Autonomic Dysreflexia following Spinal Cord Injury.

Autonomic dysreflexia (AD) is a potentially life-threatening condition of the autonomic nervous system following spinal cord injury at or above T6. One of the most common symptoms is a sudden increase in blood pressure induced by afferent sensory stimulation owing to unmodulated reflex sympathetic hyperactivity. Such episodes of high blood pressure might be associated with a high risk of cerebral or retinal hemorrhage, seizures, heart failure, or pulmonary edema. In-depth knowledge is, therefore, crucial for the proper management of the AD, especially for spine surgeons, who encounter these patients quite often in their clinical practice. Systematical review of the literature dealing with strategies to prevent and manage this challenging condition was done by two independent reviewers. Studies that failed to assess primary (prevention, treatment strategies and management) and secondary outcomes (clinical symptomatology, presentation) were excluded. A bibliographical search revealed 85 eligible studies that provide a variety of preventive and treatment measures for the subjects affected by AD. As these measures are predominantly based on noncontrolled trials, long-term prospectively controlled multicenter studies are warranted to validate these preventive and therapeutic proposals.

Transcriptomic Profiling Revealed Lnc-GOLGA6A-1 as a Novel Prognostic Biomarker of Meningioma Recurrence.

BACKGROUND: Meningioma is the most common primary central nervous system neoplasm, accounting for about a third of all brain tumors. Because their growth rates and prognosis cannot be accurately estimated, biomarkers that enable prediction of their biological behavior would be clinically beneficial. OBJECTIVE: To identify coding and noncoding RNAs crucial in meningioma prognostication and pathogenesis. METHODS: Total RNA was purified from formalin-fixed and paraffin-embedded tumor samples of 64 patients with meningioma with distinct clinical characteristics (16 recurrent, 30 nonrecurrent with follow-up of >5 years, and 18 with follow-up of <5 years without recurrence). Transcriptomic sequencing was performed using the HiSeq 2500 platform (Illumina), and biological and functional differences between meningiomas of different types were evaluated by analyzing differentially expression of messenger RNA (mRNA) and long noncoding RNA (IncRNA). The prognostic value of 11 differentially expressed RNAs was then validated in an independent cohort of 90 patients using reverse transcription quantitative (real-time) polymerase chain reaction. RESULTS: In total, 69 mRNAs and 108 lncRNAs exhibited significant differential expression between recurrent and nonrecurrent meningiomas. Differential expression was also observed with respect to sex (12 mRNAs and 59 lncRNAs), World Health Organization grade (58 mRNAs and 98 lncRNAs), and tumor histogenesis (79 mRNAs and 76 lncRNAs). Lnc-GOLGA6A-1, ISLR2, and AMH showed high prognostic power for predicting meningioma recurrence, while lnc-GOLGA6A-1 was the most significant factor for recurrence risk estimation (1/hazard ratio = 1.31; P = .002). CONCLUSION: Transcriptomic sequencing revealed specific gene expression signatures of various clinical subtypes of meningioma. Expression of the lnc-GOLGA61-1 transcript was found to be the most reliable predictor of meningioma recurrence.

Comparison of Bypass and Non-Bypass Surgical Treatments for Internal Carotid Artery Blood Blister-Like Aneurysms: A Meta-Analysis of Efficacy, Safety, and Outcomes.

BACKGROUND: The optimal surgical strategy for treating internal carotid artery (ICA) blood blister-like aneurysms (BBAs) has remained unclear. Although some have preferred bypass surgery, others have favored less-demanding surgical methods. The aim of the present meta-analysis was to assess the efficacy, safety, and outcomes of bypass and non-bypass surgical methods when intended as primary treatment of ICA BBAs. METHODS: Studies reporting data on the outcomes of interest for surgically treated patients with ICA BBAs were searched for in the PubMed/MEDLINE, Evidence-Based Medicine Reviews, Cochrane Central, ProQuest, and Scopus databases. The data were analyzed using random effects modeling. RESULTS: Seven observational studies involving 140 patients met the inclusion criteria. The patients treated with bypass surgery, compared with those treated with non-bypass techniques, had lower odds of poor outcomes (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.28-2.02; P = 0.57; I2 = 0%), postoperative vasospasm (OR, 1.73; 95% CI, 0.38-7.92; P = 0.48; I2 = 19%), intraoperative bleeding (OR, 3.37; 95% CI, 0.82-13.90; P = 0.09; I2 = 0%), postoperative bleeding (OR, 1.91; 95% CI, 0.47-7.76; P = 0.36; I2 = 0%), and postoperative recurrence of BBAs (OR, 2.16; 95% CI, 0.54-8.66; P < 0.28; I2 = 0%). No comparison, however, achieved statistical significance. CONCLUSIONS: For surgeons who use both bypass and non-bypass surgical strategies, the 2 methods seemed comparable in terms of the outcomes of interest, although the bypass technique appeared superior. However, comparisons with studies reporting bypass as the uniquely preferred technique have indicated that specialization in, and preference for, the bypass procedure has been associated with more favorable outcomes.

