Neurology and Neurosurgery

A descriptive study of clinical and radiological profile of longitudinal extensive myelitis in a tertiary hospital in Rajasthan, India Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Arti Devi, K.K. Singh, Suresh Gupta, Neeraj Bhutani, Priya Agarwal Abstract Objectives To explore the aetiological, clinical and radiological profiles of patients with LETM presenting to this tertiary care hospital in North India. Patients and methods All eligible LETM patients presenting to our hospital between April 2015 and Jan 2016 were prospectively studied. A total of 37 patients were included and after thorough history, examination, relevant laboratory and radiological investigation, were profiled according to the various aetiologies of LETM. Results Our study included 37 patients (62% males and 38% females). Most patients were young (21–30 years). Main aetiologies of LETMp were NMO (8), inflammatory (9), idiopathic (6), NMOSD (4), Vitamin B12 deficiency (4) and others (6). Most patients (62%) had acute onset of symptoms except NMOSD and B12 deficient patients who presented subacutely too. NMO group was most disabled (poor Rankin and MRC assessments) at presentation; prognostically no (87%) or minimal improvement (13%) at discharge was seen in this group compared to other aetiologies. Forty point five percent patients had thoracic sensory complaints. CSF (pleocytosis 62%) and raised protein (81%) and brain abnormalities on MRI were seen in 11% patients. Bladder and optic nerve involvement (75.7% and 35% patients respectively). Seventy five percent NMO and 67% probable inflammatory aetiology patients also had B12 deficiency. Conclusion This study concludes that LETMp has varied aetiologies with NMO having more disability and poorer outcomes. Thoracic cord segment is most commonly involved. Vitamin B12 deficiency may predispose patients to inflammatory LETM including NMO syndromes.

Retrospective analysis of accuracy and positive predictive value of preoperative lumbar MRI grading after successful outcome following outpatient endoscopic decompression for lumbar foraminal and lateral recess stenosis Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Anthony T. Yeung, Kai-Uwe Lewandrowski

Trending serial CSF samples to guide treatment of refractory coccidioidal meningitis with intrathecal liposomal amphotericin Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Brian Fiani, Alvin Nguyen, Syed A. Quadri, Mudassir Farooqui, Atif Zafar, Ajeet Sodhi, Shubha Kerkar, David Nacionales, Glenn M. Fischberg Abstract Intrathecal amphotericin B deoxycholate (AmB-d) can be prescribed as an adjunct to systemic therapy for severe or recalcitrant cases coccidioidal meningitis. Recently intravenous (IV) Liposomal amphotericin B (L-AmB) has been recommended as monotherapy therapy for refractory coccidioidal meningitis based on its advantages over (AmB-d), however, its intrathecal use has not been reported. Moreover, there is nothing in the literature quantifying clinical improvement with objective laboratory data in human patients. Consequently, there are no guidelines on how to monitor regularly for improvement of coccidioidal meningitis with treatment of intrathecal L-AmB. The present case addresses both of these. We report intrathecal use of L-AmB for refractory coccidioidal meningitis. Our data demonstrate that there is a correlation between clinical improvement and a decrease in cerebrospinal fluid (CSF) white blood cells (WBC's), protein, and coccidioidal titers with treatment of intrathecal L-AmB with serial collection of CSF studies at the same site, in our case via collection through an external ventricular drain (EVD). As a result, one may postulate that serial CSF collection can be used to monitor the treatment of coccidioidal meningitis; however this case also addresses the risk of developing ventriculitis with sustained EVD placement.

Clinical analysis of syringomyelia resulting from spinal hemangioblastoma in a single series of 38 consecutive patients Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Dingkang Xu, Mengzhao Feng, Vigneyshwar Suresh, Guoqing Wang, Fang Wang, Laijun Song, Fuyou Guo Abstract objective Syringomyelia was predominantly caused by Chiari malformation or intramedullary ependymoma. The goal of this study was to identify factors related to clinical outcomes and spinal hemangioblastoma (SH)-induced syringomyelia formation in a single series of patients. Patient and methods Thirty-eight patients with SH were treated with microsurgery from January 2013 to December 2018. Clinical features and related factors were retrospectively analyzed in SH patients with and without syringomyelia. Results Out of the total number of SH patients, 21 presented with remarkable syringomyelia, resulting in an incidence of 55.26% (21/38).Gross total resection was achieved in 36 cases (94.73%), and subtotal resection was obtained in 2 patients (5.27%). Neurological symptoms improved in 34 patients, remained stable in 2 patients and were aggravated in 2 cases during follow-up. In addition, there was a notable difference between the location of tumors and syringomyelia (P < 0.05). Syringomyelia occurred more frequently in the cervical segment than in any other spinal segment. Moreover, there was an association between symptom duration and clinical prognosis (P < 0.05). Ordinal regression analysis showed that the prognosis of middle duration groups (6–12 months) was better than early groups (0–6 months, p < 0.05, OR 20.21, 95%CI 2.34–336.97) and late groups (>12 months, p < 0.05, OR 11.54, 95%CI 1.30–102.21). Syringomyelia collapse or reduction occurred between two weeks and 15 months after surgery. An improvement of spinal function grade after surgery was more significant in syringomyelia reduction groups (p < 0.05). Conclusions The prevalence of syringomyelia due to SH is considerably high, and the initial clinical presentation of syringomyelia resulting from SH should be emphasized. Satisfactory outcomes were achieved by effective surgery in affected patients.

