SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review.

The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including spontaneous spinal hemorrhage (SSH), are diverse. SSH is a detrimental neurosurgical event requiring immediate medical attention. We aimed to investigate the association between SARS-CoV-2 and SSH and delineate a rational clinical approach. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to January 25, 2023, on SSH and SARS-CoV-2 infection. For each dataset, the authors performed pooled estimates examining three outcomes of interest: (1) early post-intervention neurological status, (2) mortality, and (3) post-intervention neurological rehabilitation outcomes. After reviewing 1341 results, seven datasets were identified for the final analysis. Fifty-seven percent of patients were females. Twenty-eight percent of the patients experienced severe systemic infection. The mean interval between the SARS-CoV-2 infection and neurological presentation was 18 days. Pain and sensorimotor deficits were the most common (57%). Spinal epidural hematoma (EDH) was the most common presentation (71.4%). Three patients were treated conservatively, while 4 received neurosurgical intervention. Pain and sensorimotor deficits had the best treatment response (100%), while the sphincter had the worst response (0%). Long-term follow-up showed that 71% of patients had good recovery. SARS-CoV-2-associated SSH is a rare complication of infection, with an often insidious presentation that requires high clinical suspicion. Patients with SARS-CoV-2 infection and new neurological symptoms or disproportionate neck or back pain require a neuroaxis evaluation. Neurosurgical intervention and conservative management are both viable options to treat SSH following COVID-19. Still, a homogenous approach to the treatment paradigm of SSH cannot be obtained, but lesions with space-occupying effects are suitable for neurosurgical evacuation-decompression while more indolent lesions could be treated conservatively. These options should be tailored individually until larger studies provide a consensus.

Radiolucent Carbon Fiber-Reinforced Implants for Treatment of Spinal Tumors-Clinical, Radiographic, and Dosimetric Considerations.

The management of spine tumors is multimodal and personalized to each individual patient. Patients often require radiation therapy after surgical fixation. Although titanium implants are used most commonly, they produce significant artifact, leading to decreased confidence in target-volume coverage and normal tissue sparing. Carbon-based materials have been found to have minimal effects on dose perturbation in postoperative radiation therapy and have shown biostability and biocompatibility that are comparable to titanium implants. Using the PubMed and Web of Sciences databases, we conducted a systematic review of carbon-based screw and rod fixation systems in the treatment of spinal tumors. We reviewed clinical studies regarding safety of spine fixation with carbon fiber-reinforced (CFR) implants and biomechanical studies, as well as radiation and dosimetric studies. The radiolucency of CFR-polyether ether ketone implants has the potential to benefit patients with spine tumor. Clinical studies have shown no increase in complications with implementation of CFR-polyether ether ketone implants, and these devices seem to have sufficient stiffness and pullout strength. However, further trials are necessary to determine if there is a clinically significant impact on local tumor control.

Retraction: Effects of the COVID-19 Pandemic on Stroke Patients.

[This retracts the article DOI: 10.7759/cureus.9995.].

Generalized Dystonia Treated With Deep Brain Stimulator: An Institutional Single Surgeon Experience.

Introduction Dystonia can cause severe disability when left untreated. Once a patient has exhausted medical management, surgical intervention may be the only treatment option. Although not curative, deep brain stimulation has been shown to be beneficial for patients affected by this condition. Our study sought to review patients undergoing deep brain stimulation for medically refractory dystonia to assess outcomes. Methods Our institution's operative database was reviewed retrospectively for all patients undergoing deep brain stimulator placement over the last six years. These medical records were reviewed for the severity of dystonia preoperatively and followed postoperatively for 24 months, focusing on the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). Patients with less than two-year postoperative follow-up were excluded from the study. The patients were further stratified by age into Group A, consisting of patients less than 40 years old, and Group B, patients greater than or equal to 40 years old. Other attributes such as age, sex, age of disease onset, disease duration at the time of surgery, genetic tests for dystonia-related genes, and any complication associated with surgery were also reviewed. Results Four hundred fifty-five operative cases for deep brain stimulator placement were reviewed, and 16 patients met inclusion criteria for the study. The mean age for our patient cohort was 43.75 years, with four males and 12 females. The average time from the age of disease onset to time of surgery was 9.7 years for Group A and 10.8 years for Group B; the overall average was 10.3 years. All patients had globus pallidus interna (GPi) as their surgical target. The first incidence of a statistically significant decrease in BFMDRS score was noted at three months postoperatively (p<0.001) when compared to preoperative values. Fourteen patients in our cohort underwent preoperative genetic testing for DYT gene mutations, out of which four were found to have a mutation. Conclusion Our review of outcomes for primary generalized dystonia at our institution found that deep brain stimulator targeting the GPi is safe and effective. We found an overall 88% response rate with younger patients (< 40-year-old) showing a better response at two years than older patients.

