1. Spetzler RF, McDougall CG, Zabramski JM, et al. The Barrow Ruptured Aneurysm Trial: 6-year results. J Neurosurg. 2015;123(3):609–617. doi:10.3171/2014.9.JNS141749.
The authors report the results of this ongoing randomized trial (with the final goal of a 10-year follow-up) comparing the safety and efficacy of surgical clip occlusion and endovascular coil embolization in patients presenting with subarachnoid hemorrhage from a ruptured aneurysm. 471 patients were randomly assigned to the treatments: 238 to surgical clipping and 233 to endovascular coiling. Whether to treat patients in the assigned group or to cross over to the other group was at the discretion of the treating physician. 38% (75/199) of the patients assigned to coiling were crossed over to clipping and 1.9% (4/209) assigned to clipping were crossed over to coiling. On the basis of a modified Rankin Scale (mRS) score of > 2, no significant difference in outcomes was detected between the 2 treatment groups. When aneurysm location was considered, the 6-year results showed no difference in outcome for anterior circulation aneurysms. Outcomes for posterior circulation aneurysms continued to favor coiling. With coiling, obliteration rates were significantly lower and retreatment rates significantly higher. Despite this, no recurrent hemorrhages were seen out to 6 years.
2. Macdonald RL. Editorial: Clip or coil? Six years of follow-up in BRAT. J Neurosurg. 2015;123(3):605–608. doi:10.3171/2014.11.JNS142261.
This is the editorial that accompanies the BRAT trial paper, as well as the author’s response to the editorial from Dr.’s McDougall and Spetzler. The author concludes that “advocates of neurosurgical clipping of ruptured aneurysms are fighting an increasingly uphill battle with fewer and fewer troops.”
I like the summary by Dr.’s McDougall and Spetzler at the end of their response: “What can be seen in BRAT and in ISAT is that, while subgroups of patients seem to benefit from coiling, there really are not many differences overall in outcomes between open surgery and aneurysm coiling. With clipping, an increased upfront surgical morbidity rate is offset by a decreased rate of delayed rehemorrhage. Whether this means that one should favor clipping or coiling is somewhat of a value judgment. If the overall difference is ultimately not great, then the implication is that, within a given institution, relatively small differences in any one of the many elements of patient care (for example, practice pattern, judgment, and technical ability) could render irrelevant the results of even the most comprehensive trial.”
3. Ghobrial GM, Viereck MJ, Margiotta PJ, et al. Surgical Management in 40 Consecutive Patients With Cervical Spinal Epidural Abscesses. Spine. 2015;40(17):E949–E953. doi:10.1097/BRS.0000000000000942.
This is a retrospective review covering 1997-2011 that identified 40 consecutive patients with cervical spinal epidural abscess. The most common risk factor associated with cervical spinal epidural abscess was intravenous drug abuse which was found in 10 patients (25%). The most common level of discitis involvement was C6–C7 in 12 (30%). The most common neurologic grades at presentation were American Spinal Injury Association Impairment scale (AIS) D in 20 (50%) (motor incomplete) followed by AIS E in 9 (28%) (normal) . Sixty-five percent of patients underwent anterior followed by posterior decompression and stabilization. The authors note that there was a shift toward circumferential stabilization for cervical spondylodiscitis without the use of halo devices and this did not result in an increase in reported periprocedural complications.
Nice case series marred from my narrow perspective for not having any figures.
4. Griauzde J, Gemmete JJ, Pandey AS, Chaudhary N. Intrathecal preservative-free normal saline challenge magnetic resonance myelography for the identification of cerebrospinal fluid leaks in spontaneous intracranial hypotension. J Neurosurg. 2015;123(3):732–736. doi:10.3171/2014.12.JNS142057.
This is a retrospective review of 5 patients who underwent preservative-free normal saline challenge followed by intrathecal gadolinium contrast infusion and MR myelography (CEMRM) from 2010 to 2012 (6 procedures). The concept is to use this technique to provoke and detect a CSF leak in patients with SIH. Preservative free normal saline was instilled into the subarachnoid space at a rate of 1 ml/min to a total volume of approximately one-third of the total CSF fluid volume (sort of 50cc, although this is not explicitly stated). They were able to detect a CSF leak in 5 of 6 infusion procedures. In 4 cases, a leakage site had not been identified on previous CTM images from outside institutions, and in 1 case, they identified multiple additional leakage sites not detected with a previous CT myelogram. Three patients (60%) did experience immediate transient symptoms, which included feelings of anxiety, shortness of breath, pelvic pressure, headache, and numbness and tingling in both upper and lower extremities, so close neurologic monitoring is required. They conclude that preservative-free normal saline challenge combined with CEMRM imaging is a relatively safe procedure and may aid in improved detection of CSF leaks in patients with SIH.
