledronic acid group at the femoral neck, and total hip at 1 year. Bone loss was reduced in the zoledronic acid treated group as compared to the standard treatment group. Significant differences in the aBMD between the groups at 6 months post-infusion was also observed at these sites. The authors concluded that zoledronic acid 5 mg infusion given within 3 month significantly could reduce bone loss at the hip 6 months post-infusion in patients with acute SCI.

Contributed by Dr. Kanwaljeet Garg

Hammad R, et al. Lymphedema techniques to manage edema after SCI: A retrospective analysis. Spinal Cord. 2018;56:1158-65.

This retrospective study aimed at evaluating the safety, feasibility, and benefit of a modified lymphedema treatment approach for treatment of chronic lower extremity edema in persons with SCI. The standard complete decongestive therapy (CDT) techniques were modified to accommodate sensory and motor impairments and skin safety in patients with spinal cord injury. This modified CDT (mCDT) approach of treatment was used in 105 lower extremities in 59 adult patients with SCI and lower extremity edema. It included an intensive phase and a maintenance phase. The intensive phase involved four components: skin care, daily range of motion and breathing exercises, manual lymphatic drainage (MLD), and compression wrapping with multi-layered short-stretch bandaging which was replaced by compression garments in the maintenance phase. It was observed that the mCDT was associated with significant reduction in limb volumes, significant decreases in pitting edema, and the mean pitting scale score (which was reduced from a 3/4 to a ¼). The authors concluded that the mCDT approach was safe and well-tolerated by the patients with SCI.

Contributed by Dr. Kanwaljeet Garg

Coulombe MA, et al. Deep brain stimulation for Gilles de la Tourette syndrome in children and youth: A meta-analysis with individual participant data. J Neurosurg Pediatr. 2018. doi: 10.3171/2018.7.PEDS18300.

Gilles de la Tourette syndrome (GTS) is a disorder characterized by motor and vocal tics. Although by definition, the onset of GTS is before the age of 18 years, clinical trials of deep brain stimulation (DBS) have been conducted only in adults. This study was a systematic review studying individual participant data (IPD) of 58 children and youth (ages 12–21 years). The average improvement was 57.5% ±24.6% across the studies on the Yale Global Tic Severity Scale score. They also found that comorbid depression and stimulation pulse width correlated negatively with outcome (P < 0.05). In patients with less severe GTS, greater improvements were evident following thalamic stimulation. More than one-quarter (n = 16, 27.6%) of participants experienced side effects, most being minor complications. The authors concluded that DBS in the pediatric population may be an effective option with a moderate safety profile for treatment of GTS in carefully selected children and youth.

Contributed by Dr.Kanwaljeet Garg

Lorente R, et al. Radiological evaluation does not reflect the clinical outcome after surgery in unstable thoracolumbar and lumbar type a fractures without neurological symptoms: A comparative study of 2 cohorts treated by open or percutaneous surgery. Clin Spine Surg 2018. doi: 10.1097/BSD.0000000000000737.

This prospective study aimed to compare the clinical and radiologic outcome of 2 cohorts of unstable thoracolumbar and lumbar fractures treated by open posterior fixation (OPF) with bone graft or by percutaneous fixation (PCF) without grafting. Patients with traumatic unstable thoracolumbar and lumbar fractures (type A2, A3, and A4) without neurological symptoms were included in the study and underwent either OPF (n = 91) or PCF (n = 54). The authors found that the correction (change in fracture angle, kyphotic deformity, vertebral compression, and displacement) was significantly greater in patients who underwent OPF. The patients who underwent PCF suffered greater loss of correction at a 2-year follow-up. Besides, PCF cases showed better Visual Analog Scale (P < 0.001) and Oswestry Disability Index scores (P < 0.001) at the final follow-up. The percentage of patients returning to the same heavy work position was higher in the PCF group (P < 0.001) and in a shorter period of time (P < 0.001). The authors concluded that the greater loss of correction of patients undergoing PCF does not reflect the clinical outcomes that were significantly better as compared to the open approach.

Contributed by Dr.Kanwaljeet Garg

Uehara M, et al. How much surface registration accuracy is required using ct-based navigation system in adolescent idiopathic scoliosis surgery? Clin Spine Surg 2018. doi: 10.1097/BSD.0000000000000759.