Recurrence of surgically treated parasagittal meningiomas: a meta-analysis of risk factors.

BACKGROUND: As the predictive role of many risk factors for parasagittal meningioma (PM) recurrence remains unclear, the objective of the meta-analysis was to make a comprehensive assessment of the predictive value of selected risk factors in these lesions. METHODS: Studies including data on selected risk factors, such as histology, tumor and sinus resection, sinus invasion, tumor localization, and immediate postoperative radiotherapy for PMs recurrence, were searched in the NCBI/NLM PubMed/MEDLINE, EBM Reviews/Cochrane Central, ProQuest, and Scopus databases, and analyzed using random effects modeling. RESULTS: Thirteen observational studies involving 1243 patients met the criteria for inclusion in the meta-analysis. WHO grading of meningiomas was identified as the most powerful risk factor for recurrence. WHO grade II meningiomas (OR 11.61; 95% CI 4.43-30.43; P < .01; I2 = 31%) or composite group of WHO grades II and III (OR 14.84; 95% CI 5.10-43.19; P < .01; I2 = 48%) had a significantly higher risk of recurrence than benign lesions. Moreover, an advanced sinus involvement (types IV-VI according to the Sindou classification) (OR 3.49; 95% CI 1.30-9.33; P = .01; I2 = 0%) and partial tumor resection (Simpson grades III-V) (OR 2.73; 95% CI 1.41-5.30; P = .03; I2 = 52%) were associated with a significantly higher risk of recurrence than their counterparts. CONCLUSION: Among the selected risk factors, high-grade WHO lesions, advanced sinus invasion, and partial tumor resection were associated with a higher risk of PM recurrence, with WHO grading system being the most powerful risk factor.

Identification of Meningioma Patients at High Risk of Tumor Recurrence Using MicroRNA Profiling.

BACKGROUND: Meningioma growth rates are highly variable, even within benign subgroups, with some remaining stable, whereas others grow rapidly. OBJECTIVE: To identify molecular-genetic markers for more accurate prediction of meningioma recurrence and better-targeted therapy. METHODS: Microarrays identified microRNA (miRNA) expression in primary and recurrent meningiomas of all World Health Organization (WHO) grades. Those found to be deregulated were further validated by quantitative real-time polymerase chain reaction in a cohort of 172 patients. Statistical analysis of the resulting dataset revealed predictors of meningioma recurrence. RESULTS: Adjusted and nonadjusted models of time to relapse identified the most significant prognosticators to be miR-15a-5p, miR-146a-5p, and miR-331-3p. The final validation phase proved the crucial significance of miR-146a-5p and miR-331-3p, and clinical factors such as type of resection (total or partial) and WHO grade in some selected models. Following stepwise selection in a multivariate model on an expanded cohort, the most predictive model was identified to be that which included lower miR-331-3p expression (hazard ratio [HR] 1.44; P < .001) and partial tumor resection (HR 3.90; P < .001). Moreover, in the subgroup of total resections, both miRNAs remained prognosticators in univariate models adjusted to the clinical factors. CONCLUSION: The proposed models might enable more accurate prediction of time to meningioma recurrence and thus determine optimal postoperative management. Moreover, combining this model with current knowledge of molecular processes underpinning recurrence could permit the identification of distinct meningioma subtypes and enable better-targeted therapies.

A Case Series of Double Bypass Technique Used for the Treatment of Internal Carotid Blood Blister-like Aneurysms in Patients in Poor Initial Neurological Condition at the Early Stage of Subarachnoid Hemorrhage.

