1. Jia B, Zhang X, Ma N, et al. Comparison of drug-eluting stent with bare-metal stent in patients with symptomatic high-grade intracranial atherosclerotic stenosis. JAMA Neurol 2022;79:176–84. Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2787238
Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide, accounting for 8%to 10% of strokes in North America and 30% to 50% of strokes in Asia. The current recommended strategy for stroke prevention in patients with ICAS is standard medical therapy. In recent years, standard medical therapy has substantially reduced stroke recurrence in patients with ICAS. However, a subset of patients are at a high risk for stroke recurrence despite medical treatment. For instance, patients with border zone infarcts and impaired collaterals in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial had a 37% 1-year stroke recurrence rate. As a potential treatment for ICAS with impaired flow, intracranial stenting was found to be inferior to medical management in the SAMMPRIS trial and the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) trial mainly because of the high complication rate associated with stenting. More recently, the Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China and the Wingspan Stent System Post Market Surveillance (WEAVE) trial showed rates of 2.6% to 4.3% for periprocedural complications, suggesting that intracranial stenting may be safe in strictly selected patients with ICAS.
This study asked the question whether a drug-eluting stent (DES) superior to a standard bare-metal stent in reducing in-stent restenosis and stroke recurrence in patients with symptomatic high-grade intracranial atherosclerotic stenosis? Patients were randomly assigned to receive drug-eluting stent (NOVA intracranial sirolimus-eluting stent system) or BMS (Apollo intracranial stent system) treatment in a 1:1 ratio. A total of 263 participants (194 men [73.8%]) were included in the analysis, with 132 participants randomly assigned to the drug-eluting stent group and 131 to the BMS group. The 1-year in-stent restenosis rate was lower in the DES group than in the BMS group (10 [9.5%] vs 32 [30.2%]). The DES group also had a significantly lower ischemic stroke recurrence rate from day 31 to 1 year (1 [0.8%] vs 9 [6.9%]). No significant difference in the rate of any stroke or death within 30 days was observed between the DES and BMS groups.
The findings of this trial indicated that DESs were superior to BMSs in reducing the incidence of ISR and risk of ischemic stroke recurrence in the target vessel territory in patients with high-grade symptomatic ICAS.
3 tables, 2 figures, no images
2. Swanson LC, Ahmed R. Epilepsy syndromes: current classifications and future directions. Neurosurg Clin N Am 2022;33:113–34. Available from: https://doi.org/10.1016/j.nec.2021.09.009
Epilepsy is one of the most common neurologic diseases with an estimated lifetime prevalence of 7.6 per 1000 people. It is a heterogeneous disorder with significant variability in etiology, clinical presentation, treatment, and prognosis across the human lifespan. Individual epilepsies were, therefore, initially categorized in syndromes, with shared clinicopathological features, to facilitate a uniform approach for diagnosis and treatment. However, ongoing diagnostic advancements and delineation of epilepsy subtypes challenge the concept and utility of syndromic classifications in clinical practice. Classification of epilepsy syndromes is, therefore, expected to evolve from shared clinical features toward the molecular underpinnings of the disease process that may facilitate tailored therapeutic approaches. Although the most recent report from the International League Against Epilepsy (ILAE) in 2017 classifies seizure types based on initial clinical manifestation (focal, generalized, mixed, and unknown), this review discusses major pediatric epilepsy syndromes categorized by the age of onset.
The review will provide summarized clinical descriptions of current syndromic epilepsies (Table 1) and characterizes epilepsies of structural etiology that may be amenable to surgical intervention (Table 2). Lastly, emerging technologies are highlighted that will facilitate future syndromic classifications through an improved understanding of the underlying pathophysiological basis of epilepsy.
2 giant tables, no images
3. Voglis S, Romagna A, Germans MR, et al. Spinal arachnoid web—a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection: analysis of a multicenter patient population. Spine J 2022;22:126–35. Available from: https://doi.org/10.1016/j.spinee.2021.06.018
Spinal arachnoid web (SAW) is a rare pathology causing spinal cord compression due to the formation of thickened arachnoid tissue. It can lead to spinal cord compression or focal syrinx formation causing symptoms of myelopathy such as progressive (neuropathic) pain, weakness, sensory deficits, or other less common neurological findings. Syringomyelia is frequent and caused by mass effect of the SAW or obstruction of cerebrospinal fluid (CSF) flow. In the present study, the authors retrospectively analyzed 12 surgically treated Spinal arachnoid webs from three different neurosurgical centers and compared the multicentric experience regarding diagnosis, surgical treatment, and clinical outcome with the available literature.
In all cases, the spinal arachnoid web was localized in the upper and mid thoracic spine (83%, 10/12 involving Th 3-6), with the mass effect located in the dorsal aspect of the dural sac, compressing the spinal cord from posterior. MR revealed the presence of the previously described “scalpel sign” in all 12 cases. In some cases, constructive interference in steady-state (CISS) or cardiac-gated phase-contrast cine mode MR sequences were used to visualize the adhesive arachnoid membranes or the CSF flow obstruction.
