Stroke prevention by direct revascularization for patients with adult-onset moyamoya disease presenting with ischemia

Journal of Neurosurgery, Ahead of Print.
OBJECT Moyamoya disease (MMD) is a progressive disease that can cause recurrent stroke. The authors undertook this retrospective case-control study with a large sample size in an attempt to assess the efficacy of direct or combined revascularization surgery for ischemia in adults with MMD. METHODS The authors investigated cases involving patients with moyamoya disease presenting with ischemia who visited Seoul National University Bundang Hospital and Seoul National University Hospital between 2000 and 2014. Among 441 eligible patients, 301 underwent revascularization surgery and 140 were treated conservatively. Variables evaluated included age at diagnosis, sex, surgical record, Suzuki stage, and occurrence of stroke. Patients were stratified into 2 groups based on whether or not they had undergone revascularization surgery. Actuarial 1-, 5-, and 10-year stroke rates were calculated using the life table method. Risk factor analysis for 5-year stroke occurrence was conducted with multivariate regression. RESULTS Of the 441 patients, 301 had been surgically treated (revascularization group) and 140 had not (control group). The mean follow-up durations were 45 and 77 months, respectively. The actuarial 10-year cumulative incidence rate for any kind of stroke was significantly lower in the revascularization group (9.4%) than in the control group (19.6%) (p = 0.041); the relative risk reduction (RRR) was also superior (52.0%) in the revascularization group, and the number needed to treat was 10. The 10-year rate of ischemic stroke was greater (13.3%) in the control group than in the revascularization group (3.9%) (p = 0.019). The RRR for ischemic stroke in the revascularization group was 70.7%, and the number needed to treat was 11. However, the actuarial 1- and 5-year rates of ischemic stroke did not significantly differently between the groups. Overall, revascularization surgery was shown to be an independent protective factor, as revealed by multivariate analysis. CONCLUSIONS Direct or combined revascularization for patients with adult-onset moyamoya disease presenting with ischemia can prevent further stroke.

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Growth hormone–secreting macroadenoma of the pituitary gland successfully treated with the radiolabeled somatostatin analog 90Y-DOTATATE: case report

Journal of Neurosurgery, Ahead of Print.
Pituitary tumors causing acromegaly are usually macroadenomas at the time of diagnosis, and they can grow aggressively, infiltrating surrounding tissues. Difficulty in achieving complete tumor removal at surgery can lead toward a strong tendency for recurrence, making it necessary to consider a means of treatment other than those currently used such as somatostatin analogs (SSAs), growth hormone (GH) receptor antagonist, surgical removal, and radiotherapy. The purpose of this paper is to describe a patient diagnosed with an aggressive, giant GH-secreting tumor refractory to medical therapy but ultimately treated with the radiolabeled somatostatin analog 90Y-DOTATATE. A 26-year-old male with an invasive macroadenoma of the pituitary gland (5.6 × 2.5 × 3.6 cm) and biochemically confirmed acromegaly underwent 2 partial tumor resections: the first used the transsphenoidal approach and the second used the transcranial method. The patient received SSAs pre- and postoperatively. Because of the progression in pituitary tumor size, he underwent classic irradiation of the tumor (50 Gy). One and a half years later, the patient presented with clinically and biochemically active disease, and the tumor size was still 52 mm in diameter (height). Two neurosurgeons disqualified him from further surgical procedures. After confirming the presence of somatostatin receptors in the pituitary tumor by using 68Ga-DOTATATE PET/CT, we treated the patient 4 times with an SSA bound with 90Y-DOTATATE. After this treatment, the patient attained partial biochemical remission and a reduction in the tumor mass for the first time. Treatment with an SSA bound with 90Y-DOTATATE may be a promising option for some aggressive GH-secreting pituitary adenomas when other methods have failed.

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Metabolic approach for tumor delineation in glioma surgery: 3D MR spectroscopy image–guided resection

Journal of Neurosurgery, Ahead of Print.
OBJECT The extent of resection is one of the most essential factors that influence the outcomes of glioma resection. However, conventional structural imaging has failed to accurately delineate glioma margins because of tumor cell infiltration. Three-dimensional proton MR spectroscopy (1H-MRS) can provide metabolic information and has been used in preoperative tumor differentiation, grading, and radiotherapy planning. Resection based on glioma metabolism information may provide for a more extensive resection and yield better outcomes for glioma patients. In this study, the authors attempt to integrate 3D 1H-MRS into neuronavigation and assess the feasibility and validity of metabolically based glioma resection. METHODS Choline (Cho)–N-acetylaspartate (NAA) index (CNI) maps were calculated and integrated into neuronavigation. The CNI thresholds were quantitatively analyzed and compared with structural MRI studies. Glioma resections were performed under 3D 1H-MRS guidance. Volumetric analyses were performed for metabolic and structural images from a low-grade glioma (LGG) group and high-grade glioma (HGG) group. Magnetic resonance imaging and neurological assessments were performed immediately after surgery and 1 year after tumor resection. RESULTS Fifteen eligible patients with primary cerebral gliomas were included in this study. Three-dimensional 1H-MRS maps were successfully coregistered with structural images and integrated into navigational system. Volumetric analyses showed that the differences between the metabolic volumes with different CNI thresholds were statistically significant (p < 0.05). For the LGG group, the differences between the structural and the metabolic volumes with CNI thresholds of 0.5 and 1.5 were statistically significant (p = 0.0005 and 0.0129, respectively). For the HGG group, the differences between the structural and metabolic volumes with CNI thresholds of 0.5 and 1.0 were statistically significant (p = 0.0027 and 0.0497, respectively). All patients showed no tumor progression at the 1-year follow-up. CONCLUSIONS This study integrated 3D MRS maps and intraoperative navigation for glioma margin delineation. Optimum CNI thresholds were applied for both LGGs and HGGs to achieve resection. The results indicated that 3D 1H-MRS can be integrated with structural imaging to provide better outcomes for glioma resection.

