1. Huizinga R, van den Berg B, van Rijs W, et al. Innate Immunity to C ampylobacter jejuni in Guillain-Barré Syndrome. Ann Neurol. 2015;78(3):343–354. doi:10.1002/ana.24442.

Guillain-Barre syndrome (GBS) is an acute antibody mediated polyneuropathy that occurs shortly after common infections such as Campylobacter jejuni. One in 3,000-5,000 symptomatic infections is followed by the development of GBS.  The production of GBS requires sialylation of lipo-oligosaccharides (LOS), given that this leads to molecular mimicry with human neural gangliosides. Half of the strains of C. jejuni with uncomplicated gastroenteritis also express sialylated LOS. Therefore, other factors must be involved in its production.  In this paper, the authors evaluated the intrinsic responsiveness of dendritic cells (DC)(a type of myeloid cell) to C. jejuni though Toll-like receptor 4 (TLR4) activation (there are signaling pathways between TLR4 and production of type 1 interferon).  Through a bunch of biochemistry that I don’t understand, the authors conclude that former GBS patients exhibit increased DC responsiveness to C. jejuni LOS.  Extent of CD38 and CD40 expression on DCs was significantly correlated with residual disability.  High innate responsiveness to C. jejuni LOS through TLR4 is a prerequisite for development of GBS after an infection with C. jejuni.

2. Mooney M a., Kalani MYS, Nakaji P, et al. Long-term Patient Outcomes After Microsurgical Treatment of Blister-Like Aneurysms of the Basilar Artery. Neurosurgery. 2015;11(3):387–393. doi:10.1227/NEU.0000000000000866.

Blister-like aneurysms (BLAs) are small, hemisphere-shaped defects that arise from nonbranching points of the cerebral arteries and are associated with a high risk of rupture. They are formed by a platelet plug covering a thin layer of adventitia, which overlies a defect in the intima and media.  They are thought to be secondary to atherosclerosis, hemodynamic stress, dissection, or a combination of all these factors.  Most occur in the anterior circulation, and basilar artery BLAs are a small subset.  They treated 4 patients with BLAs with a mean age of 52, and mean size of the base of the aneurysm of 2.25mm.  All were located at nonbranching points of the basilar, and all the patients presented with SAH.  In 3 patients, the aneurysms were treated by using a microsurgical technique, and, in 1 patient, a combined microsurgical/endovascular approach was used.  In the Barrow Ruptured Aneurysm Trial, patients with basilar trunk or basilar tip aneurysms made up 5.4% (22/408) of the cases of ruptured aneurysms enrolled in the study.  BLAs of the basilar artery are a rare subset of basilar artery aneurysms, and over the 7-year study period at the author’s institution, only 4 patients with these lesions were encountered.

Two figures.  Figure one is artwork of the clip/stent approach to the different patients.

3. Wang X, Zhao X, Johnston SC, et al. Effect of clopidogrel with aspirin on functional outcome in TIA or minor stroke: CHANCE substudy. Neurology. 2015;85(7):573–9. doi:10.1212/WNL.0000000000001844.

The authors compared the effect of clopidogrel plus aspirin vs aspirin alone on functional outcome and quality of life after acute minor stroke or TIA.  Participants were assessed at 90 days for functional outcome using the modified Rankin Scale (mRS) and quality of life using the EuroQol-5 Dimension (EQ-5D). Poor functional outcome occurred in 254 patients (9.9%) in the clopidogrel-aspirin group, as compared with 299 (11.6%) in the aspirin group. Disabling stroke at 90 days occurred in 166 (6.5%) in the clopidogrel-aspirin group and in 219 (8.5%) in the aspirin group.  They conclude that the study provides Class II evidence for patients with acute minor stroke or TIA, clopidogrel plus aspirin compared to aspirin alone improves 90-day functional outcome.

The authors note in the discussion that the rate of disability or death at 90 days was high, and clopidogrel was associated with 1.7% absolute reduction of poor functional outcome, which was equivalent to a number needed to treat of 59 patients to prevent a functional disability.  The ongoing Triple Antiplatelets for Reducing Dependency After Ischaemic Stroke (TARDIS) trial will determine whether triple antiplatelet strategy will be superior to dual antiplatelet therapy.

4. Finnsson J, Sundblom J, Dahl N, Melberg A, Raininko R. LMNB1-related autosomal-dominant leukodystrophy: Clinical and radiological course. Ann Neurol. 2015;78(3):412–425. doi:10.1002/ana.24452.

Duplication of the LMNB1 gene encoding lamin B1 causes adult-onset autosomal-dominant leukodystrophy (ADLD) starting with autonomic symptoms, which are followed by pyramidal signs and ataxia. The authors describe the first longitudinal study on this disease in 23 subjects in two families studied over two decades. Signal intensity abnormalities started with small T2 hyperintensities under the motor cortex and extended downward through the pyramidal tracts, affecting the cerebral and cerebellar peduncles and pyramids even in subjects who still were asymptomatic. With increasing disease duration, T2 hyperintensities became more widespread and confluent throughout the cerebral white matter, affecting the cerebral lobes in the order frontal–parietal–occipital– temporal. Most subjects over the age of 40 years had widespread signal intensity changes in the white matter.  Periventricular white matter was less affected.  All subjects, even asymptomatic ones, exhibited abnormal T2 signal in the white matter of the spinal cord.

