Novel treatment of intracerebral hemorrhage with mechanical tissue resuscitation.

OBJECTIVE: The previous laboratory and clinical experience of the authors had demonstrated that application of controlled subatmospheric pressure directly to injured soft tissue can result in increased survival of compromised tissues. Mechanical tissue resuscitation (MTR) is a new concept evolving from these discoveries. The authors' recent studies have demonstrated that traumatic brain injury tissue can also be salvaged. The aim of this study was to examine the effects of MTR application to injuries from intracerebral hemorrhages (ICHs) in a swine model. METHODS: The ICHs in swine were simulated by infusion of autologous artery blood into the right frontal lobe. A specially designed silicone manifold device was introduced directly into the hematoma. Continuous negative pressure at -50 mm Hg was applied through this device. T2- and T2*-weighted MRI, histological H&E staining, and immunostaining were examined. RESULTS: After 1 week of treatment, MTR significantly decreased gross hematoma volume by more than 60%, from 472.62 ± 230.19 mm3 in the nontreated group to 171.25 ± 75.38 mm3 in the MTR-treated group (p < 0.05). Total hypointense volumes measured on T2*-weighted MR images decreased from 791.99 ± 360.47 mm3 in the nontreated group to 371.16 ± 105.75 mm3 in the MTR-treated group (p < 0.05). The hyperintense area on the T2-weighted MR image decreased significantly from 2656.23 ± 426.26 mm3 in the nontreated group to 1816.66 ± 525.26 mm3 in the MTR-treated group (p < 0.05). When ICHs were treated with MTR for 2 weeks, the gross hematomas were reduced by 94%, from 112.23 ± 66.21 mm3 in the nontreated group to 6.12 ± 10.99 mm3 in the MTR-treated group (p = 0.003). MTR significantly decreased the total necrotic tissue volume in H&E staining from 120.42 ± 48.35 mm3 in the nontreated group to 60.94 ± 38.99 mm3 in the MTR-treated group (p < 0.05). The total hypointense volumes on T2*-weighted MR images were significantly reduced, from 385.54 ± 93.85 mm3 in the nontreated group to 220.54 ± 104.28 mm3 in the MTR-treated group (p < 0.05), while their mean T2 hyperintense volume decreased significantly from 2192.83 ± 728.27 mm3 in the nontreated group to 1366.97 ± 463.36 mm3 in the MTR-treated group (p < 0.05). Histology revealed that the capillary diameter in the reactive tissue rim adjacent to the hematoma increased in both the 1- and 2-week MTR-treated groups. Both von Willebrand factor and CD31 signals were detectable in endothelial cells within the hematoma cavity of both MTR-treated groups. CONCLUSIONS: This study demonstrates that local continuous application of controlled subatmospheric pressure to an ICH can safely remove more than half of a clot in 1 week and more than 90% in 2 weeks.

Usefulness of the measurement of neurite outgrowth of primary sensory neurons to study cancer-related painful complications.

Abnormal outgrowth of sensory nerves is one of the important contributors to pain associated with cancer and its treatments. Primary neuronal cultures derived from dorsal root ganglia (DRG) have been widely used to study pain-associated signal transduction and electrical activity of sensory nerves. However, there are only a few studies using primary DRG neuronal culture to investigate neurite outgrowth alterations due to underlying cancer-related factors and chemotherapeutic agents. In this study, primary DRG sensory neurons derived from mouse, non-human primate, and human were established in serum and growth factor-free conditions. A bovine serum albumin gradient centrifugation method improved the separation of sensory neurons from satellite cells. The purified DRG neurons were able to maintain their heterogeneous subpopulations, and displayed an increase in neurite growth when exposed to cancer-derived conditioned medium, while they showed a reduction in neurite length when treated with a neurotoxic chemotherapeutic agent. Additionally, a semi-automated quantification method was developed to measure neurite length in an accurate and time-efficient manner. Finally, these exogenous factors altered the gene expression patterns of murine primary sensory neurons, which are related to nerve growth, and neuro-inflammatory pain and nociceptor development. Together, the primary DRG neuronal culture in combination with a semi-automated quantification method can be a useful tool for further understanding the impact of exogenous factors on the growth of sensory nerve fibers and gene expression changes in sensory neurons.

Continuous improvement in patient safety and quality in neurological surgery: the American Board of Neurological Surgery in the past, present, and future.