Histologically, the resected membrane (specimens of three patients available) consisted of fibrovascular connective tissue as well as small nests of meningothelial cells. Immunohistochemical preparations showed reactivity for epithelial membrane antigen (EMA) in the meningothelial cells, confirming arachnoid origin.
In the current study, the authors evaluate the largest series of surgically confirmed SAW and illustrate the distinctive radiographic, histopathological, and intraoperative features of this unique form of focal spinal arachnopathy. In addition, they document the favorable clinical course after microsurgical excision of the arachnoid web.
5 figures, 3 tables, including MR, histopathology and ultrasound
4. Baig AM. Counting the neurological cost of COVID-19. Nat Rev Neurol 2021;18(January):5–6
This is a commentary on a Neurology paper (Refers to Misra, S. et al. Frequency of neurologic manifestations in COVID-19: a systematic review and meta-analysis. Neurology https://doi.org/10.1212/WNL.0000000000012930 (2021)).
Although COVID-19 was initially thought to be a disease of the respiratory passages, SARS-CoV-2 was recognized as a potential neurotropic virus in the early months of 2020, and the possibility that the virus could access the brain via the olfactory mucosa and the cribriform plate was raised. Subsequent studies have reported involvement of the olfactory pathways in the spread of SARS-CoV-2 to the brain. The neurotropism of SARS-CoV-2 could be mediated by angiotensin-converting enzyme 2 receptors on olfactory mucosal cells and/or neuropilin-1 on the olfactory epithelium. Other potential routes of SARS-CoV-2 entry into the CNS could include the bloodstream, a breached blood–brain barrier and retrograde axonal transport.
With the ongoing COVID-19 pandemic, clusters of patients have emerged with symptoms that continue beyond the acute phase of the disease — a condition commonly known as ‘long COVID’. A substantial proportion of these so-called ‘long-haulers’ have neurological manifestations, and there is an urgent need to address their health issues. A global consensus is needed on diagnostic approaches, management modalities and follow-up to ensure the well-being of long-haulers in general, and to address the neurological features of COVID-19 in particular.
1 graphic showing COVID-19 related neurologic deficits
5. Abola MV, Lin CC, Colasanti CA, et al. Treatment outcomes in American football players after intervertebral disk herniation: systematic review and meta-analysis. Neurosurgery 2022;90:51–58. Available from: https://journals.lww.com/10.1227/NEU.0000000000001746
American football players are at increased risk for many forms of spinal injury. Intervertebral disk herniations are particularly concerning as they are the leading cause of days lost to injury and can have long-term effects on player careers. Disc herniation management plays a major role in the likelihood and success of return-to-play (RTP). A systematic review of the literature investigating disc herniations in American football players using PubMed, Cochrane Library, and Embase was performed. RTP estimates were calculated by pooling study-specific data using a random-effects model.
Four hundred twenty-two studies were identified, with 18 meeting inclusion criteria. Offensive and defensive linemen were the 2 most injured positions. Players undergoing operations were on average younger, with higher body mass indexes, fewer seasons played, and longer post-treatment careers than nonsurgical counterparts. Postsurgical recovery periods lasted an average 106 d, with a mean RTP duration of 33 games over 2.7 yr and an 8.45% reoperation rate. Operative treatment offered a nonsignificant increase in the likelihood of return-to-play compared with nonoperative treatment.
Disc herniations are a common injury, with surgery potentially improving post-treatment outcomes. The literature suffers from heterogeneous definitions of RTP and varying performance metrics, making it difficult to draw clear conclusions. To better understand the impact of disk herniation and treatment on player health and performance, more studies should be performed prospectively and with standardized metrics.
3 figures, 4 tables, no imaging
6. Cole BL. Neuropathology of pediatric brain tumors: a concise review. Neurosurgery 2022;90:7–15. Available from: https://journals.lww.com/10.1093/neuros/nyab182
Pediatric brain tumors are an incredibly diverse group of neoplasms and neuropathological tumor classification is an essential part of patient care. Classification of pediatric brain tumors has changed considerably in recent years as molecular diagnostics have become incorporated with routine histopathology in the diagnostic process. This article focuses on the fundamental major histologic, immunohistochemical, and molecular features that neuropathologists use to make an integrated diagnosis of pediatric brain tumors. This concise review will focus on tumors that are integral to the central nervous system in pediatric patients including: embryonal tumors, low- and high-grade gliomas, glioneuronal tumors, ependymomas, and choroid plexus tumors.
