Month: November 2017

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The Role of Hypoxia in Angiogenesis and Extracellular Matrix Regulation of Intervertebral Disc Cells During Inflammatory Reactions

Neurosurgery 81:867–875, 2017

The intervertebral disc (IVD) is an avascular structure, and is therefore stable under hypoxic conditions. Previous studies have demonstrated that hypoxia might be related to symptomatic degenerative disc diseases (DDDs); however, the pathomechanism is still poorly understood.

OBJECTIVE: To identify the effect of hypoxia on the production of inflammatory mediators, angiogenic factors, and extracellularmatrix-regulating enzymes of IVD cells during inflammatory reactions.

METHODS: Human nucleus pulposus (NP) and annulus fibrosus (AF) cells harvested during surgery for DDDs were cultured in macrophage conditioned media or interleukin (IL)-1β-stimulated media under hypoxic (2%) and normoxic (21%) conditions. Hypoxiainducible factor-1α transcription factor activation was analyzed by western blotting. IL-6, IL-8, vascular endothelial growth factor (VEGF), vascular cell adhesion molecule (VCAM), matrix metalloproteinase (MMP)-1,MMP-3, tissue inhibitor ofmetalloprotease (TIMP)-1, and TIMP-2 in conditioned media weremeasured by an enzyme-linked immunosorbent assay.

RESULTS: NP cells expressed higher hypoxia-inducible factor-1α in the IL-1β-stimulated group under hypoxic condition. MMP-1 was significantly increased in the AF cells under hypoxic condition; TIMP-1 and TIMP-2 were significantly decreased in both naïve NP and AF cells during hypoxia. Both cells in macrophage conditioned media significantly diminished the production of IL-6 and VCAM, while VEGF significantly increased during hypoxia. After 1 ng/mL IL-1β stimulation, IL-8, VEGF, MMP-1, and MMP-3 were significantly increased in both cell types during hypoxia, while VCAM, TIMP-1, and TIMP-2 were decreased.

CONCLUSION: We found that hypoxia can enhance the angiogenic ability of IVD during inflammatory reactions, and cause progress in development of DDD via extracellular matrix regulation in this in vitro study.

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A novel weighted scoring system for estimating the risk of rapid growth in untreated intracranial meningiomas

J Neurosurg 127:971–980, 2017

Advances in neuroimaging techniques have led to the increased detection of asymptomatic intracranial meningiomas (IMs). Despite several studies on the natural history of IMs, a comprehensive evaluation method for estimating the growth potential of these tumors, based on the relative weight of each risk factor, has not been developed. The aim of this study was to develop a weighted scoring system that estimates the risk of rapid tumor growth to aid treatment decision making.

METHODS The authors performed a retrospective analysis of 232 patients with presumed IM who had been prospectively followed up in the absence of treatment from 1997 to 2013. Tumor volume was measured by imaging at each follow-up visit, and the growth rate was determined by regression analysis. Predictors of rapid tumor growth (defined as ≥ 2 cm3/year) were identified using a logistic regression model; each factor was awarded a score based on its own coefficient value. The probability (P) of rapid tumor growth was estimated using the following formula:

[Eq. 1]

RESULTS Fifty-nine tumors (25.4%) showed rapid growth. Tumor size (OR per cm3 1.07, p = 0.000), absence of calcification (OR 3.87, p = 0.004), peritumoral edema (OR 2.74, p = 0.025), and hyperintense or isointense signal on T2- weighted MRI (OR 3.76, p = 0.049) were predictors of tumor growth rate. In the Asan Intracranial Meningioma Scoring System (AIMSS), tumor size was categorized into 3 groups of < 2.5 cm, ≥ 2.5 to < 4.0 cm, and ≥ 4.0 cm in diameter and awarded a score of 0, 3, and 6, respectively; the parameters of calcification and peritumoral edema were categorized into 2 groups based on their presence or absence and given a score of 0 or 2 and 1 or 0, respectively; and the signal on T2-weighted MRI was categorized into 2 groups of hypointense and hyperintense/isointense and given a score of 0 or 2, respectively. The risk of rapid tumor growth was estimated to be < 10% when the total score was 0–2, 10%–50% when the total score was 3–6, and ≥ 50% when the total score was 7–11 (Hosmer-Lemeshow goodness-of-fit test, p = 0.9958). The area under the receiver operating characteristic curve was 0.86.

