Validation of the Revised Neuroimaging Radiological Interpretation System For Acute Traumatic Brain Injury in Adult and Pediatric Population

Aim Our study aimed to validate the revised neuroimaging radiological interpretation system (NIRIS), which would standardize the interpretation of noncontrast head CT of acute traumatic brain injury (TBI) patient and consolidate imaging finding into ordinal severity categories that would not only inform specific patient management actions but could also be used as a clinical decision support tool.

Methods We retrospectively studied dispositions and their outcomes of consecutive patients brought to the Sawai Man Singh Hospital Trauma Centre, Jaipur, India, by any means of transport and who underwent a noncontrast CT scan for suspected TBI between April and December 2018.

Results The revised NIRIS correctly predicted disposition and outcome in 62.9% (750/1192) of patients. After excluding patients with OMEI (other major extracranial injuries) and OMII (other major intracranial injuries), a correct prediction was observed in 88.3% (670/758) of patients. After excluding OMEI and OMII, the predictability of revised NIRIS in the adult population is 87.6% (446/509), while predictability in the pediatric population is 92.1% (224/249).

Conclusion Revised NIRIS is a good tool for predicting patient dispositions, to specific management categories, and outcomes in TBI patients after noncontrast CT head.

Endovascular treatment for aneurysms at the A1 segment of the anterior cerebral artery: current difficulties and solutions

Aneurysms located at the A1 segment of the anterior cerebral artery are considered rare and unique entities. Endovascular treatment (EVT) is effective in preventing aneurysmal bleeding. However, EVT for A1 aneurysms is difficult due to their distinctive configurations. A current review of EVT for A1 aneurysms is lacking. Therefore, we focused on the available literature on this specific issue. To more clearly expound this entity, we also provided some illustrative cases. The A1 segment can be equally divided into the proximal, middle, and distal segments. Proximal aneurysms are most common and difficult to treat via EVT. The A1 segment has a complex anatomy and many important branches. Due to the small size, predominant posterior direction, and sharp upturn of the microcatheter from the parent artery, microcatheter positioning and support is difficult for A1 aneurysms. EVT for A1 aneurysms mainly includes reconstructive and deconstructive strategies. The complications of EVT for A1 aneurysms include aneurysmal perforation, thromboembolic events, and coil protrusion related to stent-assisted embolization. A1 aneurysms represent rare and difficult vascular lesions. EVT is quite challenging for A1 aneurysms due to their distinctive configurations. The outcomes are acceptable.

A Review of Pharmacologic Neurostimulant Use During Rehabilitation and Recovery After Brain Injury

OBJECTIVE

To describe the efficacy and safety of pharmacologic neurostimulants after neurological injuries such as ischemic or hemorrhagic stroke and traumatic brain injury (TBI), critically evaluate the available literature, and make recommendations regarding which neurostimulants should be considered for use in clinical practice.

DATA SOURCES

A literature search of PubMed was performed (1953 to October 2020) to identify relevant articles. Search terms included the following: "neurostimulant, neurorehabilitation" AND "traumatic brain injury, cerebrovascular accident, or stroke." This review is limited to prospective studies and observational trials.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies conducted in humans were considered.

DATA SYNTHESIS

Cognitive and motor deficits caused by stroke and TBI account for high rates of long-term disability. Although not well-established, pharmacologic agents, broadly characterized as neurostimulants, may be prescribed after brain injury to treat these deficits. When prescribing these medications, it is imperative to be aware of the supporting evidence in order to accurately gauge the risk-benefit profile of each agent.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

The following presents a literature review critically evaluating clinical studies that investigate neurostimulant use after brain injury. The intent of this review is to serve as an evidence-based guide for clinicians.

CONCLUSIONS

The pharmacologic agent with the most supporting literature is amantadine used for cognitive improvement after TBI. Other neurostimulants with positive, despite more limited, evidence include methylphenidate, modafinil, levodopa, and citalopram. Caution is warranted with other neurostimulants given higher rates of adverse effects or lack of benefit observed in clinical trials.

The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges

Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.