Once more thing to add to my weird differential for bilateral middle cerebellar peduncle signal abnormality (such as Fragile X premutation tremor/ataxia syndrome). 10 figures total, including 6 MRIs.  36 references.

5. Sugawara R, Tsuji T, Saito T, Nohara A, Kawakami K, Kawakami N. Medially misplaced pedicle screws in patients without neurological deficits following scoliosis surgery: to observe or to remove? Eur Spine J. 2015:1450–1456. doi:10.1007/s00586-015-3860-y.

The authors investigated whether pedicle screws medially misplaced into the spinal canal without neurological complications should be removed or not.  86 patients with scoliosis that underwent spinal fusion using 988 pedicle screws were retrospectively reviewed after a minimum follow-up of 2 years. Medial perforations were evaluated using immediate postoperative helical CT images and classified into three grades: grade 1 (0–2 mm), grade 2 (2–4 mm), and grade 3 (over 4 mm). CSF leakage from screw holes were recognized in 3/87 medially misplaced screws (3.4%).  The conclude that screws medially misplaced at a distance greater than 2 mm (especially 4 mm), may be a cause of negative effects on the neural structure and should be removed during the early phase of the postoperative period even in the face of no neurological abnormalities.

Incidence of pedicle screw malposition in thoracic pedicles in the treatment of spinal deformities ranges from 3-25 %, with screw-related neurological complications in 0–0.9 %.

6. Kalani MYS, Wilson DA, Koechlin NO, et al. Pineal cyst resection in the absence of ventriculomegaly or Parinaud’s syndrome: clinical outcomes and implications for patient selection. J Neurosurg. 2015;123(2):352–356. doi:10.3171/2014.9.JNS141081.

Surgical indications for patients with pineal cysts remains controversial. The majority of patients with a pineal cyst require no treatment.  Still, surgery is a well-accepted option for a subset of those patients with secondary hydrocephalus or Parinaud’s syndrome.  The authors retrospectively reviewed medical records and imaging of all patients surgically treated between 2001 and 2014 with a pineal cyst in the absence of ventriculomegaly and Parinaud’s syndrome.  Eighteen patients (14 female and 4 male; mean age 24 years) underwent cyst resection in the absence of ventriculomegaly or Parinaud’s syndrome. Presenting symptoms included headache (17 patients), visual disturbances (10 patients), gait instability (5 patients), dizziness (5 patients), episodic loss of consciousness (2 patients), and hypersomnolence (1 patient). At a mean clinical follow-up of 19.1 months, 17 (94%) patients had symptom resolution or improvement.  They conclude that ventriculomegaly and Parinaud’s syndrome are not absolute requisites for a pineal cyst to be symptomatic.

I never know what to do with these types of results.  The wide variation in symptoms that were treated is confusing and I guess anything can be related to a pineal cyst. I wonder how this group would have done with a sham procedure, a la the vertebroplasty results.

7. D’Cruz AK, Vaish R, Kapre N, et al. Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer. N Engl J Med. 2015;373(6):521–529. doi:10.1056/NEJMoa1506007.

The authors evaluated 596 patients in a prospective, randomized, controlled trial, evaluating the effect on survival of elective node dissection (ipsilateral neck dissection at the time of the primary surgery) versus therapeutic node dissection (watchful waiting followed by neck dissection for nodal relapse) in patients with lateralized stage T1 or T2 oral squamous cell carcinomas. There were 81 recurrences and 50 deaths in the elective-surgery group and 146 recurrences and 79 deaths in the therapeutic-surgery group. At 3 years, elective node dissection resulted in an improved rate of overall survival.  They conclude that with early-stage oral squamous-cell cancer, elective neck dissection resulted in higher rates of overall and disease-free survival than did therapeutic neck dissection.

The authors note in the Discussion that the results show an absolute overall survival benefit of 12.5 percentage points and a disease-free survival benefit of 23.6 percentage points. This means that eight patients would need to be treated with elective neck dissection to prevent one death, and 4 patients treated to prevent one relapse.

8. Goni VG, Singh Jhala S, Gopinathan NR, et al. Efficacy of Epidural Perineural Injection of Autologous Conditioned Serum in Unilateral Cervical Radiculopathy. Spine. 2015;40(16):E915–E921. doi:10.1097/BRS.0000000000000924.

The authors studied the efficacy of epidural perineural injection of autologous conditioned serum (ACS) versus methylprednisone (MPS) in 40 unilateral cervical radiculopathy patients.   Patients were equally allocated into ACS and MPS groups and were injected with 2.5 to 3 mL of ACS or MPS, respectively, under image guidance into the perineural area of the affected nerve root.  Patients who had received injections of ACS and MPS both had improvements in the scores of the evaluation tools.  They conclude that ACS can be considered an equally good or better modality of nonoperative management in patients of unilateral cervical radiculopathy as MPS.

Not exactly a resounding endorsement for ACS.  Like the last paper, I wonder what the group would do if you injected saline only?  Check out figures 3 and 4, which shows placement of the needle on an oblique fluoroscopy spot film, plus a nice view of the operator’s fingers!