The American Board of Neurological Surgery (ABNS) was incorporated in 1940 in recognition of the need for detailed training in and special qualifications for the practice of neurological surgery and for self-regulation of quality and safety in the field. The ABNS believes it is the duty of neurosurgeons to place a patient's welfare and rights above all other considerations and to provide care with compassion, respect for human dignity, honesty, and integrity. At its inception, the ABNS was the 13th member board of the American Board of Medical Specialties (ABMS), which itself was founded in 1933. Today, the ABNS is one of the 24 member boards of the ABMS.To better serve public health and safety in a rapidly changing healthcare environment, the ABNS continues to evolve in order to elevate standards for the practice of neurological surgery. In connection with its activities, including initial certification, recognition of focused practice, and continuous certification, the ABNS actively seeks and incorporates input from the public and the physicians it serves. The ABNS board certification processes are designed to evaluate both real-life subspecialty neurosurgical practice and overall neurosurgical knowledge, since most neurosurgeons provide call coverage for hospitals and thus must be competent to care for the full spectrum of neurosurgery.The purpose of this report is to describe the history, current state, and anticipated future direction of ABNS certification in the US.

Orbital Reconstruction via Deformable Titanium Mesh Following Spheno-Orbital Meningioma Resection: Ophthalmic Presentation and Outcomes.

PURPOSE: To present a surgical approach to reconstruction of the bony orbit following resection of spheno-orbital meningioma utilizing deformable titanium mesh while emphasizing the ophthalmic presentation and outcomes of the repair. METHODS: A retrospective chart review received International Review Board approval, and 20 patients met the inclusion criteria. All patients underwent resection of spheno-orbital meningioma followed by orbital reconstruction with deformable titanium mesh. Pre- and postoperative ophthalmic exam findings were recorded. Outcome measures include Snellen visual acuity, performance on automated Humphry 30-2 perimetry, extraocular motility, Hertel exophthalmometry, associated complications, and recurrence. A literature review of the use of titanium to reconstruct the orbit following resection of spheno-orbital meningioma was performed. RESULTS: Visual acuity improved (9/20) or remained the same (8/20) in 85% of patients. Fifteen of the 20 patients had pre- and postoperative visual fields performed, and 93% (14/15) experienced substantial improvement or no change with full fields. Of the 12 patients who had extraocular motility disturbance following surgery, 25% (3/12) had preexisting defects that did not change, 58% (7/12) returned to normal, and 17% (2/12) had new onset dysfunction that did not improve. Proptosis was reduced by a mean of 4.4 mm. Complications were rare and inconsequential, and recurrence was observed in 20% (4/20) at an average of 43 months following surgery. CONCLUSIONS: Orbital reconstruction using deformable titanium mesh is both safe and effective in the setting of resection of spheno-orbital meningioma. This study is the largest known report of orbits reconstructed with deformable titanium mesh in the available literature.The ophthalmic presentation of spheno-orbital meningioma and postoperative results are presented following description of orbital reconstruction utilizing deformable titanium mesh.

Craniocervical Osteoradionecrosis Treated with Neoadjuvant and Adjuvant Hyperbaric Oxygen in Combination with Posterior Spinal Fusion.

BACKGROUND: Radiation therapy for malignant head and neck cancers includes a risk for off-target effects to bony structures, posing a risk for osteoradionecrosis (ORN). Patients in whom ORN develops can also harbor concomitant osteomyelitis and reduced healing capacity, making for a particularly challenging entity to treat. Hyperbaric oxygen therapy (HBO) has been shown to be effective in the treatment of mandibular ORN in the otolaryngology literature; yet, few reports exist detailing its utility when treating ORN of the craniocervical junction. Herein, we report 2 cases of ORN of the craniocervical junction who received both neoadjuvant and adjuvant HBO in combination with posterior spinal fusion. CASE DESCRIPTION: Two patients with craniocervical junction ORN were treated with HBO delivered over 20 sessions before and after surgery in 90-minute treatments to 2.5 atmospheres of pressure. The patients underwent posterior occipital-cervical fusions with an average operative time of 301 (±21.5) minutes with 250 (±150) mL of blood loss. Both patients stayed in the hospital for 5 days, with no periprocedural complications. Outcomes included a 30% improvement of global assessment of function on follow-up EuroQol 5-Dimension Questionnaire. Postoperative imaging demonstrated solid bony fusion, and both patients returned to full work duty. CONCLUSIONS: ORN is a difficult-to-treat radiation complication in head and neck cancers. Few reports exist detailing treatment options for ORN of the craniocervical junction in conjunction with surgical stabilization. We report 2 successful cases of HBO-assisted treatment of ORN and highlight the important role HBO can play in promoting bony fusion in these at-risk patients.

A survey of intracranial aneurysm treatment practices among United States physicians.