Downregulation of microRNA-9-5p promotes synaptic remodeling in the chronic phase after traumatic brain injury

The level of microRNA-9-5p (miRNA-9-5p) in brain tissues is significantly changed in the chronic phase after traumatic brain injury (TBI). However, the effect of miRNA-9-5p on brain function after TBI has not been elucidated. In this study, we used a controlled cortical impact (CCI) model to induce TBI in Sprague-Dawley rats. Brain microvascular endothelial cells (BMECs), astrocytes, and neurons were extracted from immature Sprague-Dawley rats and cocultured to reconstruct the neurovascular unit (NVU) in vitro. The results showed that downregulation of miRNA-9-5p in the chronic phase contributed to neurological function recovery by promoting astrocyte proliferation and increasing the release of astrocyte-derived neurotrophic factors around injured brain tissues after TBI. A dual-luciferase reporter assay validated that miRNA-9-5p was a post-transcriptional modulator of thrombospondin 2 (Thbs-2), and downregulation of miRNA-9-5p promoted Thbs-2 expression in astrocytes. Furthermore, we verified that Thbs-2 can promote Notch pathway activation by directly binding to Jagged and Notch. Through in vitro experiments, we found that the expression of synaptic proteins and the number of synaptic bodies were increased in neurons in the NVU, which was constructed using astrocytes pretreated with miRNA-9-5p inhibitor. Moreover, we also found that downregulation of miRNA-9-5p promoted Thbs-2 expression in astrocytes, which activated the Notch/cylindromatosis/transforming growth factor-β-activated kinase 1 pathway in neurons and promoted the expression of synaptic proteins, including post-synaptic density protein 95 and synaptotagmin. Based on these results, miRNA-9-5p may be a new promising prognostic marker and treatment target for TBI.

Putting 'CSF-Shift Edema' Hypothesis to Test: Comparing Cisternal and Parenchymal Pressures After Basal Cisternostomy for Head Injury

BACKGROUND

Increased brain edema in head injury is due to shift of cerebrospinal fluid (CSF) from cisterns at high pressure to brain parenchyma at low pressure. By opening basal cisterns and decreasing the increased cisternal pressure, basal cisternostomy (BC) results in reversal of CSF shift from parenchyma to cisterns, leading to decreased brain edema. Though the CSF-shift edema hypothesis is based on pressure difference between cisterns and brain parenchyma, the relationship of these pressures has not been studied.

METHODS

A prospective clinical study was conducted from November 2018 to March 2020 including adult patients with head injury who were candidates for standard decompressive hemicraniectomy (DHC). All patients had neurological assessment and head computed tomography preoperatively and postoperatively. All patients underwent BC with DHC. Postoperatively, parenchymal and cisternal pressures and neurological condition were monitored hourly for 72 hours.

RESULTS

Nine (5 men, 4 women) patients with head injury (mean age, 45.7 years; range, 25-72 years) underwent DHC-BC. Median Glasgow Coma Scale score of patients at admission was 8 (range, 4-14), and median midline shift on computed tomography was 8 mm (range, 7-12 mm). There was a significant difference between opening (25.70 ± 10.48 mm Hg) and closing (11.30 ± 5.95 mm Hg) parenchymal pressures (t₉ = 3.963, P = 0.003). Immediate postoperative cisternal pressure was 1-11 mm Hg and was lower than immediate postoperative parenchymal pressure in all except 1 patient. Postoperatively, if cisternal pressure remained low, parenchymal pressure also decreased, and patients showed clinical improvement. Patients showing increased cisternal pressure showed increased parenchymal pressure and clinical worsening.

CONCLUSIONS

Our study supports the CSF-shift edema hypothesis. Following DHC-BC, cisternal pressure is lowered to near-atmospheric pressure, and its relationship to parenchymal pressure predicts the future course of patients by reversal or re-reversal of CSF shift.

A Systematic Review on the Impact of the COVID-19 Pandemic on Neurosurgical Practice and Indian Perspective

OBJECTIVE

The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19.

MATERIALS AND METHODS

A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as "COVID-19" and "Neurosurgery."

RESULTS

Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms.

CONCLUSION

In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.

Sterile processing in low- and middle-income countries: an integrative review

BACKGROUND

Worldwide disparities in surgical capacity are a significant contributor to health inequalities. Safe surgery and infection prevention and control depend on effective sterile processing (SP) of surgical instruments; however, little is known about SP in low- and middle-income countries (LMICs), where surgical site infection is a major cause of postoperative morbidity and mortality.

AIM

To appraise and synthesise available evidence on SP in LMICs.