Posterior spinal fusion using pedicle screws is widely used for scoliosis correction. This technique, however, has a risk of serious neurovascular or visceral structural injury. Computed tomography (CT)-based navigation system during screw insertion is one of the means to accurately place these screws and to avoid these complications. However, insufficient surface registration may negatively impact the accuracy of the neuronavigation compromising the screw placement. This retrospective study investigated the screw perforation rate according to the surface registration accuracy in pedicle screw fixation using a CT- based navigation system for adolescent idiopathic scoliosis (AIS). The authors evaluated 116 AIS patients who underwent a total of 1553 pedicle screws insertions into the T2-L4 vertebrae using CT-based navigation system. Receiver operating characteristic curve analysis revealed a cut-off surface registration accuracy of 0.5 mm. The major screw perforation rate for a surface registration accuracy of ≥0.5 mm was significantly higher than that for <0.5 mm (P < 0.01). The authors concluded that surface registration accuracy should optimally be <0.5 mm for scoliosis surgery with CT-based navigation system.

Contributed by Dr. Kanwaljeet Garg

Liu X, et al. Percutaneous albumin/doxycycline injection versus open surgery for aneurysmal bone cysts in the mobile spine. Eur Spine J. 2018. doi: 10.1007/s00586-018-5836-1.

The purpose of this study was to evaluate the effectiveness of percutaneous doxycycline/albumin injection for spinal aneurysmal bone cysts (ABCs) as an alternative treatment to open surgery. Twenty-five patients with no/minor neurological deficits (modified Frankel scale D or E) and acceptable local stability (spinal instability neoplastic score <12) were included in the study. Out of these, 14 were treated with percutaneous doxycycline/albumin injection (injection group) and 11 with open surgery (surgery group). In the injection group, the lesion size was significantly reduced in all 14 patients, all patients showed complete neurological recovery, and 13 patients had complete relief of neck pain. No complication or recurrence was observed during the follow-up (mean 30.7-month, range 24-50 months). In the surgery group, 9 patients had complete neurological recovery. Two had local recurrence during their follow-up (mean 66.5 months, range 50-96 months). Compared with the surgery group, the injection group showed no significant difference in the rate of recurrence and complication. The authors concluded that percutaneous doxycycline/albumin injection for spinal ABCs could be safely and effectively performed in spinal ABCs lesions with acceptable local stability and in patients without severe neurological deficits.

Contributed by Dr. Kanwaljeet Garg

Takatori R, et al. Leg muscle strength after lateral interbody fusion surgery recovers over time after temporary muscle weakness. Clin Spine Surg 2018. doi: 10.1097/BSD.0000000000000756.

Muscle trauma and damage to the intermuscular nerves during the dissection of the psoas are recognized as important perioperative complications of lateral interbody fusion (LIF). Although reduced leg strength has been reported to be temporary in many cases, the underlying changes have not been studied in details. The objective of this study was to reveal the changes of leg muscle strength after LIF.

Leg muscle strength was measured quantitatively before LIF surgery and 1 week, 2 weeks, 3 weeks, 4 weeks, 8 weeks, and 12 weeks after surgery (n = 38). Reduced muscle strength was defined as < 80% of the preoperative measurement. The psoas position (PP%) was calculated from axial T2-weighted magnetic resonance images and compared with the degree of psoas and quadriceps muscle strength reduction at 1 week after surgery on the approach side. Twenty cases that underwent a posterior lumbar approach (posterior group) acted as controls.

The proportion of patients with reduced psoas muscle strength 1 week after LIF was 60.5% on the approach side and 39.5% on the healthy side, versus 30.0% in the posterior group. The corresponding results for the quadriceps were 34.2%, 39.5%, and 25.0%, respectively. All cases had strength improvement on the approach side by 12 weeks of surgery in the psoas and by 4 weeks for the quadriceps. Psoas muscle strength and quadriceps strength at 1 week after surgery were correlated. There was a low inverse correlation between PP% and quadriceps strength at 1 week. The authors concluded that muscle strength declined in both the muscle groups after LIF; however, the effect was temporary and strength recovered over time. Reduced postoperative quadriceps muscle strength may be due to the irritation of lumbar plexus during the splitting manoeuvre.