“Relatively” safe. With only 5 patients, too small of an ‘n’ to really know. Not a procedure for the faint of heart on both the patient and physician sides.
5. Jorgensen AY, Ahn J, Aboushaala K, Singh K. Current concepts in the use of stem cells for the treatment of spinal cord injury. Semin Spine Surg. 2015;27(2):90–92. doi:10.1053/j.semss.2015.03.005.
A concise review of the current status of stem cells for the treatment of spinal cord injury, including 1 Figure, 28 references. This review also gives a nice summary of the history of human trials, and notes the current phase I/II cervical and thoracic spine trials using Stem Cells Inc.’s HuCNS-SC stem cells.
See http://www.stemcellsinc.com/Clinical-Programs/SCI.
6. Li CQ, Cho A a., Edward NJ, Edward DP, Fajardo RG, Mafee MF. Magnetic resonance imaging of uveitis. Neuroradiology. 2015;57(8):825–832. doi:10.1007/s00234-015-1531-7.
Uveitis is inflammation of any part of the uveal tract, the vascular middle layer of the globe made up of the choroid posteriorly and ciliary body and iris anteriorly. Uveitis is a nonspecific diagnosis, and can be caused by a variety of idiopathic, infectious and noninfectious inflammatory systemic diseases. Some of the noninfectious causes include ankylosing spondylitis/ulcerative colitis, rheumatoid arthritis, sarcoidosis, Behcet’s disease, relapsing polychondritis, and Vogt-Koyanagi-Harada (VKH) disease. The anatomical classification scheme divides the inflammation into four groups: anterior (anterior chamber), intermediate (posterior ciliary body), posterior (retina/choroid), and panuveitis. As with every other part of the body, the differential includes sarcoid and TB, particularly for the posterior and panuveitis types. This case series highlights the MRI and CT studies of seven patients with uveitis and the clinical history of three of them. Etiologies included ankylosing spondylitis, relapsing polychondritis, Vogt-Koyanagi-Harada disease (thought to result from autoimmune targeting of melanocytes and characterized by bilateral granulomatous panuveitis), sarcoidosis, and tuberculosis.
7 figures, 33 references.
7. Sneed PK, Mendez J, Vemer-van den Hoek JGM, et al. Adverse radiation effect after stereotactic radiosurgery for brain metastases: incidence, time course, and risk factors. J Neurosurg. 2015;123(2):373–386. doi:10.3171/2014.10.JNS141610.
The authors use the term adverse radiation effect (ARE) generically, to include both reversible and irreversible radiation injury. The purpose of the study was to perform a rigorous, in-depth analysis of the incidence, time course, and risk factors for both overall ARE and symptomatic ARE after stereotactic radiosurgery (SRS) for brain metastases. 435 patients with 2200 brain metastases were evaluated, and the median patient survival time was 17.4 months and median lesion imaging follow-up was 9.9 months. Among the 118 cases of adverse radiation effect, 60% were symptomatic and 85% occurred 3–18 months after SRS (median 7.2 months). Multivariate analysis (considering only metastases with target volume > 1.0 cm3), the risk factors for ARE included prior SRS, kidney primary tumor, connective tissue disorder, and systemic therapy with capecitabine.
7 Tables, 6 figures with several Kaplan-Meier plots.
8. George B, Bresson D, Herman P, Froelich S. Chordomas: A Review. Neurosurg Clin N Am. 2015;26(3):437–452. doi:10.1016/j.nec.2015.03.012.
I am conflicted on the quality of this review article. On the one hand, I learned things about chordomas that I have not seen in print previously, such as the role of the protein brachyury in making a specific diagnosis of chordoma (linked to a specific gene locus, 6q27) since this protein is expressed in any tissue that is derived from the notochord. This review also covers in some depth the various treatment modalities, including the potential use of tyrosine kinase receptor inhibitors and the use of proton beam therapy. On the other hand, this paper did not receive much in the way of copyediting, and there are multiple errors that make reading very difficult (at least for me). One problem is the over aggressive use of abbreviations: my favorite being the abbreviation for sacrum (S)! This overaggressive use leads to sentences that are nearly incomprehensible: “Brachyury is always found in any tissue or lesion that is derived from the NC including CHs, EP, and BNCTs, as well as in the NC itself.” There are also considerable problems with the figure legends, with swapped legends (fig 3 and 4), and legends in French on the graphs that is otherwise completely in English. To summarize: nuggets of information, but approach with caution.