CONCLUSIONS The authors suggest a weighted scoring system (AIMSS) that predicts the specific probability of rapid tumor growth for patients with untreated IM. This scoring system will aid treatment decision making in clinical settings by screening out patients at high risk for rapid tumor growth.

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The medial orbito-frontal approach for orbital tumors

Acta Neurochir (2017) 159:2223–2227

A variety of lesions can affect the orbit. Surgical approaches must be available to provide 360 degrees of access. For tumors occupying the superomedial intraconal quadrant, there is a rationale to selecting the medial orbito-frontal approach.

Methods This article outlines the relevant surgical anatomy and the different surgical steps of this approach.

Results The medial orbito-frontal approach offers a full exposure of the superomedial intraconal quadrant and avoids crossing the plane of the optic nerve.

Conclusion In selected intraconal tumor cases, this transcranial epidural intraorbital approach is a straightforward corridor through reliable landmarks that can be routinely performed.

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Correlation of volumetric growth and histological grade in 50 meningiomas

Acta Neurochir (2017) 159:2169–2177

Advances in radiological imaging techniques have enabled volumetric measurements of meningiomas to be easily monitored using serial imaging scans. There is limited literature on the relationship between tumour growth rates and the WHO classification of meningiomas despite tumour growth being a major determinant of type and timing of intervention. Volumetric growth has been successfully used to assess growth of low-grade glioma; however, there is limited information on the volumetric growth rate (VGR) of meningiomas. This study aimed to determine the reliability of VGR measurement in patients with meningioma, assess the relationship between VGR and 2016 WHO grading as well as clinical applicability of VGR in monitoring meningioma growth.

Methods All histologically proven intracranial meningiomas that underwent resection in a single centre between April 2009 and April 2014 were reviewed and classified according to the 2016 edition of the Classification of the Tumours of the CNS. Only patients who had two pre-operative scans that were at least 3 months apart were included in the study. Two authors performed the volumetric measurements using the Slicer 3D software independently and the inter-rater reliability was assessed. Multiple regression analyses of factors affecting the VGR and VDE of meningiomas were performed using the R statistical software with p < 0.05 considered to be statistically significant.

Results Of 548 patients who underwent resection of their meningiomas, 66 met the inclusion criteria. Sixteen cases met the exclusion criteria (NF2, spinal location, previous surgical or radiation treatment, significant intra-osseous component and poor quality imaging). Forty-two grade I and 8 grade II meningiomas were included in the analysis. The VGR was significantly higher for grade II meningiomas. Using receiver-operator characteristic (ROC) curve analysis, the optimal threshold that distinguishes between grade I and II meningiomas is 3 cm3/year. Higher histological grade, high initial tumour volume, MRI T2-signal hyperintensity and presence of oedema were found to be significant predictors of higher VGR.

Conclusion Reliable tools now exist to evaluate and monitor volumetric growth of meningiomas. Grade II meningiomas have significantly higher VGR compared with grade I meningiomas and growth of more than 3 cm3/year is strongly suggestive of a higher grade meningioma. A larger, multi-centre prospective study to investigate the applicability of velocity of growth to predict the outcome of patients with meningioma is warranted.

Keywords

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The superior fovea triangle approach: a novel safe entry zone to the brainstem

J Neurosurg 127:1134–1138, 2017

The authors describe a safe entry zone, the superior fovea triangle, on the floor of the fourth ventricle for resection of deep dorsal pontine lesions at the level of the facial colliculus.

Clinical data from a patient undergoing a suboccipital telovelar transsuperior fovea triangle approach to a deep pontine cavernous malformation were reviewed and supplemented with 6 formalin-fixed adult human brainstem and 2 silicone-injected adult human cadaveric heads using the fiber dissection technique to illustrate the utility of this novel safe entry zone.

The superior fovea has a triangular shape that is an important landmark for the motor nucleus of the trigeminal, abducens, and facial nerves. The inferior half of the superior fovea triangle may be incised to remove deep dorsal pontine lesions through the floor of the fourth ventricle.

The superior fovea triangle may be used as a safe entry zone for dorsally located lesions at the level of the facial colliculus.

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Surgical Performance in Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation

Neurosurgery 81:860–866, 2017

Minimally invasive thrombolytic evacuation of intracerebral hematoma is being investigated in the ongoing phase III clinical trial of Minimally Invasive Surgery plus recombinant Tissue plasminogen activator for Intracerebral hemorrhage Evacuation (MISTIE III).

