Functional Balance Deterioration on Daily Activities in Patients With Migraine: A Controlled Study

Objective This study aimed to assess functional activities in different subgroups of patients with migraine. Design One-hundred forty subjects were uniformly divided into the following four groups: headache-free controls, migraine with aura, without aura, and chronic migraine. Subjects performed the tests walk across, tandem walk, sit to stand, and step up and over at the Balance Master system (Neurocom). Results All migraine groups had slower velocity and shorter step length at the walk across test (P

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Could Activity Modifications Indicate Physical Decline Among Adults With Symptomatic Knee Osteoarthritis?

Objectives Mobility activity modifications indicate early functional losses that act as precursors to future declines among community-dwelling older adults. However, there is scarce evidence on whether activity modifications indicate poorer physical health among adults with symptomatic osteoarthritis, a major cause of disability. Our purpose was to investigate whether patient-reported mobility activity modifications indicated poorer physical health among adults with symptomatic knee osteoarthritis. Design Secondary cross-sectional analysis of randomized trial data was performed. Preclinical Disability Questionnaire was used to group participants into the following three categories: difficulty, modified, and no difficulty walking/stair climbing. Kruskal Wallis and χ2 tests were used to compare clinical factors across groups. Results Among 121 participants (median age = 60 yrs; 73% female; 60% white), less than 10% had modified walking/stair climbing. Compared with those with no walking difficulty, participants with modified walking had significantly less balance (P = 0.01) and global health (P = 0.01) as well as greater knee pain (P = 0.05) and physical disability (P = 0.04). Those with modified stair climbing had significantly smaller walking distances (P = 0.03) compared with those with no difficulty stair climbing. Conclusions Activity modifications may signal early impairments in physical health among people with symptomatic knee osteoarthritis. If confirmed, patient-reported activity modifications may enhance symptom evaluation in osteoarthritis and enable a better understanding of the disablement process.

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Alterations in the Mechanical Response of Deep Dorsal Neck Muscles in Individuals Experiencing Whiplash-Associated Disorders Compared to Healthy Controls: An Ultrasound Study

Objective The aim of this study was to investigate and compare the mechanical responses of dorsal neck muscles in individuals with whiplash-associated disorders (WAD) versus healthy individuals. Design This study included 36 individuals with WAD (26 women and 10 men) and 36 healthy controls (26 women and 10 men). Ultrasound imaging with speckle tracking was used to measure deformation and deformation rate in five dorsal neck muscles during a neck extension task. Results Compared with controls, individuals with WAD showed higher deformations of the semispinalis cervicis (P = 0.02) and multifidus (P = 0.002) muscles and higher deformation rates (P = 0.03 and 0.0001, respectively). Among individuals with WAD, multifidus deformation and deformation rate were significantly associated with pain, disability, and fatigue (r = 0.31–0.46, P = 0.0001–0.01). Conclusions These findings indicate that the mechanical responses of the deep dorsal neck muscles differ between individuals with WAD and healthy controls, possibly reflecting that these muscles use altered strategies while performing a neck extension task. This finding provides new insight into neck muscles pathology in patients with chronic WAD and may help improve rehabilitation programs. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://ift.tt/1l80W45 CME Objectives Upon completion of this article, the reader should be able to: (1) Summarize the mechanical responses of dorsal neck muscles during loading of the neck muscles via an extension task in individuals with chronic whiplash associated disorders and healthy volunteers; (2) Differentiate mechanical responses between five dorsal neck muscles while loading the neck via an extension task; and (3) Describe the relationships between the mechanical responses of the dorsal neck muscles with the patients' perception of neck pain, disability, and fatigue. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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Effect of Group Exercising and Adjusting the Brace at Shorter Intervals on Cobb Angle and Quality of Life of Patients With Idiopathic Scoliosis

Objective The aim of the study was to evaluate the effect of group exercise with brace adjustment at shorter intervals than used in routine practice in late-onset idiopathic scoliosis patients. Design This was a quasi-experimental study. Thirty patients with progressive scoliosis curves of 15–50 degrees and a prescription for a brace were divided into experimental and control groups, both of which participated in an 11-wk treatment program. Those in the experimental group underwent brace adjustment twice per week and performed group exercise, whereas those in the control group received a routine protocol. The quality of life and Cobb angle of patients in both groups were evaluated based on baseline and final results of the 22-item Scoliosis Research Society questionnaire and primary and secondary radiographs. Results In the experimental group, the improvement in Cobb angle and patient satisfaction was greater than that in the control group (P

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Implementation of a Multifaceted Interactive Electrodiagnostic Medicine Workshop in a Physical Medicine and Rehabilitation Residency Program

Electrodiagnostic medicine is a required component of Physical Medicine and Rehabilitation residency education, but limited resources exist to guide curriculum development. Our objective was to create a focused workshop to enhance our residency program's electrodiagnostic curriculum. We created two separate 1.5-day workshops, one basic and one advanced, for all residents. Each workshop included didactic sessions, case discussion, question and answer sessions, demonstrations, and hands-on participation with direct supervision and feedback. Presurveys and postsurveys were administered to evaluate the value of the workshops. We also assessed trends in electrodiagnostic self-assessment examination scores. Residents reported clinical electrodiagnostic rotations to be more valuable to their education than previous didactic sessions and independent learning. Self-reported knowledge of electrodiagnostic concepts, resident comfort level in planning, performing, and interpreting studies, and perceived value in independent learning of electrodiagnostic medicine improved after implementation of the workshops. There was a 7% improvement in the American Association of Neuromuscular and Electrodiagnostic Medicine electrodiagnostic self-assessment examination score compared with the previous year and a 15% improvement in the Physical Medicine and Rehabilitation self-assessment examination electrodiagnostic subscore compared with the previous 5 yrs. All participants recommended similar educational experience for other residents. This successful workshop may serve as a resource for other training programs.

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Effectiveness of a Group Physiotherapy Intervention in Nontraumatic, Inoperable Painful Shoulder: A Randomized Clinical Trial

Purpose The aim of the study was to assess the effectiveness of a group intervention in painful shoulder. Design This was a two-arm controlled clinical trial with a 5-wk follow-up and 1:1 allocation ratio with pretreatment and posttreatment assessments in a Spanish hospital in 2015–2016. This study comprised 74 patients with nontraumatic, inoperable painful shoulder. Patients were randomized into two groups: (1) in intervention, patients underwent group rehabilitation exercises supervised by a physical therapist and (2) in control, patients performed the same exercises as the intervention group but in their own home. The main variables were the differences preintervention and postintervention between scores on the visual analog scale, Constant-Murley scale, and Disabilities of the Arm, Shoulder and Hand scale. The mean differences in the main variables were compared between the two interventions (t test). Registration code is NCT02541279 (clinicaltrials.gov). Results Differences were found in favor of the intervention group: (1) visual analog scale = −0.1 (P = 0.723), (2) Constant-Murley = 4.1 (P = 0.085), and (3) Disabilities of the Arm, Shoulder and Hand = 14.7 (P

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Tibialis Posterior Tenosynovitis: A Unique Musculoskeletal Manifestation of Gout

Extra-articular manifestations of gout can present in several ways, including tenosynovitis. We present a rare case of acute tibialis posterior gouty tenosynovitis. An 82-year-old man with a history of well-controlled gout presented with acute onset of left ankle pain, occurring without inciting event. The medial ankle was slightly erythematous with moderate dorsal-medial swelling and mild dorsal-lateral swelling, with severe tenderness to palpation over the medial retro-malleolar region. Range of motion and manual muscle testing were pain limited throughout. Ultrasound examination revealed a left posterior tibialis tendon sheath tenosynovitis with effusion and overlying soft tissue edema. Tendon sheath aspirate revealed sodium urate crystals and a white blood cell count of 6400/μL. Tendon sheath injection with a mixture of 1% lidocaine and dexamethasone 4 mg resulted in symptom resolution. Repeat ultrasound examination demonstrated no evidence of tibialis posterior tendon sheath effusion. This case is unique not only because acute gouty posterior tibialis tenosynovitis is very rare, particularly in a normouricemic individual, but also because the sonographic evidence of gouty infiltration into the posterior tibialis tendon and overlying subcutaneous tissue considerably aided in arriving at the correct diagnosis in a timely manner.

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Aquatic Exercises in the Treatment of Low Back Pain: A Systematic Review of the Literature and Meta-Analysis of Eight Studies

Objective Low back pain is the most common musculoskeletal condition with a high prevalence. There was no sufficient evidence to recommend that aquatic exercise was potentially beneficial to patients with low back pain. The aim of this study was to systematically analyze all evidence available in the literature about effectiveness of the aquatic exercise. Design A comprehensive search of PubMed, the Cochrane Library, Embase, and Cumulative Index to Nursing and Allied Health was conducted from their inceptions to November 2016 for randomized controlled trials, which concerned the therapeutic aquatic exercise for low back pain. The results were expressed in terms of standardized mean difference and the corresponding 95% confidence interval. Results Eight trials involving 331 patients were included in the meta-analysis, and the results showed a relief of pain (standardized mean difference = −0.65, 95% confidence interval = −1.16 to −0.14) and physical function (standardized mean difference = 0.63, 95% confidence interval = 0.17 to 1.09) after aquatic exercise. However, there was no significant effectiveness with regard to general mental health in aquatic group (standardized mean difference = 0.46; 95% confidence interval = −0.22 to 1.15). Conclusions Aquatic exercise can statistically significantly reduce pain and increase physical function in patients with low back pain. Further high-quality investigations on a larger scale are required to confirm the results.