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Comparison of computer-assisted planning and manual planning for depth electrode implantations in epilepsy

Journal of Neurosurgery, Ahead of Print.
OBJECT The objective of this study was to evaluate the clinical utility of multitrajectory computer-assisted planning software (CAP) to plan stereoelectroencephalography (SEEG) electrode arrangements. METHODS A cohort of 18 patients underwent SEEG for evaluation of epilepsy at a single center between August 2013 and August 2014. Planning of electrodes was performed manually and stored using EpiNav software. CAP was developed as a planning tool in EpiNav. The user preselects a set of cerebral targets and optimized trajectory constraints, and then runs an automated search of potential scalp entry points and associated trajectories. Each trajectory is associated with metrics for a safety profile, derived from the minimal distance to vascular structures, and an efficacy profile, derived from the proportion of depth electrodes that are within or adjacent to gray matter. CAP was applied to the cerebral targets used in the cohort of 18 previous manually planned implantations to generate new multitrajectory implantation plans. A comparison was then undertaken for trajectory safety and efficacy. RESULTS CAP was applied to 166 electrode targets in 18 patients. There were significant improvements in both the safety profile and efficacy profile of trajectories generated by CAP compared with manual planning (p < 0.05). Three independent neurosurgeons assessed the feasibility of the trajectories generated by CAP, with 131 (78.9%) of 166 trajectories deemed suitable for implementation in clinical practice. CAP was performed in real time, with a median duration of 8 minutes for each patient, although this does not include the time taken for data preparation. CONCLUSIONS CAP is a promising tool to plan SEEG implantations. CAP provides feasible depth electrode arrangements, with quantitatively greater safety and efficacy profiles, and with a substantial reduction in duration of planning within the 3D multimodality framework.

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Effects of intracranial meningioma location, size, and surgery on neurocognitive functions: a 3-year prospective study

Journal of Neurosurgery, Ahead of Print.
OBJECT Current recommendations stress the need for cognitive parameters to be integrated in the evaluation of outcomes for intracranial meningioma surgery. The aim of this prospective study was to examine neurocognitive function in meningioma patients pre- and postoperatively. METHODS Patients with skull base (anterior and middle fossa) and convexity (anterior and posterior) meningiomas (n = 54) underwent neuropsychological examination prior to and 1 year after surgery. A control group (n = 52) of healthy volunteers matched for age, sex, and education underwent the same examination. Assessments included executive, memory, and motor functions with standardized testing. Patients with convexity meningiomas were clinically assessed for parietal association cortex functions. RESULTS All patients performed significantly worse (p < 0.05) in most neurocognitive domains than controls. The skull base group showed more disturbances in memory than the convexity group (p < 0.05). The anterior convexity group showed more deficits in executive function than the posterior convexity group, which presented with parietal association cortex deficits. Verbal deficits were more pronounced in the left hemisphere than in the right hemisphere. Patients with a large tumor (> 4 cm) had more severe neurocognitive deficits than those with a small tumor (< 4 cm). Postoperatively, patients showed no deterioration in neurocognitive function. Instead, significant improvement (p < 0.05) was observed in some executive, motor, and parietal association cortex functions. CONCLUSIONS According to the authors' findings, intracranial meningiomas may cause neurocognitive deficits in patients. Surgery does not cause a deterioration in cognitive function; instead, it may lead to improvements in some functions. Permanent neuropsychological postoperative deficits should be interpreted as tumor-induced rather than due to surgery.

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Prospective, multidisciplinary recording of perioperative errors in cerebrovascular surgery: is error in the eye of the beholder?

Journal of Neurosurgery, Ahead of Print.
OBJECT Surgery requires careful coordination of multiple team members, each playing a vital role in mitigating errors. Previous studies have focused on eliciting errors from only the attending surgeon, likely missing events observed by other team members. METHODS Surveys were administered to the attending surgeon, resident surgeon, anesthesiologist, and nursing staff immediately following each of 31 cerebrovascular surgeries; participants were instructed to record any deviation from optimal course (DOC). DOCs were categorized and sorted by reporter and perioperative timing, then correlated with delays and outcome measures. RESULTS Errors were recorded in 93.5% of the 31 cases surveyed. The number of errors recorded per case ranged from 0 to 8, with an average of 3.1 ± 2.1 errors (± SD). Overall, technical errors were most common (24.5%), followed by communication (22.4%), management/judgment (16.0%), and equipment (11.7%). The resident surgeon reported the most errors (52.1%), followed by the circulating nurse (31.9%), the attending surgeon (26.6%), and the anesthesiologist (14.9%). The attending and resident surgeons were most likely to report technical errors (52% and 30.6%, respectively), while anesthesiologists and circulating nurses mostly reported anesthesia errors (36%) and communication errors (50%), respectively. The overlap in reported errors was 20.3%. If this study had used only the surveys completed by the attending surgeon, as in prior studies, 72% of equipment errors, 90% of anesthesia and communication errors, and 100% of nursing errors would have been missed. In addition, it would have been concluded that errors occurred in only 45.2% of cases (rather than 93.5%) and that errors resulting in a delay occurred in 3.2% of cases instead of the 74.2% calculated using data from 4 team members. Compiled results from all team members yielded significant correlations between technical DOCs and prolonged hospital stays and reported and actual delays (p = 0.001 and p = 0.028, respectively). CONCLUSIONS This study is the only of its kind to elicit error reporting from multiple members of the operating team, and it demonstrates error is truly in the eye of the beholder—the types and timing of perioperative errors vary based on whom you ask. The authors estimate that previous studies surveying only the attending physician missed up to 75% of perioperative errors. By finding significant correlations between technical DOCs and prolonged hospital stays and reported and actual delays, this study shows that these surveys provide relevant and useful information for improving clinical practice. Overall, the results of this study emphasize that research on medical error must include input from all members of the operating team; it is only by understanding every perspective that surgical staff can begin to efficiently prevent errors, improve patient care and safety, and decrease delays.