OBJECTIVE: To assess the accuracy of catheter placement and efficacy of hematoma evacuation in relation to surgical approach and surgeon experience.

METHODS:We performed a trial midpoint interim assessment of 123 cases that underwent the surgical procedure. Accuracy of catheter placement was prospectively assessed by the trial Surgical Center based on prearticulated criteria. Hematoma evacuation efficacy was evaluated based on absolute volume reduction, percentage hematoma evacuation, and reaching the target end-of-treatment volume of <15 mL. One of 3 surgical trajectories was used: anterior (A), posterior (B), and lobar (C). Surgeonswere classified based on experience with the MISTIE procedure as prequalified, qualified with probation, and fully qualified.

RESULTS: The average hematoma volume was 49.7 mL (range 20.0-124), and the mean evacuation rate was 71% (range 18.4%-99.8%). First placed catheters were 58% in good position, 28% suboptimal (but suitable to dose), and 14% poor (requiring repositioning). Posterior trajectory (B) was associated with significantly higher rates of poor placement (35%, P = .01). There was no significant difference in catheter placement accuracy among surgeons of varying experience. Hematoma evacuation efficacy was not significantly different among the 3 surgical approaches or different surgeons’ experience.

CONCLUSION: Ongoing surgical education and quality monitoring in MISTIE III have resulted in consistent rates of hematoma evacuation despite technical challenges with the surgical approaches and among surgeons of varying experience.

 

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Efficacy of deep rTMS for neuropathic pain in the lower limb: a randomized, double-blind crossover trial of an H-coil and figure-8 coil

J Neurosurg 127:1172–1180, 2017

Electrical motor cortex stimulation can relieve neuropathic pain (NP), but its use requires patients to undergo an invasive procedure. Repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortex (M1) using a figure-8 coil can relieve NP noninvasively, but its ability to relieve lower limb pain is still limited. Deep rTMS using an H-coil can effectively stimulate deep brain regions and has been widely used for the treatment of various neurological diseases; however, there have been no clinical studies comparing the effectiveness of figure-8 coils and H-coils. This study assessed the clinical effectiveness of 5 once-daily stimulations with H-coils and figure-8 coils in patients with NP.

METHODS This randomized, double-blind, 3-way crossover trial examined 18 patients with NP who sequentially received 3 types of stimulations in the M1 for 5 consecutive days; each 5-day stimulation period was followed by a 17-day follow-up period before crossing over to the next type of stimulation. During each rTMS session, patients received a 5-Hz rTMS to the M1 region corresponding to the painful lower limb. The visual analog scale (VAS) and the Japanese version of the short-form McGill Pain Questionnaire 2 (SF-MPQ2-J) were used to measure pain intensity. The primary outcome was VAS score reduction immediately after and 1 hour after intervention.

RESULTS Both the VAS and SF-MPQ2-J showed significant pain improvement immediately after deep rTMS with an H-coil as compared with the sham group (p < 0.001 and p = 0.049, respectively). However, neither outcome measure showed significant pain improvement when using a figure-8 coil. The VAS also showed significant pain improvement 1 hour after deep rTMS with an H-coil (p = 0.004) but not 1 hour after rTMS using a figure-8 coil. None of the patients exhibited any serious adverse events.

CONCLUSIONS The current findings suggest that the use of deep rTMS with an H-coil in the lower limb region of the M1 in patients with NP was tolerable and could provide significant short-term pain relief.

Clinical trial registration no.: UMIN000010536 (http://www.umin.ac.jp/ctr/) https://thejns.org/doi/abs/10.3171/2016.9.JNS16815

 

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The predictive value of T-tau and AB1-42 levels in idiopathic normal pressure hydrocephalus

Acta Neurochir (2017) 159:2293–2300

Idiopathic normal pressure hydrocephalus (INPH) has no reliable biomarker to assist in the selection of patients who could benefit from ventriculo-peritoneal (VP) shunt insertion. The neurodegenerative markers Ttau and Aβ1-42 have been found to successfully differentiate between Alzheimer’s disease (AD) and INPH and therefore are candidate biomarkers for prognosis and shunt response in INPH. The aim of this study was to test the predictive value of cerebrospinal fluid (CSF) T-tau and Aβ1-42 for shunt responsiveness. In particular, we pay attention to the subset of INPH patients with raised T-tau, who are often expected to be poor surgical candidates.

