The endoscopic anterior transmaxillary temporal pole approach for mesial temporal lobe epilepsies: a feasibility study.

OBJECTIVE: In mesial temporal lobe epilepsy (MTLE), the ideal surgical approach to achieve seizure freedom and minimize morbidity is an unsolved question. Selective approaches to mesial temporal structures often result in suboptimal seizure outcomes. The authors report the results of a pilot study intended to evaluate the clinical feasibility of using an endoscopic anterior transmaxillary (eATM) approach for minimally invasive management of MTLEs. METHODS: The study is a prospectively collected case series of four consecutive patients who underwent the eATM approach for the treatment of MTLE and were followed for a minimum of 12 months. All participants underwent an epilepsy workup and surgical care at a tertiary referral comprehensive epilepsy center and had medically refractory epilepsy. The noninvasive evaluations and intracranial recordings of these patients confirmed the presence of anatomically restricted epileptogenic zones located in the mesial temporal structures. Data on seizure freedom at 1 year, neuropsychological outcomes, diffusion tractography, and adverse events were collected and analyzed. RESULTS: By applying the eATM technique and approaching the far anterior temporal lobe regions, mesial-basal resections of the temporal polar areas and mesial temporal structures were successfully achieved in all patients (2 with left-sided approaches, 2 with right-sided approaches). No neurological complications or neuropsychological declines were observed. All 4 patients achieved Engel class Ia outcome up to the end of the follow-up period (19, 15, 14, and 12 months). One patient developed hypoesthesia in the left V2 distribution but there were no other adverse events. The low degree of white matter injury from the eATM approach was analyzed using high-definition fiber tractography in 1 patient as a putative mechanism for preserving neuropsychological function. CONCLUSIONS: The described series demonstrates the feasibility and potential safety profile of a novel approach for medically refractory MTLE. The study affirms the feasibility of performing efficacious mesial temporal lobe resections through an eATM approach.

Depression history modulates effects of subthalamic nucleus topography on neuropsychological outcomes of deep brain stimulation for Parkinson's disease.

Patients with psychiatric symptoms, such as depression, anxiety, and visual hallucinations, may be at increased risk for adverse effects following deep brain stimulation of the subthalamic nucleus for Parkinson's disease, but there have been relatively few studies of associations between locations of chronic stimulation and neuropsychological outcomes. We sought to determine whether psychiatric history modulates associations between stimulation location within the subthalamic nucleus and postoperative affective and cognitive changes. We retrospectively identified 42 patients with Parkinson's disease who received bilateral subthalamic nucleus deep brain stimulation and who completed both pre- and postoperative neuropsychological testing. Active stimulation contacts were localized in MNI space using Lead-DBS software. Linear discriminant analysis identified vectors maximizing variance in postoperative neuropsychological changes, and Pearson's correlations were used to assess for linear relationships. Stimulation location was associated with postoperative change for only 3 of the 18 neuropsychological measures. Variation along the superioinferior (z) axis was most influential. Constraining the analysis to patients with a history of depression revealed 10 measures significantly associated with active contact location, primarily related to location along the anterioposterior (y) axis and with worse outcomes associated with more anterior stimulation. Analysis of patients with a history of anxiety revealed 5 measures with location-associated changes without a predominant axis. History of visual hallucinations was not associated with significant findings. Our results suggest that a history of depression may influence the relationship between active contact location and neuropsychological outcomes following subthalamic nucleus deep brain stimulation. These patients may be more sensitive to off-target (nonmotor) stimulation.

Delayed haemorrhage and pseudoaneurysms following liver trauma.