BACKGROUND: Recent surveys have failed to examine cerebrovascular aneurysm treatment practices among US physicians. OBJECTIVE: To survey physicians who are actively involved in the care of patients with cerebrovascular aneurysms to determine current aneurysm treatment preferences. METHODS: A 25-question SurveyMonkey online survey was designed and distributed electronically to members of the Society of NeuroInterventional Surgery, Society of Vascular and Interventional Neurology, and the American Association of Neurological Surgeons/Congress of Neurological Surgeons Combined Cerebrovascular Section. RESULTS: 211 physicians completed the survey. Most respondents recommend endovascular treatment as the first-line management strategy for most ruptured (78%) and unruptured (71%) aneurysms. Thirty-eight per cent of respondents indicate that they routinely treat all patients with subarachnoid hemorrhage regardless of grade. Most physicians use the International Study of Unruptured Intracranial Aneurysms data for counseling patients on natural history risk (80%); a small minority (11%) always or usually recommend treatment of anterior circulation aneurysms of <5 mm. Two-thirds of respondents continue to recommend clipping for most middle cerebral artery aneurysms, while most (51%) recommend flow diversion for wide-necked internal carotid artery aneurysms. Follow-up imaging schedules are highly variable. Neurosurgeons at academic institutions and those practicing longer were more likely to recommend clipping surgery for aneurysms (p<0.05). CONCLUSIONS: This survey demonstrates considerable variability in patient selection for intracranial aneurysm treatment, preferred treatment strategies, and follow-up imaging schedules among US physicians.

A Pivotal Randomized Clinical Trial Evaluating the Safety and Effectiveness of a Novel Hydrogel Dural Sealant as an Adjunct to Dural Repair.

BACKGROUND: A watertight dural repair is critical to minimizing the risk of postoperative complications secondary to cerebrospinal fluid (CSF) leaks. OBJECTIVE: To evaluate the safety and efficacy of a novel hydrogel, Adherus Dural Sealant, when compared with control, DuraSeal Dural Sealant System, as an adjunct to standard methods of dural repair. METHODS: In this 17-center, prospective, randomized clinical trial designed as a noninferiority, single-blinded study, 124 patients received Adherus Dural Sealant (test sealant) and 126 received DuraSeal (control). The primary composite endpoint was the proportion of patients who were free of any intraoperative CSF leakage during Valsalva maneuver after dural repair, CSF leak/pseudomeningocele, and unplanned retreatment of the surgical site. Each component was then analyzed individually as a secondary endpoint. Patients were followed for 4 mo after surgery. RESULTS: The primary composite endpoint at the 120-d follow-up was achieved in 91.2% of the test sealant group compared with 90.6% of the control, thus showing that the test sealant was statistically significantly noninferior to DuraSeal ( P = .0049). Post hoc analysis of the primary composite endpoint at 14 d demonstrated superiority of the test sealant over the control ( P = .030). Primary endpoint failures in the control group tended to occur early in follow-up period, while a majority of test dural sealant failures were identified through protocol-required radiographic imaging at the 120-d follow-up visit. CONCLUSION: The test sealant, Adherus Dural Sealant, is a practical, safe, and effective adjunct to achieving a watertight dural closure after primary dural closure in cranial procedures.

A Pilot Study of the Level of Evidence and Collaboration in Published Neurosurgical Research.

OBJECTIVE: Large-scale studies analyzing neurosurgical published research are lacking. This pilot study was designed to assess feasibility of an ongoing annual neurosurgical literature and research analysis of published articles in English-language neurosurgery journals. METHODS: All scientific articles published during 2015 in the print version of 14 English-language neurosurgery journals were reviewed individually. RESULTS: During 2015, 4065 articles were published in 14 neurosurgical journals. Of these, 1116 (27.5%) were nonscientific articles and were excluded from the analysis, and 2949 scientific articles were analyzed. Of these, 2% and 8.5% of publications met criteria for levels of evidence 1 and 2, respectively. One third of published manuscripts (33.2%) were retrospective chart reviews. There were 1742 different centers (mean 1.95 centers per article; range, 1-19) represented in 2949 articles from 67 countries (mean 1.23 countries per article; range, 1-12). Multicenter collaboration was present in 47.5% of published articles, and international collaboration was present in 17.5%. The highest numbers of U.S. author international collaborations were with Canada (70 collaborations), China (33 collaborations) and Italy (25 collaborations). Data for levels of evidence, multicenter collaborations, and international collaborations are presented for each individual journal and subject within neurosurgery. CONCLUSIONS: This pilot analysis provides a descriptive assessment of levels of evidence and collaboration based on journal, general subject matter, and subcategories of subject allowing for comparison. This methodology may be used on an annual basis to establish neurosurgery publication trends and to identify underrepresented areas of research within the specialty.

Evaluation of a Traumatic Vertebral Artery Occlusion.