Methods: Single-centre retrospective analysis of probable INPH patients with CSF samples collected from 2006 to 2016. Index test: CSF levels of T-tau and Aβ1-42. Reference standard: postoperative outcome. ROC analysis assessed the predictive value.

Results: A total of 144 CSF samples from INPH patients were analysed. Lumbar T-tau was a good predictor of postoperative mobility (AUROC 0.80). The majority of patients with a co-existing neurodegenerative disease responded well, including those with high T-tau levels.

Conclusion: INPH patients tended to exhibit low levels of CSF T-tau, and this can be a good predictor outcome. However levels are highly variable between individuals. Raised T-tau and being shunt-responsive are not mutually exclusive, and such patients ought not necessarily be excluded from having a VP shunt.A combined panel of markers may be a more specific method for aiding selection of patients for VP shunt insertion. This is the most comprehensive presentation of CSF samples from INPH patients to date, thus providing further reference values to the current literature.

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Interactive iBook-Based Patient Education in a NeuroTrauma Clinic

Neurosurgery 81:787–794, 2017

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Educational interventions may alleviate the burden of TBI for patients and their families. Interactive modalities that involve engagement with the educational material may enhance patient knowledge acquisition when compared to static text-based educational material.

OBJECTIVE: To determine the effects of educational interventions in the outpatient setting on self-reported patient knowledge, with a focus on iPad-based (Apple, Cupertino, California) interactive modules.

METHODS: Patients and family members presenting to a NeuroTrauma clinic at a tertiary care academic medical center completed a presurvey assessing baseline knowledge of TBI or concussion, depending on the diagnosis. Subjects then received either an interactive iBook (Apple) on TBI or concussion, or an informative pamphlet with identical information in text format. Subjects then completed a postsurvey prior to seeing the neurosurgeon.

RESULTS: All subjects (n = 152) significantly improved on self-reported knowledge measures following administration of either an iBook (Apple) or pamphlet (P < .01, 95% confidence interval [CI]). Subjects receiving the iBook (n = 122) performed significantly better on the postsurvey (P < .01, 95% CI), despite equivalent presurvey scores, when compared to those receiving pamphlets (n = 30). Lastly, patients preferred the iBook to pamphlets (P < .01, 95% CI).

CONCLUSION: Educational interventions in the outpatient NeuroTrauma setting led to significant improvement in self-reported measures of patient and family knowledge. This improved understanding may increase compliance with the neurosurgeon’s recommendations and may help reduce the potential anxiety and complications that arise following a TBI.

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Long-term outcomes of microvascular decompression and Gamma Knife surgery for trigeminal neuralgia: a retrospective comparison study

Acta Neurochir (2017) 159:2127–2135

There is still no clear guideline for surgical treatment for patients with medically refractory trigeminal neuralgia (TN). When it comes to which surgical treatment to choose, microvascular decompression (MVD) or Gamma Knife surgery (GKS), we should know the long-term outcome of each treatment.

Methods We analyzed 179 patients undergoing MVD and 52 patients undergoing GKS followed for 1 year or longer. We evaluated the patient’s neurological status including pain relief, complications and recurrence. Results were assessed with Barrow Neurological Institute (BNI) pain intensity and facial numbness scores. Overall outcomes were compared between the two groups based on pain relief and complications.

Results BNI pain intensity and facial numbness scores at the final visit were significantly lower in the MVD group than in the GKS group (P < 0.001, P = 0.04, respectively). Overall outcomes were superior following MVD than following GKS (P < 0.001). Following whichever treatment, there were initially high rates of pain-free status “without medication”: 96.6% in the MVD group and 96.2% in the GKS group. However, 6.1% in the MVD group and 51.9% in the GKS group fell into a “with medication” state within median periods of 1.83 and 3.92 years, respectively (P < 0.001). Kaplan- Meier analysis revealed that pain recurred more often and later in the GKS group than in the MVD group (P < 0.001).

Conclusions Considering the long-term outcomes, MVD should be chosen as the initial surgical treatment for patients with medically refractory TN.

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Morphological and Hemodynamic Differences Between Aneurysmal Middle Cerebral Artery Bifurcation and Contralateral Nonaneurysmal Anatomy

Neurosurgery 81:779–786, 2017

The morphological and hemodynamic features differ between middle cerebral artery (MCA) bifurcations with and without aneurysms.