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Regarding: Radial Extracorporeal Shockwave Therapy Is No More Effective Than Placebo in the Management of Lateral Epicondylitis A Double-Blind, Randomized, Placebo-Controlled Trial

No abstract available

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Evaluation of the Effectiveness of Neuromuscular Electrical Stimulation After Total Knee Arthroplasty: A Meta-Analysis

Objective The aim of the study was to evaluate the efficacy of the use of the neuromuscular electrical stimulation after total knee arthroplasty. Design The study used a systematic review of randomized controlled trials (MEDLINE, PubMed, Cochrane Library, and PEDro) using Patient Population or Problem, Intervention, Comparison, Outcomes, Setting approach to formulate the research question, controlled terms, and Boolean operators. Inclusion and exclusion criteria were defined in advance. "Neuromuscular electrical stimulation" and "total knee arthroplasty" were used as keywords. The overall risk of bias was determined according to the following: random sequence generation, concealment, blinding mass of participants and staff, commissioning blind assessment results, incomplete data, and loans received. Results Of the 36 identified studies, six were included in the review (496 participants). In these studies, one group of patients followed a rehabilitation protocol (control group) and the other followed a rehabilitation program plus a session of neuromuscular electrical stimulation (neuromuscular electrical stimulation group). Patients of neuromuscular electrical stimulation groups got the best scores (timed up and go test, stair climbing test, and walk test). Neuromuscular electrical stimulation benefits were strong in the first postoperative weeks/months and gradually diminished. Conclusions Neuromuscular electrical stimulation allows a slightly better functional recovery after total knee arthroplasty, especially in the first period, with more evident benefits in patients with a severe lack of muscular activation. Nevertheless, there is no difference at medium-long term.

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Dynamic Change in Ultrasonographic Findings in Iliotibial Band Syndrome After Running

No abstract available

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Is dipyrone effective as a preemptive analgesic in third molar surgery? A pilot study

Abstract

Purpose

Studies on preemptive analgesia in maxillofacial surgery have shown several controversial clinical results, mainly due to the absence of a methodological standard, besides a wide variety of studied drugs. This study intended to answer the following hypothesis: Is the administration of dipyrone preemptively capable of decreasing trans- and postoperative pain in the third molar surgical extraction?

Methods

A pilot prospective double-blind placebo-controlled study was carried out with 25 patients submitted to the third molar surgical extraction at two moments, one side in each intervention. Dipyrone (1 g) was preemptively administered (study group) for the extraction of two third molars on the same side and, in a second surgical procedure, dipyrone (1 g) was administered in the immediate postoperative period (control group). Evaluated variables were the amount of anesthetic, pain perceived through the visual analogue scale (VAS) in transoperative and immediate postoperative periods, and over 12-h investigation period, analgesic consumption, duration of surgery, and time to rescue analgesia.

Results

The results were submitted to Student's t test and statistical differences were observed in transoperative (p < 0.05) and immediate postoperative (p < 0.01) periods, while the other studied variables did not present statistical differences.

Conclusion

The preemptive administration of dipyrone decreased the perception of transoperative and immediate postoperative pain when compared to its use after surgery only.

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Is dipyrone effective as a preemptive analgesic in third molar surgery? A pilot study

Abstract

Purpose

Studies on preemptive analgesia in maxillofacial surgery have shown several controversial clinical results, mainly due to the absence of a methodological standard, besides a wide variety of studied drugs. This study intended to answer the following hypothesis: Is the administration of dipyrone preemptively capable of decreasing trans- and postoperative pain in the third molar surgical extraction?

Methods

A pilot prospective double-blind placebo-controlled study was carried out with 25 patients submitted to the third molar surgical extraction at two moments, one side in each intervention. Dipyrone (1 g) was preemptively administered (study group) for the extraction of two third molars on the same side and, in a second surgical procedure, dipyrone (1 g) was administered in the immediate postoperative period (control group). Evaluated variables were the amount of anesthetic, pain perceived through the visual analogue scale (VAS) in transoperative and immediate postoperative periods, and over 12-h investigation period, analgesic consumption, duration of surgery, and time to rescue analgesia.

Results

The results were submitted to Student's t test and statistical differences were observed in transoperative (p < 0.05) and immediate postoperative (p < 0.01) periods, while the other studied variables did not present statistical differences.

Conclusion

The preemptive administration of dipyrone decreased the perception of transoperative and immediate postoperative pain when compared to its use after surgery only.

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Aprepitant did not modify global disease activity in cutaneous T cell lymphomas

Abstract

Recent investigations are focused on the potential antitumor effect of neurokinin-1 receptor (NK1R) antagonists in different neoplastic diseases¹. Consequently, Kwatra et al. raised an interesting observation about the possible influence of aprepitant on CTCL outcome².

This article is protected by copyright. All rights reserved.

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Effects of neuroimmune axis modulation by aprepitant on anti-pruritic and global disease severity in patients with cutaneous T-cell lymphoma

Abstract

Itch pathogenesis involves modulation of the neuroimmune axis, with several immunosuppressants such as azathioprine¹ and mycophenolate mofetil² demonstrating significant anti-pruritic activity in subsets of patients with pruritus. These immunosuppressive agents are contraindicated in patients with malignancy, and thus there is a need for novel anti-pruritic agents without significant immunosuppressive effects in neoplastic conditions such as cutaneous T cell lymphoma (CTCL).

This article is protected by copyright. All rights reserved.

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From Foundation to Demolition: The Influence of Perioperative Tranexamic Acid

No abstract available

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The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients

BACKGROUND: There is limited data on prehospital administration of tranexamic acid (TXA) in civilian trauma. The aim of this study was to evaluate changes in coagulation after severe trauma from on-scene to the hospital after TXA application in comparison to a previous study without TXA. METHODS: The study protocol was registered at ClinicalTrials.gov (NCT02354885). A prospective, multicenter, observational study investigating coagulation status in 70 trauma patients receiving TXA (1 g intravenously) on-scene versus a control group of 38 patients previously published without TXA. To account for potential differences in patient and trauma epidemiology, crystalloid and colloidal resuscitation fluid, 2 propensity score matched groups (n = 24 per group) were created. Measurements included ROTEM, standard coagulation tests and blood gas analyses on-scene and emergency department admission. Presented values are mean and [standard deviation], and difference in means and 95% confidence intervals. RESULTS: Patient epidemiology was not different between groups. Coagulation assays on-scene were comparable between the TXA and C. Prehospital hyperfibrinolysis was blunted in all 4 patients in the TXA group. Viscoelastic FIBTEM maximum clot firmness (MCF), representing functional fibrinogen levels, did not change from on-scene to the emergency department in the TXA group, whereas MCF decreased −3.7 [1.8] mm in the control group. Decrease of MCF was significantly reduced in the TXA group in EXTEM by 9.2 (7.2–11.2) mm (P

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A Tale of Two Solutions: High vs Low-Chloride Intravenous Fluids

No abstract available

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Low- Versus High-Chloride Content Intravenous Solutions for Critically Ill and Perioperative Adult Patients: A Systematic Review and Meta-analysis

BACKGROUND: To assess whether use of low-chloride solutions in unselected critically ill or perioperative adult patients for maintenance or resuscitation reduces mortality and renal replacement therapy (RRT) use when compared to high-chloride fluids. METHODS: Systematic review and meta-analysis with random-effects inverse variance model. PubMed, Cochrane library, EMBASE, LILACS, and Web of Science were searched from inception to October 2016. Published and unpublished randomized controlled trials in any language that enrolled critically ill and/or perioperative adult patients and compared a low- to a highchloride solution for volume maintenance or resuscitation. The primary outcomes were mortality and RRT use. We conducted trial sequential analyses and assessed risk of bias of individual trials and the overall quality of evidence. Fifteen trials with 4067 patients, most at low risk of bias, were identified. Of those, only 11 and 10 trials had data on mortality and RRT use, respectively. A total of 3710 patients were included in the mortality analysis and 3724 in the RRT analysis. RESULTS: No statistically significant impact on mortality (odds ratio, 0.90; 95% confidence interval, 0.69–1.17; P = .44; I2 = 0%) or RRT use (odds ratio, 1.12; 95% confidence interval, 0.80–1.58; P = .52; I2 = 0%) was found. Overall quality of evidence was low for both primary outcomes. Trial sequential analyses highlighted that the sample size needed was much larger than that available for properly powered outcome assessment. CONCLUSIONS: The current evidence on low- versus high-chloride solutions for unselected critically ill or perioperative adult patients demonstrates no benefit, but suffers from considerable imprecision. We noted a limited exposure volume for study fluids and a relatively low risk of the populations in each study. Together with the relatively small pooled sample size, these data leave us underpowered to detect potentially important differences. Results from well-conducted, adequately powered randomized controlled trials examining sufficiently large fluid exposure are necessary.

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Brain Monitoring and the Depth of Anesthesia: Another Goldilocks Dilemma

No abstract available

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Translational potential of human brain organoids

Abstract

The recent technology of 3D cultures of cellular aggregates derived from human stem cells have led to the emergence of tissue-like structures of various organs including the brain. Brain organoids bear molecular and structural resemblance with developing human brains, and have been demonstrated to recapitulate several physiological and pathological functions of the brain. Here we provide an overview of the development of brain organoids for the clinical community, focusing on the current status of the field with an critical evaluation of its translational value.

