1. Fiorella, D. J., Turk, A. S., Levy, E. I., Pride, G. L., Woo, H. H., Albuquerque, F. C., et al. (2011). US Wingspan Registry: 12-Month Follow-Up Results. Stroke, 42, 1976-1981. doi: 10.1161/STROKEAHA.111.613877.
158 patients with 168 intracranial atherostenotic lesions (50% to 99%) were treated with the Gateway-Wingspan system with the average follow-up duration of 14.2 months. 13 ipsilateral strokes occurred after 30 days of which 3 resulted in death. Of these strokes, 76.9% (10 of 13) occurred within the first 6 months. In-stent restenosis was associated with almost 40% of postprocedural stroke events. 40% of delayed strokes were associated with interruption of antiplatelet medications.
2. Jiang, W.-J., Yu, W., Du, B., Gao, F., & Cui, L.-Y. (2011). Outcome of Patients With >=70% Symptomatic Intracranial Stenosis After Wingspan Stenting. Stroke, 42, 1971-1975. doi:10.1161/STROKEAHA.110.595926.
In a multicenter registry, Wingspan stenting seemed to have no advantage compared with medical therapy (Neurology. 2008;70:1518–1524). That study showed a significantly lower stroke rate in high-volume centers versus low-volume centers. In this current paper, the authors treated 100 consecutive patients with intracranial atherosclerotic stenosis of >70% and symptoms within 90 days. The 1-year risk of the outcome events was lower than that in similar Warfarin and Aspirin for Symptomatic Intracranial Atherosclerotic Disease (WASID) patients: 7.3% versus 18%.
3. Abou-Chebl, A. (2011). Intracranial Stenting With Wingspan: Still Awaiting a Safe Landing. Stroke, 42, 1809-1811. doi: 10.1161/STROKEAHA.111.620229.
In this editorial on the Fiorella and Jiang articles (above), Dr. Abou-Chebl notes that the “Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis” (SAMMPRIS) trial has been halted. This was a randomized trial of best medical therapy versus angioplasty and stenting with the Wingspan system plus best medical therapy in patients with symptomatic >70% intracranial atherosclerotic disease. After enrolling 451 patients, the data safety monitoring board recommended that the trial be halted due to a 14% 30-day rate of stroke or death with stenting compared with 5.8% in the medical arm, which was a “highly significant difference” (National Institute of Neurological Disorders and Stroke Clinical Alert, April 11, 2011). Given the controversy and apparent failure of Wingspan technology, Dr. Abou-Chebl outlines various limitations of current studies and future directions for research. One that caught my particular attention was “functional imaging in all patients to determine that distal territory tissue is at risk rather than tissue supplied by perforators”.
4. Alaraj, A., Munson, T., Herrera, S. R., Aletich, V., Charbel, F. T., & Amin-Hanjani, S. (2011). Angiographic features of “brain sag”. Journal of Neurosurgery. doi: 10.3171/2011.4.JNS101168.
Severe CSF hypovolemia, or “brain sag” phenomenon is seen most commonly in patients with aneurysmal SAH after craniotomy for aneurysm clipping along with presurgical placement of a lumbar drain. Angiographically, the level of the basilar artery apex was displaced inferiorly with respect to the posterior clinoid processes and this displacement was significant enough to create kink in the basilar artery (“cobra sign). Other angiographic findings included foreshortening or kinking of the intracranial vertebral artery. In all patients, the posterior cerebral arteries were displaced medially and inferiorly. Good to keep in mind for all the post clip angiograms done for neurologic deterioration where vasospasm is suspected.
5. Flanagan, E. P., Mckeon, A., Lennon, V. A., Kearns, J., Weinshenker, B. G., Krecke, K. N., et al. (2011). Paraneoplastic isolated myelopathy : Clinical course and neuroimaging clues. Neurology, 76, 2089-2095.
Clinical, serologic, and MRI data were evaluated for 31 patients who presented with an isolated myelopathy and coexisting cancer or a paraneoplastic autoantibody. MR cord abnormalities were seen in 20 patients and were longitudinally extensive in 14. Lesions involved symmetric tract or gray matter specific signal abnormalities in 15, and enhanced in 13. Add this to my list of “things I have seen but did not know what they were”. Now I at least have a something to put into the differential diagnosis.
6. Jacobs, W., Willems, P. C., Kruyt, M., Limbeek, J. van, Anderson, P. G., Pavlov, P., et al. (2011). Systematic review of anterior interbody fusion techniques for single- and double-level cervical degenerative disc disease. Spine, 36(14). doi: 10.1097/BRS.0b013e31821cbba5.
Meta-analysis of 33 studies with 2267 patients. The major treatments were discectomy alone and addition of an ACIF procedure (graft, cement, cage, and plates). There was little or no difference in pain relief between the different techniques. Like much spine literature, there are multiple techniques, but no clear winner.
7. Langner, S., Fleck, S., Seipel, R., Schroeder, H. W. S., Hosten, N., & Kirsch, M. (2011). Perfusion CT scanning and CT angiography in the evaluation of extracranial-intracranial bypass grafts. Journal of Neurosurgery, 114(4), 978-83. doi: 10.3171/2010.6.JNS10117.
The authors evaluated 10 patients with perfusion CT and CTA before and after bypass surgery. They concluded that computed tomography angiography is a noninvasive and reliable tool for evaluating patients with EC-IC bypass. Perfusion CT allows monitoring of hemodynamic changes after bypass surgery. The combination of both modalities enables noninvasive anatomical and functional analysis of superficial temporal artery–middle cerebral artery anastomoses using a single CT protocol. I thought we already knew this…guess I was wrong.