OBJECTIVE: To investigate the morphological and hemodynamic differences between aneurysmal MCA bifurcation and contralateral nonaneurysmal anatomy.

METHODS: Computed tomography angiography of 36 patients with unilateral small saccular MCA bifurcation aneurysms was evaluated. The parent–daughter angles (ϕ1 for larger branch and ϕ2 for smaller branch), bifurcation angle (ϕ = ϕ1 + ϕ2), inclination angle (γ angle), and their relationships with the MCA bifurcation locations were analyzed. Computational fluid dynamics simulation was performed in 6 cases to explore the hemodynamics influenced by the bifurcation morphology.

RESULTS: The ϕ angle was significantly higher in aneurysmal than contralateral nonaneurysmal bifurcations (160.8◦ ± 31.0◦ vs 99.0◦ ± 19.2◦, respectively; P = .000); the ϕ1, ϕ2, and γ angles were also higher. However, by regression analysis combined with MCA bifurcation locations, only the ϕ angle might be associated with the aneurysm presence (odds ratio = 1.120, 95% confidence interval = 1.059-1.185) and a ϕ angle cut-off of 124.8◦ was established. Computational fluid dynamics simulation demonstrated that flow resistance of the wider aneurysmal MCA bifurcation was significantly higher than that on the contralateral side.

CONCLUSION: A larger ϕ angle was more prevalent in aneurysmal than nonaneurysmal MCA bifurcations, and the higher flow resistance caused by the larger ϕ angle might be a potential hemodynamic factor associated with MCA aneurysm presence.

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A Staged Protocol for Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity

Neurosurgery 81:733–739, 2017

Minimally invasive surgery (MIS) techniques used for management of adult spinal deformity (ASD) aim to decrease the physiological demand on patients and minimize postoperative complications. A circumferential MIS (cMIS) protocol offers the potential to maximize this advantage over standard open approaches, through the concurrent use of multiple MIS techniques.

OBJECTIVE: To demonstrate through a case example the execution of a cMIS protocol for management of an ASD patient with severe deformity.

METHODS: Thorough preoperative assessment, surgical planning, and medical optimization were completed. Deformity correction was performed over 2 stages. During the first stage, interbody fusion was performed via an oblique lateral approach at all levels of the lumbar spine intended to be included in the final construct. The patient was kept as an inpatient and mobilized postoperatively. They were then re-imaged with standing films. The second stage occurred after 3 d and involved percutaneous instrumentation of all levels. Posterior fusion of the thoracic levels was achieved through decortication of pars and facets. These areas were accessed through the intermuscular plane established by the percutaneous screws. The patient was mobilizing on their first postoperative day.

RESULTS: In a 66-yr-old female with severe sagittal imbalance and debilitating back pain, effective use of this cMIS protocol allowed for correction of the Cobb angle from 52◦ to 4◦ correction of spinopelvic parameters and 13 cm of sagittal vertical axis improvement. No complications were identified by 2 yr postoperative.

CONCLUSION: As a systematization of multiple MIS techniques combined, in a specific and staged manner, this cMIS protocol could provide a safe and effective approach to the management of ASD.

 

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A Reliable Grading System for Prediction of Chronic Subdural Hematoma Recurrence Requiring Reoperation After Initial Burr-Hole Surgery

Neurosurgery 81:752–760, 2017

There is no widely adopted grading system for the prediction of postoperative recurrence requiring reoperation (RrR) in patients with chronic subdural hematoma (CSDH).

OBJECTIVE: We developed a CSDH grading system to predict RrR based on predictive characteristics that can be objectively assessed at the time of first presentation and initial surgery.

METHODS: Prospectively collected data from 107 consecutive surgical patients with CSDH were reviewed. Predictors of RrR were identified via logistic and lasso regression analyses. A prognostic CSDH grading system was proposed, with the weighing of predictors based on strength of association. The scoring systemwas then applied to the same set of patients in our database for internal validation.

RESULTS: The strongest predictors of RrR were an isodense or hyperdense lesions and laminar or separated lesions, and a postoperative CSDH cavity volume greater than 200 mL. The moderate predictors of RrR were a postoperative CSDH cavity volume of 80 to 200 mL and a preoperative CSDH volume greater than 130 mL. According to the prognostic CSDH grading system, no patients with a score of 0 points had RrR. RrR was observed in 6% of patients with a score of 1 to 2 points, 30% of patients with a score of 3 to 4 points, and 63% of patients with a score of 5 points (ie, the maximum score). The rate of RrR increased steadily with increases in the prognostic CSDH grading score (P < .001).