METHODS

An integrative review of research literature was conducted on SP in LMICs published between 2010 and 2020. Studies were appraised and synthesised to identify challenges and opportunities in practice and research.

RESULTS

Eighteen papers met the inclusion criteria for qualitative analysis. Challenges to advancing SP include limited available evidence, resource constraints and policy-practice gaps. Opportunities for advancing SP include tailored education and mentoring initiatives, emerging partnerships and networks that advance implementation guidelines and promote best practices, identifying innovative approaches to resource constraints, and designing and executing quality assurance and surveillance programmes.

DISCUSSION

Research investigating safe surgery, including SP, in LMICs is increasing. Further research and evidence are needed to confirm the generalisability of study findings and effectiveness of strategies to improve SP practice in LMICs. This review will help researchers and stakeholders identify opportunities to contribute. The burdens of unsafe surgery transcend geopolitical borders, and the global surgery and research communities are called upon to negotiate historical and present-day inequities to achieve safe surgery for all.

Reconversion of neurosurgical practice in times of the SARS-CoV-2 pandemic: a narrative review of the literature and guideline implementation in a Mexican neurosurgical referral center

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has forced the modification of surgical practice worldwide. Medical centers have been adapted to provide an efficient arrangement of their economic and human resources. Although neurosurgeons are not in the first line of management and treatment of COVID-19 patients, they take care of patients with neurological pathology and potential severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Here, the authors describe their institutional actions against the pandemic and compare these actions with those in peer-reviewed publications.

METHODS

The authors conducted a search using the MEDLINE, PubMed, and Google Scholar databases from the beginning of the pandemic until July 11, 2020, using the following terms: "Neurosurgery," "COVID-19/SARS-CoV-2," "reconversion/modification," "practice," "academy," and "teaching." Then, they created operational guidelines tailored for their institution to maximize resource efficiency and minimize risk for the healthcare personnel.

RESULTS

According to the reviewed literature, the authors defined the following three changes that have had the greatest impact in neurosurgical practice during the COVID-19 pandemic: 1) changes in clinical practices; 2) changes in the medical care setting, including modifications of perioperative care; and 3) changes in the academic teaching methodology.

CONCLUSIONS

The Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez" is one of the major referral centers for treating highly complex neurosurgical pathologies in Mexico. Its clinical and neurosurgical practices have been modified with the implementation of specific interventions against the spread of COVID-19. These practical and simple actions are remarkably relevant in the context of the pandemic and can be adopted and suited by other healthcare centers according to their available resources to better prepare for the next event.

Challenges posed by COVID-19 and neurosurgical nursing strategies in developing countries

Background:

Neurosurgical patients with stroke, trauma, and brain tumors can be among the victims of the COVID-19 pandemic in developing countries, which need to be managed efficiently.

Methods:

This is an overview of neurosurgical nurses’ challenges and strategies in the current COVID-19 pandemic environment in developing countries.

Results:

Here, we reviewed the unique challenges of providing neurosurgical nursing services during the COVID-19 pandemic in developing countries. We address specific issues such as transferring neurosurgical patients, allocating medical supplies, prioritizing neurosurgical services, COVID-19 testing protocols, and patient triage (emergent vs. urgent vs. delayed surgery). Teleconsultation, telenursing services for outpatient treatment, follow-up and virtual teaching strategies associated with neurosurgical nursing are discussed.

Conclusion:

Neurosurgical nursing during the COVID-19 pandemic in developing countries requires transparent planning, implementation, and careful consideration of various telemedicine strategies.

Day-of-Injury Computed Tomography and Longitudinal Rehabilitation Outcomes: A Comparison of the Marshall and Rotterdam Computed Tomography Scoring Methods

OBJECTIVE

The aim of the study was to compare the relative predictive value of Marshall Classification System and Rotterdam scores on long-term rehabilitation outcomes. This study hypothesized that Rotterdam would outperform Marshall Classification System.

DESIGN

The study used an observational cohort design with a consecutive sample of 88 participants (25 females, mean age = 42.0 [SD = 21.3]) with moderate to severe traumatic brain injury who were admitted to trauma service with subsequent transfer to the rehabilitation unit between February 2009 and July 2011 and who had clearly readable computed tomography scans. Twenty-three participants did not return for the 9-mo postdischarge follow-up. Day-of-injury computed tomography images were scored using both Marshall Classification System and Rotterdam criteria by two independent raters, blind to outcomes. Functional outcomes were measured by length of stay in rehabilitation and the cognitive and motor subscales of the Functional Independence Measure at rehabilitation discharge and 9-mo postdischarge follow-up.