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Panventriculomegaly with a wide foramen of Magendie and large cisterna magna

Journal of Neurosurgery, Ahead of Print.
OBJECT The authors' goal in this paper is to provide the first clinical, radiological, and genetic studies of panventriculomegaly (PaVM) defined by a wide foramen of Magendie and large cisterna magna. METHODS Clinical and brain imaging data from 28 PaVM patients (including 10 patients from 5 families) were retrospectively studied. Five children were included. In adult patients, the age at onset was 56.0 ± 16.7 years. Tetraventricular dilation, aqueductal opening with flow void on T2-weighted images, and a wide foramen of Magendie and large cisterna magna (wide cerebrospinal fluid space at the fourth ventricle outlet) were essential MRI findings for PaVM diagnosis. 3D fast asymmetrical spin echo sequences were used for visualization of cistern membranes. Time-spatial labeling inversion pulse examination was performed to analyze cerebrospinal fluid movement. Copy number variations were determined using high-resolution microarray and were validated by quantitative polymerase chain reaction with breakpoint sequencing. RESULTS Adult patients showed gait disturbance, urinary dysfunction, and cognitive dysfunction. Five infant patients exhibited macrocranium. Patients were divided into 2 subcategories, those with or without downward bulging third ventricular floors and membranous structures in the prepontine cistern. Patients with bulging floors were successfully treated with endoscopic third ventriculostomy. Genetic analysis revealed a deletion in DNAH14 that encodes a dynein heavy chain protein associated with motile cilia function, and which co-segregated with patients in a family without a downward bulging third ventricular floor. CONCLUSIONS Panventriculomegaly with a wide foramen of Magendie and a large cisterna magna may belong to a subtype of congenital hydrocephalus with familial accumulation, younger age at onset, and symptoms of normal pressure hydrocephalus. In addition, a family with PaVM has a gene mutation associated with dysfunction of motile cilia.

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Seizures in supratentorial meningioma: a systematic review and meta-analysis

Journal of Neurosurgery, Ahead of Print.
OBJECT Meningioma is the most common benign intracranial tumor, and patients with supratentorial meningioma frequently suffer from seizures. The rates and predictors of seizures in patients with meningioma have been significantly under-studied, even in comparison with other brain tumor types. Improved strategies for the prediction, treatment, and prevention of seizures in patients with meningioma is an important goal, because tumor-related epilepsy significantly impacts patient quality of life. METHODS The authors performed a systematic review of PubMed for manuscripts published between January 1980 and September 2014, examining rates of pre- and postoperative seizures in supratentorial meningioma, and evaluating potential predictors of seizures with separate meta-analyses. RESULTS The authors identified 39 observational case series for inclusion in the study, but no controlled trials. Preoperative seizures were observed in 29.2% of 4709 patients with supratentorial meningioma, and were significantly predicted by male sex (OR 1.74, 95% CI 1.30–2.34); an absence of headache (OR 1.77, 95% CI 1.04–3.25); peritumoral edema (OR 7.48, 95% CI 6.13–9.47); and non–skull base location (OR 1.77, 95% CI 1.04–3.25). After surgery, seizure freedom was achieved in 69.3% of 703 patients with preoperative epilepsy, and was more than twice as likely in those without peritumoral edema, although an insufficient number of studies were available for formal meta-analysis of this association. Of 1085 individuals without preoperative epilepsy who underwent resection, new postoperative seizures were seen in 12.3% of patients. No difference in the rate of new postoperative seizures was observed with or without perioperative prophylactic anticonvulsants. CONCLUSIONS Seizures are common in supratentorial meningioma, particularly in tumors associated with brain edema, and seizure freedom is a critical treatment goal. Favorable seizure control can be achieved with resection, but evidence does not support routine use of prophylactic anticonvulsants in patients without seizures. Limitations associated with systematic review and meta-analysis should be considered when interpreting these results.

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Risk factors for worsened muscle strength after the surgical treatment of arteriovenous malformations of the eloquent motor area

Journal of Neurosurgery, Ahead of Print.
OBJECT Case selection for the surgical treatment of arteriovenous malformations (AVMs) of the eloquent motor area remains challenging. The aim of this study was to determine the risk factors for worsened muscle strength after surgery in patients with this disorder. METHODS At their hospital the authors retrospectively studied 48 consecutive patients with AVMs involving motor cortex and/or the descending pathway. All patients had undergone preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI), followed by resection. Both functional and angioarchitectural factors were analyzed with respect to the change in muscle strength. Functional factors included lesion-to-corticospinal tract distance (LCD) on DTI and lesion-to-activation area distance (LAD) and cortical reorganization on fMRI. Based on preoperative muscle strength, the changes in muscle strength at 1 week and 6 months after surgery were defined as short-term and long-term surgical outcomes, respectively. Statistical analysis was performed using the statistical package SPSS (version 20.0.0, IBM Corp.). RESULTS Twenty-one patients (43.8%) had worsened muscle strength 1 week after surgery. However, only 10 patients (20.8%) suffered from muscle strength worsening 6 months after surgery. The LCD was significantly correlated with short-term (p < 0.001) and long-term (p < 0.001) surgical outcomes. For long-term outcomes, patients in the 5 mm ≥ LCD > 0 mm (p = 0.009) and LCD > 5 mm (p < 0.001) categories were significantly associated with a lower risk of permanent motor worsening in comparison with patients in the LCD = 0 mm group. No significant difference was found between patients in the 5 mm ≥ LCD > 0 mm group and LCD > 5 mm group (p = 0.116). Nidus size was the other significant predictor of short-term (p = 0.021) and long-term (p = 0.016) outcomes. For long-term outcomes, the area under the ROC curve (AUC) was 0.728, and the cutoff point was 3.6 cm. Spetzler-Martin grade was not associated with short-term surgical outcomes (0.143), although it was correlated with long-term outcomes (0.038). CONCLUSIONS An AVM with a nidus in contact with tracked eloquent fibers (LCD = 0) and having a large size is more likely to be associated with worsened muscle strength after surgery in patients with eloquent motor area AVMs. Surgical treatment in these patients should be carefully considered. In patients with an LCD > 5 mm, radical resection may be considered to eliminate the risk of hemorrhage.