CONCLUSION: The prognostic CSDH grading system is an applicable tool for RrR risk stratification in patients with CSDH.

 

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Microsurgery for Spetzler-Ponce Class A and B arteriovenous malformations utilizing an outcome score adopted from Gamma Knife radiosurgery

J Neurosurg 127:1105–1116, 2017

The purpose of this study was to adapt and apply the extended definition of favorable outcome established for Gamma Knife radiosurgery (GKRS) to surgery for brain arteriovenous malformations (bAVMs). The aim was to derive both an error around the point estimate and a model incorporating angioarchitectural features in order to facilitate comparison among different treatments.

METHODS A prospective microsurgical cohort was analyzed. This cohort included patients undergoing embolization who did not proceed to microsurgery and patients denied surgery because of perceived risk of treatment. Data on bAVM residual and recurrence during long-term follow-up as well as complications of surgery and preoperative embolization were analyzed. Patients with Spetzler-Ponce Class C bAVMs were excluded because of extreme selection bias. First, patients with a favorable outcome were identified for both Class A and Class B lesions. Patients were considered to have a favorable outcome if they were free of bAVM recurrence or residual at last follow-up, with no complication of surgery or preoperative embolization, and a modified Rankin Scale score of more than 1 at 12 months after treatment. Patients who were denied surgery because of perceived risk, but would otherwise have been candidates for surgery, were included as not having a favorable outcome. Second, the authors analyzed favorable outcome from microsurgery by means of regression analysis, using as predictors characteristics previously identified to be associated with complications. Third, they created a prediction model of favorable outcome for microsurgery dependent upon angioarchitectural variables derived from the regression analysis.

RESULTS From a cohort of 675 patients who were either treated or denied surgery because of perceived risk of surgery, 562 had Spetzler-Ponce Class A or B bAVMs and were included in the analysis. Logistic regression for favorable outcome found decreasing maximum diameter (continuous, OR 0.62, 95% CI 0.51–0.76), the absence of eloquent location (OR 0.23, 95% CI 0.12–0.43), and the absence of deep venous drainage (OR 0.19, 95% CI 0.10–0.36) to be significant predictors of favorable outcome. These variables are in agreement with previous analyses of microsurgery leading to complications, and the findings support the use of favorable outcome for microsurgery. The model developed for angioarchitectural features predicts a range of favorable outcome at 8 years following microsurgery for Class A bAVMs to be 88%–99%. The same model for Class B bAVMs predicts a range of favorable outcome of 62%–90%.

CONCLUSIONS Favorable outcome, derived from GKRS, can be successfully used for microsurgical cohort series to assist in treatment recommendations. A favorable outcome can be achieved by microsurgery in at least 90% of cases at 8 years following microsurgery for patients with bAVMs smaller than 2.5 cm in maximum diameter and, in the absence of either deep venous drainage or eloquent location, patients with Spetzler-Ponce Class A bAVMs of all diameters. For patients with Class B bAVMs, this rate of favorable outcome can only be approached for lesions with a maximum diameter just above 6 cm or smaller and without deep venous drainage or eloquent location.

 

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Patterns of C-2 fracture in the elderly: comparison of etiology, treatment, and mortality among speci c fracture types

J Neurosurg Spine 27:494–500, 2017

Previous studies have focused on Type II odontoid fractures and have failed to report on the effect of other C-2 fracture types on treatment and outcome. The purpose of this study was to compare patient characteristics, cause of injury, predisposing factors to fracture, treatments, and mortality rates among C-2 fracture types in a cohort of elderly patients 70 years of age and older.

METHODS A retrospective cohort study design was used. Patients who sustained a C-2 fracture between 2002 and 2011 and who were admitted to the authors’ Level 1 trauma center were identified using the Discharge Abstract Database and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code S12.1. Fractures were classified as odontoid Type I, II, or III; hangman’s; C-2 complex (hangman’s appearance on sagittal images, Type III odontoid on coronal cuts); and other (miscellaneous). Age, sex, predisposing factors to falls, cause of injury, treatment, presence of autofusion in the subaxial cervical spine, and mortality rates were compared between fracture patterns.

