Enhanced sleep staging with artificial intelligence: a validation study of new software for sleep scoring.

Manual sleep staging (MSS) using polysomnography is a time-consuming task, requires significant training, and can lead to significant variability among scorers. STAGER is a software program based on machine learning algorithms that has been developed by Medibio Limited (Savage, MN, USA) to perform automatic sleep staging using only EEG signals from polysomnography. This study aimed to extensively investigate its agreement with MSS performed during clinical practice and by three additional expert sleep technicians. Forty consecutive polysomnographic recordings of patients referred to three US sleep clinics for sleep evaluation were retrospectively collected and analyzed. Three experienced technicians independently staged the recording using the electroencephalography, electromyography, and electrooculography signals according to the American Academy of Sleep Medicine guidelines. The staging initially performed during clinical practice was also considered. Several agreement statistics between the automatic sleep staging (ASS) and MSS, among the different MSSs, and their differences were calculated. Bootstrap resampling was used to calculate 95% confidence intervals and the statistical significance of the differences. STAGER's ASS was most comparable with, or statistically significantly better than the MSS, except for a partial reduction in the positive percent agreement in the wake stage. These promising results indicate that STAGER software can perform ASS of inpatient polysomnographic recordings accurately in comparison with MSS.

High prevalence of major depression in US sleep clinics: the need for routine depression screening in sleep services.

Depression screening is not part of routine clinical practice in US sleep clinics. Our study aimed to report the prevalence of depression among individuals referred to US sleep clinics. According to our findings, approximately 21% of patients had depression, with about 4% reporting severe symptoms, 9% had frequent death and/or self-harming thoughts, and 61% were taking antidepressants. Our results highlighted a considerable risk of prevalent depression in sleep clinics and supported the limited existing data on this topic. Our study advocates for the need for routine depression screening in sleep services to reduce the detrimental consequences of a delayed depression diagnosis and the risk of a worse prognosis for both depression and sleep-wake disorders. CITATION: Daccò S, Caldirola D, Grassi M, Alciati A, Perna G, Defillo A. High prevalence of major depression in US sleep clinics: the need for routine depression screening in sleep services. J Clin Sleep Med. 2023;19(4):835-836.

Heart rate variability: Can it serve as a marker of mental health resilience?: Special Section on "Translational and Neuroscience Studies in Affective Disorders" Section Editor, Maria Nobile MD, PhD.

BACKGROUND: Stress resilience influences mental well-being and vulnerability to psychiatric disorders. Usually, measurement of resilience is based on subjective reports, susceptible to biases. It justifies the need for objective biological/physiological biomarkers of resilience. One promising candidate as biomarker of mental health resilience (MHR) is heart rate variability (HRV). The evidence for its use was reviewed in this study. METHODS: We focused on the relationship between HRV (as measured through decomposition of RR intervals from electrocardiogram) and responses to laboratory stressors in individuals without medical and psychiatric diseases. We conducted a bibliographic search of publications in the PubMed for January 2010-September 2018. RESULTS: Eight studies were included. High vagally mediated HRV before and/or during stressful laboratory tasks was associated with enhanced cognitive resilience to competitive/self-control challenges, appropriate emotional regulation during emotional tasks, and better modulation of cortisol, cardiovascular and inflammatory responses during psychosocial/mental tasks. LIMITATIONS: All studies were cross-sectional, restricting conclusions that can be made. Most studies included only young participants, with some samples of only males or females, and a limited array of HRV indexes. Ecological validity of stressful laboratory tasks remains unclear. CONCLUSIONS: Vagally mediated HRV may serve as a global index of an individual's flexibility and adaptability to stressors. This supports the idea of HRV as a plausible, noninvasive, and easily applicable biomarker of MHR. In future longitudinal studies, the implementation of wearable health devices, able to record HRV in naturalistic contexts of real-life, may be a valuable strategy to gain more reliable insight into this topic.

Extradural petromastoid calcifying pseudoneoplasm of the neuraxis (CAPNON): Case report and literature review.

BACKGROUND: Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a very rare tumor with fewer than 70 cases reported in the literature. In general, this tumor occurs intracranially either within the brain parenchyma or in an extra-axial location, but it has also been described within the spine as an extra-axial lesion. CASE DESCRIPTION: We describe an unusual case of intracranial-extradural CAPNON involving the mastoid region. This may be only the second such case reported in the literature, as one patient with CAPNON has been reported involving the sinonasal region. Our patient was managed with surgical resection through a translabyrinthine approach with good early result. CONCLUSIONS: We describe an unusual case of extradural CAPNON involving the mastoid bone. It appears that when located extradurally, this tumor may have a predilection for the bony sinuses. This little-known, generally benign entity can mimic more common lesions such as meningiomas, and should be considered in the differential diagnosis of skull base tumors, particularly when associated with heavy calcification.