BACKGROUND: Optimal surgical treatment of blood-blister aneurysms (BBA) remains controversial. Some surgeons prefer clipping reconstruction while others favor primary bypass with trapping. OBJECTIVE: To analyze of benefit of double bypass technique to surgical outcomes in patients with ruptured BBA in poor initial neurological condition (PINC). METHODS: Retrospective analysis of clinical, radiological, and surgical data in 9 patients treated between January 2009 and December 2015. Intraoperative middle cerebral artery blood pressure (MCABP) measurement was used for selection of bypass procedure. RESULTS: Seven patients presented with World Federation of Neurosurgical Societies (WFNS) subarachnoid hemorrhage (SAH) score 4 or 5. No pulse pressure in the MCA after internal carotid artery (ICA) clamping was found in 3 patients, although their ACoA or PCoA were well visualized on preoperative angiograms. By contrast, only a minimal drop in MCABP following ICA clamping was detected in two cases, although their collaterals were slim/nonvisualized on imaging. Although angiographic vasospasms were not observed in our patients, two of them experienced cerebral infarction, attributable more to the mass effect and postoperative ICA thrombosis than to SAH-induced vasospasm. There were 2 premature intraoperative ruptures, but no perioperative mortality, aneurysm recurrence, or rebleeding. Five patients with WFNS SAH score 4 or 5 achieved favorable outcomes. CONCLUSION: Early double bypass technique guided by MCABP measurement and combined with trapping (or rarely clipping) seems to be a safe method with excellent long-term outcomes in patients in PINC. This study may thus contribute to the debate on the optimal treatment strategy for BBA.

Safe and bloodless exposure of the third segment of the vertebral artery: a step-by-step overview based on over 50 personal cases.

Craniovertebral junction surgery usually requires the exposure of the third segment of the vertebral artery (V3). However, the complexity of musculature, a relatively high incidence of anomalies in the course of the vertebral artery (VA), and the presence of a rich venous plexus in this region make the V3 exposure challenging with a high risk of serious complications while taking down the suboccipital muscles in a single layer. A muscle dissection in interfascial layers, however, overcomes the drawbacks inherent in a blind dissection of the V3 as each of the muscles represents substantial landmark aiding subsequent step of the procedure and thus helping identify underlying anatomical structure early and safely. Moreover, along with a bloodless VA dissection off its surrounding venous plexus, it permits a safe and comfortable V3 exposure during the surgically demanding procedures.

Variability in Wall Thickness and Related Structures of Major Dural Sinuses in Posterior Cranial Fossa: A Microscopic Anatomical Study and Clinical Implications.

BACKGROUND: Regional variability in dural sinus (DS) wall thickness in posterior cranial fossa (PCF) have not been studied in detail yet. OBJECTIVE: To clarify the possible regional variability in DS wall thickness and determine the occurrence and localization of the chordae Willisii (CW) in PCF. METHODS: Fifty-nine human cadaveric DSs of PCF were investigated. A measurement of the DS walls/dura mater/CW thickness of parafin-embedded/hematoxylin-eosin stained axial sections was performed by using Cell Sens Science Imaging Software (Olympus Corporation, Tokyo, Japan). RESULTS: The osseus wall (OW) was the thickest one in the confluens sinuum (CS) and the thinnest one in the jugular bulb (JB) and sigmoid sinus (P < .05). The biggest differences between individual walls were observed in the JB where the superior wall was almost twice as thick as the OW. At the transverse-sigmoid junction, the thickness of the walls was comparable. In the CS and transverse sinuses, the OW was even thicker than the surrounding dura mater. The occurrence and thickness of the CW increased from the JB towards CS and prevailed on the right side. An overall number of the CW in PCF was comparable to that observed in the superior sagittal sinus. CONCLUSION: The present study displayed for the first time the regional variability in the DS walls thickness and occurrence of the CW in PCF. Application of these findings may afford greater freedom in exposure of the DSs or neoplasms adhering to the DSs.

Redistribution of acute traumatic infratentorial subdural hematoma to the spinal subdural space.

Spinal subdural hematoma is a rare and potentionally life-threatening condition associated with trauma and other pathological conditions. In this paper we report the autopsy findings of a 64 year old male who was repeatedly hospitalized with traumatic head injuries in the past. In this case spinal subdural hematoma was diagnosed post-mortem and later comfirmed by ante-mortem CT scan revaluation. Keywords: intracranial subdural hematoma - recurrent spinal subdural hematoma - diffuse axonal injury - autopsy findings.