BACKGROUND: Delayed Haemorrhage (DH) is a potential complication following liver trauma. Hepatic artery pseudoaneurysms (HAPAs) are also a frequently considered delayed complication of liver trauma, yet their incidence is rare. Furthermore, little is known about their natural history, with some observed to resolve spontaneously. Some authors postulate that DH following liver trauma may in fact originate from HAPAs. AIM: To investigate the incidence of DH and HAPA following liver trauma, review subsequent management and explore a possible association between the two. METHODS: A retrospective study of liver trauma over a 14 year period at a trauma centre, including a case-control analysis comparing patients with DH and HAPA to liver injury grade matched controls. RESULTS: 450 patients were admitted with liver trauma of which 10 patients had DH (2.2%) and 7 HAPA (1.6%). Both DH and HAPA patients had significantly greater blood transfusion requirements, lower haemoglobin (Hb) levels and a greater Hb decrease compared to controls. No patient with an HAPA had a large volume of haemoperitoneum on imaging, and there were no patients in the clinical DH group with previous or concurrent HAPA identified, and no deaths in either group. CONCLUSION: DH and HAPA following liver trauma are rare. DH following liver trauma was not associated with HAPA on imaging. This study shows that HAPAs cause ongoing insidious bleeding and Hb decline, but we did not find evidence to support the commonly held perception of a risk of 'rupture' and catastrophic haemorrhage.

Exploring the effect of napping on sleep quality and duration in collegiate athletes.

Purpose: The purpose of this study was to extend research on napping and sleep behaviors in collegiate athletes, and to compare nappers and non-nappers on sleep quality and duration. Methods: Current varsity, club, and intramural athletes between 18-29 years completed the Short Napping Behavior Scale, Pittsburgh Quality Sleep Index, Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9. Results: Approximately 72% (129/179) reported napping. There were no significant differences in outcomes between nap frequency groups on sleep quality (Χ2(3)=4.97, p=.17) or duration (Χ2(3)=1.20, p=.75). Moreover, there was no significant differences for nap length groups on sleep quality (Χ2(3)=7.03, p=.07) or duration (Χ2(3)=1.32, p=.72). Furthermore, there were no significant differences for nap timing groups on sleep quality (Χ2(3)=1.54, p=.67) or duration (Χ2(3)=2.43, p=.49). Conclusion: In a sample of collegiate athletes, nap frequency, length, and timing were not associated with worse sleep quality or duration.

Socioeconomic inequality: accessibility and outcomes after renal transplantation in New Zealand.

BACKGROUND: Socioeconomic deprivation (SED) is a risk factor for worse outcomes after renal transplantation (RTx). This study aimed to evaluate access to RTx in different SED strata of the New Zealand population. We also assessed patient survival, acute cellular allograft rejection (AR) and allograft loss. METHODS: This was an Australian and New Zealand Dialysis and Transplantation and Organ Donation Registries-based retrospective cohort study. Patients who underwent RTx in New Zealand from 2008 to 2018 were identified. Patients younger than 16 years of age and those who left the country after RTx were excluded. RESULTS: In the higher SED stratum of New Zealanders, the rate of RTx was 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval: 1.33-1.76; p < 0.00005). RESULTS: One hundred and thirteen (23%) patients from the lower SED group and 51 (14.8%) patients from the higher SED group underwent living unrelated RTx, p = 0.0033. In 233 (67.5%) patients from the higher SED group and 265 (53.9%) patients from the lower SED group, transplanted kidneys were from deceased donors RTx, p = 0.0001. The incidence of allograft loss and patient survival were similar in these groups. CONCLUSION: Our data demonstrated a lower overall survival in the more socioeconomically deprived patients than in the lower SED group however this was not statistically significant after adjustment for covariates. A larger study is required to determine whether SED is associated with reduced survival.

Lateralized Effect of Thalamic Deep Brain Stimulation Location on Verbal Abstraction.

