Remarkable improvement of neurological deficits after surgery in patients with Idiopathic spinal cord herniations. The impact of peroperative neuromonitoring. Case reports.

Introduction: Chronic Idiopathic Spinal Cord Herniation (ISCH) is a very rare spinal cord deformation occurring predominantly in thoracic levels. ISCH lead to progressive myelopathy, spastic paraparesis and Brown Séquard syndrome. Research question: We want to hypothesize that a) the herniated segment can regain its function after untethering despite long-term and complete neurologic dysfunction. b) Intraoperative Electrophysiologic Monitoring (IOEPM) may identify intraoperative changes by monitoring specific neural pathways confirming the efficacy of the intervention in the forthcoming cases. Material & method: It is a retrospective review of data of two cases prospectively collected showing improvement of neurological deficit in cases of ISCH in thoracic levels. We describe two patients with progressive neurological deficits due to ISCH who underwent surgery using electrophysiologic monitoring and have been followed to reach remarkable clinical improvement. Results: The spastic paraparesis of the first case improved remarkably after surgery. Complete foot drop of the other case, persistent for 7 months before intervention, improved after the release of the herniated segment of the cord. Peroperative electrophysiological monitoring did not show changes during surgery. Conclusion: We want to hypothesize that the herniated segment can regain its function after untethering despite long-term and complete neurologic dysfunction. Intraoperative Electrophysiologic Monitoring (IOEPM) may confirm the efficacy of the intervention in the forthcoming cases.

Development of a comprehensive assessment tool to measure the quality of care for individuals with traumatic spinal cord injuries.

OBJECTIVE: To develop a comprehensive assessment tool to evaluate the Quality of Care (QoC) in managing individuals with traumatic spinal cord injuries (TSCI). METHOD: At first, the concepts of QoC for TSCI were identified by conducting a qualitative interview along with re-evaluation of the results of a published scoping review (conceptualization). After operationalization of indicators, they were valued by using the expert panel method. Afterward, the content validity index (CVI) and content validity ratio (CVR) were calculated and served as cut-offs for indicator selection. Then specific questions were developed for each indicator and classified into three categories: pre-hospital, in-hospital, and post-hospital. Data availability of the National Spinal Cord Injury Registry of Iran (NSCIR-IR) was subsequently used to design questions that represent indicators in an assessment tool format. The comprehensiveness of the tool was evaluated using a 4-item Likert scale by the expert panel. RESULT: Twelve experts participated in conceptualization and 11 experts participated in operationalization phase. Overall, 94 concepts for QoC were identified from published scoping review (87 items) and qualitative interviews (7 items). The process of operationalization and indicator selection led to the development of 27 indicators with acceptable content validity. Finally, the assessment tool contained three pre-hospital, twelve in-hospital, nine post-hospital, and three mixed indicators. Ninety-one percent of experts evaluated the entire tool as comprehensive. CONCLUSION: Our study presents a health-related QoC tool that contains a comprehensive set of indicators to assess the QoC for individuals with TSCI. However, this tool should be used in various situations to establish construct validity further.

Prognostic Factors of the Primary Central Nervous System Lymphoma: Clinical Experience from a Tertiary Care Center in the Middle East.

Aim Primary central nervous system lymphoma (PCNSL) is a rare extra nodal non-Hodgkin's lymphoma. The optimal treatment for PCNSL is still unclear. In this study, we present our experience with management of PCNSL in a tertiary care center in Iran. Methods In this retrospective study, 58 patients with tissue diagnosis of PCNSL were studied. All patients were treated with chemotherapy including intravenous high-dose methotrexate, rituximab and temozolomide and radiotherapy by the same oncologist. Statistical analysis was performed using SPSS. Results The mean overall survival (OS) in this study was 37.4 ± 13.6 months and the mean progression free survival (PFS) was 35.1 ± 9.8 months. The mean time to progression was 15.2 ± 8.79 months among 8 patients who experienced progression in this series. Finding of a positive CSF cytology was not linked with disease progression, while HIV infection and multifocal involvement at initial presentation were strongly linked to a lower PFS. The single most important factor affecting the OS was the histopathologic type of the PCNSL; two of the three patients who died from their disease in this series had non-B cell PCNSL, whereas only one patient with DLBCL died because of brainstem involvement. Conclusion The results of this study show a lower rate of HIV-infection in patients with PCNSL as compared to the series from the western countries. Non-B cell histopathology and HIV-infection were found to be associated with the dismal prognosis.