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Phase-contrast magnetic resonance imaging reveals net retrograde aqueductal flow in idiopathic normal pressure hydrocephalus

Journal of Neurosurgery, Ahead of Print.
OBJECT The objective of this study was to assess the net aqueductal stroke volume (ASV) and CSF aqueductal flow rate derived from phase-contrast MRI (PC-MRI) in patients with probable idiopathic normal pressure hydrocephalus (iNPH) before and after ventriculoperitoneal shunt surgery, and to compare observations with intracranial pressure (ICP) scores. METHODS PC-MRI at the level of the sylvian aqueduct was undertaken in patients undergoing assessment for probable iNPH. Aqueductal flow in the craniocaudal direction was defined as positive, or antegrade flow, and net ASV was calculated by subtracting retrograde from antegrade aqueductal flow. Aqueductal flow rate per minute was calculated by multiplying net ASV by heart rate. During the same hospital admission, clinical examination was performed using NPH score and overnight continuous ICP monitoring. Twelve patients were followed prospectively 12 months after shunt placement with clinical assessment and a second PC-MRI. The study also included 2 healthy controls. RESULTS Among 21 patients examined for iNPH, 17 (81%) received a shunt (shunt group), and 4 were treated conservatively (conservative group). Among the patients with shunts, a clinical improvement was observed in 16 (94%) of the 17. Net ASV was negative in 16 (76%) of 21 patients before shunt placement and in 5 (42%) of 12 patients after shunt placement, and increased from a median of −5 μl (range −175 to 27 μl) to a median of 1 μl (range −61 to 30 μl; p = 0.04). Among the 12 patients with PC-MRI after shunt placement, 11 were shunt responders, and in 9 of these 11 either a reduced magnitude of retrograde aqueductal flow, or a complete reversal from retrograde to antegrade flow, occurred. Net ASV was significantly lower in the shunt group than in the conservative group (p = 0.01). The aqueductal flow rate increased from −0.56 ml/min (range −12.78 to 0.58 ml/min) to 0.06 ml/min (range −4.51 to 1.93 ml/min; p = 0.04) after shunt placement. CONCLUSIONS In this cohort of patients with iNPH, retrograde net aqueductal flow was observed in 16 (76%) of 21 patients. It was reversed toward the antegrade direction after shunt placement either by magnitude or completely in 9 (75%) of 12 patients examined using PC-MRI both before and after shunt placement (p = 0.04); 11 of the 12 were shunt responders. The study results question previously established concepts with respect to both CSF circulation pathways and CSF formation rate.

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Tumors of the peripheral nervous system: analysis of prognostic factors in a series with long-term follow-up and review of the literature

Journal of Neurosurgery, Ahead of Print.
OBJECT Only a few published studies of the surgical treatment of benign peripheral nerve sheath tumors (BPNSTs), malignant peripheral nerve sheath tumors (MPNSTs), and peripheral non–neural sheath tumors (PNNSTs) have analyzed the results and possible prognostic factors using multivariate analysis. The authors report on their surgical series of cases of BPNSTs, MPNSTs, and PNNSTs with long-term follow-up and analyze the role of selected factors with respect to the prognosis and risk of recurrence of these tumors using multivariate analysis. They also review the pertinent literature and discuss their results in its context. METHODS The authors retrospectively reviewed data from cases involving patients who underwent resection of a peripheral nerve tumor between January 1983 and December 2013 at their institution. Of a total of 200 patients, 150 patients (with 173 surgically treated tumors) had adequate follow-up data available for analysis. Pain was assessed using a visual analog scale (VAS), and motor and sensory function were assessed by means of the Louisiana State University grading system. They also analyzed the relationship between tumor recurrence and patient sex, patient age, diagnosis of neurofibromatosis (NF), tumor histopathology, tumor size, tumor location, and extent of resection (subtotal vs gross-total resection), using univariate and multivariate analyses. RESULTS There was a statistically significant improvement in the mean VAS pain score (preoperative 3.96 ± 2.41 vs postoperative 0.95 ± 1.6, p = 0.0001). Motor strength and sensory function were significantly improved after resection of tumors involving the brachial plexus (p = 0.0457 and p = 0.0043, respectively), tumors involving the upper limb (p = 0.0016 and p = 0.0016, respectively), BPNSTs (p = 0.0011 and p < 0.0001, respectively), and tumors with dimensions less than 5 cm (motor strength: p = 0.0187 and p = 0.0021 for ≤ 3 cm and 3–5 cm tumors, respectively; sensory function: p = 0.0003 and p = 0.0001 for ≤ 3 cm and 3–5 cm tumors, respectively). Sensory function showed a statistically significant improvement also in patients who had undergone resection of tumors involving the lower limb (p = 0.0118). Total resection was associated with statistically significant improvement of motor strength (p = 0.0251) and sensory function (p < 0.0001). In univariate analysis, a history of NF (p = 0.0034), a diagnosis of MPNST or PNNST (p < 0.0001), and subtotal resection (p = 0.0042) were associated with higher risk of tumor recurrence. In multivariate analysis (logistic regression analysis), a history of NF (OR 9.28%, 95% CI 1.62–52.94, p = 0.0121) and a diagnosis of MPNST (OR 0.03%, 95% CI 0.002–0.429, p = 0.0098) or PNNST (OR 0.081%, 95% CI 0.013–0.509, p = 0.0077) emerged as independent prognostic factors for tumor recurrence. CONCLUSIONS A total resection should be attempted in all cases of peripheral nervous system tumors (irrespective of the supposed diagnosis and tumor dimensions) because it is associated with better prognosis in term of functional outcome and overall survival. Moreover, a total resection predicts a lower risk of tumor recurrence. Patients with a history of NF and tumors with malignant histology remain a challenge both for neurosurgeons and oncologists due to higher recurrence rates and the lack of standardized adjuvant therapies.