BACKGROUND: Regionalized thalamic activity has been implicated in language function, and yet the effect of thalamic deep brain stimulation (DBS) on language-related clinical outcomes is underexplored. OBJECTIVE: The objective of this study was to determine if the location of stimulation within the thalamus correlates with changes in language-related neuropsychological outcomes following DBS for essential tremor. METHODS: Thirty patients with essential tremor underwent comprehensive neuropsychological evaluations before and after DBS surgery targeting the ventral intermediate nucleus of the thalamus. Changes in neuropsychological functions were evaluated. The relationships between language-related outcomes and stimulation location were assessed using both categorical and linear methods. Any significant results were further validated using linear discriminant analysis. RESULTS: Most neuropsychological functions remained unchanged at the group level. However, outcome on a measure of verbal abstraction was significantly dependent on stimulation location along the anterior-posterior axis within the left ventral lateral thalamus, with anterior stimulation associated with reduced verbal abstraction performance. This result was supported by linear discriminant analysis, which showed that stimulation locations with improved and reduced verbal abstraction function were best separated by a vector nearly parallel to the anterior-posterior axis. No stimulation location dependence was found for verbal abstraction outcome in the right thalamus or for outcomes of other language functions in either hemisphere. CONCLUSION: We demonstrate an effect of thalamic DBS on verbal abstraction as a function of left thalamic topography. This finding provides clinical evidence for the lateralization and regionalization of thalamic language function that may be relevant for understanding nonmotor effects of stimulation. © 2021 International Parkinson and Movement Disorder Society.

Comparing Before- and After-School Neurocognitive Performance in High School Athletes: Implications for Concussion Management.

OBJECTIVE: To compare before- and after-school neurocognitive performance and total symptoms in a sample of nonconcussed high school athletes. DESIGN: Repeated-measures, counterbalanced design. SETTING: Midwest high schools. PARTICIPANTS: Thirty-nine nonconcussed high school athletes. INTERVENTIONS: The Immediate Post-Concussion Assessment and Cognitive Testing battery was administered before and after school in a counterbalanced testing order. MAIN OUTCOME MEASURES: Neurocognitive and total symptom scores. RESULTS: Paired-sample t tests revealed no significant differences in verbal memory (P = 0.43), visual memory (P = 0.44), processing speed (P = 0.94), reaction time (P = 0.16), or total symptoms (P = 0.52) between before- and after-school testing sessions. CONCLUSIONS: The results of this study expand on best practice guidelines for baseline and postinjury concussion computerized neurocognitive testing and symptom report administration. This study suggests that sports medicine professionals can administer computerized neurocognitive testing before or after school without concern of confounding factors affecting performance or total symptoms.

Association of Preoperative Visual Hallucinations With Cognitive Decline After Deep Brain Stimulation for Parkinson's Disease.

OBJECTIVE: Deep brain stimulation (DBS) is effective for the motor symptoms of Parkinson's disease (PD). Although most patients benefit with minimal cognitive side effects, cognitive decline is a risk, and there is little available evidence to guide preoperative risk assessment. Visual illusions or visual hallucinations (VHs) and impulse-control behaviors (ICBs) are relatively common complications of PD and its treatment and may be a marker of more advanced disease, but their relationship with postoperative cognition has not been established. The authors aimed to determine whether any preoperative history of VHs or ICBs is associated with cognitive change after DBS. METHODS: Retrospective chart review identified 54 patients with PD who received DBS of the subthalamic nucleus or globus pallidus internus and who completed both pre- and postoperative neuropsychological testing. Linear regression models were used to assess whether any preoperative history of VHs or ICBs was associated with changes in attention, executive function, language, memory, or visuospatial cognitive domains while controlling for surgical target and duration between evaluations. RESULTS: The investigators found that a history of VHs was associated with declines in attention (b=-4.04, p=0.041) and executive function (b=-4.24, p=0.021). A history of ICBs was not associated with any significant changes. CONCLUSIONS: These results suggest that a history of VHs may increase risk of cognitive decline after DBS; thus, specific preoperative counseling and targeted remediation strategies for these patients may be indicated. In contrast, a history of ICBs does not appear to be associated with increased cognitive risk.

Observations from Social Media Regarding the Symptomatology of Adult Hydrocephalus Patients.