Contributed by Dr. Kanwaljeet Garg

Derakhshanrad N, et al. Subcutaneous granulocyte colony-stimulating factor administration for subacute traumatic spinal cord injuries, report of neurological and functional outcomes: A double-blind randomized controlled clinical trial. J Neurosurg Spine. 2018. doi: 10.3171/2018.6.SPINE18209.

Granulocyte-colony stimulating factor (G-CSF) is a major cytokine that has already been clinically verified for chronic traumatic spinal cord injuries (>6 months old injury, TSCIs). In this phase II/III, prospective, double-blind, placebo-controlled, parallel randomized clinical trial, the authors aimed to determine the safety and efficacy of G-CSF administration for neurological and functional improvement in subacute, incomplete TSCI (less than 6-month old injury). Among 60 participants, 28 patients (93.3%) in the G-CSF group and 26 patients (86.6%) in the placebo group completed the study protocol. The study patients received 7 daily subcutaneous administrations of 300 μg/day of G-CSF in the treatment group and a placebo in the control group. After 6 months of follow-up, the American Spinal Injury Association Impairment Scale (AIS) grade remained unchanged in the placebo group, while in the G-CSF group 11 patients showed improvement of AIS scale (5 patients from AIS grade B to C and AIS grade C to D each, and 1 patient from AIS grade D to E). The light-touch and pinprick sensory scores improvement in the G-CSF group was significantly greater than in the placebo group. The authors concluded that incomplete subacute TSCI was associated with significant motor, sensory, and functional improvement after administration of G-CSF.

Contributed by Dr. Kanwaljeet Garg

Ghadirpour R, et al. Intraoperative neurophysiological monitoring for intradural extramedullary spinal tumors: Predictive value and relevance of D-wave amplitude on surgical outcome during a 10-year experience. J Neurosurg Spine. 2018:1-9. doi: 10.3171/2018.7.SPINE18278.

This retrospective study aimed to evaluate the technical feasibility, accuracy, and relevance on surgical outcome of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during resection of intradural extramedullary (IDEM) spinal tumors. A total of 108 patients were included in this study and a monitorable D-wave was achieved in 71 of the 77 patients harbouring cervical and thoracic IDEM tumors. Recording of D-waves in IDEM tumors was significantly associated only with a preoperative deeply compromised neurological status evaluated using the modified McCormick Scale. Overall, significant intraoperative neurophysiological monitoring (IONM) changes were registered in 14 of 108 patients and 9 of these patients had a permanent loss of at least one of the 3 evoked potentials. In 7 patients, the presence of an s18278 caudal D-wave was predictive of a favourable long-term motor outcome even when the MEPs and/or SSEPs were lost during the tumor resection. However, in the remaining 2 cases, D-wave permanently decreased by approximately 50%, and surgery was definitively abandoned to prevent permanent paraplegia. Cumulatively, SSEP, MEP, and D-wave monitoring significantly predicted postoperative deficits, with a sensitivity of 85.7% and a specificity of 97%. Comparing the area under the receiver operating characteristic curves of these tests, D-waves appeared to have a significantly greater predictive value than MEPs and especially SSEPs alone. On multiple logistic regression, the independent risk factors associated with significant IONM changes in the entire population were age older than 65 years and an anterolateral location of the tumor. The authors concluded that D-wave monitoring was feasible in all patients without severe preoperative motor deficits. D-waves demonstrated a significantly higher ability to predict postoperative deficits compared with SSEPs and MEPs alone and allowed the surgeons to proceed with IDEM tumor resection, even in cases of SSEP and/or MEP loss.

Contributed by Dr. Kanwaljeet Garg

MacDowall A, et al. Artificial disc replacement versus fusion in patients with cervical degenerative disc disease with radiculopathy: 5-year outcomes from the National Swedish Spine Register. J Neurosurg Spine. 2018. doi: 10.3171/2018.7.SPINE18657.