Primary isolated skull base eosinophilic granuloma confined to the anterior clinoid process: illustrative case.

BACKGROUND: Solitary eosinophilic granuloma (EG) occurs anecdotally in the skull base region, and it has been described in only three previous publications. The authors report the first case of EG of the anterior clinoid process (ACP), which was confined to the ACP and presented with decreased vision. OBSERVATIONS: A 38-year-old woman presented with decreased vision of the left eye of 5 months' duration. Her visual acuity was 3/10, other neurological examinations were intact, and there were no other osseous or soft tissue lesions. The lesion was excised using a left-sided craniotomy and transdural clinoidectomy, decompressing the optic nerve both intra- and extradurally. The lesion was characteristic for EG, and no recurrence was detected after 2 years. LESSONS: EG can be confined to the ACP and impair vision. Imaging studies are sensitive but not specific, and surgical decompression is both diagnostic and treatment oriented. Close observation and even adjuvant therapy may be indicated in similar cases.

Adopting Clinical Practice Guidelines for Pharmacologic Management of Acute Spinal Cord Injury from a Developed World Context to a Developing Global Region.

BACKGROUND: Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients' outcomes on the ability and knowledge of "individual" health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods. METHODS: This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each suggestion and the triad of feasibility, acceptance and adoptability for the Iranian health-care context. RESULTS: Two guidelines were included in the adaptation process. Based on high-quality of these guidelines and the feasibility and adoptability evaluation of the organizing committee, we decided to adopt the suggestion of both guidelines. Overall, seven suggestions were extracted from the source guidelines. CONCLUSION: This work provides a framework to apply guidelines for acute SCI to the developing regions of the world. Attempts should be made to implement these suggestions in order to improve the health outcomes of Iranian SCI patients.

Neuroscience20 (BRAIN20, SPINE20, and MENTAL20) Health Initiative: A Global Consortium Addressing the Human and Economic Burden of Brain, Spine, and Mental Disorders Through Neurotech Innovations and Policies.

Neurological disorders significantly impact the world's economy due to their often chronic and life-threatening nature afflicting individuals which, in turn, creates a global disease burden. The Group of Twenty (G20) member nations, which represent the largest economies globally, should come together to formulate a plan on how to overcome this burden. The Neuroscience-20 (N20) initiative of the Society for Brain Mapping and Therapeutics (SBMT) is at the vanguard of this global collaboration to comprehensively raise awareness about brain, spine, and mental disorders worldwide. This paper aims to provide a comprehensive review of the various brain initiatives worldwide and highlight the need for cooperation and recommend ways to bring down costs associated with the discovery and treatment of neurological disorders. Our systematic search revealed that the cost of neurological and psychiatric disorders to the world economy by 2030 is roughly $16T. The cost to the economy of the United States is $1.5T annually and growing given the impact of COVID-19. We also discovered there is a shortfall of effective collaboration between nations and a lack of resources in developing countries. Current statistical analyses on the cost of neurological disorders to the world economy strongly suggest that there is a great need for investment in neurotechnology and innovation or fast-tracking therapeutics and diagnostics to curb these costs. During the current COVID-19 pandemic, SBMT, through this paper, intends to showcase the importance of worldwide collaborations to reduce the population's economic and health burden, specifically regarding neurological/brain, spine, and mental disorders.

The impact of data quality assurance and control solutions on the completeness, accuracy, and consistency of data in a national spinal cord injury registry of Iran (NSCIR-IR).