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Hemodynamic and morphological characteristics of unruptured posterior communicating artery aneurysms with oculomotor nerve palsy

Journal of Neurosurgery, Ahead of Print.
OBJECT Unruptured posterior communicating artery (PCoA) aneurysms with oculomotor nerve palsy (ONP) have a very high risk of rupture. This study investigated the hemodynamic and morphological characteristics of intracranial aneurysms with high rupture risk by analyzing PCoA aneurysms with ONP. METHODS Fourteen unruptured PCoA aneurysms with ONP, 33 ruptured PCoA aneurysms, and 21 asymptomatic unruptured PCoA aneurysms were included in this study. The clinical, morphological, and hemodynamic characteristics were compared among the different groups. RESULTS The clinical characteristics did not differ among the 3 groups (p > 0.05), whereas the morphological and hemodynamic analyses showed that size, aspect ratio, size ratio, undulation index, nonsphericity index, ellipticity index, normalized wall shear stress (WSS), and percentage of low WSS area differed significantly (p < 0.05) among the 3 groups. Furthermore, multiple comparisons revealed that these parameters differed significantly between the ONP group and the asymptomatic unruptured group and between the ruptured group and the asymptomatic unruptured group, except for size, which differed significantly only between the ONP group and the asymptomatic unruptured group (p = 0.0005). No morphological or hemodynamic parameters differed between the ONP group and the ruptured group. CONCLUSIONS Unruptured PCoA aneurysms with ONP demonstrated a distinctive morphological-hemodynamic pattern that was significantly different compared with asymptomatic unruptured PCoA aneurysms and was similar to ruptured PCoA aneurysms. The larger size, more irregular shape, and lower WSS might be related to the high rupture risk of PCoA aneurysms.

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Editorial: Seizures with meningioma

Journal of Neurosurgery, Ahead of Print.


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Letter to the Editor: Innovations in neurosurgery

Journal of Neurosurgery, Ahead of Print.


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A biomechanical comparison of 3 different posterior fixation techniques for 2-level lumbar spinal disorders

Journal of Neurosurgery: Spine, Ahead of Print.
OBJECT This study sought to make a biomechanical comparison of 3 different posterior fixation techniques for 2-level lumbar spinal disorders. METHODS Eight fresh-frozen human cadaver lumbar spines (4 from L-1 to L-5, 4 from L-1 to S-1) were tested by applying pure moments of ± 8 Nm. Each specimen was first tested intact, and then the left facetectomies of L3–4 and L4–5 were performed to establish an unstable condition without removal of discs. Three instrumentation systems were then tested randomly: unilateral pedicle screw (UPS), UPS with contralateral translaminar facet screw (UPSFS), and bilateral pedicle screw (BPS). The range of motion (ROM) and the neutral zone (NZ) of L3–5 were measured. RESULTS All fixation types could reduce the ROM of L3–5 significantly in flexion, extension, and lateral bending, compared with the intact state. In axial torsion, only BPS reduced the ROM significantly, compared with the intact state. The UPSFS technique provided intermediate stability, which was superior to the UPS in flexion-extension and lateral bending, and inferior to the BPS in lateral bending. Compared with the intact state, the NZs decreased significantly for UPS, UPSFS, and BPS in flexion-extension, while not significantly in lateral bending and axial torsion. CONCLUSIONS In this study, among the 3 fixation techniques, BPS offered the highest stability, UPSFS provided intermediate stability, and UPS was the least stable for 2-level lumbar spinal disorders. UPSFS appeared to be able to offer a less invasive choice than BPS in well-selected patients with 2-level lumbar spinal disorders.

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The unusual presentation of a vascular injury after lumbar microdiscectomy: case report

Journal of Neurosurgery: Spine, Ahead of Print.
Vascular injury during lumbar spine surgery is a relatively rare complication but can have devastating outcomes. The injury may not be apparent during surgery and can present acutely or late in various manners, and some injuries can be asymptomatic. This report discusses the unusual case of a 35-year-old woman who underwent a right L4–5 microdiscectomy for disc herniation and 4 days postoperatively presented with a pulmonary embolus. A subsequent CT scan revealed a pseudoaneurysm and arteriovenous fistula of the right common iliac vein and artery, which gave rise to the embolus. The patient received a right iliac artery stent, and at 4 months after surgery she continues to be symptom free. This report describes the atypical presentation of vascular injury after lumbar microdiscectomy and stresses the importance of cautiously using the pituitary rongeur when removing deeper disc fragments.