BACKGROUND: Patients with hydrocephalus experience symptoms related to hydrocephalus in an age-dependent manner. However, prevalence estimates of hydrocephalus symptoms in young and middle-aged (YMA) adult patients are rare and variable. Highlighting the importance of hydrocephalus symptom management, the persistence and intensity of headache or gait disturbance have been associated with signs of brain white matter integrity loss, including in treated YMA adult patients. Thus, it is important to ascertain which symptoms adult patients with hydrocephalus report most to confirm their relative importance. METHODS: Observations of symptom complaints were made from publicly viewable online responses to an inquiry posted by the Hydrocephalus Association to 2 Facebook webpages. RESULTS: Within 7 days of inquiry posting, 381 complaints of signs and symptoms were identified in 82 online responses. Headache, cognitive deficits (cognition and memory), and mobility issues (dizziness, balance, or gait problems) were most commonly reported by 63%, 45%, and 40% of respondents, respectively. Results were highly similar for the subgroup of 53 patients reported as treated. For self-identified YMA patients (<60 years old), results were similar, but with fewer mobility complaints. Not previously reported, hypersensitivity to external stimuli was reported by one-half of the patients that reported headache. CONCLUSIONS: The current results provide further quantitative support for the prioritization of study of headache, cognitive deficits, and mobility issues in YMA adult patients with hydrocephalus. Warranting further study, cranial hypersensitivity to external stimuli may represent a novel outcome measure, and treated YMA adult hydrocephalus patients continue to report symptoms associated with signs of brain damage.

Comparison of baseline ImPACT performance in amateur motocross riders to football and basketball athletes.

PRIMARY OBJECTIVE: The American Motorcyclist Association requires professional riders to undergo baseline computerized neurocognitive testing (CNT) using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test for concussion management. It is recommended this practice be expanded to the amateur level, but limited research has explored whether baseline testing is necessary for youth when normative data is available. This study evaluates the utility of baseline testing for amateur riders by comparing their performance to those of traditional youth sports comprising normative datasets. DESIGN/METHODS: An cross-sectional study comparing amateur motocross (N = 100) riders matched by age and sex to football (N = 100) and basketball (N = 100) athletes performance on baseline ImPACT testing. RESULTS: ANCOVAs revealed a significant medium effect of group on measures of visual motor speed (F = 11.25, p < 0.001) and reaction time (F = 13.61, p < 0.001). Post hoc analyses revealed that motocross riders were significantly slower compared to football and basketball athletes. There were no significant differences (p > .05) between sport on measures of memory or symptoms. CONCLUSIONS: Youth motocross riders performed significantly slower on speed measures compared to football and basketball athletes, providing preliminary support for the expansion of baseline ImPACT testing to the amateur level.

Association of Concussion With Abnormal Menstrual Patterns in Adolescent and Young Women.

Importance: Brain injury may interrupt menstrual patterns by altering hypothalamic-pituitary-ovarian axis function. Investigators have yet to evaluate the association of concussion with menstrual patterns in young women. Objective: To compare abnormal menstrual patterns in adolescent and young women after a sport-related concussion with those after sport-related orthopedic injuries to areas other than the head (nonhead). Design, Setting, and Participants: This prospective cohort study of adolescent and young women with a sport-related concussion (n = 68) or a nonhead sport-related orthopedic injury (n = 61) followed up participants for 120 days after injury. Patients aged 12 to 21 years who presented within 30 days after a sport-related injury to a concussion or sports medicine clinic at a single academic center were eligible. Menstrual patterns were assessed using a weekly text message link to an online survey inquiring about bleeding episodes each week. The first patient was enrolled on October 14, 2014, and follow-up was completed on January 24, 2016. Inclusion criteria required participants to be at least 2 years postmenarche, to report regular menses in the previous year, and to report no use of hormonal contraception. Exposures: Sport-related concussion or nonhead sport-related orthopedic injury. Main Outcomes and Measures: Abnormal menstrual patterns were defined by an intermenstrual interval of less than 21 days (short) or more than 35 days (long) or a bleeding duration of less than 3 days or more than 7 days. Results: A total of 1784 survey responses were completed of the 1888 text messages received by patients, yielding 487 menstrual patterns in 128 patients (mean [SD] age, 16.2 [2.0] years). Of the 68 patients who had a concussion, 16 (23.5%) experienced 2 or more abnormal menstrual patterns during the study period compared with 3 of 60 patients (5%) who had an orthopedic injury. Despite similar gynecologic age, body mass index, and type of sports participation between groups, the risk of 2 or more abnormal menstrual bleeding patterns after injury was significantly higher among patients with concussion than among those with an orthopedic injury (odds ratio, 5.85; 95% CI, 1.61-21.22). Conclusions and Relevance: Adolescent and young women may have increased risk of multiple abnormal menstrual patterns after concussion. Because abnormal menstrual patterns can have important health implications, monitoring menstrual patterns after concussion may be warranted in this population. Additional research is needed to elucidate the relationship between long-term consequences of concussion and the function of the hypothalamic-pituitary-ovarian axis.