RESULTS

Neither Marshall Classification System nor Rotterdam scales as a whole significantly predicted Functional Independence Measure motor or cognitive outcomes at discharge or 9-mo follow-up. Both scales, however, predicted length of stay in rehabilitation. Specific Marshall scores (3 and 6) and Rotterdam scores (5 and 6) significantly predicted subacute outcomes such as Functional Independence Measure cognitive at discharge from rehabilitation and length of stay.

CONCLUSIONS

Marshall Classification System and Rotterdam scales may have limited utility in predicting long-term functional outcome, but specific Marshall and Rotterdam scores, primarily linked to increased severity and intracranial pressure, may predict subacute outcomes.

Laparoscopic resection of a large clinically silent paraganglioma at the organ of Zuckerkandl: a rare case report and review of the literature

Background

Large paraganglioma of the Zuckerkandl organ (POZ) is extremely rare. The patient can occasionally be paucisymptomatic, further obscuring the diagnosis and carrying high mortality. Recommended treatment for large paraganglioma (PGL) is open surgical removal. We report a case of successful laparoscopic resection of a large POZ with normal blood pressure in a 45-year-old man.

Case presentation

A 45-year-old man was hospitalized because of hyperglycemia. Computed tomography of the abdomen and the serum and urinary catecholamine levels confirmed the diagnosis of large POZ. But his blood pressure was normal and he underwent laparoscopic tumor excision successfully. During 6 months follow-up after laparoscopy, serum and urinary catecholamines were normal but glycaemia remained high level. DNA analysis of the succinate dehydrogenase complex subunits B (SDHB) and SDHD revealed no mutation.

Conclusions

POZ is an unusual mass and preoperative diagnosis can be difficult in clinically silent cases. PGL cannot be excluded in patients with normal blood pressure. Even a large POZ can be excised laparoscopically by following proper techniques.

Computed tomography angiography accuracy in brain death diagnosis

OBJECTIVE

The present study was designed to answer several concerns disclosed by systematic reviews indicating no evidence to support the use of computed tomography angiography (CTA) in the diagnosis of brain death (BD). Therefore, the aim of this study was to assess the effectiveness of CTA for the diagnosis of BD and to define the optimal tomographic criteria of intracranial circulatory arrest.

METHODS

A unicenter, prospective, observational case-control study was undertaken. Comatose patients (Glasgow Coma Scale score ≤ 5), even those presenting with the first signs of BD, were included. CTA scanning of arterial and venous vasculature and transcranial Doppler (TCD) were performed. A neurological determination of BD and consequently determination of case (BD group) or control (no-BD group) was conducted. All personnel involved with assessing patients were blinded to further tests results. Accuracy of BD diagnosis determined by using CTA was calculated based on the criteria of bilateral absence of visualization of the internal cerebral veins and the distal middle cerebral arteries, the 4-point score (4PS), and an exclusive criterion of absence of deep brain venous drainage as indicated by the absence of deep venous opacification on CTA, the venous score (VS), which considers only the internal cerebral veins bilaterally.

RESULTS

A total of 106 patients were enrolled in this study; 52 patients did not have BD, and none of these patients had circulatory arrest observed by CTA or TCD (100% specificity). Of the 54 patients with a clinical diagnosis of BD, 33 met the 4PS (61.1% sensitivity), whereas 47 met the VS (87% sensitivity). The accuracy of CTA was time related, with greater accuracy when scanning was performed less than 12 hours prior to the neurological assessment, reaching 95.5% sensitivity with the VS.

CONCLUSIONS

CTA can reliably support a diagnosis of BD. The criterion of the absence of deep venous opacification, which can be assessed by use of the VS criteria investigated in this study, can confirm the occurrence of cerebral circulatory arrest.Clinical trial registration no.: 12500913400000068 (clinicaltrials.gov).