RESULTS One hundred forty-one patients were included; their mean age was 82 years. Fractures included Type II odontoid (57%), complex (19%), Type III odontoid (11%), hangman’s (8%), and other (5%). Falls from a standing height accounted for 47% of injuries, and 65% of patients had ≥ 3 risk factors for falls. Subaxial autofusion was more common in odontoid fractures (p = 0.002). Treatment was mainly nonoperative (p < 0.0001). The 1-year mortality rate was 27%. Four patients died of spinal cord injury.

CONCLUSIONS Although not as common as Type II odontoid fractures, other C-2 fractures including hangman’s, complex, and Type III odontoid fractures accounted for close to half of the injuries in the study cohort. There were few differences between the fracture types with respect to cause of injury, predisposing factors, or mortality rate. However, surgical treatment was more common for Type II odontoid fractures.

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Timing of surgery for ruptured supratentorial arteriovenous malformations

Acta Neurochir (2017) 159:2103–2112

There are conflicting opinions regarding the optimal waiting time to perform surgery after rupture of supratentorial arteriovenous malformations (AVMs) to achieve the best possible outcome.

Objective To analyze factors influencing outcomes for ruptured supratentorial AVMs after surgery, paying particular attention to the timing of the surgery.

Methods We retrospectively investigated 59 patients admitted to our center between 2000 and 2014 for surgical treatment of ruptured supratentorial AVMs. We evaluated the effect of timing of surgery and other variables on the outcome at 2– 4 months (early outcome), at 12 months (intermediate outcome) after surgery, and at final follow-up at the end of 2016 (late outcome).

Results Age over 40 years (OR 18.4; 95% CI 1.9–172.1; p = 0.011), high Hunt and Hess grade (4 or 5) before surgery (OR 13.5; 95% CI 2.1–89.2; p = 0.007), hydrocephalus on admission (OR 12.9; 95% CI 1.8–94.4; p = 0.011), and over 400 cm3 bleeding during surgery (OR 11.5; 95% CI 1.5–86.6; p = 0.017) were associated with an unfavorable early outcome. Age over 40 years (OR 62.8; 95% CI 2.6–1524.9; p = 0.011), associated aneurysms (OR 34.7; 95% CI 1.4– 829.9; p = 0.029), high Hunt and Hess grade before surgery (OR 29.2; 95% CI 2.6–332.6; p = 0.007), and over 400 cm3 bleeding during surgery (OR 35.3; 95% CI 1.7–748.7; p = 0.022) were associated with an unfavorable intermediate outcome. Associated aneurysms (OR 8.2; 95% CI 1.2–55.7; p = 0.031), high Hunt and Hess grade before surgery (OR 5.7; 95% CI 1.3–24.3; p = 0.019), and over 400 cm3 bleeding during surgery (OR 5.8; 95% CI 1.2–27.3; p = 0.027) were associated with an unfavorable outcome at last follow-up. Elapsed time between rupture and surgery did not affect early or final outcome. Conclusions Early surgery in patients with ruptured supratentorial arteriovenous malformation is

Conclusions Early surgery in patients with ruptured supratentorial arteriovenous malformation is feasible strategy, with late results comparable to those achieved with delayed surgery. Many other factors than timing of surgery play significant roles in long-term outcomes for surgically treated ruptured supratentorial AVMs.

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Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma

J Neurosurg 127:1117–1125, 2017

Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage in elderly patients. Many studies have suggested various factors that may be associated with the recurrence of CSDH. However, the results are inconsistent. The purpose of this study was to determine the associations among patient factors, recurrence, and clinical outcomes of CSDH after burr hole surgery performed during an 11-year period at twin hospitals.

METHODS Kaplan-Meier analysis was performed to evaluate the risk factors for CSDH recurrence. Univariate and multivariate Cox proportional hazards regression analyses were used to calculate hazard ratios with 95% CIs for CSDH recurrence based on many variables. One-way repeated-measures ANOVA was used to assess the differences in the mean modified Rankin Scale score between categories for each risk factor during each admission and at the last follow-up.

RESULTS This study was a retrospective analysis of 756 consecutive patients with CSDH who underwent burr hole surgery at the Hanyang University Medical Center (Seoul and Guri) between January 1, 2004, and December 31, 2014. During the 6-month follow-up, 104 patients (13.8%) with recurrence after surgery for CSDH were identified. Independent risk factors for recurrence were as follows: age > 75 years (HR 1.72, 95% CI 1.03–2.88; p = 0.039), obesity (body mass index ≥ 25.0 kg/m2), and a bilateral operation.