Migraine in patients with fibromyalgia and outcomes of greater occipital nerve blockage Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Volkan Yilmaz, Berke Aras, Fatma Avsar Erturk, Fatma Aytul Cakcı, Ebru Umay Abstract Objectives The aim of this study is to evaluate the efficacy of greater occipital nerve (GON) blockage in patients with migraine and fibromyalgia (FM) comorbidity. Patients and method 20 patients who were diagnosed as FM according to 2010 American College of Rheumatology (ACR) diagnostic criteria and migraine according to International Classification of Headache Disorers II criteria and did not recieve any medication or GON block for both disorders were included for the study. GON blocks were repeated every week in the first month and repeated montly for the following 2 months. The frequency and duration of the migraine attacks, pain severity with visual analogue scale (VAS), quality of life (QoL) with revised fibromyalgia impact questionnaire (FIQR) and migraine disability assesment questionnaire (MIDAS) before,1 st month and 3rd months after treatment were recorded and compared. Results 95% of 20 patients were female (n = 19) and 5% was male (n = 1). The affected site was left in 60% of the patients (n = 12) and 40% was right (n = 8). There was significant improvement in terms of all evaluation parameters both at 1 st month and 3rd months after treatment compared to the baseline. Likely, all parameters were significantly improved at 3rd month compared to the 1 st month. Conclusions GON blockage reduces pain severity, headache frequency and duration and increases QoL in patients with migraine and FM comorbidity.

Association between perioperative stroke and 30-day mortality in carotid endarterectomy: A meta-analysis Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Rajiv P. Reddy, Tejas Karnati, Robyn E. Massa, Parthasarathy D. Thirumala Abstract Objectives Perioperative stroke is a known complication of carotid endarterectomy (CEA) for patients with symptomatic and asymptomatic carotid stenosis. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) has shown that stroke following CEA is associated with nearly a 3-fold increase in the 4-year mortality compared to patients without such an event. However, no studies to date can establish whether the stroke was the cause of the short term mortality. Thus, our objective is to evaluate if perioperative stroke after CEA increases the risk of 30-day mortality. Patients and Methods We performed a meta-analysis of the literature from PubMed and the World Science Database on studies reporting perioperative strokes and 30-day mortality in symptomatic and asymptomatic CEA patients. 3400 articles were retrieved, and abstracts were further screened using the inclusion criteria to obtain a final set of 83 randomized controlled trials and retrospective/prospective studies. Results A total of 123,507 CEA procedures were included among the 83 studies. The 30-day perioperative stroke rate for all included studies was 2.15%. The 30-day all-cause mortality rate was 0.93%. In patients with perioperative strokes, the 30-day mortality rate was found to be 17.01%. Among patients without perioperative strokes, the 30-day mortality rate was much lower at 0.57%. The summary odds ratio of perioperative stroke and 30-day mortality was 39.86 (95% CI, 29.30–54.23, p < 0.001). Conclusion Patients with perioperative stroke have an almost 40 times increased risk of 30-day stroke-related mortality. This study highlights the importance of developing a preoperative risk assessment and neuroprotective treatment trial for perioperative stroke.