Extra-spinal sciatica and sciatica mimics: a scoping review

Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment. While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are: piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome, cluneal nerve disorder, and osteitis condensans ilii. In some cases, extra-spinal sciatica may have a catastrophic course when the sciatic nerve is involved in cyclical sciatica, or the piriformis muscle in piriformis pyomyositis. In addition to cases of sciatica with clear spinal or extra-spinal origin, some cases can be a product of both origins; the same could be true for pseudo-sciatica or sciatica mimics, we simply don't know how prevalent extra-spinal sciatica is among total sciatica cases. As treatment regimens differ for spinal, extra-spinal sciatica, and sciatica-mimics, their precise diagnosis will help physicians to make a targeted treatment plan. As published works regarding extra-spinal sciatica and sciatica mimics include only a few case reports and case series, and systematic reviews addressing them are hardly feasible at this stage, a scoping review in the field can be an eye-opener for the scientific community to do larger-scale prospective research.

Disseminated Primary Pulmonary Choriocarcinoma Successfully Treated by Chemotherapy: A Case Report and Literature Review

Primary pulmonary choriocarcinoma (PPC) is frequently fatal due to difficulties in diagnosis. Few cases of PPC are bilateral and involve exceptionally large nodules. Here, we report an unusual case of PPC involving disseminated bilateral nodules, which was misdiagnosed as tuberculosis, but successfully treated using chemotherapy. A review of 65 cases revealed six cases of bilateral disease, including the present one. Patients treated with surgery, chemotherapy, or a combination of both showed similar treatment outcomes; however, chemotherapy may be the preferred option. Despite its rarity, PPC should be included in the differential diagnosis for all lung nodules to enable early detection.

Labbé vein thrombosis

PURPOSE

Evaluate the prevalence of Labbé vein thrombosis (LVT) and its liability for the lesions observed in the case of associated ipsilateral transverse sinus thrombosis (TST).

METHODS

MRI findings of 58 consecutive patients (≥ 18 years) with acute LVT and TST (group 1) were compared with those of 149 patients with acute TST-no LVT (group 2) observed during the same period.

RESULTS

The prevalence of LVT was 15.2%. Group 1: TST extended to sigmoid sinus in 94.8%, resulting in complete sinuses occlusion. Any lesion was observed in 81% within LV territory: swelling (n = 5, 8.6%), edema (n = 9; 15.5%), non-hemorrhagic Infarct (n = 1; 1.7%), multiple temporal lobe hemorrhages (n = 31; 53.5%), temporal lobe hematoma (n = 13; 22.4%), and pericerebral hemorrhages (n = 28; 50%). The hemorrhagic lesions were not related to dominant TST or to extensive venous thrombosis. There was a prevalence of left TST- LVT (n = 32; 55.2%) and a higher prevalence of hemorrhagic lesions in this subset (59.4%). Risk factors were also associated (p = 0.03). Group 2: the TST resulted in an occlusion of the TS: (i) complete (n = 16; 10.7%); (ii) incomplete (n = 97; 82.8%); and (iii) segmental, involving the TS before (n = 32; 21.5%) or after (n = 10; 6.7%) LV ending within the TS. No parenchymal/pericerebral lesions were associated.

CONCLUSION

This study shows a strong association between the following: (i) the extent of thrombosis in the TS and the presence of LVT (p < 0.0001), (ii) the concomitance of LVT-TST and the presence of lesions in the LV territory and at the temporo-frontal convexity, (iii) risk factors and group 1 (p = 0.03).

Subtle ocular movements in a patient with brain death

Introduction and Case Presentation: Brain death can be associated with limb movements that are attributed to spinal reflexes. Although head/face movements have been rarely reported, no case of overt eye movements in brain death has been documented. We report a case of a patient with subtle eye movements whose exam was otherwise consistent with brain death. The presence of eye movements delayed pronouncing the patient as brain dead and delayed organ donation. We agree with American Academy of Neurology Position statement from 2019 that brain death does not mean demise of every neuron. Discussion: This case raises important questions about the types of movements that should be "allowed" during the determination of brain death to avoid delays in diagnosis.

A rare cause of sciatica: Sciatic nerve schwannoma - Report of one case with long subclinical course and misleading presentation

The authors report one case of schwannoma located in the sciatic nerve, just above the popliteal fossa. A sciatic localization is rare, observed in 1% of the patients. The misleading clinical presentation of this localization causes a delay in diagnosis. Magnetic Resonance Imaging (MRI) is the imaging modality of choice, but the final diagnosis is made by the histological examination of the tumor. Schwannoma should be surgically removed without division of the nerve trunk.