CONCLUSIONS This study determined the risk factors for recurrence of CSDH and their effects on outcomes. Further studies are needed to account for these observations and to determine their underlying mechanisms.

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Clinical relevance of anterior cerebral artery asymmetry in aneurysmal subarachnoid hemorrhage

J Neurosurg 127:1070–1076, 2017

An asymmetry of the A1 segments (A1SA) of the anterior cerebral arteries (ACAs) is an assumed risk factor for the development of anterior communicating artery aneurysms (ACoAAs). It is unknown whether A1SA is also clinically relevant after aneurysm rupture. The authors of this study investigated the impact of A1SA on the clinical course and outcome of patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS The authors retrospectively analyzed data on consecutive SAH patients treated at their institution between January 2005 and December 2012. The occurrence and severity of cerebral infarctions in the ACA territories were evaluated on follow-up CT scans up to 6 weeks after SAH. Moreover, the risk for an unfavorable outcome (defined as > 3 points on the modified Rankin Scale) at 6 months after SAH was assessed.

RESULTS A total of 594 patients were included in the final analysis. An A1SA was identified on digital subtraction angiography studies from 127 patients (21.4%) and was strongly associated with ACoAA (p < 0.0001, OR 13.7). An A1SA independently correlated with the occurrence of ACA infarction in patients with ACoAA (p = 0.047) and in those without an ACoAA (p = 0.015). Among patients undergoing ACoAA coiling, A1SA was independently associated with the severity of ACA infarction (p = 0.023) and unfavorable functional outcome (p = 0.045, OR = 2.4).

CONCLUSIONS An A1SA is a common anatomical variation in SAH patients and is strongly associated with ACoAA. Moreover, the presence of A1SA independently increases the likelihood of ACA infarction. In SAH patients undergoing ACoAA coiling, A1SA carries the risk for severe ACA infarction and thus an unfavorable outcome.

 

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Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation

Spine 2017;42:E1259–E1265

The aim of this study was to evaluate the clinical and radiological outcomes of mini-open ALIF (MO-ALIF) with self-anchored stand-alone cages for the treatment of lumbar disc herniation in comparison with transforaminal lumbar interbody fusion (TLIF). Summary of Background Data. Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

Summary of Background Data. Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

Methods. This study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n=42) or TLIF (n=40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

Results. Patients who underwent TLIF had a significantly higher volume of blood loss (295.2±81.4 vs. 57.0±15.2mL) and longer surgery time (130.7±45.1 vs. 60.4±20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group. Conclusion. MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

Conclusion. MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

Level of Evidence: 3

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Long-term surgical results of supplementary motor area epilepsy surgery

J Neurosurg 127:1153–1159, 2017

Supplementary motor area (SMA) epilepsy is a well-known clinical condition; however, long-term surgical outcome reports are scarce and correspond to small series or isolated case reports. The aim of this study is to present the surgical results of SMA epilepsy patients treated at 2 reference centers in Mexico City.

METHODS For this retrospective descriptive study (1999–2014), 52 patients underwent lesionectomy and/or corticectomy of the SMA that was guided by electrocorticography (ECoG). The clinical, neurophysiological, neuroimaging, and pathological findings are described. The Engel scale was used to classify surgical outcome. Descriptive statistics, Student t-test, and Friedman, Kruskal-Wallis, and chi-square tests were used.

RESULTS Of these 52 patients, the mean age at epilepsy onset was 26.3 years, and the mean preoperative seizure frequency was 14 seizures per month. Etiologies included low-grade tumors in 28 (53.8%) patients, cortical dysplasia in 17 (32.7%) patients, and cavernomas in 7 (13.5%) patients. At a mean follow-up of 5.7 years (range 1–10 years), 32 patients (61%) were classified as Engel Class I, 16 patients (31%) were classified as Engel Class II, and 4 (8%) patients were classified as Engel Class III. Overall seizure reduction was significant (p = 0.001). The absence of early postsurgical seizures and lesional etiology were associated with the outcome of Engel Class I (p = 0.05). Twenty-six (50%) patients had complications in the immediate postoperative period, all of which resolved completely with no residual neurological deficits.

CONCLUSIONS Surgery for SMA epilepsy guided by ECoG using a multidisciplinary and multimodality approach is a safe, feasible procedure that shows good seizure control, moderate morbidity, and no mortality.

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