The study aimed to compare the long-term efficacy of artificial disc replacement (ADR) surgery with fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy. This retrospective study included patients with cervical degenerative disc disease and radiculopathy who were in the national Swedish Spine Registry (Swespine). The authors found that the neck disability index (NDI) scores were approximately halved in both the groups after 5 years. There was no significant mean difference in the NDI between the groups. There were no differences between the groups in EuroQol–5 dimensions or in pain scores for the neck and arm. The authors concluded that decompression plus ADR surgery did not result in a clinically important difference in outcomes after 5 years, compared with decompression and fusion surgery in patients with cervical degenerative disc disease and radiculopathy.

Contributed by Dr. Kanwaljeet Garg

Herrick DB, et al. The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: A multicenter retrospective study. J Neurosurg Spine. 2018;29:628-34.

The benefit of the use of surgical site drains following posterior cervical spine surgery is not clear unlike in lumbar spine where drains have not been shown to be associated with reduction of reoperations for wound infection or hematoma. This multicenter retrospective study aimed to examine the relationship between surgical site drains and reoperation rates for wound-related complications following posterior cervical spine surgery. This study included 1799 consecutive patients undergoing posterior cervical decompression with instrumentation at 4 tertiary care centres. A drain was placed in 1180 (65.6%) of the patients. Multivariate logistic regression analysis identified history of diabetes and the total number of levels operated as independent predictors of reoperations following drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no- drain groups. Similarly, rates of reoperation for surgical site infection and hematoma were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection but not for hematoma. The authors concluded that patients with drains were less likely to need reoperation for surgical site infection, but not for postoperative hematoma.

Contributed by Dr. Kanwaljeet Garg

Boutet A, et al. Focused ultrasound thalamotomy location determines clinical benefits in patients with essential tremor. Brain 2018;141:3405-14.

This important clinical study revisits the topic on this novel and noninvasive focussed ultrasound therapy in patients with essential tremor. The optimal target inside the thalamus that leads to the best response and minimal side effects in this procedure is not clearly known. The authors recruited 66 patients and assessed them at three time points. The patients underwent tremor severity scoring in the pre-lesioning period, then at the 1st day after the procedure (acute phase) and finally at 3 months (long term). In the acute phase, the patients were evaluated for speech, ataxia, sensory and motor problems. At 1 day, the location and size of the lesion were correlated with the adverse effects. Diffusion weighted MR was used to assess the proximity of lesion to the major white matter tracts like the medial lemniscus, pyramidal tract and dentatorubrothalamic tract. They found that the area of optimal tremor response at 3 months of the postoperative period was the posterior portion of the ventral intermediate nucleus (VIM). Those lesions that had spread to lateral and posterior part of the thalamus had a higher propensity to develop side effects like dysmetria, sensory and motor problems. Also, they found that lesions larger than 170 mm3 were associated with an increased risk of acute adverse effects. Thus, the authors concluded that the accuracy of the lesion was of paramount importance in MR guided focused ultrasound thalamotomy to minimize the adverse effects and to obtain a good tremor control.

Contributed by Dr. Ravi Yadav

Van Bergen NJ, et al. NAD (P) HX dehydratase (NAXD) deficiency: A novel neurodegenerative disorder exacerbated by febrile illnesses. Brain 2019;142:50-8.

This study describes a novel mitochondrial disorder which has a catastrophic presentation in infants and children with neurodegeneration, cardiac involvement and, at times, death, following an episode of fever. The authors present the data from 6 unrelated families. Whole exome sequencing and clinical exome sequencing showed the recessive NAXD variant in each case. These variants were shown to be deleterious in the in silico analysis. Muscle biopsy and fibroblasts showed an impaired mitochondrial function. Subject fibroblasts showed highly elevated concentrations of damaged cofactors such as SNADHX, R-NADHX and cyclic NADHX. The authors demonstrated that NAXD deficiency was a metabolite repair disorder in which a build up of the damaged metabolites led to damaging effects in the cardiac and neural tissues, eventually culminating into an early childhood death.

Contributed by Dr. Ravi Yadav

Feigin VL, et al. Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016. N Engl J Med 2018;379:2429-37.