Cervical epidural neurosarcoidosis: A case report and literature review

Background:

Neurosarcoidosis is a rare disease. In the spine, it commonly presents as an intramedullary lesion. Epidural spinal lesions are extremely rare.

Case Description:

A 29-year-old patient presented with a 22-month history of progressive neck, upper limb pain, and myelopathy. The cervical MRI showed a large epidural mass infiltrating the paraspinal soft tissue. After an open biopsy, the diagnosis of neurosarcoidosis was established and was followed-up by appropriate medical management.

Conclusion:

To manage cervical epidural neurosarcoidosis, first, you must obtain a tissue diagnosis and then follow with appropriate medical management.

Schwannomas of the sciatic nerve: A rare and neglected diagnosis. A review of the literature with two illustrative cases

OBJECTIVE

Schwannomas of the sciatic nerve, which is the largest nerve of the human body, are very rare accounting for ≤ 1% of all schwannomas. They often may raise confusion with other more common causes of sciatica, such as lumbar degenerative and inflammatory diseases or spinal tumors, which may often lead to a late correct diagnosis.

PATIENTS AND METHODS

We present two cases of sciatic nerve schwannomas that were recently treated at our Institution, and we review the pertinent English literature on this topic over the last 15 years, yielding twenty three cases to analyze.

RESULTS

Even if sciatic nerve schwannomas are a rare occurrence, a thorough clinical and radiological evaluation of the sciatic nerve should be considered whenever a sciatic pain is not otherwise explained. A positive Tinel sign and a palpable mass along the course of the sciatic nerve may be strong clues to achieve the diagnosis. Combined morphological and advanced functional MRI imaging may help to differentiate benign from malignant peripheral nerve sheath tumors, avoiding unnecessary preoperative biopsy.

CONCLUSIONS

A standard microsurgical technique guided by ultrasound and neurophysiologic monitoring, allows in most of the cases a safe removal of the tumor and very satisfactory post-operative results for the patients.

Intracranial Gorgon: Surgical Case Report of a Large Calcified Brain Arteriovenous Malformation

Patient: Male, 55-year-old

Final Diagnosis: Right frontal arteriovenous malformation, partially calcified • multiple generalised epileptic seizures • chronic headache

Symptoms: Epilectic seizure • headache

Medication: —

Clinical Procedure: Neurosurgical resection of the right frontal AVM

Specialty: Neurosurgery

Metastatic disease in head & neck oncology

The head and neck district represents one of the most frequent sites of cancer, and the percentage of metastases is very high in both loco-regional and distant areas. Prognosis refers to several factors: a) stage of disease; b) loco-regional relapses; c) distant metastasis. At diagnosis, distant metastases of head and neck cancers are present in about 10% of cases with an additional 20-30% developing metastases during the course of their disease. Diagnosis of distant metastases is associated with unfavorable prognosis, with a median survival of about 10 months. The aim of the present review is to provide an update on distant metastasis in head and neck oncology. Recent achievements in molecular profiling, interaction between neoplastic tissue and the tumor microenvironment, oligometastatic disease concepts, and the role of immunotherapy have all deeply changed the therapeutic approach and disease control. Firstly, we approach topics such as natural history, epidemiology of distant metastases and relevant pathological and radiological aspects. Focus is then placed on the most relevant clinical aspects; particular attention is reserved to tumours with distant metastasis and positive for EBV and HPV, and the oligometastatic concept. A substantial part of the review is dedicated to different therapeutic approaches. We highlight the role of immunotherapy and the potential effects of innovative technologies. Lastly, we present ethical and clinical perspectives related to frailty in oncological patients and emerging difficulties in sustainable socio-economical governance.

Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.

Initial classification of low back and leg pain based on objective functional testing: a pilot study of machine learning applied to diagnostics

OBJECTIVE

The five-repetition sit-to-stand (5R-STS) test was designed to capture objective functional impairment and thus provided an adjunctive dimension in patient assessment. The clinical interpretability and confounders of the 5R-STS remain poorly understood. In clinical use, it became apparent that 5R-STS performance may differ between patients with lumbar disk herniation (LDH), lumbar spinal stenosis (LSS) with or without low-grade spondylolisthesis, and chronic low back pain (CLBP). We seek to evaluate the extent of diagnostic information contained within 5R-STS testing.