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Far caudally migrated extraforaminal lumbosacral disc herniation treated by a microsurgical lateral extraforaminal transmuscular approach: case report

Journal of Neurosurgery: Spine, Ahead of Print.
A 33-year-old man presented with moderate low-back pain and L-5 radiculopathy that progressed to severe paresis of L-5. On initial imaging, a corresponding spinal lesion was overlooked. Further CT and contrast-enhanced MRI demonstrated a presacral mass along the L-5 root far extraforaminally. A herniated disc was suspected, but with standard imaging a schwannoma could not be ruled out. The presacral L-5 root was explored via a microsurgical lateral extraforaminal transmuscular approach. To the best of the authors' knowledge, there have been no reports of sequestered extraforaminal lumbosacral disc herniations that herniated into the presacral region.

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Effects of fusion and conservative treatment on disc degeneration and rates of subsequent surgery after thoracolumbar fracture

Journal of Neurosurgery: Spine, Ahead of Print.
OBJECT The objective of this study was to compare the incidence of degeneration and need for subsequent fusion surgery between patients who were treated nonsurgically and patients treated with fusion after a diagnosis of thoracic-or lumbar-level fracture without degenerative disease. METHODS The authors performed a retrospective study of Orthopedic United Healthcare patients diagnosed with thoracic or lumbar fracture. Patients were filtered into thoracic and lumbar fracture groups using diagnostic codes and then assigned to one of 2 treatment subgroups (fusion surgery or no surgery) on the basis of procedural codes. Disc degeneration and follow-up surgery were recorded. Chi-square statistical analysis was used. RESULTS Of 3699 patients diagnosed with a thoracic fracture, 117 (3.2%) underwent thoracic fusion and 3215 (86.9%) were treated nonsurgically. Within 3 years, 147 (4.6%) patients from the nonsurgical subgroup and fewer than 11 (0.9%–8.5%) from the fusion subgroup were diagnosed with thoracic disc degeneration. From the nonsurgical subgroup, 11 (0.3%) patients underwent a thoracic surgery related to disc degeneration compared with zero from the fusion group (p > 0.05). Of 5016 patients diagnosed with lumbar fracture, 150 (3.0%) underwent fusion and 4371 (87.1%) had no surgery. Within 3 years, 503 patients (11.5%) from the nonsurgical subgroup and 35 (23.3%) from the fusion subgroup were diagnosed with lumbar disc degeneration (p < 0.05). From the nonsurgical subgroup, 42 (1.0%) went on to have surgery related to disc degeneration, compared with fewer than 11 (0.7%–6.7%) from the fusion subgroup (values not precise due to privacy limitations). CONCLUSIONS Fusion surgery for thoracic fracture does not appear to increase the likelihood of undergoing future surgery. In the lumbar region, initial fusion surgery appears to increase the incidence of disc degeneration and could potentially necessitate future surgeries.

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Editorial: Vascular injury during spinal procedures

Journal of Neurosurgery: Spine, Ahead of Print.


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Therapiekonzepte der diffusen Peritonitis

Zusammenfassung

Die sekundäre diffuse Peritonitis weist bis heute eine hohe Morbidität und Mortalität auf. Umso mehr sind die verschiedenen operativen Therapiemöglichkeiten in der evidenzbasierten Überprüfung. So stehen sich mit der laparoskopischen Lavage ohne Resektion des Sepsisfokus bis zur Damage-control-basierten Strategie des initialen Laparostomas mit verzögert durchgeführter Anastomosierung extreme Unterschiede im Behandlungskonzept der diffusen Peritonitis gegenüber. Gelten die Daten für die Peritonitis bei Appendizitis, Cholezystitis und ulzerierten Perforationen des Magens und Duodenums im minimal-invasiven Zugangsweg als vergleichsweise gut evidenzbasiert, so lassen sich für die beiden genannten Verfahren nach wie vor bei derzeit noch schwacher Evidenzstärke keine eindeutigen Empfehlungen ableiten. Die vorliegende Arbeit soll eine Übersicht über die aktuellen Therapieverfahren der diffusen Peritonitis in kritischer Betrachtung ihrer jeweiligen Evidenzlage ermöglichen. Als Schlüsselempfehlung wird dargestellt, dass die Entscheidung für ein Operationsverfahren im Spiegel der aktuellen Datenlage letztlich in Abhängigkeit von der Schwere der abdominellen Sepsis, ihrer Dauer, dem Alter des Patienten und seiner Komorbidität getroffen werden sollte.

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Peritonitis

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Long term results of postoperative Intensity-Modulated Radiation Therapy (IMRT) in the treatment of Squamous Cell Carcinoma (SCC) located in the oropharynx or oral cavity

To report our long-term results with postoperative intensity-modulated radiation therapy (IMRT) in patients suffering from squamous-cell carcinoma (SCC) of the oral cavity or oropharynx.

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First evidence of the European wildcat ( Felis silvestris silvestris ) as definitive host of Angiostrongylus chabaudi

Abstract

Angiostrongylus chabaudi (Strongylida, Angiostrongylidae) is a parasitic nematode described for the first time last century from the pulmonary arteries of six European wildcats (Felis silvestris silvestris) in central Italy. Since then, this parasite remained practically unknown until recently, when immature A. chabaudi have been reported from one wildcat in Germany and two domestic cats (Felis silvestris catus) in Italy. The present report describes the first record of A. chabaudi in Greece and, most importantly, the first known case of patent infection by A. chabaudi. The necropsy of a road-killed F. s. silvestris found near the lake Kerkini, in the municipality of Serres (Macedonia, Greece), revealed the presence of nematodes of both sexes in the right ventricle and the pulmonary artery of the heart. All parasites were mature adults and numerous eggs were present in the uteruses of females. The morphological characteristics of the parasites were consistent with those of A. chabaudi. Moreover, Angiostrongylus-like first stage larvae (L1) were present in the faeces of the animal that was negative for any other cardio-pulmonary parasite. Genetic examination of adult parasites and L1 confirmed the morphological identification as A. chabaudi. Histopathological examination of the lungs showed severe, multifocal to coalescing, chronic, interstitial granulomatous pneumonia due to the presence of adult parasites, larvae and eggs. These findings demonstrate for the first unequivocal time that this nematode reproduces in the European wildcat which should be ultimately considered a definitive host of A. chabaudi. Finally, the L1 of A. chabaudi are described here for the first time, opening new prospects for further studies on this neglected parasite.