8. Martinez-Biarge, M., Diez-Sebastian, J., Kapellou, O., Gindner, D., Allsop, J. M., Rutherford, M. A., et al. (2011). Predicting motor outcome and death in term hypoxic-ischemic encephalopathy. Neurology, 76, 2055-2061.
The authors evaluated the accuracy of early brain MRI for predicting death, the presence and severity of motor impairment, and ability to walk at 2 years in 175 term infants with hypoxic-ischemic encephalopathy (HIE) and basal ganglia–thalamic (BGT) lesions. The severity of BGT lesions was strongly associated with the severity of motor impairment. Brainstem injury was the only factor with an independent association with death. I have had the “what does this mean” question on some of these cases which I have always found disturbing, so now I have a reasonable reference to fall back on.
9. Panczykowski, D. M., Tomycz, N. D., & Okonkwo, D. O. (2011). Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. Journal of Neurosurgery, 1-9. doi: 10.3171/2011.4.JNS101672.
Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury. Interesting Discussion section where the authors note: “while 1 patient every 14 years might be missed by a CT-only protocol, between 325 and 3200 patients would sustain a complication from prolonged cervical collar use during the same time frame.”
10. Parpaley, Y., Urbach, H., Kovacs, A., Klehr, M., & Kristof, R. A. (2011). Pseudohypoxic Brain Swelling (Postoperative Intracranial Hypotension-Associated Venous Congestion) After Spinal Surgery: Report of 2 Cases. Neurosurgery, 68(1), 277-283. doi: 10.1227/NEU.0b013e3181fead14.
The authors hypothesize that pseudohypoxic brain swelling is induced by acute intracranial hypotension, and can occur after spinal surgery with minimal dura laceration and use of subfascial suction drainages. It seems to be part of a condition that may be called intracranial hypotension-associated venous congestion. The images are quite striking.
11. Pimenta, L., Oliveira, L., Schaffa, T., Coutinho, E., & Marchi, L. (2011). Lumbar total disc replacement from an extreme lateral approach: clinical experience with a minimum of 2 yearsʼ follow-up. Journal of Neurosurgery. Spine, 14(1), 38-45. doi: 10.3171/2010.9.SPINE09865.
Placement of a total disc replacement (TDR) device from a true lateral (extreme lateral interbody fusion [XLIF]) approach is thought to offer a less invasive option to access the disc space, preserving the stabilizing ligaments and avoiding scarring of anterior vasculature. The authors performed 36 surgeries including 15 single-level TDR procedures at L3–4 or L4–5, three 2-level TDR procedures spanning L3–4 and L4–5, and 18 hybrid procedures (anterior lumbar interbody fusion [ALIF]) at L5–S1 and TDR at L4–5 or L3–4). In 2 cases (5.6%), removal of the TDR device and revision to fusion were required due to unresolved pain. 5 patients (13.8%) had psoas weakness and 3 patients (8.3%) had anterior thigh numbness postoperatively, which resolved within 2 weeks. That is rather amazing given the trauma to the ipsilateral psoas muscle with this approach.
12. Tamburrelli, F. C., Proietti, L., & Logroscino, C. A. (2011). Critical analysis of lumbar interspinous devices failures: a retrospective study. European Spine Journal, 20(Suppl 1), S27-S35. doi: 10.1007/s00586-011-1763-0.
No guidelines exist in the literature about the proper selection of patients suitable for the use of these devices. The authors review their experience with 19 patients referred for revision of previously placed interspacing devices, of a bewildering array (11 X-Stop, 5 DIAM, 3 U-Coflex, 2 BacJak, 2 Wallis, 1 Aperius, 1 Viking, 1 Superion). The authors delineated the indication errors they encountered including lack of decompression, placement for disc herniation, wrong level placement.
13. Wong, G. K. C., Yeung, J. H. H., Graham, C. a, Zhu, X.-L., Rainer, T. H., & Poon, W. S. (2011). Neurological outcome in patients with traumatic brain injury and its relationship with computed tomography patterns of traumatic subarachnoid hemorrhage. Journal of Neurosurgery, 114(June), 1510-1515. doi: 10.3171/2011.1.JNS101102.
Two hundred fourteen patients (32%) had traumatic SAH according to admission CT studies. Maximum thickness of traumatic SAH was a strong independent prognostic factor for death and clinical outcome (not its anatomical location or extent). 4mm or less survived, 7 mm or more died.
14. Young, R. J., Gupta, a, Shah, a D., Graber, J. J., Zhang, Z., Shi, W., et al. (2011). Potential utility of conventional MRI signs in diagnosing pseudoprogression in glioblastoma. Neurology, 76(22), 1918-24. doi: 10.1212/WNL.0b013e31821d74e7.
This was a retrospective study reviewing initial postradiotherapy MRI scans of 321 patients with glioblastoma undergoing chemotherapy and radiotherapy. 11 MRI signs potentially helpful in the differentiation between pseudoprogression (PsP) and early progression (EP) were examined on the initial post-RT MRI. Subependymal enhancement was predictive for EP with 38.1% sensitivity, 93.3% specificity, and 41.8% negative predictive value. The other 10 signs had no predictive value. Worth repeating….NO predictive value.
