Middle Meningeal Artery Embolization: A Paradigm Shift in Approach of Chronic Subdural Hematoma.

Chronic subdural hematoma (SDH) is commonly seen in the aged population. It is hypothesized to occur due to damage to the dural border cells, resulting in an inflammation-proliferation reaction. Inadequate repair leads to the formation of an external layer of cells and fragile capillaries, which are vulnerable to damage, contributing to worsening of the condition. Conventionally, asymptomatic chronic SDH was managed by observation, while symptomatic cases by surgical evacuation. However, the recurrence rate of chronic SDH after surgical evacuation was high. The middle meningeal artery (MMA) provides blood supply to the dura mater and feeds the capillaries of the membranes covering the SDH. MMA embolization blocks blood flow to this system and promotes hematoma resolution. In this manuscript, we discuss the underlying pathophysiology and current management options for chronic SDH. We also discuss the existing literature on MMA embolization.

Association of Guillain-Barre syndrome with COVID-19 infection: An updated systematic review.

OBJECTIVE: The systematic review aimed to determine demographic characteristics, clinical features, lab evaluation, management and complications of the studies focusing on Guillain-Barre syndrome (GBS) as a sequele of novel coronavirus (COVID-19) infection. METHODS: After protocol registration, PubMed, Web of Science and Cumulative Index to Nursing & Allied Health Literature (CINHAL) databases were searched for relevant articles using MeSH key-words and imported into referencing/review softwares. The data, regarding demographic and clinical characteristics, diagnostic workup and management, was analyzed in International Business Machines (IBM) Statistics SPSS 21. Many statistical tests, such as t-test and the Mann-Whitney U test, were used. P < 0.05 was considered significant. RESULTS: We identified 64 relevant articles. The mean age of the patients was 56 ± 16 years; the majority were males (64.9%). Among the neurological findings, paresthesia was the most typical symptom (48.9%). Most of the patients had been diagnosed by reverse transcriptase-polymerase chain reaction (RT-PCR) (69.2%). Two-third of the patients received immunoglobulins (IVIg) (77.7%). Although functions recovered in most patients, there were four patients with facial diplegia during follow-up (4.26%). Acute inflammatory demyelinating polyneuropathy (AIDP) was more likely to be associated with paresis of the lower extremity (p < 0.05) and higher levels of glucose on cerebrospinal fluid (CSF) analysis (p < 0.05). These patients were more likely to receive IVIg (p < 0.05) and develop respiratory insufficiency, subsequently (p < 0.05). CONCLUSIONS: GBS is being recognized as one of the many presentations of the COVID-19 infection. Although the common form is AIDP that might lead to complications, other variants are possible as well, and more studies are needed to focus on those subvariants.

Neurological Complications Among Native Americans with COVID-19: Our Experience at a Tertiary Care Academic Hospital in the U.S.

OBJECTIVE: To study the central nervous system (CNS) complications in patients with COVID-19 infection especially among Native American population in the current pandemic of severe acute respiratory syndrome virus (COVID-19). METHODS: Patients with confirmed COVID-19 infection at University of New Mexico hospital (UNMH) were screened for development of neurological complications during Feb 01 to April 29, 2020 via retrospective chart review. RESULTS: Total of 90 hospitalized patients were screened. Out of seven patients, majority were Native Americans females, and developed neurological complications including subarachnoid hemorrhage (SAH), Intraparenchymal hemorrhage (IPH), Ischemic stroke (IS) and seizure. All 7 patients required Intensive care unit (ICU) level of care. Patients who developed CNS complications other than seizure were females in the younger age group (4 patients, 38-58 years) with poor outcome. Out of 7, three developed subarachnoid hemorrhage, two developed ischemic infarction, and four developed seizure. Two patients with hemorrhagic complication expired during the course of hospitalization. All three patients with seizure were discharged to home. CONCLUSION: Patients with serious CNS complications secondary to COVID-19 infection were observed to be Native Americans. Patients who developed hemorrhagic or ischemic events were observed to have poor outcomes as compared to patients who developed seizures.