Response Letter Regarding "Utility of CT angiography in screening for traumatic cerebrovascular injury" Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Hilary L.P. Orlowski, Akash P. Kansagra, Michelle M. Miller-Thomas, Katie D. Vo, Manu S. Goyal

Frameless stereotactic neuronavigated biopsy: A retrospective study of morbidity, diagnostic yield, and the potential of fluorescence: A single-center clinical investigation Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Andreas M. Æbelø, Victor R. Noer, Mette K. Schulz, Bjarne W. Kristensen, Christian B. Pedersen, Frantz R. Poulsen Abstract Objective The primary objective of this retrospective study was to evaluate the diagnostic yield and morbidity/mortality associated with frameless stereotactic neuronavigated intracranial biopsies with and without the use of fluorescein. Patients and methods Patient cases from January 2007 to December 2017 were identified using the ICD-10 procedure code AAG00. Relevant clinical data, including histological diagnosis, were collected retrospectively from the electronic patient charts and independently reviewed by two authors. Results 111 biopsies obtained from 103 patients were identified. Of these, 109 biopsies yielded a diagnosis and resulted in a diagnostic yield of 98.2%. Fluorescein was used in 13 biopsies (11.7%). Twelve patients (10.8%) experienced postoperative complications, and the mortality attributed to the surgery was 1.8%. In 12.6% of cases, the biopsies showed inflammation or nonspecific reactive changes. No statistically significant differences were observed in diagnostic yield or number and severity of complications according to whether intraoperative histological examination was used or not. Conclusion Although direct comparisons between studies are difficult due to lack of consensus about the definition of diagnostic yield, the present study reports a similar diagnostic yield to other studies. Intraoperative histopathological analysis appeared to give little extra benefit.

Prognostic value of preoperative neutrophil to lymphocyte ratio is superior to systemic immune inflammation index for survival in patients with Glioblastoma Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Yajuan Lv, Shaohua Zhang, Zhen Liu, Yuan Tian, Ning Liang, Jiandong Zhang Abstract Objective This study evaluated the prognostic value of preoperative neutrophil to lymphocyte ratio(NLR), platelet to lymphocyte ratio(PLR), and systemic immune inflammation index(SII) in patients with Glioblastoma(GBM). Patients and methods The peripheral blood indexes and other clinical data were obtained within 1 week before surgery. Receiving operating characteristics(ROC) curve was used to find the optimal cut-off value of NLR, SII and PLR, respectively. Kaplan-Meier (KM) analysis and cox proportional hazard models were used to assess the prognostic value of SII and other indexes. Results The optimal cut-off values for NLR, SII, PLR were 2.7, 718, 87, respectively. The high NLR group has a higher proportion of Ki67 expression than the low NLR group. KM survival curves revealed that patients with high NLR (>2.7) or high SII (>718) had worse overall survival. Multivariable Cox analysis revealed NLR, adjuvant therapy and age were prognostic factors for overall survival(OS). The AUC area (the area under the receiver operating characteristics curves) of the NLR was higher than the area of PLR or SII. Conclusion Preoperative NLR was superior to SII in prognostic value of patients with glioblastoma.

Determinants of reoperation after decompressive craniectomy in patients with traumatic brain injury: A comparative study Publication date: June 2019 Source: Clinical Neurology and Neurosurgery, Volume 181 Author(s): Hosseinali Khalili, Fariborz Ghaffarpasand, Amin Niakan, Nasim Golestani, Iman Ahrari, Hamid Reza Abbasi, Ali Rasti Abstract Objectives: Reoperation after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) remains a dilemma and the risk factors are to be identified. The aim of the current study was to determine the determinants and risk factors of reoperation after DC in patients with TBI. Patients and methods: This retrospective case-controlled study was conducted during a 4-year period from September 2013 to October 2017 in a level I trauma center affiliated with Shiraz University of Medical Sciences in southern Iran. We included all the adult (≥18 years) patients with TBI who underwent primary or secondary DC in our center during the study period. Those who underwent reoperation were compared to those who underwent DC only regarding the demographic findings, clinical features and neuroimaging findings. A univariate and multivariate logistic regression analysis was performed to determine the determining factors of reoperation. Results: Overall we included 371 patients with mean age of 36.45 ± 14.18 years. Among the patients there were 325 (87.6%) men and 46 (12.4%) women. The reoperation in patients undergoing DC due to TBI was associated with primary DC (p = 0.039) and higher Marshall grade (p = 0.027). Those who underwent reoperation after DC for TBI had significantly higher ICU (p = 0.007) and hospital LOS (p = 0.001) and lower 6-month GOSE (p = 0.010). Age (p < 0.001), GCS (p < 0.001) and pupils (p = 0.027) were predictors of outcome in reoperation group. Reoperation in primary DC group was associated with pupil reactivity (p = 0.002) and number of episodes with INR above 1.5 (p = 0.037) Conclusion: Reoperation after DC for TBI is associated with primary DC, and Marshall grade. The reoperation after DC is associated with worse outcome and longer ICU and hospital stay. The age, GCS and pupil reactivity are the main predictors of outcome in those with reoperation after DC for TBI.