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Incidence of Ascaris suum -specific antibodies in Austrian patients with suspected larva migrans visceralis (VLM) syndrome

Abstract

The pig roundworm, Ascaris suum, is commonly found in domestic pigs all over the world. The transmission to humans takes place by ingestion of infective A. suum eggs present in soil because pig manure is widely used as fertilizer. The possible role of A. suum in the human visceral larva migrans (VLM) syndrome has been discussed controversially during past decades, even though various case reports, particularly from Japan document pulmonal, hepatic and even cerebral symptoms caused by migrating A. suum larvae after ingestion of infected row meat (liver) or contaminated vegetables. We examined 4481 sera by A. suum immunoblot (As-IB) and 5301 sera by Toxocara-ELISA from patients with symptoms associated with the VLM syndrome during three consecutive years (2012–2014). The incidence of A. suum-specific antibodies was 13.2 %, the incidence of T. canis specific antibodies 12.9 % and from a part of the As-IB positive sera (n = 417) additional Toxocara serology was performed to demonstrate the specificity of our tests. Only 56 out of the 417 (13.4 %) sera showed antibodies to both helminth species demonstrating that double infections exist. Interestingly the age distribution of the patients showed that 2.8 % of the Ascaris-positive patients were younger than 21 years, while in the Toxocara-positive group 13.4 % were <21 years. These results are in accordance with a Dutch study suspecting different ways of transmission as cause for this interesting age distribution. Due to the fact that large amounts of untreated pig manure are used as fertilizer and that the expulsion of adult A. suum worms causing intestinal ascariosis is extremely rare in Central European countries, the zoonotic potential of A. suum is considerably underestimated. We suggest that the performance of reliable immunoserological tests, in all industrialized countries where pigs are raised and their manure is used as fertilizer, could help to assess the actual potential of A. suum as causative agent of the VLM syndrome in humans.

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A mucin-like peptide from Fasciola hepatica induces parasite-specific Th1-type cell immunity

Abstract

Fasciolosis, caused by the liver fluke Fasciola hepatica, is a major parasitic disease of livestock that causes significant economic losses worldwide. Although drugs are effective against liver flukes, they do not prevent reinfection, and continuous treatment is costly. Moreover, resistant fluke strains are emerging. In this context, vaccination is a good alternative since it provides a cost-effective long-term prevention strategy to control fasciolosis. In this paper, we evaluate the Fhmuc peptide as a potential vaccine against fasciolosis. This peptide derives from a mucin-like protein highly expressed in the infective stage of Fasciola hepatica. Mucin-like molecules expressed by parasites can contribute to several infection processes by protecting the parasite from host proteases and recognition by the immune system. We show that the Fhmuc peptide induces Th1-like immune responses specific for F. hepatica excretion-secretion products (FhESP) with a high production of IFNγ. We also investigated whether this peptide could protect animals from infection, and present preliminary data indicating that animals treated with Fhmuc exhibited reduced liver damage compared to non-immunised animals and that this protection was associated with a recruitment of B and T lymphocytes in the peritoneum, as well as eosinophils and mature dendritic cells. These results suggest that the mucin-like peptide Fhmuc could constitute a potential vaccine candidate against fasciolosis and pave the way towards the development of vaccines against parasites.

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Georgia Primary Care Providers’ Knowledge of Hereditary Breast and Ovarian Cancer Syndrome

Abstract

Hereditary breast and ovarian cancer syndrome (HBOC) is an inherited condition associated with mutations in the BRCA1 or BRCA2 (BRCA) genes. Identification of individuals with HBOC requires that primary care providers understand the genetic principles required to appropriately collect family history and refer individuals for genetic evaluation. A survey was developed and administered to primary care providers in Georgia to assess their existing knowledge of HBOC and direct targeted educational efforts.

We found that Georgia providers demonstrate some knowledge of basic genetic principles but were unable to consistently identify individuals at risk for HBOC. Knowledge deficits included lack of understanding of inheritance patterns and failure to recognize the significance of ovarian cancer history. Strategies for improving identification of patients with HBOC include increasing provider knowledge and integrating HBOC risk assessment tools into practice. Identification of individuals at risk is the critical first step in the process of reducing incidence of breast and ovarian cancer associated with BRCA mutations.

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Goodness and Desire

Boyle, M; Lavin, D; (2010) Goodness and Desire. In: Tenenbaum, S, (ed.) Desire, Practical Reason, and the Good. (pp. 161-201). Oxford University Press: Oxford, UK.

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Why do East Asian children perform so well in PISA? An investigation of Western-born children of East Asian descent

Jerrim, J; (2015) Why do East Asian children perform so well in PISA? An investigation of Western-born children of East Asian descent. Oxford Review of Education , 41 (3) pp. 310-333. 10.1080/03054985.2015.1028525 .

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In the Long Cool Hour: "The Ethical Project" by Philip Kitcher. Harvard, 422 pp, £36.95, November 2011, ISBN 9780674061446

Srinivasan, A; (2012) In the Long Cool Hour: "The Ethical Project" by Philip Kitcher. Harvard, 422 pp, £36.95, November 2011, ISBN 9780674061446. [Review]. London Review of Books , 34 (23) pp. 17-18.

