Prolactinoma extension as a contributing factor in dopamine agonist-induced CSF rhinorrhea: a systematic review of the literature.

BACKGROUND: Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus. OBJECTIVE: The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment. METHODS: A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed. RESULTS: Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%). CONCLUSION: Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients.

OBJECTIVE: Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS: This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS: Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS: Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

A combined approach for stabilization and endoscopic/ endonasal odontoid and clivus resection for treatment of basilar invagination.

BACKGROUND: Basilar invagination (BI) is a complex condition characterized by prolapse of the odontoid into the brain stem/upper cervical cord. This lesion is often associated with Chiari malformations, and rheumatoid arthritis (RA). Treatment options for BI typically include cervical traction, an isolated anterior transoral odontoidectomy, anterior endonasal odontoidectomy, an isolated posterior fusion, or combined anterior/ posterior surgical approach. CASE DESCRIPTION: A 45-year-old female with a Chiari I malformation and RA underwent a combined posterior C0-C5 posterior decompression/fusion, followed by an anterior odontoidectomy (i.e. endoscopic/endonasal under neuronavigation). Postoperatively, the patient's symptoms and neurological signs resolved. CONCLUSION: BI in was successfully managed with a combined posterior C0-C5 decompression/fusion followed by an anterior endoscopic/endonasal odontoidectomy performed under neuronavigation.

Treatment of unusually located traumatic intracranial aneurysms and severe vasospasm following a gunshot wound to the head: A case report.

BACKGROUND: Traumatic intracranial aneurysms (TICAs) represent up to 1% of all intracranial aneurysms. They can be the result of non-penetrating and penetrating brain injury (PBI). Approximately 20% of TICA are caused by PBI. Endovascular treatments as well as surgical clipping are reported in the literature. Other vascular complications of PBI include vasospasm although the literature is lacking on this topic. CASE DESCRIPTION: The authors present a unique case of multiple TICAs after a PBI in a 15-year-old patient who sustained a gunshot wound to the head. The patient sustained injury through the middle cranial fossa and was taken emergently for a right-sided decompressive hemicraniectomy. Diagnostic cerebral angiogram (DCA) identified multiple TICAs along the right internal carotid artery (ICA) terminus and right middle cerebral artery as well as severe vasospasm. The patient was taken for clipping of those aneurysms and intraoperative treatment of vasospasm. Intraoperative blood flow measurements were taken before and after administration of intracisternal papaverine and arterial soft tissue dissection showing a significant increase in blood flow and improvement of vasospasm. CONCLUSION: While the literature has shifted towards endovascular treatment for TICAs, surgery still offers a safe and efficacious treatment strategy especially when TICAs present at large vessel bifurcation points where parent vessel sacrifice and stent assisted coiling are less favorable strategies. Severe flow limiting vasospasm can be seen in post-traumatic setting specifically PBI. Vasospasm can be treated during open surgery with intracisternal papaverine and arterial soft dissection as confirmed in this case report with intraoperative micro-flow probe measurements.

C1 Transverse Process Resection for Management of Jugular Stenosis.

BACKGROUND AND IMPORTANCE: Idiopathic intracranial hypertension, also known as pseudotumor cerebri, often presents with severe headache and associated vision loss. Venous outflow obstruction has been noted as a prominent etiologic factor in many cases, and previous anatomic studies have shown that the internal jugular (IJ) vein at the skull base can be prone to compression by the neighboring bony structures. CLINICAL PRESENTATION: We present a case of 13-yr-old male with a multifactorial intracranial hypertension including compression of the IJ vein by the transverse process of C1. Computerized tomography angiographic imaging revealed bilateral stenosis of the IJ veins due to compression from the transverse processes of C1. Medical management and shunt were attempted without resolution of symptoms. A hemodynamically significant stenosis at the right IJ was confirmed with manometry and so the C1 transverse process was resected and a stent placed endovascularly with resolution of pressure gradient and clinical symptoms. CONCLUSION: Contribution of C1 compression to this patient's intracranial hypertension suggests that evaluation for IJ compression below the skull base may be needed to identify the underlying cause of intracranial hypertension in certain patients. Furthermore, surgical decompression of the IJ vein may be required as part of the treatment strategy. If venous stenting is being considered, this decompressive step must be taken before stenting is performed. We offer this case as evidence that decompression of the IJ vein by C1 lateral mass resection can be an effective and novel technique in the repertoire of neurosurgical management of intracranial hypertension.

Restrictive cerebral cortical venopathy: A new clinicopathological entity.

We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child's presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.