Hormone replacement therapy and the risk of subarachnoid hemorrhage in postmenopausal women.

OBJECT The incidence of subarachnoid hemorrhage (SAH) increases after menopause. Anecdotal data suggest that hormone replacement therapy (HRT) may reduce the rate of SAH and aneurysm formation in women. The goal of this study was to determine the effect of HRT on occurrence of SAH in a large prospective cohort of postmenopausal women. METHODS The data were analyzed for 93, 676 women 50-79 years of age who were enrolled in the observational arm of the Women's Health Initiative Study. The effect of HRT on risk of SAH was determined over a period of 12 ± 1 years (mean ± SD) using Cox proportional hazards analysis after adjusting for potential confounders. Additional analysis was performed to identify the risk associated with "estrogen only" and "estrogen and progesterone" HRT among women. RESULTS Of the 93, 676 participants, 114 (0.1%) developed SAH during the follow-up period. The rate of SAH was higher among women on active HRT compared with those without HRT used (0.14% vs 0.11%, absolute difference 0.03%, p < 0.0001). In unadjusted analysis, participants who reported active use of HRT were 60% more likely to suffer an SAH (RR 1.6, 95% CI 1.1-2.3). Compared with women without HRT use, the risk of SAH continued to be higher among women reporting active use of HRT (RR 1.5, 95% CI 1.0-2.2) after adjusting for age, systolic blood pressure, cigarette smoking, alcohol consumption, body mass index, race/ethnicity, diabetes, and cardiovascular disease. The risk of SAH was nonsignificantly higher among women on "estrogen only" HRT (RR 1.4, 95% CI 0.91-2.0) than "estrogen and progesterone" HRT(RR 1.2, 95% CI 0.8-2.1) after adjusting for the above-mentioned confounders. CONCLUSIONS Postmenopausal women, particularly those at risk for SAH due to presence of unruptured aneurysms, family history, or cardiovascular risk factors, should be counseled against use of HRT.

Hematoma Enlargement Among Patients with Traumatic Brain Injury: Analysis of a Prospective Multicenter Clinical Trial.

Observational studies suggest that hematomas continue to enlarge during hospitalization in patients with traumatic brain injury (TBI). There is limited data regarding factors associated with hematoma enlargement and on whether hematoma enlargement contributes directly to death and disability in patients with TBI. We analyzed data collected as part of the Resuscitation Outcomes Consortium Hypertonic Saline and TBI Study. Hematoma enlargement was ascertained and collected as a predefined safety endpoint. We evaluated the effect of hematoma enlargement on the risk of death and disability at 6 months based on the Extended Glasgow Outcome Scale (GOSE) (dichotomized as >4 or ≤4) using stepwise logistic regression analysis. We adjusted for age (continuous variable), admission GCS score (dichotomized at >5 and ≤5), and computed tomography (CT) scan classification (Marshall grades entered as a categorical variable). Of the 1200 patients with severe TBI analyzed, 238 (19.8%) patients were reported to have hematoma enlargement as an adverse event. The proportion of patients who reached favorable outcome at 6 months was significantly lower (defined by GOSE of >4) among patients with hematoma enlargement (29.0% vs. 40.1%, p<.0001). The proportion of patients who died within 6 months was significantly higher among patients with hematoma enlargement (31.9% vs. 20.7%, p<.0001). After adjusting for age, admission GCS score, and initial injury score, the odds of favorable outcome was lower in patients with hematoma enlargement (odds ratio 0.7, 95% confidence interval [CI]; 0.5-0.97). Our results suggest that hematoma enlargement may be a direct contributor to death and disability in patients with TBI at 6 months. Future clinical trials must continue to evaluate new therapeutic interventions aimed at reducing hematoma enlargement with a favorable risk benefit ratio in patients with TBI.

A population-based study of the incidence and case fatality of non-aneurysmal subarachnoid hemorrhage.