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Predicting progression from normal cognition to mild cognitive impairment for individuals at 5 years

Abstract

Recent evidence indicates that measures from cerebrospinal fluid, MRI scans and cognitive testing obtained from cognitively normal individuals can be used to predict likelihood of progression to mild cognitive impairment several years later, for groups of individuals. However, it remains unclear whether these measures are useful for predicting likelihood of progression for an individual. The increasing focus on early intervention in clinical trials for Alzheimer's disease emphasizes the importance of improving the ability to identify which cognitively normal individuals are more likely to progress over time, thus allowing researchers to efficiently screen participants, as well as determine the efficacy of any treatment intervention. The goal of this study was to determine which measures, obtained when individuals were cognitively normal, predict on an individual basis, the onset of clinical symptoms associated with a diagnosis of mild cognitive impairment due to Alzheimer's disease. Cognitively normal participants (n = 224, mean baseline age = 57 years) were evaluated with a range of measures, including: cerebrospinal fluid amyloid-β and phosphorylated-tau, hippocampal and entorhinal cortex volume, cognitive tests scores and APOE genotype. They were then followed to determine which individuals developed mild cognitive impairment over time (mean follow-up = 11 years). The primary outcome was progression from normal cognition to the onset of clinical symptoms of mild cognitive impairment due to Alzheimer's disease at 5 years post-baseline. Time-dependent receiver operating characteristic analyses examined the sensitivity and specificity of individual measures, and combinations of measures, as predictors of the outcome. Six measures, in combination, were the most parsimonious predictors of transition to mild cognitive impairment 5 years after baseline (area under the curve = 0.85; sensitivity = 0.80, specificity = 0.75). The addition of variables from each domain significantly improved the accuracy of prediction. The incremental accuracy of prediction achieved by adding individual measures or sets of measures successively to one another was also examined, as might be done when enrolling individuals in a clinical trial. The results indicate that biomarkers obtained when individuals are cognitively normal can be used to predict which individuals are likely to develop clinical symptoms at 5 years post-baseline. As a number of the measures included in the study could also be used as subject selection criteria in a clinical trial, the findings also provide information about measures that would be useful for screening in a clinical trial aimed at individuals with preclinical Alzheimer's disease.

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Migraine with visual aura associated with thicker visual cortex

Abstract

Until recent years it was believed that migraine with aura was a disorder causing intermittent neurological symptoms, with no impact on brain structure. However, recent MRI studies have reported increased cortical thickness of visual and somatosensory areas in patients with migraine with aura, suggesting that such structural alterations were either due to increased neuronal density in the areas involved, or a result of multiple episodes of cortical spreading depression as part of aura attacks. Subsequent studies have yielded conflicting results, possibly due to methodological reasons, e.g. small number of subjects. In this cross-sectional study, we recruited females aged 30–60 years from the nationwide Danish Twin Registry. Brain MRI of females with migraine with aura (patients), their co-twins, and unrelated migraine-free twins (controls) were performed at a single centre and assessed for cortical thickness in predefined cortical areas (V1, V2, V3A, MT, somatosensory cortex), blinded to headache diagnoses. The difference in cortical thickness between patients and controls adjusted for age, and other potential confounders was assessed. Comparisons of twin pairs discordant for migraine with aura were also performed. Comparisons were based on 166 patients, 30 co-twins, and 137 controls. Compared with controls, patients had a thicker cortex in areas V2 [adjusted mean difference 0.032 mm (95% confidence interval 0.003 to 0.061), V3A [adjusted mean difference 0.037 mm (95% confidence interval 0.008 to 0.067)], while differences in the remaining areas examined were not statistically significant [adjusted mean difference (95% confidence interval): V1 0.022 (−0.007 to 0.052); MT: 0.018 (−0.011 to 0.047); somatosensory cortex: 0.020 (−0.009 to 0.049)]. We found no association between the regions of interest and active migraine, or number of lifetime aura attacks. Migraine with aura discordant twin pairs (n = 30) only differed in mean thickness of V2 (0.039 mm, 95% CI 0.005 to 0.074). In conclusion, females with migraine with aura have a thicker cortex corresponding to visual areas and our results indicate this may be an inherent trait rather than a result of repeated aura attacks.

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Multiple sclerosis risk variants alter expression of co-stimulatory genes in B cells

Abstract

The increasing evidence supporting a role for B cells in the pathogenesis of multiple sclerosis prompted us to investigate the influence of known susceptibility variants on the surface expression of co-stimulatory molecules in these cells. Using flow cytometry we measured surface expression of CD40 and CD86 in B cells from 68 patients and 162 healthy controls that were genotyped for the multiple sclerosis associated single nucleotide polymorphisms (SNPs) rs4810485, which maps within the CD40 gene, and rs9282641, which maps within the CD86 gene. We found that carrying the risk allele rs4810485*T lowered the cell-surface expression of CD40 in all tested B cell subtypes (in total B cells P ≤ 5.10 × 10⁻⁵ in patients and ≤4.09 × 10⁻⁶ in controls), while carrying the risk allele rs9282641*G increased the expression of CD86, with this effect primarily seen in the naïve B cell subset (P = 0.048 in patients and 5.38 × 10⁻⁵ in controls). In concordance with these results, analysis of RNA expression demonstrated that the risk allele rs4810485*T resulted in lower total CD40 expression (P = 0.057) but with an increased proportion of alternative splice-forms leading to decoy receptors (P = 4.00 × 10⁻⁷). Finally, we also observed that the risk allele rs4810485*T was associated with decreased levels of interleukin-10 (P = 0.020), which is considered to have an immunoregulatory function downstream of CD40. Given the importance of these co-stimulatory molecules in determining the immune reaction that appears in response to antigen our data suggest that B cells might have an important antigen presentation and immunoregulatory role in the pathogenesis of multiple sclerosis.

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Spike-related haemodynamic responses overlap with high frequency oscillations in patients with focal epilepsy

Abstract

Simultaneous scalp EEG/functional MRI measures non-invasively haemodynamic responses to interictal epileptic discharges, which are related to the epileptogenic zone. High frequency oscillations are also an excellent indicator of this zone, but are primarily recorded from intracerebral EEG. We studied the spatial overlap of these two important markers in patients with drug-resistant epilepsy to assess if their combination could help better define the extent of the epileptogenic zone. We included patients who underwent EEG-functional MRI and later intracerebral EEG. Based on intracerebral EEG findings, we separated patients with unifocal seizures from patients with multifocal or unknown onset seizures. Haemodynamic t-maps were coregistered with the intracerebral electrode positions. Each EEG channel was classified as pertaining to one of the following categories: primary haemodynamic cluster (maximum t-value), secondary cluster (t-value > 90% of the primary cluster) or outside the primary and secondary clusters. We marked high frequency oscillations (ripples: 80–250 Hz; fast ripples: 250–500 Hz) during 1 h of slow wave sleep, and compared their rates in each haemodynamic category. After classifying channels as high- or low-rate, the proportion of high-rate channels within the primary or primary plus secondary clusters was compared to the proportion expected by chance. Twenty-five patients, 11 with unifocal and 14 with multifocal/unknown seizure onsets, were studied. We found a significantly higher median high frequency oscillation rate in the primary cluster compared to secondary cluster and outside these two clusters for the unifocal group (P < 0.0001), but not for the multifocal/unknown group. For the unifocal group, the number of high-rate channels within the primary or primary plus secondary clusters was significantly higher than expected by chance. This held only for the high-ripple-rate channels in the multifocal/unknown group. At the patient level, most patients (18/25, or 72%) had at least one high-rate channel within a primary cluster. In patients with unifocal epilepsy, the maximum haemodynamic response (primary cluster) related to scalp interictal discharges overlaps with the tissue generating high frequency oscillations at high rates. If intracranial EEG is warranted, this response should be explored. As a tentative clinical use of the combination of these techniques we propose that higher high frequency oscillation rates inside than outside the maximum response indicates that the patient has indeed a focal epileptogenic zone demarcated by this response, whereas similar rates inside and outside may indicate a widespread epileptogenic zone or an epileptogenic zone not covered by the implantation.

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Correlation of Concussion Symptom Profile with Head Impact Biomechanics: A Case for Individual-Specific Injury Tolerance

Journal of Neurotrauma , Vol. 0, No. 0.


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Multiple primary malignancies and prolonged survival in a patient with widespread metastatic cutaneous melanoma

No abstract available

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Sleep Interventions Designed to Improve Athletic Performance and Recovery: A Systematic Review of Current Approaches

Abstract

Background

Athletes experience various situations and conditions that can interfere with their sleep, which is crucial for optimal psychological and physiological recovery as well as subsequent performance. Conventional sleep screening and intervention approaches may not be efficacious for athletes given their lifestyle, the demands of training and travel associated with interstate/international competition.

Objectives

The present systematic review aimed to summarize and evaluate sleep intervention studies targeting subsequent performance and recovery in competitive athletes. Based on the findings, a secondary aim was to outline a possible sleep intervention for athletes, including recommendations for content, mode of delivery and evaluation.

Methods

A systematic review was conducted based on the PRISMA guidelines in May 2016 with an update completed in September 2017. Ten studies met our inclusion criteria comprising a total of 218 participants in the age range of 18–24 years with athletes from various sports (e.g., swimming, soccer, basketball, tennis). A modified version of the quality assessment scale developed by Abernethy and Bleakley was used to evaluate the quality of the studies.

Results

The included studies implemented several sleep interventions, including sleep extension and napping, sleep hygiene, and post-exercise recovery strategies. Evidence suggests that sleep extension had the most beneficial effects on subsequent performance. Consistent with previous research, these results suggest that sleep plays an important role in some, but not all, aspects of athletes' performance and recovery.

Conclusion

Future researchers should aim to conduct sleep interventions among different athlete populations, compare results, and further establish guidelines and intervention tools for athletes to address their specific sleep demands and disturbances.

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Telotristat ethyl: a novel agent for the therapy of carcinoid syndrome diarrhea

Future Oncology, Ahead of Print.


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Abiraterone acetate and its use in the treatment of metastatic prostate cancer: a review

Future Oncology, Ahead of Print.