Recent update on basic mechanisms of spinal cord injury.

Spinal cord injury (SCI) is a life-shattering neurological condition that affects between 250,000 and 500,000 individuals each year with an estimated two to three million people worldwide living with an SCI-related disability. The incidence in the USA and Canada is more than that in other countries with motor vehicle accidents being the most common cause, while violence being most common in the developing nations. Its incidence is two- to fivefold higher in males, with a peak in younger adults. Apart from the economic burden associated with medical care costs, SCI predominantly affects a younger adult population. Therefore, the psychological impact of adaptation of an average healthy individual as a paraplegic or quadriplegic with bladder, bowel, or sexual dysfunction in their early life can be devastating. People with SCI are two to five times more likely to die prematurely, with worse survival rates in low- and middle-income countries. This devastating disorder has a complex and multifaceted mechanism. Recently, a lot of research has been published on the restoration of locomotor activity and the therapeutic strategies. Therefore, it is imperative for the treating physicians to understand the complex underlying pathophysiological mechanisms of SCI.

Ideal sedation for stroke thrombectomy: a prospective pilot single-center observational study.

OBJECTIVESeveral retrospective studies have supported the use of conscious sedation (CS) over general anesthesia (GA) as the preferred methods of sedation for stroke thrombectomy, but a recent randomized controlled trial showed no difference in outcomes after CS or GA. The purpose of the Ideal Sedation for Stroke Thrombectomy (ISST) study was to evaluate the difference in time and outcomes in the reperfusion of anterior circulation in ischemic stroke using GA and monitored anesthesia care (MAC).METHODSThe ISST study was a prospective, open-label registry. A total of 40 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke were enrolled. Informed consent was obtained from each patient before enrollment. The primary endpoint included the interval between the patient's arrival to the interventional radiology room and reperfusion time. Secondary endpoints were evaluated to estimate the effects on the outcome of patients between the 2 sedation methods.RESULTSOf the 40 patients, 32 received thrombectomy under MAC and 8 patients under GA. The male-to-female ratio was 18:14 in the MAC group and 4:4 in the GA group. The mean time from interventional radiology room arrival to reperfusion in the GA group was 2 times higher than that in the MAC group. Complete reperfusion (TICI grade 3) was achieved in more than 50% of patients in both groups. The mean modified Rankin Scale score at 3 months was < 2 in the MAC group and > 3 in the GA group (p = 0.021).CONCLUSIONSThe findings from the pilot study showed a significantly shorter time interval between IR arrival and reperfusion and better outcomes in patients undergoing reperfusion for ischemic stroke in the anterior circulation using MAC compared with GA.Clinical trial registration no.: NCT03036631 (clinicaltrials.gov).

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.

Design, Application and Infield Validation of a Pre-Hospital Emergent Large Vessel Occlusion Screening Tool: Ventura Emergent Large Vessel Occlusion Score.

BACKGROUND: The outcome of endovascular treatment for emergent large vessel occlusion (ELVO) is dependent on timely recanalization. To identify ELVO in the field, we present a simplified score, which has been applied and validated in the field by emergency medical services (EMS). Methods and Analysis: Ventura ELVO Scale (VES) comprise of 4 components: Eye Deviation, Aphasia, Neglect, and Obtundation with score range 0-4. The score of greater than or equal to 1 will be considered as ELVO positive. A positive VES along with positive Cincinnati scale prompts ELVO activation. EMS then notify to neurointervention protocol at the receiving stroke center. The performance of VES was evaluated retrospectively. For statistical analysis, SAS version 9.4 was used and Fisher's modelling was used for the comparative analysis. RESULTS: Total 184 patients were included in the final analysis, 62 (33.7%) patients were called VES positive from the field. Out of 62, 36 (58%) patients had ELVO. The mean NIHSS on arrival was 16 in VES positive and 5 in VES negative patients. VES was 94.7% sensitive and 82.4% specific while the PPV and NPV of VES were 58.1% and 98.4%, respectively. It showed 84.9% accuracy. CONCLUSIONS: VES is an effective and simplified prehospital screening tool for detection of ELVO in the field. Its implementation can beat the target door to groin time to improve outcomes and in future it can be used for rerouting of ELVO patients to comprehensive stroke center.