BACKGROUND: There is a paucity of reliable and recent data regarding epidemiology of non-aneurysmal subarachnoid hemorrhage (SAH) in population-based studies. OBJECTIVES: To determine the incidence and case fatality of non-aneurysmal SAH using a population-based design. METHODS: Medical records and angiographic data of all patients from Stearns and Benton Counties, Minnesota, admitted with SAH were reviewed to identify incident case of non-aneurysmal SAH. Patients with a first-time diagnosis of non-aneurysmal SAH (based on two negative cerebral angiograms performed ≥7 days apart) between June 1st, 2012 and June 30th, 2014 were considered incident cases. We calculated the incidences of non-aneurysmal and aneurysmal SAH adjusted for age and sex based on the 2010 US census. RESULTS: Of the 18 identified SAH among 189,093 resident populations, five were true incident cases of non-aneurysmal SAH in this population-based study. The age- and sex-adjusted incidence of non-aneurysmal SAH were 2.8 [95 % confidence interval (CI) 2.7-2·9] per 100,000 person-years which was lower than aneurysmal SAH incidence of 7.2 [95 % CI 7.1-7.4] per 100,000 person-years. The age-adjusted incidence of non-aneurysmal SAH was similar (compared with aneurysmal SAH) among men; 3.2 [95 % CI 3.1-3.3] per 100,000 person-years versus 2.2 [95 % CI 2.1-2.3] per 100,000 person-years, respectively. The age-adjusted case fatality rate at 3 months was 4.46 and 0.0 per 100,000 persons for aneurysmal and non-aneurysmal SAH, respectively. CONCLUSIONS: The incidence of non-aneurysmal SAH was higher than previously reported particularly among men.

Diffuse idiopathic intracranial fusiform aneurysm development. Case report and literature review.

BACKGROUND: Fusiform intracranial aneurysms (FIAs) are uncommon lesions representing less than 15% of all intracranial aneurysms in most large series. Their etiology has been linked to a variety of causes including atherosclerosis, fibromuscular dysplasia, cystic medial necrosis, connective tissue disease, hypertension, diabetes, hyperlipidemia, infection, cardiac myxoma, oral contraceptive use, vasculitis, and lymphoproliferative disorders. The finding of numerous lesions in a single patient is distinctly uncommon. CASE DESCRIPTION: We describe the unique case of a 47-year-old female who developed multiple FIAs over a 6-year period without an obvious underlying pathology. The patient's medical history was significant for obesity, migraine headaches, insomnia, breast cancer, and chronic skin rash. Various diagnoses were explored including infectious etiologies, autoimmune vasculopathies, malignancy-related causes, connective tissue disorders, and underlying genetic conditions. However, all investigations, including aneurysm wall and skin biopsies were negative or deemed noncontributory toward making a definitive diagnosis. CONCLUSION: We report an unusual case of a patient with a normal cerebral angiogram developing numerous, FIAs without obvious underlying etiology over a 6-year period. Close clinical and radiological follow-up is recommended in this case because the natural history of the disease is unclear at this point. The literature regarding potential causes of multiple fusiform intracranial aneuryms is reviewed.

"Microbleeding" from intracranial aneurysms: Local hemosiderin deposition identified during microsurgical treatment of unruptured intracranial aneurysms.

BACKGROUND: During elective surgery for unruptured aneurysms, we have identified a group of patients with hemosiderin staining of the pial surface immediately adjacent to the aneurysm dome suggesting a remote and unrecognized history of microbleeding from the aneurysm. These cases form the basis for this report. METHODS: Medical records of 421 unruptured cerebral aneurysm patients treated surgically between January 2003 and September 2010 were retrospectively reviewed. Patients with a history of prior subarachnoid hemorrhage, craniotomy, or significant closed head injury were excluded from review. Records were reviewed for intraoperative descriptions of hemosiderin deposition in the vicinity of the aneurysm as well as history of headaches, time to presentation, comorbidities, aneurysm characteristics, procedures, and radiologic imaging. RESULTS: Local hemosiderin staining immediately adjacent to the aneurysm was identified intraoperatively in 13 cases. Each of these patients had a history of remote atypical headache prior to presentation. Eight of these patients (62%) had aneurysms described as particularly "thin-walled" at the time of surgery. Aneurysm locations included the internal carotid artery (ICA) (54%), middle cerebral artery (MCA) (23%), anterior communicating artery (ACOMMA) (15%), and the anterior cerebral artery (ACA) (8%). More than half (54%) of these patients had a history of smoking, while 31% had hypertension, and 23% had a history of alcohol abuse. Dyslipidemia and family history of aneurysms were present in 15% and hypercholesterolemia was noted in one patient (8%). CONCLUSION: We suggest this group of patients had suffered a "microbleed" resulting in local hemosiderin deposition next to the aneurysm. The origins and clinical implications of such microbleeds are unknown and warrant further investigation.