5 figures, all histopathology
Central Nervous System Tumours: WHO Classification of Tumours 5th Edition Amazon $140
7. Brown DA, Goyal A, Richter KR, et al. Clinical utility of brain biopsy for presumed CNS relapse of systemic lymphoma. J Neurosurg 2022;136:30–39. Available from: https://thejns.org/view/journals/j-neurosurg/136/1/article-p30.xml
The objective of this study was to determine the frequency with which brain biopsy for presumed CNS relapse of systemic hematological malignancies yields new, actionable diagnostic information. Hematological malignancies represent a disparate group of genetic and histopathological disorders. Proclivity for brain involvement is dependent on the unique entity and may occur synchronously or metasynchronously with the systemic lesion. Diffuse large B-cell lymphomas (DLBCLs) have a high propensity for brain involvement. Patients in remission from systemic DLBCL may present with a lesion suspicious for brain relapse. These patients often undergo brain biopsy. The authors’ a priori hypothesis was that brain biopsy in patients with a history of systemic DLBCL and a new brain MRI lesion would have lower diagnostic utility compared with patients with non-DLBCL systemic malignancies.
The authors performed a retrospective review of patients who underwent brain biopsy between 2000 and 2019. Inclusion criteria were patients ≥ 18 years of age with a prior systemic hematological malignancy in remission presenting with a new brain MRI lesion concerning for CNS relapse.
Sixty patients met inclusion criteria (40 males and 20 females); the median age at brain biopsy was 67 years (range 23–88 years). The median follow-up was 8.5 months. Thirty-nine (65.0%) patients had DLBCL and 21 (35%) had non-DLBCL malignancies. Thirty-five of 36 (97.2%) patients with prior systemic DLBCL and a diagnostic biopsy had histopathological confirmation of the original systemic disease versus 0 of 21 patients with non- DLBCL systemic malignancies. Morbidity and 30-day mortality were 8.3% and 10.0%, respectively; 2 of 6 30-day mortalities were directly attributable to the biopsy.
The authors found that in patients with a prior systemic DLBCL and brain MRI concerning for CNS relapse, virtually all cases of systemic DLBCL yielded histopathological confirmation of brain DLBCL. In non-DLBCL systemic cases, brain biopsy results were completely heterogeneous. Their results support empirical treatment for presumed CNS relapse in patients with known systemic DLBCL and a brain lesion consistent with lymphoma on MRI. The risks of empirical cancer treatment must be weighed against the potential treatment delays and the risk of morbidity inherent with performing brain biopsies in this population.
While there are some characteristic features of lymphomas on brain MRI, such as homogeneous contrast enhancement without a necrotic core (in almost 99%) along with restricted diffusion and T2 hyperintensity, these features are not pathognomonic, and the specificity for lymphoma is low.
5 tables, 2 figures including MR imaging of three patients
8. Borg A, Hill CS, Nurboja B, et al. A randomized controlled trial of the X-Stop interspinous distractor device versus laminectomy for lumbar spinal stenosis with 2-year quality-of-life and cost-effectiveness outcomes. J Neurosurg Spine 2021;34:544–52. Available from: https://thejns.org/view/journals/j-neurosurg-spine/34/4/article-p544.xml
Interspinous distractor devices (IDDs) have been used in the management of LSS for over a decade. Their use is controversial due to mixed reports on their success rates, cost, and high failure rates. The X-Stop Interspinous Process Decompression System (Medtronic Spine LLC) was the first Interspinous distractor device to be approved by the US FDA for the treatment of LSS. This device is intended to provide relief of the symptoms of neurogenic claudication from LSS while being minimally invasive. The procedure time for insertion is short, with potentially fewer complications than a laminectomy, and the device can be removed if necessary. X-Stop use has become increasingly popular in the management of LSS. The safety of the device was confirmed by the FDA in the US and by the National Institute for Health and Care Excellence (NICE) in the United Kingdom (UK), and its clinical efficacy was found to be similar to that of laminectomy, with a reported 70% success rate for improvement in symptoms. However, questions have arisen regarding cost-effectiveness of Interspinous distractor devices in the UK, and the long-term impact on QOL needs to be determined. The objective of this study was to determine whether the device is cost effective when compared with the standard treatment of laminectomy and how the device influences QOL.
This was a multicenter, open-label randomized controlled trial of 47 patients with LSS was conducted; 21 patients underwent insertion of the X-Stop device and 26 underwent laminectomy.
The mean monetary cost for the laminectomy group was $3316 USD, and the mean cost for the X Stop group was $6295. Using an intention-to-treat analysis, the authors found that the mean quality-adjusted life-year (QALY) gain for the laminectomy group was 0.92 and that for the X-Stop group was 0.81. The incremental cost-effectiveness ratio was −$27,078. The revision rate for the X-Stop group was 19%.
Laminectomy was more cost-effective than the X-Stop for the treatment of LSS, primarily due to device cost. The X-Stop device led to an improvement in QOL, but it was less than that in the laminectomy group. The complication rate was lower for X-Stop than for a laminectomy, but the reoperation rate was higher. The use of the X-Stop interspinous distractor device should be reserved for cases in which a less-invasive procedure is required. There is no justification for its regular use as an alternative to decompressive surgery.
5 figures, 3 tables, no imaging
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