METHODS

Patients were classified into gold standard diagnostic categories based on history, physical examination, and imaging. Crude and adjusted comparisons of 5R-STS performance were carried out among the three diagnostic categories. Subsequently, a machine learning algorithm was trained to classify patients into the three categories using only 5R-STS test time and patient age, gender, height, and weight.

RESULTS

From two prospective studies, 262 patients were included. Significant differences in crude and adjusted test times were observed among the three diagnostic categories. At internal validation, classification accuracy was 96.2% (95% CI 87.099.5%). Classification sensitivity was 95.7%, 100%, and 100% for LDH, LSS, and CLBP, respectively. Similarly, classification specificity was 100%, 95.7%, and 100% for the three diagnostic categories.

CONCLUSION

5R-STS performance differs according to the etiology of back and leg pain, even after adjustment for demographic covariates. In combination with machine learning algorithms, OFI can be used to infer the etiology of spinal back and leg pain with accuracy comparable to other diagnostic tests used in clinical examination. These slides can be retrieved under Electronic Supplementary Material.

Prognostics of Hospitalization Length and Mortality in Patients with Traumatic Frontal Brain Contusions

Traumatic brain injury has ripple effect on the physical, cognitive, behavioral, and emotional domains of quality of life and portends a long-term neurological disability in survivors. In this study we evaluated the prognostic role of demographic and clinico-radiological variables on the hospitalization length and mortality in 71 of patients with frontal brain contusions. The receiver operating characteristic (ROC) plots were performed, with area under the curve (AUC) values, for graphical comparison of variables that would predict mortality and hospitalization length. We found that the best prognostics of mortality were the Glasgow Coma Scale score, the motor function score, and the Rotterdam CT score, with AUC values of 0.873, 0.836, and 0.711, respectively. Concerning the prediction of hospitalization length, the AUC showed inappreciable differences, with the highest values for the Glasgow Coma Scale score, Rotterdam CT score, and the serum cortisol level in a 0.550-0.600 range. Curve estimation, based on multivariate analysis, showed that the scores of motor function, Glasgow Coma Scale, and Rotterdam CT correlated best with the prediction of both mortality and hospitalization length, along with the upward dynamic changes of serum cortisol for the latter. We conclude that basically simple and non-invasive assessment in survivors of acute traumatic brain contusion is helpful in predicting mortality and the length of hospital stay, which would be of essential value in better allocation of healthcare resources for inpatient treatment and rehabilitation and for post-hospital patient's functioning.

Pendular Oscillation and Ocular Bobbing After Pontine Hemorrhage

The pathophysiology of acute, vertical spontaneous eye movements following pontine hemorrhage is not well understood. Here, we present and discuss the video-oculography findings of a patient with acute pontine hemorrhage who developed vertical pendular oscillation and ocular bobbing while comatose. The amplitudes, peak velocities, frequency distribution, and phase planes (velocity versus position) of the eye movements were analyzed. The vertical pendular oscillation was rhythmic with a peak frequency of 1.7 Hz, but amplitudes (mean 1.9°, range 0.2-8.2°) and peak velocities (mean 20.6°/s; range 5.9-60.6°/sec) fluctuated. Overall, their peak velocities were asymmetric, faster with downward than upward. Higher peak velocities were seen with larger amplitudes (downward phase r = 0.95, p < 0.001; upward phase r = 0.91, p < 0.001) and with movements beginning at eye positions lower in the orbit (downward phase r = - 0.64, p < 0.001; upward phase r = - 0.86, p < 0.001). Interspersed were typical ocular bobbing waveforms with a fast (peak velocity 128.8°/s), large-amplitude (17.5°) downward movement, sometimes followed by a flat interphase interval (0.5 s) when the eye was nearly stationary, and then a slow return to mid-position with a decaying velocity waveform. To account for the presence and co-existence of pendular oscillations and bobbing, we present and discuss three hypothetical models, not necessarily mutually exclusive: (1) oscillations originating in the inferior olives due to disruption of the central tegmental tract(s); (2) unstable neural integrator function due to pontine cell group damage involving neurons involved in gaze-holding; (3) low-frequency saccadic intrusions following omnipause neuron damage.