STUDY DESIGN: Descriptive study. OBJECTIVE: This study aimed to develop and evaluate a systematic arrangement for improvement and monitoring of data quality of the National Spinal Cord (and Column) Injury Registry of Iran (NSCIR-IR)-a multicenter hospital-based registry. SETTING: SCI community in Iran. METHODS: Quality assurance and quality control were the primary objectives in improving overall quality of data that were considered in designing a paper-based and computerized case report. To prevent incorrect data entry, we implemented several validation algorithms, including 70 semantic rules, 18 syntactic rules, seven temporal rules, and 13 rules for acceptable value range. Qualified and trained staff members were also employed to review and identify any defect, inaccuracy, or inconsistency in the data to improve data quality. A set of functions were implemented in the software to cross-validate, and feedback on data was provided by reviewers and registrars. RESULTS: Socio-demographic data items were 100% complete, except for national ID and education level, which were 97% and 92.3% complete, respectively. Completeness of admission data and emergency medical services data were 100% except for arrival and transfer time (99.4%) and oxygen saturation (48.9%). Evaluation of data received from two centers located in Tehran proved to be 100% accurate following validation by quality reviewers. All data was also found to be 100% consistent. CONCLUSIONS: This approach to quality assurance and consistency validation proved to be effective. Our solutions resulted in a significant decrease in the number of missing data.

A global, regional, and national survey on burden and Quality of Care Index (QCI) of brain and other central nervous system cancers; global burden of disease systematic analysis 1990-2017.

Primary brain and other central nervous system (CNS) cancers cause major burdens. In this study, we introduced a measure named the Quality of Care Index (QCI), which indirectly evaluates the quality of care given to patients with this group of cancers. Here we aimed to compare different geographic and socioeconomic patterns of CNS cancer care according to the novel measure introduced. In this regard, we acquired age-standardized primary epidemiologic measures were acquired from the Global Burden of Disease (GBD) study 1990-2017. The primary measures were combined to make four secondary indices which all of them indirectly show the quality of care given to patients. Principal Component Analysis (PCA) method was utilized to calculate the essential component named QCI. Further analyses were made based on QCI to assess the quality of care globally, regionally, and nationally (with a scale of 0-100 which higher values represent better quality of care). For 2017, the global calculated QCI was 55.0. QCI showed a desirable condition in higher socio-demographic index (SDI) quintiles. Oppositely, low SDI quintile countries (7.7) had critically worse care quality. Western Pacific Region with the highest (76.9) and African Region with the lowest QCIs (9.9) were the two WHO regions extremes. Singapore was the country with the maximum QCI of 100, followed by Japan (99.9) and South Korea (98.9). In contrast, Swaziland (2.5), Lesotho (3.5), and Vanuatu (3.9) were countries with the worse condition. While the quality of care for most regions was desirable, regions with economic constraints showed to have poor quality of care and require enforcements toward this lethal diagnosis.

Prevalence of Abnormal Urodynamic Study Results in Patients with Congenital and Idiopathic Scoliosis and Its Predictive Value for the Diagnosis of Tethered Cord Syndrome: A Single Institution Clinical Study.

STUDY DESIGN: A total of 110 patients with scoliosis were enrolled in this analytical cross-sectional study. PURPOSE: We aimed to compare the urodynamic study (UDS) results of patients with idiopathic scoliosis (ISC) and congenital scoliosis (CSC) and to evaluate the clinical significance of abnormal UDS findings in predicting underlying tethered cord syndrome (TCS). OVERVIEW OF LITERATURE: An abnormal UDS finding is commonly found in patients with CSC. However, there is no consensus regarding its prevalence in patients with ISC. METHODS: Using the STROBE checklist for cross-sectional studies, 110 patients with scoliosis were selected based on our inclusion and exclusion criteria. Among the patients, 76 presented with ISC and 34 with CSC. Demographic data and other details, such as the results of spine radiography, UDS, and magnetic resonance imaging of the spine in both supine and prone positions, were recorded and analyzed. RESULTS: Approximately 50% of patients with CSC had normal UDS findings; 8.8%, mild impairment; and 41.2%, significant abnormalities. Moreover, 67.1% of patients with ISC had normal UDS findings; 9.2%, mild impairment; and 23.7%, significant abnormalities (p =0.166). TCS was identified in 38.2% and 26.3% of patients with CSC and ISC, respectively (p =0.571). In patients with ISC, a significantly abnormal UDS finding indicated that the risk of TCS increased from 26.3% to 50% (odds ratio [OR], 4.2; p =0.009). Meanwhile, in patients with CSC, the risk was almost similar (OR, 0.8; p =0.8). CONCLUSIONS: Even with the absence of subjective urinary symptoms, subclinical urologic impairments can be observed in a significant number of patients with ISC. An abnormal UDS finding can be a sign of underlying spinal cord tethering in a patient with ISC who is a candidate for corrective spine surgery even though it is an independent variant and is not exclusive to candidates for surgery. This finding has high clinical utility for neuro- and ortho-spine surgeons who aim to correct scoliosis (OR, 4.2; p =0.009).