Effects of Sleep Loss on Subjective Complaints and Objective Neurocognitive Performance as Measured by the Immediate Post-Concussion Assessment and Cognitive Testing.

OBJECTIVE: This study examined the effects of total and partial sleep deprivation on subjective symptoms and objective neurocognitive performance, as measured by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) in a sample of healthy adults. METHOD: One-hundred and two, right-handed, healthy participants (between ages 18 and 30 years old) completed three consecutive nights in the sleep laboratory with concurrent continuous polysomnography monitoring. Night 1 served as a baseline night. Prior to Night 2, they were randomly assigned to one of three sleep conditions: undisrupted normal sleep (N = 34), sleep restriction (50% of habitual sleep, N = 37), or total sleep deprivation (N = 31). Participants slept undisturbed on Night 3. ImPACT was administered on three separate occasions. RESULTS: Sleep loss was associated with increased severity of subjectively reported affective, cognitive, physical, and sleep symptoms. Although objective neurocognitive task scores derived from the ImPACT battery did not corroborate subjective complaints, sleep loss was associated with significant differences on tasks of visual memory, reaction time, and visual motor speed over time. CONCLUSIONS: While self-report measures suggested marked impairments following sleep loss, deficits in neurocognitive performance were observed only on three domains measured with ImPACT. ImPACT may capture subtle changes in neurocognitive performance following sleep loss; however, independent and larger validation studies are needed to determine its sensitivity to acute sleep loss and recovery sleep. Neurocognitive screening batteries may be useful for detecting the effects of more severe or chronic sleep loss under high-stress conditions that mimic high-risk occupations.

What is the physiological time to recovery after concussion? A systematic review.

AIM OR OBJECTIVE: The aim of this study is to consolidate studies of physiological measures following sport-related concussion (SRC) to determine if a time course of postinjury altered neurobiology can be outlined. This biological time course was considered with respect to clinically relevant outcomes such as vulnerability to repeat injury and safe timing of return to physical contact risk. DESIGN: Systematic review. DATA SOURCES: PubMed, CINAHL, Cochrane Central, PsychINFO. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were included if they reported original research on physiological or neurobiological changes after SRC. Excluded were cases series <5 subjects, reviews, meta-analyses, editorials, animal research and research not pertaining to SRC. RESULTS: A total of 5834 articles were identified, of which 80 were included for full-text data extraction and review. Relatively few longitudinal studies exist that follow both physiological dysfunction and clinical measures to recovery. SUMMARY/CONCLUSIONS: Modalities of measuring physiological change after SRC were categorised into the following: functional MRI, diffusion tensor imaging, magnetic resonance spectroscopy, cerebral blood flow, electrophysiology, heart rate, exercise, fluid biomarkers and transcranial magnetic stimulation. Due to differences in modalities, time course, study design and outcomes, it is not possible to define a single 'physiological time window' for SRC recovery. Multiple studies suggest physiological dysfunction may outlast current clinical measures of recovery, supporting a buffer zone of gradually increasing activity before full contact risk. Future studies need to use generalisable populations, longitudinal designs following to physiological and clinical recovery and careful correlation of neurobiological modalities with clinical measures.

Predictors of Pharmacological Intervention in Adolescents With Protracted Symptoms After Sports-Related Concussion.