BACKGROUND: Penetrating neck injury occurs in 5%-10% of all trauma cases and carries a significant burden of morbidity and mortality (15%). We describe the evaluation and management of a 25-year-old man shot in the neck with occlusion of the left vertebral artery from its origin to C6. This is a case report in which medical data were analyzed retrospectively with institutional review board approval. CASE DESCRIPTION: Neurologic examination revealed paresthesias and dysesthesias in a left C8 dermatomal distribution. Computed tomography angiography of the neck demonstrated no opacification of the left vertebral artery from its origin to C6. Magnetic resonance imaging of the cervical spine revealed an acute infarct in the left cerebellum. A cerebral angiogram highlighted hemodynamic compromise, and the patient was felt to be at significant risk of further cerebral infarction. Augmenting flow to the posterior circulation would mitigate that risk. The patient was taken to the operating room for a transposition of the vertebral artery to the common carotid artery. CONCLUSIONS: The patient presented with silent cerebellar infarction due to a vertebral artery injury and impending vertebrobasilar insufficiency. This case demonstrates clinical evaluation of the posterior circulation and treatment with a bypass technique through mobilization of the vertebral artery from the boney vertebral foramen with anastomosis to the common carotid.

Gabapentin for the Management of Chronic Pelvic Pain in Women (GaPP1): A Pilot Randomised Controlled Trial.

Chronic pelvic pain (CPP) affects 2.1-24% of women. Frequently, no underlying pathology is identified, and the pain is difficult to manage. Gabapentin is prescribed for CPP despite no robust evidence of efficacy. We performed a pilot trial in two UK centres to inform the planning of a future multicentre RCT to evaluate gabapentin in CPP management. Our primary objective was to determine levels of participant recruitment and retention. Secondary objectives included estimating potential effectiveness, acceptability to participants of trial methodology, and cost-effectiveness of gabapentin. Women with CPP and no obvious pelvic pathology were assigned to an increasing regimen of gabapentin (300-2700 mg daily) or placebo. We calculated the proportion of eligible women randomised, and of randomised participants who were followed up to six months. The analyses by treatment group were by intention-to-treat. Interviews were conducted to evaluate women's experiences of the trial. A probabilistic decision analytical model was used to estimate cost-effectiveness. Between September 2012-2013, 47 women (34% of those eligible) were randomised (22 to gabapentin, 25 to placebo), and 25 (53%) completed six-month follow-up. Participants on gabapentin had less pain (BPI difference 1.72 points, 95% CI:0.07-3.36), and an improvement in mood (HADS difference 4.35 points, 95% CI:1.97-6.73) at six months than those allocated placebo. The majority of participants described their trial experience favorably. At the UK threshold for willingness-to-pay, the probabilities of gabapentin or no treatment being cost-effective are similar. A pilot trial assessing gabapentin for CPP was feasible, but uncertainty remains, highlighting the need for a large definitive trial.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

Relapsing intracranial plasma cell granuloma: A case report.

Plasma cell granuloma is a pathological entity reported in nearly every organ system; however, intracranial cases remain rare. In the current case report, we present a case of intracranial plasma cell granuloma with the longest known follow-up period in the literature. Medical follow-up over 14 years, detailing four recurrences following the patient's initial presentation and management, is presented. The patient's treatment course consisted of three craniotomies, 3,600-cGy fractionated radiation and two courses of glucocorticoid therapy. In addition to disease surveillance using clinical examination and imaging, this case represents the first description of the clinical utility of analyzing changes in an inflammatory blood marker, the erythrocyte sedimentation rate, which coincided with recurrence and response to therapy.

Somatostatin receptor molecular imaging for metastatic intracranial hemangiopericytoma.

Intracranial hemangiopericytomas (HPCs) are rare tumors that closely mimic meningiomas. However, in contrast to meningiomas, HPCs have a relatively high incidence of local recurrence and distant metastases, manifesting the need for sensitive noninvasive methods of detection that efficiently image the entire body. We present a rare case of a right optic nerve sheath HPC in which we identified a previously unknown distant metastasis in the thoracic spine on an 111In-pentetreotide scan. We detail the radiologic characteristics seen with somatostatin receptor imaging, FDG PET, and MRI and discuss how to exploit these findings to detect recurrence and metastatic disease in HPC.

EEG in connection with coma.

BACKGROUND: Coma is a dynamic condition that may have various causes. Important changes may take place rapidly, often with consequences for treatment. The purpose of this article is to provide a brief overview of EEG patterns in comas with various causes, and indicate how EEG contributes in an assessment of the prognosis for coma patients. METHOD: The article is based on many years of clinical and research-based experience of EEG used for patients in coma. A self-built reference database was supplemented by searches for relevant articles in PubMed. RESULTS: EEG reveals immediate changes in coma, and can provide early information on cause and prognosis. It is the only diagnostic tool for detecting a non-convulsive epileptic status. Locked-in- syndrome may be overseen without EEG. Repeated EEG scans increase diagnostic certainty and make it possible to monitor the development of coma. INTERPRETATION: EEG reflects brain function continuously and therefore holds a key place in the assessment and treatment of coma.