High-intensity focused ultrasound: past, present, and future in neurosurgery.

Since Lynn and colleagues first described the use of focused ultrasound (FUS) waves for intracranial ablation in 1942, many strides have been made toward the treatment of several brain pathologies using this novel technology. In the modern era of minimal invasiveness, high-intensity focused ultrasound (HIFU) promises therapeutic utility for multiple neurosurgical applications, including treatment of tumors, stroke, epilepsy, and functional disorders. Although the use of HIFU as a potential therapeutic modality in the brain has been under study for several decades, relatively few neuroscientists, neurologists, or even neurosurgeons are familiar with it. In this extensive review, the authors intend to shed light on the current use of HIFU in different neurosurgical avenues and its mechanism of action, as well as provide an update on the outcome of various trials and advances expected from various preclinical studies in the near future. Although the initial technical challenges have been overcome and the technology has been improved, only very few clinical trials have thus far been carried out. The number of clinical trials related to neurological disorders is expected to increase in the coming years, as this novel therapeutic device appears to have a substantial expansive potential. There is great opportunity to expand the use of HIFU across various medical and surgical disciplines for the treatment of different pathologies. As this technology gains recognition, it will open the door for further research opportunities and innovation.

Falxuplication, a Novel Method for Wrap-Clipping a Fusiform Aneurysm: Technical Note.

BACKGROUND: Various techniques have been used for wrap-clipping a ruptured, fusiform intracranial aneurysm; however, there is no available literature on use of the falx cerebri for wrap-clipping. We present a review of the literature, with an illustrative case, of a ruptured fusiform pericallosal artery aneurysm firmly attached to the lower edge of the falx cerebri and not amenable to endovascular intervention. METHODS: Although the firm attachment between the inferior falx and the fusiform aneurysm was maintained, a section of the lower thinner part of the falx cerebri firmly attached to the aneurysm was dissected and wrapped around the fusiform aneurysm, and then stabilized with a fenestrated clip. We chose a segment slightly longer than the length of the fusiform aneurysm to avoid pre- and post-wrap-clipping stenosis. RESULTS: Postprocedure, except for a small area of numbness on the left distal anterolateral left leg, the patient was neurologically intact and remained neurologically intact at a 12-month follow-up. CONCLUSIONS: An inferior thin segment of the falx cerebri can be used for wrap-clipping of ruptured fusiform anterior cerebral artery aneurysms. Furthermore, the inferior falx can be wrapped around the attached fusiform anterior cerebral artery aneurysm without compromising flow, offering a safe solution in these unusually complex cases.

Cranial Osteomyelitis: A Comprehensive Review of Modern Therapies.

BACKGROUND: Cranial osteomyelitis is a rare but potentially life-threatening condition that requires early diagnosis with prompt and appropriate management by neurosurgeons to prevent further central nervous system complications. METHODS: The literature in the Medline database was comprehensively reviewed with the keywords "cranial osteomyelitis," "skull base osteomyelitis (SBO)," "central skull base osteomyelitis," and "temporal bone osteomyelitis." Items in the reference list of each article relevant to the objective of this study were reviewed. RESULTS: This review produced 183 articles: 13 book chapters, 24 case reports, 17 case series, 98 original articles, 30 review articles, and 1 meta-analysis. We classified cranial osteomyelitis as sinorhino-otogenic, including anterior, middle, and posterior skull base osteomyelitis; and non-sinorhino-otogenic, including iatrogenic, posttraumatic, hematologic, and osteomyelitis with other causes. CONCLUSIONS: New diagnostic modalities, the introduction of broad-spectrum antibiotics, and recent advances in neurosurgical procedures have led to a decrease in the rate of treatment failure in cranial osteomyelitis. Early recognition of initial nonspecific symptoms is key to diagnosing and managing this treatable but life-threatening condition. Early identification of the causative pathogen, appropriate broad-spectrum antibiotic therapy over a period of 8-20 weeks, and aggressive surgical debridement are essential for managing cranial osteomyelitis. On the other hand, inadequate treatment is responsible for refractory cases and poses a great diagnostic challenge. A new classification dividing cranial osteomyelitis into sinorhino-otogenic versus nonsinorhino-otogenic groups could prove valuable for clinical communication and treatment.