Complicated Mild Traumatic Brain Injury and the Need for Imaging Surveillance.

OBJECTIVE: To evaluate the need for repeat head computed tomography (CT) in patients with complicated mild traumatic brain injury (TBI) determined nonoperative after the first head CT. METHODS: A total of 380 patients with mild TBI and a positive head CT not needing surgery were included. Changes between first and second head CT were categorized as decreased, increased, or stable. RESULTS: Three patients required neurosurgical intervention (0.8%) after the second CT. There were no significant differences in demographics including age, gender, alcohol consumption, anticoagulation status, time between first and second CT, Glasgow Coma Scale score at admission and discharge, and incidence of subarachnoid hemorrhage, epidural hematoma, contusion, or skull fractures between the operated and nonoperated groups. All patients in the operated group had subdural hematoma compared with 40.8% in the nonoperated group (P = 0.07). All operated patients showed symptoms of neurologic worsening after initial head CT, compared with 2.7% in the nonoperated group (P < 0.001). Moreover, patients who showed neurologic worsening were more likely to show increased intracranial bleeding on repeat head CT, whereas patients who did not show neurologic worsening were more likely to show decreased or stable intracranial bleeding (P = 0.04). CONCLUSIONS: Routine repeat head CT in patients with complicated mild TBI is very low yield to predict need for delayed surgical intervention. Instead, serial neurologic examination and observation over the first 8 hours after the injury is recommended. A second CT scan should be obtained only in patients who have neurologic worsening.

Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.

BACKGROUND: Previous studies of traumatic brain injury (TBI) outcomes in elderly patients on oral antithrombotic (OAT) therapies have yielded conflicting results. Our objective was to examine the effect of premorbid OAT medications on outcomes among elderly TBI patients with intracranial hemorrhage. METHODS: We performed a retrospective analysis of elderly TBI patients (≥65 years) with closed head injury and evidence of brain hemorrhage on computed tomography scan from 2006 to 2010. Patient demographics, injury severity, clinical course, hospital and intensive care unit length of stay, and disposition were collected. Comparison of patients stratified by premorbid OAT use was performed using nonparametric Kruskal-Wallis and Fisher's exact tests. Multivariable logistic regression was used to compare groups and identify predictors of primary outcomes, including mortality, neurosurgical intervention, hemorrhage progression, complications, and infection. RESULTS: A total of 1,552 patients were identified: 543 on aspirin only, 97 on clopidogrel only, 218 on warfarin only, 193 on clopidogrel and aspirin, and 501 on no antithrombotic agent. Blood products were administered to reverse coagulopathy in 77.3% of patients on antithrombotic medications. After adjusting for covariates, including medication reversal, OAT use was associated with increased mortality (p = 0.04). Warfarin use was identified as a key predictor (odds ratio, 2.27; p = 0.05), in contrast to the preinjury use of antiplatelet medications, which was not associated with increased risk of in-hospital death. Rates of neurosurgical intervention differed between groups, with patients on warfarin undergoing intervention more frequently. Survivor subset analysis demonstrated that hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection, hospital and intensive care unit lengths of stay, or ventilator days. CONCLUSION: Preinjury use of warfarin, but not antiplatelet medications, influences survival and need for neurosurgical intervention in elderly TBI patients with intracranial hemorrhage; hemorrhage progression and morbidity are not affected. The importance of antithrombotic therapy may lie in its impact on initial injury severity. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Enterocutaneous fistula in the setting of ventriculoperitoneal shunt extrusion through the skin and perforation through the small bowel.

The authors report a case of a 2-year-old boy with postinfectious hydrocephalus, managed with a ventriculoperitoneal (VP) shunt and complicated by shunt extrusion through the cranial skin. The shunt was removed due to concern for infection, and the child was found to have an enterocutaneous fistula (ECF) communicating along the shunt track between the small bowel and a clavicular sinus. Self-closure of the ECF was anticipated. Thus, the fistula was managed expectantly with dressing changes of the clavicular sinus, while the patient's malnutrition was managed in accordance with World Health Organization protocols. The presentation, prognosis and management of ECFs, including the likelihood of self-resolution and the role of expectant management, are discussed. Additionally, proposed mechanisms of ECF formation in the setting of a VP shunt are discussed, with an emphasis on the roles of infection and malnutrition.

Predicting the likelihood of an isocitrate dehydrogenase 1 or 2 mutation in diagnoses of infiltrative glioma.