This study funded by Bill and Melinda Gates foundation has provided us with crucial data regarding the estimate of life time risk of stroke at the country level, regional level and globally using data from a comprehensive study on the prevalence of major diseases. The authors used the global burden of disease 2016 study that estimates stroke incidence and competing causes of death other than a stroke to calculate first stroke, ischemic stroke, haemorrhagic stroke among adults 25 years of age or older. The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9%, the risk among men was 24.7% being marginally lower than women (24.7% Vs 25.1%), and the risk of hemorrhagic stroke was 8.2%. The study also found that the mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016. These findings reveal the trends over the two decades and assume importance for the policy makers and various stroke services.

Contributed by Dr. Ravi Yadav

Grunseich C, et al. BVS857 study group. 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;17:1043-52.

Spinobulbar muscular atrophy is an X linked disease due to abnormal CAG repeats in the androgen receptor gene. This disease does not have any definitive treatment. This prospective, randomized, double blind, placebo control trial was done to check the safety, tolerability, and preliminary efficacy of an IGF-1 (insulin like growth factor-1) mimetic drug at multiple centres across the world. The patients were all genetically proven, more than 18 years of age, were ambulatory, had a symptomatic weakness, and had serum IGF-1 concentrations of 170 ng/mL or lower. The patients were assessed for thigh muscle volume (TMV) using muscle MRI. BVS857 was administered once a week (0·06 mg/kg intravenously) for 12 weeks. Primary outcome measures were the effects of BVS857 on thigh muscle volume (TMV) apart from the safety and tolerability. A total of 31 patients were randomized into the treatment arm (n = 24) and 9 in the placebo arm. The analysis failed to show any difference between the groups with respect to the muscle strength and function.

Contributed by Dr. Ravi Yadav and Dr. Aastha Takkar

Rasmussen MK, et al. The glymphatic pathway in neurological disorders. Lancet Neurol 2018;17:1016-24.

The discovery of the glymphatic system in rodents and the existence of a similar system in humans call for the re-evaluation of many neurological disorders. The glymphatic system is involved in the clearance of numerous metabolites and toxic substances like amyloid from the neuropil. This pathway is managed by aquaporin 4 channels. These and other features are highlighted beautifully in the above review article This article is highly recommended for an update on this novel subject. This area needs to be explored further considering its immense therapeutic and prognostic ramifications.

Contributed by Dr. Ravi Yadav

Zhou A, et al. A wireless and artefact-free 128-channel neuromodulation device for closed-loop stimulation and recording in non-human primates. Nat Biomed Eng. 2019;3:15-26

This study presents the data on a new wireless neuromodulation device. This device has the potential to revolutionize the management of many neurological disorders. This is a close loop wireless stimulation and recording device that aims to treat disorders like Parkinson's disease and epilepsy by detection of abnormal frequencies and delivering appropriate electrical stimulation in real time. The device is a small neural interface capable of closed-loop recording and stimulation on 128 channels, with a capacity to cancel the artefacts completely. Also, it can identify biomarkers in the neural tissue and automatically adjust stimulation parameters in a closed-loop mode. The results of the device testing in a primate have been presented in this study.

Contributed by Dr. Ravi Yadav

Dawkins RL, et al. Thoracolumbar injury classification and severity score in children: a validity study. Neurosurg DOI https://doi.org/10.1093/neuros/nyy408.

The authors reviewed the medical records for pediatric patients with acute, traumatic thoracolumbar fractures at two Level 1 trauma centers. A thoraco-lumbar injury classification and severity score (TLICS) score, comprising the computed tomography and magnetic resonance images as well as neurological examination findings, was calculated for each patient. The TLICS scores were compared with the type of treatment received. Receiver operating characteristic (ROC) curve analysis was employed to quantify the validity of the TLICS scoring system. TLICS calculations were completed for 165 patients. The mean TLICS score was 2.9 (standard deviation ± 2.7). Surgery was the treatment of choice for 23% of patients. There was a statistically significant agreement between the TLICS suggested treatment strategy and the actual treatment received (P < 0.001). The ROC curve demonstrated an excellent discriminative ability, with an area under the ROC curve of 0.96 (P < 0.001). The authors concluded that the TLICS system demonstrates a good validity for selecting the appropriate thoracolumbar fracture treatment in pediatric patients.