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Correlation of Concussion Symptom Profile with Head Impact Biomechanics: A Case for Individual-Specific Injury Tolerance

Journal of Neurotrauma , Vol. 0, No. 0.


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Preserved in vitro immunoreactivity in children receiving long-term immunosuppressive therapy due to inflammatory bowel disease or autoimmune hepatitis

Abstract

Background

Children with inflammatory bowel disease (IBD) or autoimmune hepatitis (AIH) are at risk for severe infections. This is partially a result of their chronic disease condition but, moreover, a side effect of their immunosuppressive therapy. Currently, vaccinations with live vaccines are regarded as contraindicated under immunosuppressive therapy, mainly because of concerns about side effects and a lack of data showing an adequate immune reaction. As there is no systematic study on the individual immunoreactivity under immunosuppressive therapy in this patient group, we analyzed the lymphocyte subgroups and immunoreactivity of lymphocytes in children with IBD or AIH with and without immunosuppressive therapy in vitro.

Methods

We collected whole blood samples from 17 children with IBD or AIH on high-level immunosuppression (IS) (group 1) and 8 on low-level IS (group 2) in comparison with 6 patients without systemic IS (group 3). After Ficoll separation of peripheral mononuclear cells, the samples were analyzed by flow cytometry to determine the lymphocyte subgroups. Furthermore, we stimulated the isolated lymphocytes with phytohemagglutinin (PHA), tetanus antigen, and adenovirus antigen and measured their proliferation by incorporation of H₃-thymidine detected in a beta counter.

The statistical evaluation was performed by Kruskal-Wallis test and Mann-Whitney U test using a bilateral level of significance of α = 5%.

Results

Patients with low- or high-level IS showed no significant difference in the number of lymphocytes or T cells.

Interestingly, IS did not influence the lymphocyte proliferation assay significantly regarding median reaction to PHA, tetanus antigen, or adenovirus antigen between the three groups. However, comparing all immunosuppressed patients to the patients without IS, there was a significant difference towards stimulation with tetanus antigen.

Conclusions

Contrary to expectations of a strong influence of IS therapy on the immunoreactivity, this study showed only minor differences between the groups with high-level, low-level, and no IS. Particularly, the in vitro reactivity to adenovirus antigen was nearly the same in all three groups. We assume that—provided a normal distribution and count of lymphocyte subgroups—patients with moderate immunosuppression might be capable of raising an effective immune response to inactivated and live vaccines.

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Restless legs syndrome: A rarity in the Nigerian pregnant population?

The prevalence of RLS in pregnancy is higher when compared with the general population however it remains unknown among indigenous black Africans. Available data indicate that RLS is uncommon in sub-Saharan Africa. We embarked on this study to determine the prevalence and characteristics of RLS in an antenatal clinic sample of Nigerian pregnant women compared with a primary care sample of non-pregnant women.

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Personalized chemosensitivity assays for mesothelioma- is it worth the effort?

Cell-lines formed from an individual's tumor can be used to predict response to specific therapies and determine genomic predictors. For mesothelioma, where chemotherapy remains the backbone of current therapeutic paradigms, such assays could be used to treat patients with the most effective agents specific to their "chemical profile".

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Pathways impacted by genomic alterations in pulmonary carcinoid tumors

Purpose: Pulmonary carcinoid tumors account for up to 5% of all lung malignancies in adults, comprise 30% of all carcinoid malignancies, and are defined histologically as typical carcinoid (TC) and atypical carcinoid (AC) tumors. The role of specific genomic alterations in the pathogenesis of pulmonary carcinoid tumors remains poorly understood. We sought to identify genomic alterations and pathways that are deregulated in these tumors to find novel therapeutic targets for pulmonary carcinoid tumors. Experimental Design: We performed integrated genomic analysis of carcinoid tumors comprising whole genome and exome sequencing, mRNA expression profiling and SNP genotyping of specimens from normal lung, typical and atypical carcinoid, and small cell lung carcinoma (SCLC) to fully represent the lung neuroendocrine tumor spectrum. Results: Analysis of sequencing data found recurrent mutations in cancer genes including ATP1A2, CNNM1, MACF1, RAB38, NF1, RAD51C, TAF1L, EPHB2, POLR3B and AGFG1. The mutated genes are involved in biological processes including cellular metabolism, cell division cycle, cell death and apoptosis and immune regulation. The top most significantly mutated genes were TMEM41B, DEFB127, WDYHV1 and TBPL1. Pathway analysis of significantly mutated and cancer driver genes implicated MAPK/ERK and amyloid beta precursor protein (APP) pathways whereas analysis of CNV and gene expression data suggested deregulation of the NF-ĸB and MAPK/ERK pathways. The mutation signature was predominantly C>T and T>C transitions with a minor contribution of T>G transversions. Conclusions: This study identified mutated genes affecting cancer relevant pathways and biological processes that could provide opportunities for developing targeted therapies for pulmonary carcinoid tumors.

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A novel method for rapid molecular subgrouping of medulloblastoma

Purpose: The classification of medulloblastoma into WNT, SHH, Group 3 and Group 4 subgroups has become of critical importance for patient risk-stratification and subgroup-tailored clinical trials. Here, we aimed to develop a simplified, clinically applicable classification approach that can be implemented in the majority of centers treating patients with medulloblastoma. Experimental Design: We analyzed 1,577 samples comprising previously published DNA methylation microarray data (913 medulloblastomas, 457 non-medulloblastoma tumors, 85 normal tissues), and 122 frozen and formalin-fixed paraffin-embedded medulloblastoma samples. Biomarkers were identified applying stringent selection filters and Linear Discriminant Analysis (LDA) method, and validated using DNA methylation microarray data, bisulfite pyrosequencing and direct-bisulfite sequencing. Results: Using a LDA-based approach, we developed and validated a prediction method (^EpiWNT-SHH classifier) based on six epigenetic biomarkers that allowed for rapid classification of medulloblastoma into the clinically relevant subgroups WNT, SHH and non-WNT/non-SHH with excellent concordance (>99%) with current gold-standard methods, DNA methylation microarray and gene-signature profiling analysis. The ^EpiWNT-SHH classifier showed high prediction capacity using both frozen and formalin-fixed material, as well as diverse DNA methylation detection methods. Similarly, we developed a classifier specific for Group 3 and Group 4 tumors, based on five biomarkers (^EpiG3-G4) with good discriminatory capacity, allowing for correct assignment of more than 92% of tumors. ^EpiWNT-SHH and ^EpiG3-G4 methylation profiles remained stable across tumor primary, metastasis and relapse samples. Conclusions: The ^EpiWNT-SHH and ^EpiG3-G4 classifiers represent a new simplified approach for accurate, rapid and cost-effective molecular classification of single medulloblastoma DNA samples, using clinically applicable DNA methylation detection methods.

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High yield of pathogenic germline mutations causative or likely causative of the cancer phenotype in selected children with cancer

Purpose: In many children with cancer and characteristics suggestive of a genetic predisposition syndrome, the genetic cause is still unknown. We studied the yield of pathogenic mutations by applying whole exome sequencing on a selected cohort of children with cancer. Experimental design: To identify mutations in known and novel cancer predisposing genes, we performed trio-based whole exome sequencing on germline DNA of 40 selected children and their parents. These children were diagnosed with cancer and had at least one of the following features: (1) intellectual disability and/or congenital anomalies, (2) multiple malignancies, (3) family history of cancer or (4) an adult type of cancer. We first analyzed the sequence data for germline mutations in 146 known cancer predisposing genes. If no causative mutation was found, the analysis was extended to the whole exome. Results: Four patients carried causative mutations in a known cancer predisposing gene: TP53 and DICER1 (n=3). In another four patients, exome sequencing revealed mutations causing syndromes that might have contributed to the malignancy (EP300-based Rubinstein-Taybi syndrome, ARID1A-based Coffin-Siris syndrome, ACTB-based Baraitser-Winter syndrome and EZH2-based Weaver syndrome). In addition, we identified two genes, KDM3B and TYK2, which are possibly involved in genetic cancer predisposition. Conclusion: In our selected cohort of patients, pathogenic germline mutations causative or likely causative of the cancer phenotype were found in eight patients and two possible novel cancer predisposing genes were identified. Therewith, our study shows the added value of sequencing beyond a cancer gene panel in selected patients, to recognize childhood cancer predisposition.

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Exceptional response to pembrolizumab in a metastatic, chemotherapy/radiation resistant ovarian cancer patient harboring a CD274/PD-L1-genetic rearrangement

Purpose: Ovarian carcinoma no longer responsive to surgery and chemotherapy remains an incurable disease. Alternative therapeutic options remain desperately needed. Experimental Design: We describe a heavily pretreated ovarian cancer patient with recurrent disease experiencing a remarkable clinical response to treatment with the anti-PD1 immune check-point inhibitor pembrolizumab. The clinical, pathological, and genomic characteristics of this exceptional ovarian cancer responder were carefully investigated using immunohistochemistry (IHC), quantitative multiplex fluorescence methods (ie, automated quantitative analysis, AQUA) and whole exome sequencing (WES) techniques. Results: The patient harbored a recurrent/metastatic radiation and chemotherapy-resistant high grade ovarian carcinoma with clear cell features.  While progressing on any standard treatment modality she demonstrated a remarkable complete response to the anti-PD1 immune check-point inhibitor pembrolizumab. WES results were notable for the presence a relative low number of mutations (Tumor Mutation Load/Mb = 4.31, total mutations = 164) and a peculiar structural variant disrupting the 3' region of the PD-1L gene causing aberrant PD-L1 surface expression as confirmed by immunohistochemistry (IHC) and AQUA technology. Heavy infiltration of the PD-L1-mutated and PD-L1-overexpressing tumor with T cell lymphocytes (ie, CD4+/CD8+ TIL), CD68+ macrophages and CD20+ B cells was detected in the surgical specimen strongly suggesting immune evasion as a key mechanism of tumor growth and survival. Patient's complete clinical responses remain unchanged at the time of the writing of this report with no significant side-effects reported to date. Conclusions: Anti-PD1 inhibitors may represent a novel treatment option for recurrent/metastatic human tumors refractory to salvage treatment harboring PD-L1 gene structural variations causing aberrant PD-L1 expression.