Effects of the COVID-19 Pandemic on Stroke Patients.

Introduction The severe acute respiratory syndrome coronavirus 2 (SARS2-CoV-2) induced pandemic (COVID-19 pandemic) has affected healthcare in all aspects, including stroke care. We sought to investigate this effect with analysis of our hospital's stroke treatment protocols as well as stroke volume on state, regional, and national levels. Methods This was a retrospective review of prospectively collected data from our stroke registry to assess the impact of the SARS2-CoV-2 induced pandemic on the volume of stroke patients presenting to our facility. Demographics collected included age, sex, race, National Institute of Health Stroke Scale (NIHSS) on admission, discharge modified Rankin Score (mRS), type of stroke (ischemic, hemorrhagic, or transient ischemic attack), time of symptom onset, and time to initial imaging. Data were also stratified by date and comparison was made between the intra-COVID-period (March and April 2020), pre-COVID period (March and April 2019), and peri-COVID period (January and February 2020). To determine stroke trends on a national level, we utilized the Get with the Guidelines (GWTG) stroke database to compare stroke volumes in the pre-COVID, peri-COVID, and intra-COVID periods between our hospital, all California hospitals, and the West and Pacific regions. Results There was a significant increase in last known well time (LKWT) to arrival to the emergency department (ED) (LKWT to door) as well as time from arrival to the ED to obtaining a computed tomography (CT) of the head (door to CT) in March 2020 compared to 2019 (p=0.0220 and p=0.0475, respectively). There were significantly fewer transient ischemic attacks (TIAs) in California hospitals as well as in March and April 2020 in comparison to January and February 2020 (p=0.0417). Similarly, there were significantly fewer TIAs in March and April 2019 compared to March and April 2020 (p=0.0360). The decrease in TIAs was also seen at our hospital in both time frame comparisons as well as in West Regional Hospitals in March and April 2020 compared to March and April 2019 (p=0.0111, p=0.0215, and p=0.0414, respectively). Conclusion Stroke care has been disrupted by the COVID-19 pandemic worldwide. We identified a delay in LKWT to door as well as time from door to CT in March 2020 compared to March 2019 at our institution. There was a statistically significant decrease in final diagnosis of TIA at our hospital, all California hospitals, and all West Regional hospitals during the March-April 2020 window, suggesting that some patients with minor stroke symptoms may not be presenting to the hospital in the midst of the pandemic. Strategies to minimize delays in care and maximize functional recovery must continue to evolve as new challenges are met during the COVID-19 pandemic.

Cervical osteochondroma: surgical planning.

INTRODUCTION: Osteochondromas are benign bone tumors which occur as solitary lesions or as part of the syndrome multiple hereditary exostoses. While most osteochondromas occur in the appendicular skeleton, they can also occur in the spine. Most lesions are asymptomatic however some may encroach on the spinal cord or the nerve roots causing neurological symptoms. While most patients with osteochondromas undergo laminectomy without fusion, laminectomy with fusion is indicated in appropriately selected cases of spinal decompression. CASE PRESENTATION: We present a case of a 32-year-old male with history of multiple hereditary exostoses who presented with symptoms of bilateral upper extremity numbness and complaints of gait imbalance and multiple falls. He reported rapid progression of his symptoms during the 10 days before presentation. Computed tomography of the cervical spine revealed a lobulated bony tumor along the inner margin of the cervical 4 lamina. He underwent cervical 3 and 4 laminectomies, partial cervical 2 and 5 laminectomies and cervical 3-5 mass screw placement. Pathology was consistent with osteochondroma. The patient's symptoms had markedly improved at follow-up. CONCLUSION: According to our literature review, osteochondromas most commonly occur at cervical 2 and cervical 5. We present a case of an osteochondroma at a less common level, cervical 4. While most osteochondromas are addressed with laminectomy without arthrodesis, the decision of whether arthrodesis is necessary should be considered in all patients with osteochondroma as with any cervical decompression.

Brain metastases from cervical cancer reduce longevity independent of overall tumor burden.