Contributed by: Dr Anant Mehrotra

Wilson M, et al. Utilizing preprocedural 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 external ventricular drainage (EVD) placement by the freehand technique. The primary outcome variable was the optimal positioning of the EVD (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%) of the EVDs were placed into the eloquent cortex or non-target cerebrospinal fluid (CSF) places. The admitting diagnosis, head height-to-width ratio in axial plane, and side of predominant pathology were found to be significantly associated with suboptimal EVD placement (P = 0.02, 0.012, and 0.02, respectively). A decreased height-to-width ratio was also associated with wrong EVD placement into the eloquent cortex and/or nontarget CSF spaces (P = 0.003). The authors concluded that the freehand technique was associated with a significant suboptimal positioning of EVDs including placement into the eloquent cortex. Therefore, using baseline clinical and radiographic features one can predict the likelihood of inaccurate EVD placement.

Contributed by: Dr Anant Mehrotra

Tan K, et al. Diffusion tensor imaging and ventricle volume quantification in patients with chronic shunt-treated hydrocephalus: A matched case-control study. J Neurosurg 2018. DOI: 10.3171/2017.6.JNS162784.

The authors conducted a study on 21 patients of hydrocephalus and compared them with age and sex matched healthy controls. These patients had a ventriculoperitoneal shunt installed before 2 years of their lives. The authors conducted diffusion tensor imaging (DTI) on a 3T MRI scanner. Outcome was scored based on the Headache Disability Inventory and the Hydrocephalus Outcome Questionnaire. Fractional anisotropy (FA) and other DTI-based measures (axial, radial, and mean diffusivity; AD, RD, and MD, respectively) were extracted in the corpus callosum and the internal capsule with manual region-of-interest delineation and in other regions with tract-based spatial statistics (TBSS). The authors found significantly lower FA values for patients than for controls in 20 out of the 48 regions. These regions primarily involved the posterior white matter structures, periventricular as well as more distal tracts. Of these 20 regions, 17 demonstrated an increased RD, while only 5 showed an increased MD and 3 showed a decreased AD. No areas of increased FA were observed. The authors concluded that TBSS-based DTI was a sensitive technique for elucidating the changes in white matter structures due to hydrocephalus and chronic CSF shunting.

Contributed by: Dr Anant Mehrotra

Wegel PV, et al. Early surgical decompression improves neurological outcome after complete traumatic cervical spinal cord injury: A Meta-Analysis. J Neurotrauma 2019:36:835-44.

The rationale and timing of surgery in traumatic spinal cord injury (t SCI) remains one of the eternal debates in neurosurgery. This meta-analysis was an attempt to shed some light on this topic. The authors divided the surgeries into early and late, the cut-off being 24 hours since the occurrence of injury. The injury severity was assessed using the American Spinal Injury Association (ASIA) scale pre and postoperatively. In total, the authors analyzed 15 publications comprising 1126 patients (with both incomplete and complete injuries). The study conformed to the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. The authors found that the patients with complete cervical t SCI had 2.6 times better neurological outcomes (atleast two point improvement in the ASIA scale) with early surgery than when operated after 24 hours. In incomplete injuries, however, the difference was not significant (30.4% vs 32.5%, odds ratio 0.9, 95% confidence interval: 0.4–1.9]). Thus, this metanalysis clearly tells us that early surgery in complete t SCI is definitely better in terms of neurological outcome. However, we need to wait for further evidence before the same can be recommended for incomplete injuries.

Contributed by: Dr Kuntal K. Das

Texakalidis P, et al. Impact of powdered vancomycin on preventing surgical site infections in neurosurgery: A systematic review and meta-analysis Neurosurgery 2019:84:569-80.