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients.

BACKGROUND: Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran. METHODS: The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2). RESULTS: A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation. CONCLUSION: Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Sustaining the National Spinal Cord Injury Registry of Iran (NSCIR-IR) in a Regional Center: Challenges and Solutions.

BACKGROUND: The National Traumatic Spinal Cord Injury Registry in Iran (NSCIR-IR), was implemented initially in three hospitals as a pilot phase from 11 Oct 2015 to 19 Jun 2016 and has been active in eight centers from 19 Jun 2016. Poursina Hospital, a trauma care referral center in Rasht, Guilan Province of Iran is one of the registry sites, and has been involved in registering eligible patients since 1 Jan 2016. This study aimed to identify the challenges and solutions for sustaining the NSCIR-IR in a regional center. METHODS: This was a mixed-methods study. For the quantitative analysis, a retrospective observational design was used to measure case capture or case identification rate, mapping cases in the registry against those eligible for registry inclusion amongst the register of hospital admissions. For the qualitative component, data was collected using focus group discussions and semi-structured interviews, followed by thematic analysis. RESULTS: From 19 Jun 2016 to 24 Jan 2018, the proportion of case capture (case identification rate) was 17%. The median time between case identification and data entry to the system was 30.5 d (range: 2 to 193 d). Thematic analysis identified a lack of trained human resources as the most important cause of low case identification rate and delay in data completion. CONCLUSION: Recruitment and education to increase trained human resources are needed to improve case capture, the timeliness of data input and registry sustainability in a regional participating site.

Uncomplicated Wide Oblique Clivus Fracture, the First Case to be Included in the List of Classification; Report of the Case and Review of Literature.

Sheno-occipital diastasis happens more frequently in children and is accompanied with neural and vascular injuries leading to a high rate of mortality. We present a rare type of clival fracture in a 21 years old man who could survive without any deficit even though the fracture extended widely from left Asterion to the right orbit accompanied by widespread damage of the skull base air sinuses in 3D CT scan. To the best knowledge of the authors, neither this type of fracture, nor the clinical presentation, has been reported in relevant literature.

Initial Experience with Diffusion-weighted Imaging to Predict the Tumor Consistency and Surgical Success in Solid Growth Hormone Producing Pituitary Macroadenomas.

BACKGROUND: Tumor consistency is an important factor impeding transsphenoidal resection of some pituitary macroadenomas. Preoperative prediction of the tumor consistency may help neurosurgeons in preparing the patients for other therapeutic options after a subtotally resected growth hormone (GH)-producing macroadenoma. We present the preliminary results of our study about the application of the preoperative diffusion-weighted (DW) magnetic resonance imaging (MRI) to predict the consistency and resection rate of GH-producing pituitary macroadenomas. MATERIALS AND METHODS: Sixteen primary patients with solid GH-producing pituitary macroadenomas were enrolled. Hormonal assays as well as standard and DW-MRI were obtained before surgery. All the patients were operated via an endoscopic transsphenoidal approach. The intraoperative tumor consistencies (suctionable versus nonsuctionable) were documented. The samples were stained for measurement of the collagen content (low, moderate, and high). Postoperative hormonal study and MRI were performed after 8 weeks to evaluate the resection ratio and the hormonal remission. RESULTS: On DW images, the tumor diffusion was enhanced (free) in four, moderate in ten, and restricted in two patients. The tumor was suctionable in 14 cases; gross total resection and hormonal remission were achieved in 12/14 of these. All the 14 suctionable tumors had moderate to enhanced diffusion on DW imaging (DWI). The two patients with a nonsuctionable fibrous tumor had a restricted diffusion in DWI. These were the only ones to have high collagen content in the histopathologic study. CONCLUSION: DWI could help identify the fibrous nonsuctionable GH-producing adenomas from the others.

Sylvian Fissure Meningioma in Childhood: Report of 3 Cases and Review of the Literature.