State-of-art in surgical treatment of dissecting posterior circulation intracranial aneurysms.

Vertebrobasilar (VB) intracranial dissecting aneurysms (IDAs) pose difficult therapeutic issues and are especially among the most difficult to manage surgically. There are, however, some cases where selective aneurysm obliteration by endovascular approach is impossible or is associated with an unacceptable risk of morbidity. This is particularly true when the aneurysm is dissecting, giant, or has a large neck. In such cases, surgical treatment may be the only alternative. Optimal management of these lesions is therefore challenging and treatment decisions have to be made on a case-by-case basis. Ideal treatment should be a complete surgical excision of the lesion; however, this procedure might only be possible after distal and proximal vessel wall occlusion which might not be tolerated by the patient depending on the location of the aneurysm. Therefore, formulation of recommendations concerning the surgical strategy remains still difficult due to inconsistency of surgical outcomes. The literature describing surgical strategy of VB IDAs is varying in quality and content, and many studies deal with only a few patients. In the presented review, the authors summarize the current knowledge on the incidence, pathogenesis, clinical presentation, and diagnostic procedures with special emphasis on surgical treatment of IDAs in posterior circulation.

Bilateral position-related ulnar neuropathy at elbow in pediatric population and review of the literature.

Perioperative ulnar neuropathies attributed to inappropriate arm positioning and padding during surgical procedures are commonly found in adults. However, their extremely rare incidence in the pediatric population may cause absent awareness of the risk of nerve injury in anesthetized pediatric patients. Furthermore, young patients respond to conservative treatment of neuropathy less favorably than adults and their response also depends on the pathomechanism of the ulnar nerve injury. A surgeon's or anesthetist's failure to recognize all of these specifics in children may result in substantial morbidity of young patients leading to lawsuits. Fortunately, with an adequate knowledge of surgical anatomy and types of procedures and positions in which the ulnar nerve is particularly vulnerable, and familiarity with measures to minimize the potential for neuropathy, this serious complication can be prevented. The aims of this review are to highlight personal experience and current knowledge of the rare position-related ulnar neuropathy, both from a clinical and anatomical-pathophysiological perspective, and to raise awareness about this rare but serious complication in the pediatric population.

State-of-Art Surgical Treatment of Dissecting Anterior Circulation Intracranial Aneurysms.

Intracranial dissecting aneurysms (IDAs) are an important cause of subarachnoid hemorrhage, stroke, or compression of intracranial structures. Since the availability of endovascular treatment and the advantage of intraprocedural anticoagulation, an endovascular strategy has become the mainstay of their therapy. But in some cases selective aneurysm obliteration by the endovascular approach is impossible or associated with an unacceptable risk of morbidity. This is particularly true when the IDA is a blood blister-like aneurysm or when dissection affects peripheral branches of the internal carotid artery. The literature dealing with surgical treatment of IDAs in the anterior circulation is heterogeneous, and formulation of general recommendations concerning the surgical strategy remains difficult. The aim of this study was to conduct a systematic review of the current knowledge on incidence, pathogenesis, clinical presentation, and diagnostic procedures with a special emphasis on the surgical treatment of intracranial dissections of anterior circulation.

Surgical treatment of unruptured dissecting intracranial aneurysms of vertebral-posterior inferior cerebellar artery region.

A lack of published surgical experience and higher symptomatic recurrence than previously recognized prompted the authors to present their experience with the surgical treatment of unruptured intracranial dissecting aneurysms (UIDAs). Hospital records, neuroimaging studies, operative reports, and follow-up records were retrospectively reviewed. All patients underwent surgical exploration of the lesion with proximal clipping of the parent artery through a far-lateral suboccipital craniotomy with or without partial condylar resection. The surgical treatment of vertebral artery-posterior inferior cerebellar artery UIDAs has acceptable risk regarding perioperative mortality and morbidity. The incidence of aneurysmal recurrence or the need for retreatment seems to be less than that associated with anticoagulation/antiplatelet therapy or endovascular treatment.

Multifocal Supra and Infratentorial Medulloblastoma in an Adult: Histologic, Immunohistochemical, and Molecular Evaluation of a Rare Case and Review of the Literature.