Subarachnoid Trabeculae: A Comprehensive Review of Their Embryology, Histology, Morphology, and Surgical Significance.

INTRODUCTION: Brain is suspended in cerebrospinal fluid (CSF)-filled subarachnoid space by subarachnoid trabeculae (SAT), which are collagen-reinforced columns stretching between the arachnoid and pia maters. Much neuroanatomic research has been focused on the subarachnoid cisterns and arachnoid matter but reported data on the SAT are limited. This study provides a comprehensive review of subarachnoid trabeculae, including their embryology, histology, morphologic variations, and surgical significance. METHODS: A literature search was conducted with no date restrictions in PubMed, Medline, EMBASE, Wiley Online Library, Cochrane, and Research Gate. Terms for the search included but were not limited to subarachnoid trabeculae, subarachnoid trabecular membrane, arachnoid mater, subarachnoid trabeculae embryology, subarachnoid trabeculae histology, and morphology. Articles with a high likelihood of bias, any study published in nonpopular journals (not indexed in PubMed or MEDLINE), and studies with conflicting data were excluded. RESULTS: A total of 1113 articles were retrieved. Of these, 110 articles including 19 book chapters, 58 original articles, 31 review articles, and 2 case reports met our inclusion criteria. CONCLUSIONS: SAT provide mechanical support to neurovascular structures through cell-to-cell interconnections and specific junctions between the pia and arachnoid maters. They vary widely in appearance and configuration among different parts of the brain. The complex network of SAT is inhomogeneous and mainly located in the vicinity of blood vessels. Microsurgical procedures should be performed with great care, and sharp rather than blunt trabecular dissection is recommended because of the close relationship to neurovascular structures. The significance of SAT for cerebrospinal fluid flow and hydrocephalus is to be determined.

Rare Concurrent Retroclival and Pan-Spinal Subdural Empyema: Review of Literature with an Uncommon Illustrative Case.

BACKGROUND: Subdural empyema can present as a spinal subdural empyema (SSE) or a cranial subdural empyema (CSE). Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together. The aim of this article is to review the literature concerning the clinical presentation, clinical course, and treatment options for managing concurrently occurring SSE and CSE. METHODS: The literature in the Medline database was reviewed with key words including but not limited to subdural empyema, retroclival empyema, and Streptococcus mitis. No similar reports were found in the database involving infection with this type of microorganism in this anatomical region. RESULTS: Only 3 cases with concurrent CSE and SSE were found in the literature caused by various etiologic agents. Two of the patients recovered with no neurologic deficit, whereas one fatality was reported. One new illustrative case caused by Streptococcus mitis is also presented. CONCLUSIONS: CSE and SSE are neurosurgical emergencies, often requiring prompt surgical evacuation. Although very rare, Streptococcus mitis can cause spinal subdural empyema or retroclival abscesses. Natural history of this disease is grave without treatment. Delays in diagnosis and treatment are directly related to mortality and severe morbidity in patients with intracranial and spinal subdural empyema. Prompt recognition and treatment are essential to preclude severe neurologic disabilities or in rare cases a fatal outcome. A treatment paradigm for cranio-spinal empyema is proposed.

Posttraumatic stress disorder: a serious post-earthquake complication.