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XIAP regulation by MNK links MAPK and NF{kappa}B signaling to determine an aggressive breast cancer phenotype

Hyperactivation of the NFκB pathway is a distinct feature of inflammatory breast cancer (IBC), a highly proliferative and lethal disease. Gene expression studies in IBC patient tissue have linked epidermal growth factor receptor (EGFR/HER2)-mediated MAPK signaling to NFκB hyperactivity, but the mechanism(s) by which this occurs remain unclear. Here, we report that the X-linked inhibitor of apoptosis protein (XIAP) plays a central role in linking these two pathways. XIAP overexpression correlated with poor prognoses in breast cancer patients and was frequently observed in untreated IBC patient primary tumors. XIAP drove constitutive NFκB transcriptional activity, which mediated ALDH positivity (a marker of stem-like cells), in vivo tumor growth, and an IBC expression signature in patient-derived IBC cells. Using pathway inhibitors and mathematical models, we defined a new role for the MAPK-interacting (Ser/Thr)-kinase (MNK) in enhancing XIAP expression and downstream NFκB signaling. Furthermore, targeted XIAP knockdown and treatment with a MNK inhibitor decreased tumor cell migration in a dorsal skin fold window chamber murine model that allowed for intra-vital imaging of local tumor growth and migration. Together, our results indicate a novel role for XIAP in the molecular crosstalk between MAPK and NFκB pathways in aggressive tumor growth, which has the potential to be therapeutically exploited.

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Integrative genomic analysis predicts causative cis-regulatory mechanisms of the breast cancer-associated genetic variant rs4415084

Previous genome-wide association studies (GWAS) have identified several common genetic variants that may significantly modulate cancer susceptibility. However, the precise molecular mechanisms behind these associations remain largely unknown; it is often not clear whether discovered variants are themselves functional or merely genetically linked to other functional variants. Here we provide an integrated method for identifying functional regulatory variants associated with cancer and their target genes by combining analyses of expression quantitative trait loci (eQTL), a modified version of allele-specific expression (ASE) that systematically utilizes haplotype information, transcription factor (TF) binding preference, and epigenetic information. Application of our method to a breast cancer susceptibility region in 5p12 demonstrates that the risk allele rs4415084-T correlates with higher expression levels of the protein-coding gene mitochondrial ribosomal protein S30 (MRPS30) and lncRNA RP11-53O19.1. We propose an intergenic SNP rs4321755, in linkage disequilibrium (LD) with the GWAS SNP rs4415084 (r2=0.988), to be the predicted functional SNP. The risk allele rs4321755-T, in phase with the GWAS rs4415084-T, created a GATA3 binding motif within an enhancer, resulting in differential GATA3 binding and chromatin accessibility, thereby promoting transcription of MRPS30 and RP11-53O19.1. MRPS30 encodes a member of the mitochondrial ribosomal proteins, implicating the role of risk SNP in modulating mitochondrial activities in breast cancer. Our computational framework provides an effective means to integrate GWAS results with high-throughput genomic and epigenomic data and can be extended to facilitate rapid functional characterization of other genetic variants modulating cancer susceptibility.

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ER{alpha}-mediated nuclear sequestration of RSK2 is required for ER+ breast cancer tumorigenesis

Although ribosomal protein S6 kinase A3 (RSK) activation status positively correlates with patient responses to anti-estrogen hormonal therapies, the mechanistic basis for these observations is unknown. Using multiple in vitro and in vivo models of ER+ breast cancer, we report that ERα sequesters active RSK2 into the nucleus to promote neoplastic transformation and facilitate metastatic tumor growth. RSK2 physically interacted with ERα through its N-terminus to activate a pro-neoplastic transcriptional network critical to the ER+ lineage in the mammary gland, thereby providing a gene signature that effectively stratified patient tumors according to ERα status. ER+ tumor growth was strongly dependent on nuclear RSK2, and transgenic mice engineered to stably express nuclear RSK2 in the mammary gland developed high grade ductal carcinoma in situ. Mammary cells isolated from the transgenic model and introduced systemically successfully disseminated and established metastatic lesions. Anti-estrogens disrupted the interaction between RSK2 and ERα, driving RSK2 into the cytoplasm and impairing tumor formation. These findings establish RSK2 as an obligate participant of ERα-mediated transcriptional programs, tumorigenesis, and divergent patient responses to anti-estrogen therapies.

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Targeting the SphK1/S1P/S1PR1 axis that links obesity, chronic inflammation and breast cancer metastasis

Although obesity with associated inflammation is now recognized as a risk factor for breast cancer and distant metastases, the functional basis for these connections remain poorly understood. Here we show that in breast cancer patients and in animal breast cancer models, obesity is a sufficient cause for increased expression of the bioactive sphingolipid mediator sphingosine-1-phosphate (S1P) which mediates cancer pathogenesis. A high fat diet was sufficient to upregulate expression of sphingosine kinase 1 (SphK1), the enzyme that produces S1P, along with its receptor S1PR1 in syngeneic and spontaneous breast tumors. Targeting the SphK1/S1P/S1PR1 axis with FTY720/fingolimod attenuated key pro-inflammatory cytokines, macrophage infiltration and tumor progression induced by obesity. S1P produced in the lung pre-metastatic niche by tumor-induced SphK1 increased macrophage recruitment into the lung and induced IL-6 and signaling pathways important for lung metastatic colonization. Conversely, FTY720 suppressed IL-6, macrophage infiltration and S1P-mediated signaling pathways in the lung induced by a high fat diet, and it dramatically reduced formation of metastatic foci. In tumor-bearing mice, FTY720 similarly reduced obesity-related inflammation, S1P signaling and pulmonary metastasis, thereby prolonging survival. Taken together, our results establish a critical role for circulating S1P produced by tumors and the SphK1/S1P/S1PR1 axis in obesity-related inflammation, formation of lung metastatic niches and breast cancer metastasis, with potential implications for prevention and treatment.

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Editorial Board

Publication date: May 2018
Source:Computer Speech & Language, Volume 49





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Progestogen Hypersensitivity

Abstract

Purpose of Review

Progestogen hypersensitivity (PH) is a rare disorder which usually occurs in women of childbearing age with symptoms ranging from urticaria with or without angioedema, multiple organ involvement consistent with allergic anaphylaxis, to a spectrum of other non-evanescent skin eruptions. In this review, we present a clinical vignette of PH and discuss the clinical presentation and proposed pathomechanisms, diagnosis, and treatment of PH.

Recent Findings

The hypersensitivity symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. Recognition of this condition can be challenging to the clinician due to its heterogeneous clinical presentation. It has been recently proposed to use the new term "progestogen hypersensitivity" to replace "autoimmune progesterone dermatitis" due to the lack of evidence supporting an autoimmune mechanism for this disorder. In addition, diagnostic and treatment algorithms are now available that can lead to successful management of this condition. More new developments of Progesterone desensitization protocols are now available which appear to be the safest and most effective long-term treatment option for PH.

Summary

With the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone to support pregnancy in in vitro fertilization, there is likely to be a higher prevalence of PH in the future than currently recognized. Therefore, the allergist-immunologist will be required to collaborate with gynecologists and reproductive endocrinologists to diagnose and treat this condition.

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SCL20A2 mutation presenting with acute ischemic stroke: a case report

Primary familial brain calcification (PFBC) is a rare disorder characterized by distinctive bilateral brain calcification and variable clinical presentations. However, cerebrovascular attack was rarely reporte...

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Restoration of somatosensory perception via electrical stimulation of peripheral nerves

Sensory impairment hinders a person's ability to interact with their environment, and thus reduces their quality of life. In the case of impaired somatosensory perception, visual input can only provide indirect information at non-negligible cognitive cost. Therefore, restoration of natural somatosensory perception via artificial means has led to the exploration of different biological targets (Weber et al., 2012). Stimulation of the somatosensory cortex (Bensmaia, 2015), dorsal root ganglia (Weber et al., 2011), and peripheral nerves (Pasluosta et al., 2018) can produce intuitive and near-natural tactile and proprioceptive sensations, although proprioception has been studied to a lesser extent than touch (Weber et al., 2012).

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Sensorimotor integration is problematic in amyotrophic lateral sclerosis

Pathophysiological descriptions of amyotrophic lateral sclerosis (ALS) have broadened in recent years to include recognition of widespread involvement of brain pathways in the 'connectome', including corpus callosum, with degenerative neuronal pathology in associated cortical areas, basal ganglia, brainstem, cerebellum and spinal cord. In general, these pathological changes are in the anterior brain and its connections, and thus in the classical motor and also in the emotionally expressive brain, including frontal lobes anterior to primary motor areas and temporal lobes.

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Abdominal Wall Masses: CT Findings and Clues to Differential Diagnosis

The abdominal wall does not comprise a distinct organ, and is often cursorily evaluated on CT. However, it is affected by many different pathological processes. These may be categorized according to their underlying etiology - trauma, infection or inflammation, iatrogenic and neoplastic process - or according to the abdominal wall layer they affect. We chose instead to group these lesions into six distinct categories based on their CT characteristic density: solid, infiltrative, hypervascular, fluid, fat, and bone density lesions.