Multifocal medulloblastomas (MMBs) in adults are exceedingly rare with only 5 reported cases to date. Medulloblastoma in adult differ from its childhood counterpart by being more often lateral in location, desmoplastic in morphology, and better in clinical prognosis. Little is known, however, about the characteristic features of MMB. This is particularly true for their molecular profiles. To date, molecular characteristics of multifocal medulloblastoma have been reported only once. Here, we present the second case of multifocal medulloblastoma along with its detailed morphology, imaging features, and molecular profiles with a critical review of the literature. We believe that MMB should be reported in detail to better understand their behavior, characterize their molecular profiles, and establish therapeutic protocols.

Comparison of computational fluid dynamics findings with intraoperative microscopy findings in unruptured intracranial aneurysms- An initial analysis.

CONTEXT: The increase in the detection of unruptured cerebral aneurysms has led to management dilemma. Prediction of risk based on the size of the aneurysm is not always accurate. There is no objective way of predicting rupture of aneurysm so far. Computational fluid dynamics (CFDs) was proposed as a tool to identify the rupture risk. AIMS: To know the correlation of CFD findings with intraoperative microscopic findings and to know the relevance of CFD in the prediction of rupture risk and in the management of unruptured intracranial aneurysms. SETTINGS AND DESIGN: A prospective study involving nine cases over a period of 6 months as an initial analysis. SUBJECTS AND METHODS: Both males and females were included in the study. Preoperative analysis was performed using computed tomography angiogram, magnetic resonance imaging in all cases and digital substraction angiogram in some cases. Intraoperatively microscopic examination of the aneurysm wall was carried out and images recorded. The correlation was done between microscopic and CFD images. RESULTS: Seven cases were found intraoperatively to have a higher risk of rupture based on the thinning of the wall. Two cases had an atherosclerotic wall. All cases had low wall shear stress (WSS).Only two cases with atherosclerotic wall had a correlation with low WSS. CONCLUSIONS: While the pressure measured with CFD technique is a good predictor of rupture risk, the WSS component is controversial. Multicentric trials involving a larger subset of population are needed before drawing any definite conclusions. On-going development in the CFD analysis may help to predict the rupture chances accurately in future.

In vitro testing to a panel of potential chemotherapeutics and current concepts of chemotherapy in benign meningiomas.

Treatment of benign meningiomas remains a challenge, especially when they involve the skull-base or when surgery and radiation fail. Moreover, a recent in vitro MTT (3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide) study testing hydroxyurea, temozolomide and other targeting agents failed to identify drugs effective in their treatment; therefore the search for further more effective agents continues. We performed a thorough review of in vitro investigations, animal studies and human clinical trials and endeavoured to integrate our results of MTT assay into current concepts of chemotherapy in benign meningiomas. Our results demonstrated that other chemotherapeutics with various mechanisms of action have the potential to be incorporated into second line therapy. Our study shows for the first time that chemosensitivity/resistance may be associated with histopathological variants of benign meningiomas.

An adult multifocal medulloblastoma with diffuse acute postoperative cerebellar swelling: immunohistochemical and molecular genetics analysis.

Medulloblastoma (MB), the most common malignant tumor typically affecting children, occurs only exceptionally in adults. Multifocal presentation of this malignancy in adulthood is even much rarer­only four cases with favorable postoperative course have been reported, so far. The study illustrates a very rare rapid postoperative clinical deterioration due to diffuse cerebellar swelling (DCS) in an adult multifocal MB (MMB). To the best of their knowledge, authors for the first time performed genetic analysis of MMB and demonstrated expression patterns of selected markers that put the patient within the sonic hedgehog (SHH) molecular subgroup and at least partially explain her unsatisfactory clinical course. Herein, authors summarized the relevant literature concerning this issue with the aim to determine features that would facilitate diagnosis and therapy of such a scarce clinical entity.

Pharyngeal perforation after blunt cervical trauma in child.

Pharyngeal perforation caused by non-penetrating cervical trauma is an extremely rare clinical entity both in adults and children. Data concerning management of this type of injury are quite rare in surgical and even scarcer in pediatric literature. Since delay in treatment may be associated with life-threatening complications, prompt diagnosis coupled with appropriate therapy is essential for achieving favorable clinical outcome. To the best of authors' knowledge, the present study illustrates for the first time the experience with successful treatment of pharyngeal perforation caused by a blunt cervical trauma in a child.