Brain and multiorgan metastases from uterine leiomyosarcoma.

A 59-year-old woman, diagnosed 7 years ago with uterine leiomyosarcoma (ULMS), developed several intrathoracic, pelvic and lately intra-abdominal and brain metastases. On each occasion, surgical resection was followed by a course of failed chemotherapy. Lately she presented with acute neurological deterioration and focal signs. Magnetic resonance imaging demonstrated two presumed brain parenchymal lesions involving the supratentorial and infratentorial compartments. She underwent surgical resection of the left cerebellar lesion. Histological analysis of the brain specimen confirmed the presence of metastatic ULMS. Leiomyosarcoma of the uterus is an uncommon tumor with a very aggressive course and poor prognosis. Multiple organ metastases from ULMS are an extremely rare condition, and prognostically alarming despite current treatments.

Limited vertical dural opening for lesions of the vermis, 4(th) ventricle, and distal PICA segments.

BACKGROUND: Lesions of the vermis and 4(th) ventricle are commonly addressed through a midline suboccipital approach. Most neurosurgeons use either a Y-shaped or a curvilinear dural opening in this setting. Although these approaches offer a wide intraoperative surgical exposure, in occasion, the dural opening is difficult to repair primarily, often necessitating the use of a patch, which may increase the risk for development of CSF fistula. We are describing our experience with a limited, vertical, midline, dural opening for approaches to the vermis, tentorium, 4(th) ventricle, and distal posterior-inferior cerebellar artery (PICA) segments as an alternative to the classic Y-shaped or curvilinear incision. METHODS: We report our experience with a limited vertical midline durotomy in five patients with posterior fossa lesions. The lesions treated included a PICA dissecting aneurysm, three metastatic lesions (located in the vermian, floor of the 4(th) ventricle, and undersurface of the tentorium cerebelli), and one intra-axial tumor (ependymoma). All patients were positioned prone, and the lesions were accessed without difficulty through a limited, vertical, midline durotomy. RESULTS: Mass lesions and vascular abnormalities located from the midline as far lateral as the outlet foramina of the 4(th) ventricle can be accessed comfortably via a limited midline dural opening when combined with microsurgical techniques, and the use of a frameless Stealth Station Neuronavigation System (SSNS) [Medtronic Sofamor Danek, Inc., Memphis, TN]. By doing this, simple primary dural closure was achieved with a single running absorbable suture without tension in each case. CONCLUSION: In our experience, a suboccipital linear dural opening appears to be as effective as the more traditional Y-shaped incision, yet allows for quicker and easier primary dural repair.

Supratentorial metastatic enteropathy-associated T-cell lymphoma: A case report and literature review.

BACKGROUND: We are describing a rare case of supratentorial metastatic enteropathy-associated T-cell lymphoma (EATL). While these lesions are a rare complication of EATL, the implications are grave and they must be evaluated as a diagnostic possibility when a patient with known celiac disease presents with acute neurological deterioration. In addition, multidisciplinary care teams are recommended by the authors as critical to providing the most comprehensive patient care. CASE DESCRIPTION: A 65-year-old female presented to the emergency room with uncontrolled abdominal pain, nausea, and vomiting. Initial abdominal computed tomography (CT) scan indicated a small bowel obstruction with a transition point at the jejunal area. Differential diagnosis included small bowel neoplasm, adhesions, or a reactive intestinal inflammatory process. Shortly after presentation, the patient's clinical condition worsened, requiring emergency small bowel resection. Histological analysis of the resected bowel segments demonstrated medium-sized infiltrating lymphocytes with characteristic pleomorphic nuclei and prominent nucleoli. Immunohistochemical stains revealed tumor cells positive for CD-3. Immunohistochemical analysis for Ki-67 showed a markedly increased proliferative index, with 90% of lymphocytes staining positive. Polymerase chain reaction analysis for T-cell receptor-gamma gene rearrangement was positive, demonstrating the presence of a clonal population of T-cells. The combined morphological and immunophenotypic features of this lesion were consistent with jejunal EATL. Five weeks post-diagnosis, she developed new onset neurological symptoms consisting of changes in her mental status and left facio-brachial weakness. Brain magnetic resonance imaging (MRI) demonstrated a single ill-defined, irregular, right fronto-parietal enhancing lesion surrounded by vasogenic edema. Surgical resection and histopathologic evaluation of the biopsied lesion confirmed the diagnosis of metastatic EATL involving the brain. CONCLUSION: Intracranial metastasis is a rare but grave complication of EATL and must be evaluated as a diagnostic possibility when a patient with known celiac disease presents with acute neurological deterioration. Although the prognosis of these patients is dismal, aggressive oncology management is mandatory.