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The utility of preoperative acth/cortisol ratio for the diagnosis and prognosis of cushing's disease

Alev Selek, Berrin Cetinarslan, Zeynep Canturk, Ilhan Tarkun, Ozlem Zeynep Akyay, Burak Cabuk, Savas Ceylan

Journal of Neurosciences in Rural Practice 2018 9(1):106-111

Purpose: Cushing's syndrome (CS) is a rare disease having diagnostic difficulties. Many diagnostic tests have been defined but none of these are diagnostic alone. Determination of the cause is another problem which sometimes requires more sophisticated and invasive procedures. Therefore, we aimed to evaluate the utility of pretreatment plasma adrenocorticotropic hormone (ACTH)/cortisol ratios in patients with confirmed endogenous CS for the diagnosis and differential diagnosis of CS. Materials and Methods: This retrospective evaluation included 145 patients with the diagnosis of CS, 119 patients with Cushing's disease (CD), and 26 patients with ACTH-independent CS (AICS), in a university hospital. Furthermore, 114 individuals in whom CS diagnosis was excluded with at least one negative screening test were enrolled to the study as control group. The clinical, laboratory, imaging, postsurgical pathologic records and also clinical follow-up data of all patients were evaluated. Results: The median basal ACTH/cortisol ratio of the patients with CD was significantly higher than AICS and controls. A cutoff ACTH/cortisol ratio >2.5 was found to be diagnostic for CD with 82% specificity and 63% sensitivity. Among CD group, patients with recurrent disease had higher preoperative ACTH levels and ACTH/cortisol ratio than patients with sustained remission. Furthermore, these patients had more invasive, atypical, and larger tumors. Conclusion: An ACTH/cortisol ratio >2.5 would be beneficial to diagnose CD together with other diagnostic tests. It is a simple test with no additional cost. Higher ratios might be related with larger, invasive, and atypical adenoma and also might be helpful to predict recurrence.

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Radiologically indistinguishable contiguous meningioma and schwannoma in the same cerebellopontine angle in a patient with NF2: Case report and literature review

Satyashiva Munjal, Amit Srivastava, Sunila Jain, VS Mehta

Journal of Neurosciences in Rural Practice 2018 9(1):159-162



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The current state of rural neurosurgical practice: An international perspective

Pavan S Upadhyayula, John K Yue, Jason Yang, Harjus S Birk, Joseph D Ciacci

Journal of Neurosciences in Rural Practice 2018 9(1):123-131

Introduction: Rural and low-resource areas have diminished capacity to care for neurosurgical patients due to lack of infrastructure, healthcare investment, and training programs. This review summarizes the range of rural neurosurgical procedures, novel mechanisms for delivering care, rapid training programs, and outcome differences across international rural neurosurgical practice. Methods: A comprehensive literature search was performed for English language manuscripts with keywords "rural" and "neurosurgery" using the National Library of Medicine PubMed database (01/1971–06/2017). Twenty-four articles focusing on rural non-neurosurgical practice were included. Results: Time to care and/or surgery and shortage of trained personnel remain the strongest risk factors for mortality and poor outcome. Telemedicine consults to regional centers with neurosurgery housestaff have potential for increased timeliness of diagnosis/triage, improved time to surgery, and reductions in unnecessary transfers in remote areas. Mobile neurosurgery teams have been deployed with success in nations with large transport distances precluding initial transfers. Common neurosurgical procedures involve trauma mechanisms; accordingly, training programs for nonneurosurgery medical personnel on basic assessment and operative techniques have been successful in resource-deficient settings where neurosurgeons are unavailable. Conclusions: Protracted transport times, lack of resources/training, and difficulty retaining specialists are barriers to successful outcomes. Advances in telemedicine, mobile neurosurgery, and training programs for urgent operative techniques have been implemented efficaciously. Development of guidelines for paired partnerships between rural centers and academic hospitals, supplying surplus technology to rural areas, and rapid training of qualified local surgical personnel can create sustainable feed-forward programs for trainees and infrastructural solutions to address challenges in rural neurosurgery.

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Botulinum toxin for refractory trigeminal neuralgia: A trial sequential analysis of randomized clinical trials

Kannan Sridharan, Gowri Sivaramakrishnan

Journal of Neurosciences in Rural Practice 2018 9(1):3-4



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Epilepsy, behavioral problems, and intellectual disability among children in India: Conundrums and challenges

Ram Lakhan, Olúgbémiga T Ekundayo, Manoj Sharma

Journal of Neurosciences in Rural Practice 2018 9(1):1-2



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Using of fresh cadaveric cow brain in the microsurgical training model for sulcal-cisternal and fissural dissection

Raghunath Avanali

Journal of Neurosciences in Rural Practice 2018 9(1):5-5



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Clinical features and psychiatric comorbidity of epicrania fugax

K Rammohan, MM Shyma, Soumitra Das, C Velayudhan Shaji

Journal of Neurosciences in Rural Practice 2018 9(1):143-148

Background: Epicrania fugax (EF) is a rare newly described primary headache characterized by paroxysms of unilateral pain radiating across one hemicranium. Aim: We aimed to describe 10 new cases of EF and assess the psychiatric comorbidity. Materials and Methods: Cases of EF were identified from patients attending the neurology outpatient department of a tertiary level referral and teaching hospital by the first author during a period extending from January 1, 2015 to April 31, 2017. Case ascertainment was done as per ICHD 3 beta criteria from among patients presenting with complaints of headache after detailed history and clinical examination. Clinical and demographic features were noted and patients were subjected to Mini Neuropsychiatric Interview to screen for psychiatric comorbidity followed by Becks Anxiety/Depression Inventory. Results: A total of 10 subjects were obtained during the study period, 4 males, and 6 females. Mean age of subjects was 45.3 years (standard deviation-10). Seventy percent had anteroposterior, and 30% had posteroanterior radiation of pain. The most common character of pain was stabbing (50%) followed by electrical (40%) and pressing (10%). None of the subjects had autonomic symptoms or focal symptoms in the scalp while 30% subjects had hyperesthesia in the affected area of the scalp.Six subjects (60%) patients had episodic course while 40% had chronic course. Sixty percent had comorbid anxiety while one (10%) had comorbid depression. A significant relation was obtained between duration of disease and occurrence of anxiety as well as Becks Anxiety Inventory scores while there was no correlation with attack duration. There was also a nonsignificant correlation between visual analog score and occurrence of anxiety symptoms. Conclusions: Our study conclusively proves the existence of EF as a rare, distinct primary headache syndrome in our study population. It has a significant psychiatric comorbidity consisting of 60% of generalized anxiety disorder, 10% of panic attacks, and 10% of depression.

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Evaluation of predictive factors influencing community reintegration in adult patients with stroke

Olajide Ayinla Olawale, Jibrin Sammani Usman, Kayode Israel Oke, Oladunni Caroline Osundiya

Journal of Neurosciences in Rural Practice 2018 9(1):6-10

Objectives: Patients with stroke are faced with gait, balance, and fall difficulties which could impact on their community reintegration. In Nigeria, community reintegration after stroke has been understudied. The objective of this study was to evaluate the predictors of community reintegration in adult patients with stroke. Materials and Methods: Participants were 91 adult patients with stroke. Gait variables, balance self-efficacy, community balance/mobility, and fall self-efficacy were assessed using Rivermead Mobility Index, Activities-specific Balance Confidence Scale, Community Balance and Mobility Scale, and Falls Efficacy Scale-International respectively. Reintegration to Normal Living Index was used to assess satisfaction with community reintegration. Pearson Product-Moment Correlation Coefficient was used to determine the relationship between community reintegration and gait spatiotemporal variables, balance performance, and risk of fall. Multiple regression analysis was used to determine predictors of community reintegration (P ≤ 0.05). Results: There was significant positive relationship between community reintegration and cadence (r = 0.250, P = 0.017), functional mobility (r = 0.503, P = 0.001), balance self-efficacy (r = 0.608, P = 0.001), community balance/mobility (r = 0.586, P = 0.001), and duration of stroke (r = 0.220, P = 0.036). Stride time (r = −0.282, P = 0.073) and fall self-efficacy (r = 0.566, P = 0.001) were negatively correlated with community reintegration. Duration of stroke, balance self-efficacy, community balance/mobility, and fall self-efficacy (52.7% of the variance) were the significant predictors of community reintegration. Conclusion: Community reintegration is influenced by cadence, functional mobility, balance self-efficacy, community balance/mobility, and duration of stroke. Hence, improving balance and mobility during rehabilitation is important in enhancing community reintegration in patients with stroke.

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Irreversible hypersomnolence after bilateral thalamic infarction

Mihail Mogildea, Miguel Varela, Cristiana Martins, Natercia Joaquim, Jose Soleiro, Hipolito Nzwalo

Journal of Neurosciences in Rural Practice 2018 9(1):167-168



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Study of knowledge, attitude, and practice in participants with regular intake of lathyrus, but no spastic paraparesis

Rameshwar Nath Chaurasia, Abhishek Pathak, Smriti Singh, Deepika Joshi, Vijay Nath Mishra

Journal of Neurosciences in Rural Practice 2018 9(1):11-13

Background and Purpose: Neurolathyrism is now a disease of the past and also the causative agent, Lathyrus sativus (Khesari Pulse or keerai in Local Hindi and Bhojpuri language) has now been proven to be harmless and has become part of the usual diet. Materials and Methods: The population at risk was screened and studied for demography, economic status, knowledge about Khesari pulse, awareness about so-called harmful effects of Khesari pulse intake in humans, and the effects of ban of Khesari pulse on the population which is using Lathyrus (Khesari) as a major source of pulse since the past 4 years through a questionnaire of three pages. Results: Nearly 97% of total screened population totally fed on Khesari pulse as their major source of food and we did not found a single case of primary walking difficulty. We did find three cases of poststroke paralysis, a case of post-GBS lower limb weakness, and a case of recurrent myelitis as a part of questionnaire-based study and then followed by personally examining the patients to confirm the diagnosis. Conclusion: Khesari pulse if consumed in smaller quantities as a part of a normal mixed diet, its nutritional values can be optimally utilized.