Surgical site infection (SSI) remains the oldest nemesis in the surgical field across all specialities. When it comes to neurosurgery, SSIs can be more devastating, leading to occasional mortality, an increased morbidity and an invariable increase in the overall cost of surgery. With recent papers showing conflicting results with topical application of vancomycin in the powdered form in preventing SSIs in cranial and spinal surgeries, this meta-analysis assumes a great importance for all neurosurgeons. The metaanalysis included all the available literature, both randomized and observational studies. Reviewing 25 available studies, this metaanalysis found that intrawound application of vancomycin significantly lowered SSI after spinal surgery (P = 0.001). It also showed that the effect was only found with deep SSIs, not superficial SSIs. When it came to cranial surgeries, vancomycin lowered SSIs with an odds ratio of 0.33 (P = 0.003). The study failed to show any dose related effects of vancomycin (1 gm vs 2 gm dose). Despite the obvious results shown in this meta-analysis, one has to remain cautious as the studies included in this meta-analysis were mostly observational in design.

Contributed by: Dr Kuntal K. Das

Ung TH, et al. The neurologic assessment in neuro-oncology (NANO) scale as an assessment tool for survival in patients with primary glioblastoma. Neurosurgery 2019:84:687-95.

Assessment of response to the treatment modalities remains the cornerstone of neurooncology. A number of scales are available for assessment of treatment response and include the Mc Donald's criteria, Response assessment in neuro-oncology (RANO) criteria, etc. While these criterias are widely validated and very useful, all of them are based on the radiological patient assessment. None of these criteria take into account a very important aspect of the disease, i.e., the neurological function of the patient. The Neurologic Assessment in Neuro-Oncology (NANO) scale represents a composite scale and has been standardized as an objective metrix. This retrospective study aimed to assess the reliability of NANO scale in predicting survival in glioblastoma patients. The authors applied the NANO scale, Karnofsky performance score (KPS), Eastern Cooperative Oncology Group (ECOG) scale, Macdonald criteria, and the Response Assessment in Neuro-Oncology (RANO) criteria to their patients of newly diagnosed GBM at the time of diagnosis as well as at 3, 6, and 12 months. They found that only the NANO scale was associated with patient survival at 1 year and it was the only metric that was linked to decreased overall survival when compared to the RANO and Macdonald scales at 6 and 12 months. Thus it appears that the NANO scale is likely to be used more frequently in neuro-oncology in the coming days.

Contributed by: Dr Kuntal K. Das

Shoichiro O, et al. Prevention of nerve root thermal injury caused by bipolar cauterization near the nerve roots. Spine 2019;44:E321-8.

This animal study was aimed to investigating the thermal injury of the nerve root caused by bipolar cauterization in the adjoining area and to decipher ways to prevent and rescue such injuries. The authors used a rat model and carried out two specific measurements while working on their spines posteriorly: assessment of the temperature and histological evaluation of the nerve root. At the same time, the authors noted the effect of saline irrigation or changing the direction of bipolar forceps to contain the temperature. Finally, the effectiveness of locally injected corticosteroid after bipolar cauterization was evaluated. They observed that bipolar cauterization, led to a temperature increase upto 60.9°C, and as high as 48% of the nerves were found to be histologically injured. When they used saline irrigation, not only they could keep the local temperature to only about 42 degrees but also ended up saving the nerves in all of the cases. Similarly, bipolar cauterization when performed in the perpendicular direction, could restrict the local temperature to as low as 40.4°C. Thermal injury to the nerves could be reduced to nearly 25% when a corticosteroid was injected locally. However, a significant increase in nerve damage remained when compared with the sham group (P < 0.01). This paper assumes a great importance for the neurosurgical community in improving the results of spine surgery further.

Contributed by: Dr Kuntal K. Das

Kolb B, et al. Effect of revascularization on cognitive outcomes in intracranial steno-occlusive disease: A systematic review. Neurosurg Focus 2019;46:E14.

Extracranial to intracranial vascular bypass surgery remains one of the challenging aspects of neurosurgery. The role of such surgeries in the alleviation of cognitive deficits associated with atherosclerotic and Moyamoya disease remains doubtful. In this systematic review, the authors analyzed the existing literature on intracranial steno-occlusive disease, including intra- cranial atherosclerosis and Moyamoya disease (MMD), to determine if cerebral revascularization could be useful in these conditions. It included nine papers, comprising 2 randomised control trials (RCTs) and 7 observational cohort studies. While the two RCTs failed to find any benefit of revascularisation, the 7 observational studies reported otherwise. The systematic review concluded that the effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.

Contributed by: Dr Kuntal K. Das






 

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Online since 20th March '04
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