The use of indocyanine green videoangiography to optimize the dural opening for intracranial parasagittal lesions.

BACKGROUND: We describe our clinical experience with the use of indocyanine green (ICG) videoangiography to delineate the locations of the cortical draining veins before dural opening in 3 cases of parasagittal lesions. With this technique, the veins are marked through the dura, and then the dura can be opened precisely to avoid cortical venous injury. OBJECTIVE: To demonstrate in a clinical series the adjunct use of intraoperative ICG angiography to optimize the dural opening for parasagittal lesions. METHODS: We describe 3 cases of parasagittal lesions, 2 meningiomas, and 1 arteriovenous malformation treated using the described technique. RESULTS: Once the dura had been exposed, ICG at a dose of 0.25 mg/kg was injected into the patient's peripheral vein as a bolus. When the dye reached the illuminated field of interest, ICG fluorescence was induced by the use of a light source with a wave-length ICG absorption band. Thereafter, the dural cortical veins were marked through the dura and precisely opened, avoiding cortical venous injury. CONCLUSION: Indocyanine green video angiography is a safe, fast, inexpensive, and accurate investigation that allows the surgeon to strategically plan and protect important parasagittal dural venous drainage during craniotomy.

Multiple non-branching dissecting aneurysms of the mid-basilar trunk presenting with sequential subarachnoid hemorrhages.

OBJECTIVE: We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm. CASE DESCRIPTION: A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss. CONCLUSION: We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.

A short segment intracranial-intracranial jump graft bypass followed by proximal arterial occlusion for a distal MCA aneurysm.

BACKGROUND: To describe the use of a short segment cortical intracranial-intracranial (IC-IC) bypass for the treatment of a distal middle cerebral artery (MCA) aneurysm. CASE DESCRIPTION: A 54-year-old woman presented with a loss of consciousness followed by multiple seizures and was found to have a partially thrombosed distal MCA aneurysm. This possibly mycotic aneurysm was treated by creating a short segment jump graft between a normal cortical artery and a nearby cortical branch arising from the aneurysmal M3 arterial segment. The bypass allowed for subsequent occlusion of the aneurysmal vessel without ischemic consequence. At surgery, the anterior division of the superficial temporal artery (STA) was exposed and dissected. Intraoperative angiography was utilized to localize a cortical artery arising from the involved segment as well as a nearby cortical artery arising from a distinct, uninvolved MCA branch. A segment of the STA was harvested, and then 10-0 suture was utilized to anastomose this short segment, to both the involved and normal cortical arteries. This created a short jump graft allowing for subsequent sacrifice of the diseased artery. Following surgery, the patient immediately underwent coil embolization of the aneurysm back into the parent artery resulting in local vascular sacrifice. The remainder of the patient's hospital course was uneventful. She was discharged home in good condition. CONCLUSIONS: We suggest that cortical IC-IC bypass followed by endovascular arterial sacrifice as performed in our case represents a simple and safe option for treating unclippable distal MCA aneurysms including mycotic lesions.

Emergency surgical salvage for severe intracranial aneurysm rupture during endovascular coiling procedures not amenable to additional coiling.

BACKGROUND: We report the management and outcomes of six patients who underwent emergency surgical intervention in the setting of severe intraprocedural rupture during endovascular treatment of an intracranial aneurysm not amenable to additional coiling. METHODS: From July 1997 through December 2010, our neurovascular service treated 1613 patients with coil embolization. During this time, we encountered six patients who suffered severe intraprocedural aneurysm rupture, defined by contrast extravasation during the coiling procedure, in whom additional attempted coiling failed to stop the ongoing extravasation. Hospital records, neuroimaging studies, operative reports, and follow-up clinic notes were complete and reviewed in all cases. The follow-up review in surviving patients ranged from 1.5 to 9 years (average 3.8 years), and no patient was lost to the follow-up review. RESULTS: In all cases, persistent extravasation necessitated urgent surgical decompression and securing of the ruptured aneurysm. Of these six cases, three patients achieved a good functional status after prolonged rehabilitation, and one of these had only subtle cognitive changes on formal neuropsychological testing. Two patients died. CONCLUSION: Intraprocedural rupture during aneurysm coiling is a dangerous and potentially fatal event. Despite the seemingly hopeless nature of this situation, in our experience, aggressive management to control intracranial pressure combined with a rapid reversal of anticoagulation and early surgical intervention can result in reasonable outcomes in some patients.