OBJECTIVES: Earthquakes are unpredictable and devastating natural disasters. They can cause massive destruction and loss of life and survivors may suffer psychological symptoms of severe intensity. Our goal in this article is to review studies published in the last 20 years to compile what is known about posttraumatic stress disorder (PTSD) occurring after earthquakes. The review also describes other psychiatric complications that can be associated with earthquakes, to provide readers with better overall understanding, and discusses several sociodemographic factors that can be associated with post-earthquake PTSD. METHOD: A search for literature was conducted on major databases such as MEDLINE, PubMed, EMBASE, and PsycINFO and in neurology and psychiatry journals, and many other medical journals. Terms used for electronic searches included, but were not limited to, posttraumatic stress disorder (PTSD), posttraumatic symptoms, anxiety, depression, major depressive disorder, earthquake, and natural disaster. The relevant information was then utilized to determine the relationships between earthquakes and posttraumatic stress symptoms. RESULTS: It was found that PTSD is the most commonly occurring mental health condition among earthquake survivors. Major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder, social phobia, and specific phobias were also listed. CONCLUSION: The PTSD prevalence rate varied widely. It was dependent on multiple risk factors in target populations and also on the interval of time that had elapsed between the exposure to the deadly incident and measurement. Females seemed to be the most widely-affected group, while elderly people and young children exhibit considerable psychosocial impact.

Posttraumatic stress disorder: a serious post-earthquake complication / Transtorno do estresse pós-traumático: complicação séria pós-terremoto

Abstract Objectives Earthquakes are unpredictable and devastating natural disasters. They can cause massive destruction and loss of life and survivors may suffer psychological symptoms of severe intensity. Our goal in this article is to review studies published in the last 20 years to compile what is known about posttraumatic stress disorder (PTSD) occurring after earthquakes. The review also describes other psychiatric complications that can be associated with earthquakes, to provide readers with better overall understanding, and discusses several sociodemographic factors that can be associated with post-earthquake PTSD Method A search for literature was conducted on major databases such as MEDLINE, PubMed, EMBASE, and PsycINFO and in neurology and psychiatry journals, and many other medical journals. Terms used for electronic searches included, but were not limited to, posttraumatic stress disorder (PTSD), posttraumatic symptoms, anxiety, depression, major depressive disorder, earthquake, and natural disaster. The relevant information was then utilized to determine the relationships between earthquakes and posttraumatic stress symptoms. Results It was found that PTSD is the most commonly occurring mental health condition among earthquake survivors. Major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder, social phobia, and specific phobias were also listed. Conclusion The PTSD prevalence rate varied widely. It was dependent on multiple risk factors in target populations and also on the interval of time that had elapsed between the exposure to the deadly incident and measurement. Females seemed to be the most widely-affected group, while elderly people and young children exhibit considerable psychosocial impact.

Resumo Objetivos Terremotos são desastres naturais imprevisíveis e devastadores. Eles podem causar destruição em massa e morte, e os sobreviventes podem apresentar sintomas psicológicos severos. O objetivo deste estudo foi revisar estudos publicados nos últimos 20 anos pra compilar o conhecimento disponível acerca da ocorrência de transtorno do estresse pós-traumático (TEPT) após terremotos. A revisão também descreve outras complicações psiquiátricas que podem estar associadas a terremotos, oferecendo aos leitores um melhor entendimento geral sobre o assunto, e discute vários fatores sociodemográficos que podem estar associados com TEPT pós-terremoto. Métodos Foi realizada uma busca de literatura nas principais bases de dados, como MEDLINE, PubMed, EMBASE e PsycINFO, e também em revistas de neurologia e psiquiatria, e vários outros periódicos médicos. Os termos usados nas buscas eletrônicas incluíram, mas não se limitaram a, posttraumatic stress disorder (PTSD), posttraumatic symptoms, anxiety, depression, major depressive disorder, earthquake e natural disaster. As informações relevantes foram então utilizadas para determinar as relações entre terremotos e sintomas de estresse pós-traumático. Resultados A revisão revelou que o TEPT é a condição de saúde mental mais comum em sobreviventes de terremoto. Depressão maior, transtorno de ansiedade generalizada, transtorno obsessivo-compulsivo, fobia social e fobias específicas foram outras condições encontrados. Conclusão A prevalência de TEPT variou bastante. O transtorno foi dependente de múltiplos fatores de risco em populações-alvo e também do intervalo de tempo decorrido entre a exposição ao incidente fatal e a avaliação. As mulheres pareceram ser o grupo mais amplamente afetado, ao passo que idosos e crianças demonstração considerável impacto psicossocial.