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Impact of aging on nerve conduction velocities and late responses in healthy individuals

Suchitra Sachin Palve, Sachin Bhaskar Palve

Journal of Neurosciences in Rural Practice 2018 9(1):112-116

Background: Nerve conduction studies are performed to diagnose the disorders of the peripheral nervous system. The reference values for nerve conduction velocity (NCV) and late responses for different nerves considerably vary in different group and type of population. Physiological factors such as age, temperature, height, and gender affect the NCV. However, there are very few studies which show the age group at which these changes become significant. Aim and Objectives: The aim of the study was to establish the electrophysiological data of the specific age group at which changes in NCV as well as late responses of median common peroneal nerve and also see the late response in the form of F-waves and H-reflex. Methodology: Study groups were divided into three categories based on the age: Group I (18–30 years) (n = 80), Group II (31–45 years) (n = 43), and Group III (46–60 years) (n = 27). Out of which, 93 patients were male and 57 were female. The NCVs were determined for median, common peroneal nerve (motor component and sensory component) along with late responses in the form of H-reflex and F-waves. Results: The mean and standard deviation of median, ulnar, peroneal, and tibial nerve was studied for latencies, amplitude, and velocities for both sensory and motor components. Patients with older age had longer latencies, smaller amplitudes, and slower conduction velocities compared with the younger age group. The change with age was greater in sensory nerve conduction and late responses in all the peripheral nerves. Conclusions: Aging has a definite correlation with the NCV and late responses of different peripheral nerves. There is a need to have reference values with relation to age.

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Retrospective analysis of arthrodesis from various options after anterior cervical discectomy

Vinaysagar Sharma, Shashwat Kumar Singh

Journal of Neurosciences in Rural Practice 2018 9(1):14-18

Introduction: Anterior cervical discectomy is a surgical procedure performed to treat a herniated/degenerated disc in the cervical region. There have been various studies comparing arthrodesis rates among various procedures. Our patients belonged to varied socioeconomic background and underwent anterior cervical microdiscectomy without/with instrumentation. Aim: The present study was performed to study and compare the arthrodesis rates in the patients operated for anterior cervical microdiscectomy with and without fusion/instrumentation procedures at our institution. Materials and Methods: This is a retrospective study performed at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru. Pre- and post-operative X-rays were assessed in 96 patients who had undergone anterior cervical discectomy with/without fusion from June 2012 to June 2015. Radiographic arthrodesis was assessed in all patients. An arbitrary grading was designed by us and categorized into Grade I to IV. The criteria considered for adequate arthrodesis in this study were: (a) <2° movement on dynamic X-rays, (b) restored disc space height (±2 mm accepted), and (c) evidence of solid bone mass around disc space. Arthrodesis was categorized as Grade I if all the above 3 criteria on X-rays was fulfilled, Grade II if any 2 of the criteria was fulfilled, Grade III if any 1 of the criteria was fulfilled, and Grade IV when pseudoarthrosis/none of the criteria was fulfilled. Grade I arthrodesis was noted in about 79 patients (82.2%), Grade II in 14 patients, and only 3 patients had Grade III arthrodesis. There were no patients with absent arthrodesis/pseudoarthrosis. Results: Satisfactory arthrodesis was noted in 82% of the total patients, with patients undergoing fusion ± instrumentation procedure having better results. Conclusions: Arthrodesis by an interbody graft/implant with/without plating increases chances of success as compared to anterior cervical discectomy alone. Patients should be motivated for any of the available options for fusion/instrumentation

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Surgically treated primary spinal cord neoplasms in Southeastern Nigeria

Mark Chukwunweike Chikani, Okwuoma Okwunodulu, Mathew Mesi, Wilfred C Mezue, Samuel C Ohaegbulam, Chika C Ndubuisi

Journal of Neurosciences in Rural Practice 2018 9(1):137-139

Background: Primary spinal cord tumors are not as frequently encountered as their cranial counterparts. They could present in such an indolent manner that requires a reasonable index of suspicion for their diagnosis to be considered. Objective: The objective of this study is to analyze the incidence and pattern of primary spinal cord and appendage neoplasms in patients surgically treated in our institution over a decade of practice. Materials and Methods: A retrospective review of clinical, radiological, and histopathology profiles of patients surgically treated for primary spinal cord tumor from 2006 to 2016 was carried out. Retrieved data were analyzed using SPSS version 21. Results: Out of 472 spine procedures were performed within the study period 17 (3.6%) cases of histologically proven primary spinal cord tumors were identified. The age of patients ranged between 17 and 77 years with a mean age was 45 years. The male: female ratio was 1:1.1. Motor deficit and pain were the most common presenting symptoms seen in 35.3% and 29.4% of patients, respectively. Meningiomas are the most common histological diagnosis (70.6%), distantly followed by Schwannoma (17.6%). The most common location of the tumors was intradural extramedullary (70.6%). All patients had gross total resection of tumor with no perioperative mortality. Conclusion: Meningioma is the most common surgically treated primary spinal cord tumor in our setting. Surgery is associated with good outcome.

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Acute febrile encephalopathy in children: A prospective study of clinical features, etiology, mortality, and risk factors from Western India

Kirti Gupta, Charul S Purani, Anirban Mandal, Amitabh Singh

Journal of Neurosciences in Rural Practice 2018 9(1):19-25

Introduction: Acute febrile encephalopathy (AFE) in children is a medical emergency and could be a manifestation of many systemic and central nervous system pathologies. The clinical features of AFE are nonspecific and etiological spectrum variable depending on the studied population. Materials and Methods: A prospective, observational study was carried out including children aged between 1 month and 12 years with AFE admitted to the Pediatric Intensive Care Unit of a tertiary care hospital in Western India. The primary objective was to assess the clinical presentation and etiology of AFE while the secondary objectives were to correlate the clinical and etiological findings and to determine the risk factors associated with mortality. Results: Out of the ninety children with AFE included in this study, male:female ratio was 1.2:1; most of them were aged between 1 and 5 years and came with a history of

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Joubert syndrome with orofacial digital features

Parveen Bhardwaj, Minoo Sharma, Karan Ahluwalia

Journal of Neurosciences in Rural Practice 2018 9(1):152-154

Joubert syndrome (JS) is an autosomal recessive inherited disorder characterized by hypotonia, cerebellar vermis hypoplasia, ocular abnormalities (e.g., pigmentary retinopathy, oculomotor apraxia, and nystagmus), renal cysts, and hepatic fibrosis. Respiratory abnormalities, as apnea and hyperpnea, may be present, as well as mental retardation. Since the clinical findings of JS are quite heterogeneous, determination of radiological findings is essential.

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Using of fresh cadaveric cow brain in the microsurgical training model for sulcal-cisternal and fissural dissection

Ahmet Gökyar, Cengiz Cokluk

Journal of Neurosciences in Rural Practice 2018 9(1):26-29

Objective: The aim of this experimental study was to evaluate the feasibility of using fresh cadaveric cow brain as in a training model for microsurgical dissection of sulcus, cisterns, and fissure. Methods: Experimental microneurosurgical activities in this study were performed under the operating microscope. Bilateral sylvian cisterns, interhemispheric fissure, and hemispheric sulcus of the fresh cadaveric cow brain were used as an interested area for this experimental study. The dissection was continued reaching down to the floor of the cistern and total dissection of the middle cerebral artery inside the cisternal space. The suitability of a cow brain as a training model for sylvian fissure microdissection was evaluated as three groups; bad, good, and perfect. Results: Ten uncovered fresh cadaveric cow brains were used in this experimental feasibility study. The suitability of the experiment for training model was evaluated as bad in (1) 10% of the fresh cadaveric cow brains. The suitability was found as good in (6) 60% of the procedures. In the remaining (3) 30% of the brain dissection, the suitability of the experiment was evaluated as perfect. Conclusion: In conclusion, performing the sulcal, cisternal, and fissural dissection and protecting the neural and vascular tissue from the mechanical bruising effect of metallic microsurgical instruments are feasible as shown in this study. We believe that this training model will contribute to the practical micro-neurosurgery. Additionally, it provides adequate performance for the microsurgical intervention.

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Delicate situation of bipolar disorder and interferon therapy

Chadya Aarab, Rachid Aalouane, Said Boujraf, Ismail Rammouz

Journal of Neurosciences in Rural Practice 2018 9(1):164-166



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Immune-mediated neuropathies our experience over 3 years

Sadanandavalli Retnaswami Chandra, Venkata Raviteja Karru, MA Mukheem Mudabbir, Subashree Ramakrishnan, Anitha Mahadevan

Journal of Neurosciences in Rural Practice 2018 9(1):30-35

Introduction: Immune-mediated peripheral neuropathy is the term applied to a spectrum of peripheral nerve disorders where immune dysregulation plays a role. Therefore, they are treatable. We analyzed the cases seen in the past 3 years by us and evaluated the clinical, laboratory, and outcome parameters in these patients. Patients and Methods: Consecutive patients seen by the authors and diagnosed as immune-mediated neuropathy were analyzed for etiology, pathology, and outcome assessed. Results: A total of sixty patients, 31 acute and 29 chronic neuropathies, were identified. Their subtypes treatment and outcome assessed. Males were significantly more in both acute and chronic cases. Miller Fisher 4, AMAN 1, paraplegic type 1, motor dominant type 19, Sensory-motor 1, MADSAM 3, Bifacial 2. Nonsystemic vasculitis was seen in 16 out of 29 chronic neuropathy and HIV, POEMS, and diabetes mellitus one each. Discussion: There is a spectrum of immune-mediated neuropathy which varies in clinical course, response to treatment, etc., Small percentage of uncommon cases are seen. In this group, mortality was nil and morbidity was minimal. Conclusion: Immune-mediated neuropathies are treatable and hence should be diagnosed early for good quality outcome.