BACKGROUND: Several variables are associated with the likelihood of isocitrate dehydrogenase 1 or 2 (IDH1/2) mutation in gliomas, though no guidelines yet exist for when testing is warranted, especially when an R132H IDH1 immunostain is negative. METHODS: A cohort of 89 patients was used to build IDH1/2 mutation prediction models in World Health Organization grades II-IV gliomas, and an external cohort of 100 patients was used for validation. Logistic regression and backward model selection with the Akaike information criterion were used to develop prediction models. RESULTS: A multivariable model, incorporating patient age, glioblastoma multiforme diagnosis, and prior history of grade II or III glioma, was developed to predict IDH1/2 mutation probability. This model generated an area under the curve (AUC) of 0.934 (95% CI: 0.878, 0.978) in the external validation cohort and 0.941 (95% CI: 0.918, 0.962) in the cohort of The Cancer Genome Atlas. When R132H IDH1 immunostain information was added, AUC increased to 0.986 (95% CI: 0.967, 0.998). This model had an AUC of 0.947 (95% CI: 0.891, 0.995) in predicting whether an R132H IDH1 immunonegative case harbored a less common IDH1 or IDH2 mutation. The models were also 94% accurate in predicting IDH1/2 mutation status in gliomas from The Cancer Genome Atlas. An interactive web-based application for calculating the probability of an IDH1/2 mutation is now available using these models. CONCLUSIONS: We have integrated multiple variables to generate a probability of an IDH1/2 mutation. The associated web-based application can help triage diffuse gliomas that would benefit from mutation testing in both clinical and research settings.

Manual aspiration thrombectomy for basilar infarction in the setting of a persistent primitive hypoglossal artery: Case report and review of the literature.

BACKGROUND: Persistent primitive hypoglossal artery (PPHA), a remnant of embryonal circulation, is a rare variant of the posterior cerebral circulation. Seven prior cases of posterior circulation stroke in the setting of PPHA have been described in the literature, with all but one case being attributable to atherosclerotic embolization from the internal carotid artery (ICA) through the PPHA. CASE DESCRIPTION: We report a unique case of a young male with a PPHA presenting with a "top of the basilar" syndrome following the repair of his atrial septal defect who underwent emergent revascularization via endovascular mechanical aspiration thrombectomy. The patient underwent a successful aspiration thrombectomy with significant improvement in his clinical exam. CONCLUSIONS: Considering the rarity of this persistent fetal anastamosis, it is important to be aware of the propensity for unusual presentations in the context of stroke, understand the management of the problem, and expeditiously treat the patient.

Addicted to constructs: science in reverse?

Advancement in science requires clarity of constructs.Like other fields in behavioral science, addiction research is being held back by researchers' use of different terms to mean similar things (synonymy) and the same term to mean different things (polysemy). Journals can help researchers to stay focused on novel and significant research questions by challenging new terms introduced without adequate justification and requiring authors to be parsimonious in their use of terms. To support construct lucidity, new modes of thinking about research integration are needed to keep up with the aggregate of relevant research.

How molecular testing can help (and hurt) in the workup of gliomas.

Advances in genetics research have greatly expanded our ability to accurately diagnose gliomas and provide more useful prognostic information. Herein specific examples are used to show how high-yield targets such as EGFR, 1p/19q, IDH1/2, MGMT, and BRAF can expand the power of the surgical neuropathologist. To avoid errors, however, the significance and controversies associated with each test must be thoroughly understood.

A review of therapeutic uses of mirtazapine in psychiatric and medical conditions.

OBJECTIVE: To review the literature examining the use of mirtazapine with an emphasis on its therapeutic benefits for psychiatric patients with comorbid medical conditions. DATA SOURCES: MEDLINE, PsycINFO, Global Health, and AGRICOLA were searched using the terms mirtazapine OR Remeron. Limits were English language, human, year 1980-2012, treatment and prevention, and therapy. STUDY SELECTION: Two hundred ninety-three articles were identified. DATA EXTRACTION: Identified articles were reviewed with a focus on indications and therapeutic benefits in patients with medical comorbidities. RESULTS: Mirtazapine is an effective antidepressant with unique mechanisms of action. It is characterized by a relatively rapid onset of action, high response and remission rates, a favorable side-effect profile, and several unique therapeutic benefits over other antidepressants. Mirtazapine has also shown promise in treating some medical disorders, including neurologic conditions, and ameliorating some of the associated debilitating symptoms of weight loss, insomnia, and postoperative nausea and vomiting. CONCLUSIONS: Mirtazapine offers clinicians multiple therapeutic advantages especially when treating patients with comorbid medical illness.