OBJECTIVE: Sylvian fissure-based meningioma is a rare occurrence during childhood. We report a small series including 3 such cases, all attached to the arachnoid leaflets of the Sylvian fissure. We present a review of the literature and discuss the impact of possibly effective clinical, imaging, and surgical variables on the outcome. METHODS: In a retrospective chart review of children with intracranial meningioma, we encountered 3 cases with Sylvian fissure meningioma operated within the past 32 years. RESULTS: Two girls, 5 and 7 years old, and 1 boy, 7 years of age, presented with epilepsy, headache, diplopia, and hemiparesis. The duration of illness was 3, 4, and 2 months, respectively. All three tumors were attached to the arachnoid layer of the adjacent Sylvian fissure, and they were not dural based. Gross total resection could be achieved, and no recurrences were encountered after 13, 7, and 2 years. CONCLUSION: We report 3 very rare cases of Sylvian arachnoid-based meningiomas. To our knowledge, this is the study with the longest follow-up period (mean 7.3 years, median 7 years). Even though the overall prognosis of pediatric meningiomas may be worse than that of adult illness, we would like to emphasize that the "rare location" of the Sylvian fissure was not an important factor contributing to the outcome in our children.

Solitary Metastasis of Adenocarcinoma of Submandibular Gland to Choroid Plexus in Cerebellopontine Angle: First Case Reported in Literature.

BACKGROUND: Adenocarcinoma of the salivary gland (AdCASG) is a rare and malignant tumor of the salivary glands. Albeit, metastatic lesions occur anecdotally in the choroid plexus and most rarely in the cerebellopontine angle (CPA). We report the first case of metastatic AdCASG to the choroid plexus of the lateral recess of the fourth ventricle located in CPA, emphasizing the clinical presentation and neuroradiologic findings. CASE DESCRIPTION: A 40-year-old man was referred with signs of increased intracranial pressure and a unilateral hearing problem. Magnetic resonance imaging showed a pear-shaped, vividly enhancing tumor in the left CPA. The tumor was a metastatic AdCASG. Gross total resection of the lesion was followed by a conventional radiotherapy lead in a 5-year tumor-free control interval. CONCLUSIONS: Metastatic lesions to the choroid plexus may show a pedunculated shape in magnetic resonance imaging. It is hypothesized that tumor seeding may occur through the veins, lymphatics, and nerve sheaths in the skull base region. Tissue specimen is necessary to confirm such rare pathology.

Preemptive Effect of Intraurethral Instillation of Ketamine-lidocaine Gel on Postoperative Catheter-related Bladder Discomfort after Lumbar Spine Surgery.

BACKGROUND: Catheter-related bladder discomfort (CRBD) is one of the main reasons of agitation after surgery, leading to urgency and frequency during recovery. Ketamine has been used as an effective drug for reducing the signs and severity of this problem. We hypothesized that intraurethral instillation of ketamine-lidocaine gel before urinary catheterization can reduce the incidence of CRBD in the postoperative period. MATERIALS AND METHODS: A total of 136 male patients, who underwent two-level laminectomy/discectomy were enrolled in this randomized clinical trial. Patients were randomized into the two groups before urinary catheterization. The ketamine group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL (100 mg) ketamine. Patients in control group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL distilled water. The primary outcome was the incidence of CRBD. CRBD was assessed using four-stage criteria when arriving in the recovery room and at 1, 2, and 6 h after surgery. Postsurgical pain and the number of sedatives given and opioid requirement were also the secondary outcomes in this study. RESULTS: Intraurethral instillation of ketamine-lidocaine gel reduced the incidence of CRBD at recovery (P < 0.001) along with a reduction in the severity of CRBD (P < 0.05) during the 1st and 2nd visit compared with control group. The mean pain intensity score (visual analog scale) and opioid requirement to relieve postsurgical pain were lower in the ketamine group during all the study timepoints from recovery and after transfer to the ward (P < 0.008). A higher rate of sedation (72% vs. 11%) also was seen at recovery period in the ketamine group (P < 0.008). CONCLUSION: Intraurethral instillation of ketamine-lidocaine gel before bladder catheterization is an effective technique for reducing the incidence and severity of postoperative CRBD.