BACKGROUND: Isolated brain metastasis (IBM) from cervical cancer is a very rare encounter in neurosurgery. We sought to understand how patients with isolated brain metastases differ from those with metastases in the setting of widespread disease. METHODS: A systematic review was completed using PubMed and the Cochrane Library. Patients with isolated brain metastases (IBM) and non-isolated brain metastases (NIBM, or brain metastases in the setting of disseminated disease), were compared. Two-sided statistical tests were used to determine significance. Survival function was carried out using the Kaplan-Meier method. RESULTS: A total of 89 patients, 25 with IBM and 64 with NIBM, were identified. The time interval between initial diagnosis of cervical cancer and diagnosis of brain lesion was significantly shorter in the IBM group (median 7.5 vs. 20.05 months, and IBM vs. NIBM, respectively; P = 0.006). Overall survival from initial diagnosis of cervical cancer was significantly shorter for the IBM group versus the NIBM group (7.63 vs. 26.3 months, respectively; P = 0.0005). Data demonstrate a 3.4-fold reduction of median life expectancy to 7.63 months. Survival after diagnosis of brain metastases did not differ between groups (median, IBM 7 months vs. NIBM 4 months, P = 0.08). CONCLUSION: Taken together, our data suggest that for cervical cancer patients with brain metastasis intracranial metastasis itself (and not overall tumor burden) represent a sentinel event in limiting longevity. While the present study is underpowered to compare treatment options directly, further work should be focused on determining the optimal treatment for these patients.

MRI-Guided High-Intensity Focused Ultrasound as an Emerging Therapy for Stroke: A Review.

Stroke, either ischemic or hemorrhagic, accounts for significantly high morbidity and mortality rates around the globe effecting millions of lives annually. For the past few decades, ultrasound has been extensively investigated to promote clot lysis for the treatment of stroke, myocardial infarction, and acute peripheral arterial occlusions, with or without the use of tPA or contrast agents. In the age of modern minimal invasive techniques, magnetic resonance imaging-guided high-intensity focused ultrasound is a new emerging modality that seems to promise therapeutic utilities for both ischemic and hemorrhagic stroke. High-intensity focused ultrasound causes thermal heating as the tissue absorbs the mechanical energy transmitted by the ultrasonic waves leading to tissue denaturation and coagulation. Several in-vitro and in-vivo studies have demonstrated the viability of this technology for sonothrombolysis in both types of stroke and have warranted clinical trials. Apart from safety and efficacy, initiation of trials would further enable answers regarding its practical application in a clinical setup. Though this technology has been under study for treatment of various brain diseases for some decades now, relatively very few neurologists and even neurosurgeons seem to be acquainted with it. The aim of this review is to provide basic understanding of this powerful technology and discuss its clinical application and potential role as an emerging viable therapeutic option for the future management of stroke.

Multiple Extradural Spinal Meningiomas in a Patient with Acquired Immunodeficiency Syndrome: Case Report and Literature Review.

BACKGROUND: Purely extradural spinal meningiomas are uncommon. Due to their typical location in the neural foramen, they are often mistaken for schwannomas, neurofibromas, and epidural metastases. In addition, comorbid conditions such as immunodeficiency may obscure the diagnosis. We present a case of extradural spinal meningiomas in a patient with human immunodeficiency virus (HIV). This is the first reported case of multiple extradural spinal meningiomas in 2 separate regions of the spine. CASE DESCRIPTION: A 40-year-old male with a past medical history of HIV and hepatitis B infection presented with a 2-month history of progressive back pain radiating to the left flank and thigh. Magnetic resonance imaging of the thoracic and lumbar spine with intravenous gadolinium contrast revealed 2 extramedullary masses in the left neural foramina of T6 and L1. The patient underwent laminectomy, which revealed that the 2 lesions were entirely extradural. Both lesions were resected, and the histological diagnosis for both lesions was meningioma, World Health Organization grade I. CONCLUSIONS: Our experience with this 40-year-old male with AIDS who presented with radicular symptoms due to multiple purely extradural meningiomas underscores the importance of considering meningioma as a possible diagnosis in patients with tumors of the neural foramina. In addition, a wide differential diagnosis should be made for patients with spinal lesions and history of HIV, including illnesses that are related to immunodeficiency and those that are not.

Posterior-only Stabilization for Traumatic Thoracolumbar Burst Fractures.