BACKGROUND: Although recovery after concussion is spontaneous and typically occurs within 2-3 weeks, a subset of adolescents develop persistent symptoms after a sports-related concussion. Medications are frequently prescribed as part of a comprehensive treatment approach to alleviate these symptoms; however, there are no guidelines for prescription of pharmacologic therapy after concussion. OBJECTIVE: To investigate common factors that are associated with the use of medications (antiepileptic, antidepressant, neurostimulant, or sleeping medication) during recovery from a sports-related concussion. DESIGN: Retrospective observational study. SETTING: Single-center specialty concussion center. PARTICIPANTS: A total of 100 adolescents, between the ages of 12 and 18 years, who sustained concussion due to sports. ASSESSMENT OF RISK FACTORS: Independent variables collected included age at the time of concussion, gender, sports played, personal history of prior concussion or mental health disorder, and personal or family history of headache (eg, migraines) or seizure disorder. MAIN OUTCOME MEASURE: Prescription of medications for treatment of concussion. RESULTS: Twenty-four patients (24%) were prescribed medications in this study, all of whom reported headache at the time of medication prescription. Amantadine was the most commonly prescribed medication, with amitriptyline and melatonin also being prescribed. Among the demographic information collected, only age and gender met criteria for inclusion in the regression model. Logistic regression analysis demonstrated that the odds that female participants were prescribed medications was 3.790 (95% confidence interval = 1.262-11.380) higher than male participants. A higher symptom score on the initial Post Concussion Symptom Scale (PCSS) was associated with increased odds of being prescribed medications (odds ratio = 1.031, 95% CI = 1.009-1.052). CONCLUSIONS: The current study found that initial symptom severity and female gender were associated with use of medication in recovery from sports-related concussion among variables available for study. LEVEL OF EVIDENCE: II.

Long-Term Effects of Sports Concussions: Bridging the Neurocognitive Repercussions of the Injury with the Newest Neuroimaging Data.

Little is known of the long-term effects of sports-related concussion. Within the scientific literature, conclusions vary substantially where some work suggests there are no long-term consequences at all and other studies show rampant neurodegeneration thought to be caused by sometimes even a single concussive blow to the head. There is growing evidence that supports multiple long-term outcomes, showing both subclinical and clinically relevant changes in the brains of athletes, young and old alike. This article reviews the pathohistology of cerebral concussions and examines the extant literature with a focus on electrophysiological and neuroimaging findings. Neurobehavioral and neurocognitive changes are also reviewed, particularly as they are related to chronic traumatic encephalopathy. Lacunae within the literature are explored, and future research directions are proposed.

Removal From Play After Concussion and Recovery Time.

OBJECTIVE: Despite increases in education and awareness, many athletes continue to play with signs and symptoms of a sport-related concussion (SRC). The impact that continuing to play has on recovery is unknown. This study compared recovery time and related outcomes between athletes who were immediately removed from play and athletes who continued to play with an SRC. METHODS: A prospective, repeated measures design was used to compare neurocognitive performance, symptoms, and recovery time between 35 athletes (mean ± SD age, 15.61 ± 1.65 years) immediately removed after an SRC (REMOVED group) compared with 34 athletes (mean ± SD age, 15.35 ± 1.73 years) who continued to play (PLAYED group) with SRC. Neurocognitive and symptom data were obtained at baseline and at 1 to 7 days and 8 to 30 days after an SRC. RESULTS: The PLAYED group took longer to recover than the REMOVED group (44.4 ± 36.0 vs 22.0 ± 18.7 days; P = .003) and were 8.80 times more likely to demonstrate protracted recovery (≥21 days) (P < .001). Removal from play status was associated with the greatest risk of protracted recovery (adjusted odds ratio, 14.27; P = .001) compared with other predictors (eg, sex). The PLAYED group exhibited significantly worse neurocognitive and greater symptoms than the REMOVED group. CONCLUSIONS: SRC recovery time may be reduced if athletes are removed from participation. Immediate removal from play is the first step in mitigating prolonged SRC recovery, and these data support current consensus statements and management guidelines.