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Income Inequality, Intergenerational Mobility, and the Great Gatsby Curve: Is Education the Key?

Jerrim, J; Macmillan, L; (2015) Income Inequality, Intergenerational Mobility, and the Great Gatsby Curve: Is Education the Key? Social Forces , 94 (2) pp. 505-533. 10.1093/sf/sov075 . Green open access

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Meaning, signification, and suggestion: Berkeley on general words

Pritchard, TD; (2012) Meaning, signification, and suggestion: Berkeley on general words. History of Philosophy Quarterly , 29 (3) pp. 301-317. Green open access

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Microcarriers’ suspension and flow dynamics in orbitally shaken bioreactors

Pieralisi, I; Rodriguez, G; Micheletti, M; Paglianti, A; Ducci, A; (2015) Microcarriers' suspension and flow dynamics in orbitally shaken bioreactors. Chemical Engineering Research and Design (In press).

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Political risk insurance and bilateral investment treaties: a view from below

Poulsen, L; (2010) Political risk insurance and bilateral investment treaties: a view from below. Columbia FDI Perspectives , 27

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Centrifugal partition chromatography in a biorefinery context: Separation of monosaccharides from hydrolysed sugar beet pulp

Ward, DP; Cárdenas-Fernández, M; Hewitson, P; Ignatova, S; Lye, GJ; (2015) Centrifugal partition chromatography in a biorefinery context: Separation of monosaccharides from hydrolysed sugar beet pulp. Journal of Chromatography A , 1411 pp. 84-91. 10.1016/j.chroma.2015.08.006 . Green open access

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Mapping pneumonia research: A systematic analysis of UK investments and published outputs 1997-2013

Head, MG; Fitchett, JR; Newell, M-L; Scott, JAG; Harris, JN; Clarke, SC; Atun, R; (2015) Mapping pneumonia research: A systematic analysis of UK investments and published outputs 1997-2013. EBioMedicine , 2 (9) pp. 1193-1199. 10.1016/j.ebiom.2015.06.024 . Green open access

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Concurrent sexual partnerships among married Zimbabweans - implications for HIV prevention

Mugweni, E; Pearson, S; Omar, M; (2015) Concurrent sexual partnerships among married Zimbabweans - implications for HIV prevention. Int J Womens Health , 7 pp. 819-832. 10.2147/IJWH.S88884 . Green open access

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Studies of plug formation in microchannel liquid-liquid flows using advanced particle image velocimetry techniques

Chinaud, M; Roumpea, E-P; Angeli, P; (2015) Studies of plug formation in microchannel liquid-liquid flows using advanced particle image velocimetry techniques. EXPERIMENTAL THERMAL AND FLUID SCIENCE , 69 pp. 99-110. 10.1016/j.expthermflusci.2015.07.022 . Green open access

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A new small molecule inhibitor of soluble guanylate cyclase

Mota, F; Gane, P; Hampden-Smith, K; Allerston, CK; Garthwaite, J; Selwood, DL; (2015) A new small molecule inhibitor of soluble guanylate cyclase. Bioorganic & Medicinal Chemistry , 23 (17) pp. 5303-5310. 10.1016/j.bmc.2015.07.074 . Green open access

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Reconciling Magnetically Induced Vertigo and Nystagmus

Mian, OS; Glover, PM; Day, BL; (2015) Reconciling Magnetically Induced Vertigo and Nystagmus. Frontiers in Neurology , 6 , Article 201. 10.3389/fneur.2015.00201 . Green open access

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The impact of threat of shock on the framing effect and temporal discounting: executive functions unperturbed by acute stress?

Robinson, OJ; Bond, RL; Roiser, JP; (2015) The impact of threat of shock on the framing effect and temporal discounting: executive functions unperturbed by acute stress? Frontiers in Psychology , 6 , Article 1315. 10.3389/fpsyg.2015.01315 . Green open access

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Gastrointestinal stability of peptide drugs

Wang, J; (2015) Gastrointestinal stability of peptide drugs. Doctoral thesis, UCL (University College London).

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How beliefs about self-creation inflate value in the human brain

Koster, R; Sharot, T; Yuan, R; De Martino, B; Norton, MI; Dolan, RJ; (2015) How beliefs about self-creation inflate value in the human brain. Frontiers in Human Neuroscience , 9 , Article 473. 10.3389/fnhum.2015.00473 . Green open access

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Integrating Presentation Into Holistic Site Management: A Case Study of the Vesuvian Region

Wallace, AR; (2015) Integrating Presentation Into Holistic Site Management: A Case Study of the Vesuvian Region. Doctoral thesis, UCL (University College London). Green open access

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An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital.

Huynh, C; Tomlin, S; Jani, Y; Solanki, GA; Haley, H; Smith, RE; Lowey, A; Huynh, C; Tomlin, S; Jani, Y; Solanki, GA; Haley, H; Smith, RE; Lowey, A; Sinclair, A; Wilson, KA; Wong, IC; Terry, D; - view fewer (2015) An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital. Archives of Disease in Childhood 10.1136/archdischild-2015-308591 . Green open access

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The evolution of chromatin folding in mammals: a role for CTCF

Vietri Rudan, M; (2015) The evolution of chromatin folding in mammals: a role for CTCF. Doctoral thesis, UCL (University College London). Green open access

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Cutaneous Leishmaniasis - skin Barrier Properties And Drug Delivery Strategies

Van Bocxlaer, K; (2015) Cutaneous Leishmaniasis - skin Barrier Properties And Drug Delivery Strategies. Doctoral thesis, UCL (University College London).

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