Background No consensus exists for the management of unstable thoracolumbar (TL) burst fractures. Surgical options include anterior, lateral, or posterior stabilization (or a combination), depending on the fracture. The potential benefits of anterior reconstruction come with increased operative time and associated morbidity. A posterior-only approach can offer stable correction without increased operative risks but may result in loss of kyphotic correction over time. Purpose To determine whether posterior-only stabilization is a viable treatment option for patients with traumatic TL fractures as opposed to anterior and combined approaches. Methods We performed a retrospective analysis of adult patients with TL burst fractures who underwent posterior--only surgical intervention from 2005 to 2015. Operations were performed at two levels above and below the fractured segment using pedicle screw-rod fixation constructs with autograft and allograft. All patients received TL bracing for at least three months. Patients lost to follow-up were excluded. Results Sixty-four consecutive patients with posterior--only stabilization were identified, with 18 lost to follow-up. Of the remaining 46 patients, 93% (n=43) were male and 7% (n=3) were female, with a mean age of 36.8 years. All patients were followed for 12 months. The mean time until the removal of the brace was 3.54 months. No patients required additional surgical intervention for spinal stabilization. Three patients experienced postoperative complications, all of which were related to infection. Conclusions Our data indicate that posterior--only stabilization for traumatic TL burst fractures is a durable and effective option in select patients. The approach offers surgical intervention with a decreased perioperative risk as well as reduced morbidity and mortality, with a minimal increase in the risk of kyphotic deformity. Further prospective studies are necessary to validate these findings clinically.

Use of a Pediatric Craniotome Drill for Cervical and Thoracic Spine Decompression: Safety and Efficacy.

BACKGROUND: Laminectomy, using a high-speed drill with an unprotected cutting drill bit, can be rapid and effective, but it has been associated with known complications. Another technique uses a pediatric craniotome drill with the footplate attachment. At present, there are no studies comparing clinical outcomes between these 2 stated decompressive techniques. METHODS: A retrospective review was conducted at a single institution. Two cohorts of patients were considered based on the technical method of laminectomy for decompression. One group had decompression with utilization of a high-speed drill, whereas the other group had decompression with a pediatric craniotome drill with a footplate attachment. The outcomes from each group were compared based on the length of operation, estimated blood loss, and associated complications. RESULTS: A total of 91 patients were included in the final analysis. Forty-five of the patients underwent laminectomy using a footplate and 46, using a high-speed drill. The footplate group was associated with significantly shorter operative time (159 vs. 205 minutes; P = 0.008). In addition, the footplate technique demonstrated less estimated blood loss (254 vs. 349 mL), and less incidence of durotomies (2.2% vs. 10.9%); however, neither of these 2 outcomes achieved statistical significance. CONCLUSIONS: Despite being an older technique, there was a shorter operative time in the footplate group without increased blood loss or incidence of durotomy. Although comparable results are operator dependent, this technique is a safe alternative for performing cervical and thoracic laminectomies.

Chondromyxoid fibroma of the sacrum: A case report and literature review.

BACKGROUND: Chondromyxoid fibroma (CMF) is an extremely rare, benign cartilaginous tumor that makes up <0.5% of all bone tumors, typically presenting in the second or third decade of life. CMF of the sacrum is exceedingly rare, with only seven documented cases reported in the neurosurgical literature. CASE DESCRIPTION: We report a case of a 35-year-old female with a 3 month history of lower back pain after sustaining a fall on her sacrum/coccyx presenting with a progressive complaint of localized lower back pain, occasional urinary retention without incontinence, gluteal hypesthesia, and pressure below the gluteal crease. Imaging demonstrated a large, expansile enhancing soft-tissue lesion involving the sacrum, distal to the S2-3 disc space. The tumor was removed with partial sacrectomy for open en bloc resection with partial nerve sparing. The patient was found at 1.5-year follow-up with the improvement of symptoms, no recurrence, and no residual neurologic dysfunction. CONCLUSION: Sacral CMF is a rare clinical entity that may mirror more aggressive sacral pathology, including chordoma, in both clinical presentation and imaging characteristics. A review of the available literature regarding diagnosis, surgical management options, and prognosis for sacral CMF is provided.

Third Ventricular Glioblastoma Multiforme: Case Report and Literature Review.

Background Glioblastoma multiforme (GBM) typically presents in the supratentorial white matter, commonly within the centrum semiovale as a ring-enhancing lesion with areas of necrosis. An atypical presentation of this lesion, both anatomically as well as radiographically, is significant and must be part of the differential for a neoplasm in this anatomical location. Case Description We present a case of a 62-year-old woman with headaches, increasing somnolence, and cognitive decline for several weeks. Magnetic resonance imaging demonstrated mild left ventricular dilatation with a well-marginated, homogeneous, and nonhemorrhagic lesion located at the ceiling of the third ventricle within the junction of the septum pellucidum and fornix, without exhibiting the typical radiographic features of hemorrhage or necrosis. Final pathology reports confirmed the diagnosis of GBM. Conclusion This case report describes an unusual location for the most common primary brain neoplasm. Moreover, this case identifies the origin of a GBM related to the paracentral ventricular structures infiltrating the body of the fornix and leaves of the septum pellucidum. To our knowledge this report is the first reported case of a GBM found in this anatomical location with an entirely atypical radiographic presentation.

Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review.

Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.

Acute-onset cerebellar symptoms in Lhermitte-Duclos disease: case report.

Adult-onset Lhermitte-Duclos disease (LD), or dysplastic cerebellar gangliocytoma, is a hamartoma considered pathognomonic for Cowden disease. Classically, LD has a progressive and insidious onset of symptoms. In this case report, we present a patient having rapid neurological deterioration from acute-onset LD. There are only three reported cases of acute LD presentation. A 22-year-old female presented to the emergency department with diplopia, dysarthria, dysphagia, and gait instability which developed within 6 h. A non-contrast CT scan revealed diffuse attenuation in the left cerebellum and mild ventricular dilatation. LP revealed no organisms. Magnetic resonance imaging revealed salient "tiger stripe" appearance of the left cerebellar cortex and effacement of the fourth ventricle. The patient subsequently underwent suboccipital craniotomy and gross total resection of the lesion. The tumor histology showed distortion of normal cerebellar architecture with dysplastic ganglion cells, loss of Purkinje cells, atrophy of the white matter, and expansion of cerebellar folia. Findings were consistent with adult-onset Lhermitte-Duclos disease.

Supratentorial primitive neuroectodermal tumor in an adult: a case report and review of the literature.

INTRODUCTION: Supratentorial primitive neuroectodermal tumors predominantly occur in children, and are rare in the adult population. Less than 100 cases of supratentorial primitive neuroectodermal tumor have been reported in adults internationally. Our case study reports this rare incident. CASE PRESENTATION: A 22-year-old Hispanic man presented with headaches, blurry vision, diplopia, intermittent vomiting, and grossly decreased vision. A magnetic resonance image showed a left posterior parietal heterogeneously enhancing mass measuring 4.2cm × 7.2cm × 7.0cm. After craniotomy for resection and decompression, the mass was histologically revealed to be a supratentorial primitive neuroectodermal tumor. Standardized immunohistochemical studies for this mass were carried out. CONCLUSION: We have concluded that immunohistochemical and genetic workup should be included in the standardized pathological workup for primitive neuroectodermal tumors in order to provide more prognostic information. Based on our current literature review, we propose an immunohistochemical panel.

Membrane estrogen receptor-alpha interacts with metabotropic glutamate receptor type 1a to mobilize intracellular calcium in hypothalamic astrocytes.

Estradiol, acting on a membrane-associated estrogen receptor-alpha (mERalpha), induces an increase in free cytoplasmic calcium concentration ([Ca(2+)](i)) needed for progesterone synthesis in hypothalamic astrocytes. To determine whether rapid estradiol signaling involves an interaction of mERalpha with metabotropic glutamate receptor type 1a (mGluR1a), changes in [Ca(2+)](i) were monitored with the calcium indicator, Fluo-4 AM, in primary cultures of female postpubertal hypothalamic astrocytes. 17beta-Estradiol over a range of 1 nm to 100 nm induced a maximal increase in [Ca(2+)](i) flux measured as a change in relative fluorescence [DeltaF Ca(2+) = 615 +/- 36 to 641 +/- 47 relative fluorescent units (RFU)], whereas 0.1 nm of estradiol stimulated a moderate [Ca(2+)](i) increase (275 +/- 16 RFU). The rapid estradiol-induced [Ca(2+)](i) flux was blocked with 1 microm of the estrogen receptor antagonist ICI 182,780 (635 +/- 24 vs. 102 +/- 11 RFU, P < 0.001) and 20 nmof the mGluR1a antagonist LY 367385 (617 +/- 35 vs. 133 +/- 20 RFU, P < 0.001). Whereas the mGluR1a receptor agonist (RS)-3,5-dihydroxyphenyl-glycine (50 microm) also stimulated a robust [Ca(2+)](i) flux (626 +/- 23 RFU), combined treatment of estradiol (1 nm) plus (RS)-3,5-dihydroxyphenyl-glycine (50 microm) augmented the [Ca(2+)](i) response (762 +/- 17 RFU) compared with either compound alone (P < 0.001). Coimmunoprecipitation demonstrated a direct physical interaction between mERalpha and mGluR1a in the plasma membrane of hypothalamic astrocytes. These results indicate that mERalpha acts through mGluR1a, and mGluR1a activation facilitates the estradiol response, suggesting that neural activity can modify estradiol-induced membrane signaling in astrocytes.