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Prolactin secreting pituitary carcinoma with extracranial spread presenting with pathological fracture of femur

Luis Rafael Moscote-Salazar, Guru Dutta Satyarthee, Willem Guillermo Calderon-Miranda, Jorge Aquino Matus, Alfonso Pacheco-Hernandez, Paulo Cesar Puac-Polanco, Amit Agrawal

Journal of Neurosciences in Rural Practice 2018 9(1):170-173



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Factors influencing institutional-based pediatric rehabilitation services among caregivers of children with developmental delay in Southwestern Rajasthan

Kriti Mishra, V Siddharth

Journal of Neurosciences in Rural Practice 2018 9(1):36-41

Context: A limited number of caregivers of children with developmental delay access rehabilitation facilities in India. The study explored utilization of rehabilitation services at a tertiary care setup in southwestern Rajasthan and various factors influencing it. Aims: The aim of this study is to explore rehabilitation service utilization among children with developmental delay at a tertiary care setup and to ascertain factors that influence this pattern. Settings: This study was conducted at the department of physical medicine and rehabilitation at tertiary care setup. Design: This was an observational study. Subjects and Methods: Children with developmental delay who were advised institutional-based rehabilitation were identified over span of 1 year. Those who failed to return for rehabilitation after the first visit were interviewed telephonically. The interview had semi-structured open-ended questions about their reasons for inability to avail services. Statistical Analysis: SPSS statistics 22 was used for descriptive analysis and correlation of variables. Results: Of 230 children with developmental delay visiting department in 1-year duration, 48 took regular rehabilitation. Parents of 129 children with complete records were asked regarding discontinuation. Factors cited by majority were long distance from institute and service at hospital. Other reasons for discontinuation were related to belief system, family issues, time issues, socioeconomic factors, etc. Socioeconomic status was significantly associated with parental education (C = 0.488, P = 0.000) and financial issues. Location of family had significant association with long distance (C = 0.315, P = 0.000), parental education (C = 0.251, P = 0.003), and belief system (C = 0.265, P = 0.002). Conclusions: Distance from institute and quality of hospital service determined rehabilitation service use at a tertiary institute. Other factors such as socioeconomic status, family support, and social belief system must also be addressed while delivering institutional rehabilitation to children.

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Volumetric Analysis of Endoscopic and Maxillary Swing Surgical Approaches for Nasopharyngectomy

J Neurol Surg B
DOI: 10.1055/s-0037-1617432

Objectives/Hypothesis The endoscopic endonasal approach (EEA) for nasopharyngectomy is an alternative to the maxillary swing approach (MSA) for selected recurrent nasopharyngeal carcinomas (NPC). We compare the access between these approaches. Methods Three cadaver specimens were used to compare access volumes of the EEA and MSA. Exposure volumes were calculated using image guidance registration to cone beam computed tomography and tracking of accessible tissue with volumetric quantification. The area of exposure to the carotid artery was measured. Results The MSA provided higher volumes for access volume compared with the EEA (66.6 vs 39.1 cm3, p = 0.009). The working area was larger in the MSA (80.2 vs 56.9 cm2, p = 0.06). The exposure to the carotid artery was higher in the MSA (1.88 vs 1.62 cm2, p = 0.04). The MSA provided larger volume of exposure for tumors of the parapharyngeal space with exposure below the palate. Conclusions This study suggests that the MSA for nasopharyngectomy provides a larger volume of exposure. However, much of the increased exposure relates to exposure of the parapharyngeal space below the palate. The EEA provides adequate access to superior anatomical structures.
[...]

Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Hemi-transseptal versus Combined Transseptal/Transnasal Approach to the Sellar Region: Differences in Incidence of Postoperative CSF Leak Rate

J Neurol Surg B
DOI: 10.1055/s-0037-1620247

Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Three-Dimensional Volumetric Segmentation of Pituitary Tumors: Assessment of Inter-rater Agreement and Comparison with Conventional Geometric Equations

J Neurol Surg B
DOI: 10.1055/s-0037-1618577

Background The assessment of pituitary tumor (PT) volume is important in the treatment and follow-up of patients with PT. Previously, PT volume estimation has been performed by conventional geometric equations (CGE) such as abc/2 (simplified ellipsoid volume equation) and 4πr3/3 (sphere), both presuming a symmetric tumor shape, which occurs uncommonly in patients with PT. In contrast, three-dimensional (3D) voxel-based software segmentation takes the irregular and asymmetric shapes that PTs often possess into account and might be a more accurate method for PT volume segmentation.The purpose of this study is twofold. (1) To compare 3D segmentation with CGE for PT volume estimation. (2) To assess inter-rater reliability in 3D segmentation of PTs. Methods Nineteen high-resolution (1mm slice thickness) T1-weighted MRI examinations of patients with PT were independently analyzed and manually segmented, using the software ITK-SNAP, by two certified neuroradiologists. Concurrently, the volumes of the PTs were estimated with abc/2 and 4πr3/3 by a clinician, and the results were compared with the corresponding segmented volumes. Results There was a significant decrease in PT volume attained from the segmentations compared with the calculations made with abc/2 (p < 0.001, mean volume 18% higher than segmentation) and 4πr3/3 (p < 0.001, mean volume 28% higher than segmentation). The intraclass correlation coefficient (ICC) for the two sets of segmented PTs was 0.99. Conclusion CGE (abc/2 and 4πr3/3) significantly overestimates PT volume compared with 3D volumetric segmentation. The inter-rater agreement on manual 3D volumetric software segmentation is excellent.
[...]

Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Pediatric Craniopharyngiomas: A Primer for the Skull Base Surgeon

J Neurol Surg B
DOI: 10.1055/s-0037-1621738

Pediatric craniopharyngioma is a rare sellar-region epithelial tumor that, in spite of its typically benign pathology, has the potential to be clinically devastating, and presents a host of formidable management challenges for the skull base surgeon. Strategies in craniopharyngioma care have been the cause of considerable controversy, with respect to both philosophical and technical issues. Key questions remain unresolved, and include optimizing extent-of-resection goals; the ideal radiation modality and its role as an alternative, adjuvant, or salvage treatment; appropriate indications for expanded endoscopic endonasal surgery as an alternative to transcranial microsurgery; risks and benefits of skull base techniques in a pediatric population; benefits of and indications for intracavitary therapies; and the preferred management of common treatment complications. Correspondingly, we sought to review the preceding basic science and clinical outcomes literature on pediatric craniopharyngioma, so as to synthesize overarching recommendations, highlight major points of evidence and their conflicts, and assemble a general algorithm for skull base surgeons to use in tailoring treatment plans to the individual patient, tumor, and clinical course. In general terms, we concluded that safe, maximal, hypothalamic-sparing resection provides very good tumor control while minimizing severe deficits. Endoscopic endonasal, intraventricular, and transcranial skull base technique all have clear roles in the armamentarium, alongside standard craniotomies; these roles frequently overlap, and may be further optimized by using the approaches in adaptive combinations. Where aggressive subtotal resection is achieved, patients should be closely followed, with radiation initiated at the time of progression or recurrence—ideally via proton beam therapy, although three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and stereotactic radiosurgery are very appropriate in a range of circumstances, governed by access, patient age, disease architecture, and character of the recurrence. Perhaps most importantly, outcomes appear to be optimized by consolidated, multidisciplinary care. As such, we recommend treatment in highly experienced centers wherever possible, and emphasize the importance of longitudinal follow-up—particularly given the high incidence of recurrences and complications in a benign disease that effects a young patient population at risk of severe morbidity from hypothalamic or pituitary injury in childhood.
[...]

Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Contralateral Eyebrow Approach for Unilateral Suprasellar Meningioma

J Neurol Surg B
DOI: 10.1055/s-0038-1623520

Unilateral suprasellar meningiomas have distinct features compared to other midline tumors, as they may produce severe visual symptoms even if small due to an early involvement of the optic canal. Surgical treatment of these tumors from an ipsilateral approach is challenging, as the tumor is covered by the optic nerve that needs to be mobilized to access the optic canal extension. A contralateral approach allows a direct line of sight to the tumor despite a longer working distance. We report the case of a 49-year-old patient presenting with unilateral visual loss related to a left suprasellar meningioma extending to the left optic canal and displacing the optic nerve laterally. Through a right eyebrow approach, a 2.5/2 cm supraorbital bone flap was raised and the orbital floor was thoroughly flattened. After dural opening, the carotid cistern was opened and CSF evacuated allowing a surgery without fixed retractors. The intracranial part of the tumor was removed, but the optic nerve seemed to be still displaced by the intracanalicular part. Under copious irrigation, the medial part of the optic canal was drilled, the dura incised, and the tumor removed. Postoperative course was favorable and the patient made a complete visual recovery. Postoperative MRI showed complete removal of the tumor. We present different surgical steps and discuss the nuances of the procedure. The contralateral eyebrow approach is an interesting addition to the surgical armamentarium and should be discussed for unilateral suprasellar tumors.The link to the video can be found at: https://youtu.be/2LTEOaGoKzo.
[...]

Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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