Primary Dural Diffuse Large B-cell Lymphoma: A Comprehensive Review of Survival and Treatment Outcomes

Primary dural diffuse large B-cell lymphoma (PD-DLBCL) is a rare and aggressive B-cell non-Hodgkin lymphoma that can present in intracranial or intraspinal locations. Although the optimal management is unknown, PD-DLBCL therapy is often mirrored after primary central nervous system lymphoma therapy and aggressive treatment with a high dose methotrexate-based regimen is frequently used. Our comprehensive, retrospective study of 24 reported cases of PD-DLBCL provide the most complete analysis of this rare disease including data on biology, treatment outcomes, and survival. Our findings demonstrate good outcomes following induction treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), suggesting that these cases can be treated as DLBCL rather than primary central nervous system lymphoma, obviating the need for more aggressive and toxic approaches. The durable responses following R-CHOP also confirm that PD-DLBCL is not protected by the blood brain barrier.

External Validation of the Rotterdam Computed Tomography Score in the Prediction of Mortality in Severe Traumatic Brain Injury

Introduction:

Traumatic brain injury (TBI) is a public health problem. It is a pathology that causes significant mortality and disability in Colombia. Different calculators and prognostic models have been developed to predict the neurological outcomes of these patients. The Rotterdam computed tomography (CT) score was developed for prognostic purposes in TBI. We aimed to examine the accuracy of the prognostic discrimination and prediction of mortality of the Rotterdam CT score in a cohort of trauma patients with severe TBI in a university hospital in Colombia.

Materials and Methods:

We analyzed 127 patients with severe TBI treated in a regional trauma center in Colombia over a 2-year period. Bivariate and multivariate analyses were used. The discriminatory power of the score, its accuracy, and precision were assessed by logistic regression and as the area under the receiver operating characteristic curve. Shapiro–Wilk, Chi-square, and Wilcoxon tests were used to compare the real outcomes in the cohort against the predicted outcomes.

Results:

The median age of the patient cohort was 33 years, and 84.25% were male. The median injury severity score was 25, the median Glasgow Coma Scale motor score was 3, the basal cisterns were closed in 46.46% of the patients, and a midline shift of >5 mm was seen in 50.39%. The 6-month mortality was 29.13%, and the Rotterdam CT score predicted a mortality of 26% (P < 0.0001) (area under the curve: 0.825; 95% confidence interval: 0.745–0.903).

Conclusions:

The Rotterdam CT score predicted mortality at 6 months in patients with severe head trauma in a university hospital in Colombia. The Rotterdam CT score is useful for predicting early death and the prognosis of patients with TBI.

Hydrocephalus after foramen magnum decompression for Chiari I malformation successfully treated with the aspiration of pseudomeningocele: a case report

Background

Pseudomeningocele or cerebrospinal fluid leakage is one of the most common complications of foramen magnum decompression with duraplasty for Chiari I malformation. Usually, cerebrospinal fluid leakage is treated with lumbar drainage and/or secondary suture. However, if hydrocephalus occurs, spinal drainage may cause brain herniation.

Case presentation

A 54-year-old Japanese woman presented to our hospital with a 10-month history of bilateral finger extension weakness and clumsiness. Magnetic resonance imaging showed displacement of her cerebellar tonsils below the foramen magnum level, with syringomyelia presenting from the C4 to T8 level. Suboccipital craniectomy and C1 laminectomy with duraplasty were performed under general anesthesia. At 1 month after discharge, she again presented to our hospital due to severe headache and nausea. Magnetic resonance imaging of her cervical spine showed pseudomeningocele compressing her cerebellum and spinal cord. Magnetic resonance imaging of her brain also showed ventriculomegaly. Pseudomeningocele aspiration was performed, with 25 ml of fluid removed under X-ray control. Immediately after aspiration her headache and nausea decreased, and she reported improvement in her symptoms with increasing bilateral finger extension strength and decreasing bilateral upper extremity numbness at her 1-year follow-up.

Conclusions

Although there is a considerable risk of meningitis with the aspiration procedure of pseudomeningocele, an aspiration procedure may be an easy and effective treatment option for postoperative hydrocephalus after suboccipital craniotomy with duraplasty in a patient treated for Chiari I malformation.

Demographics and clinical characteristics of acute traumatic brain injury patients in the different Neuroimaging Radiological Interpretation System (NIRIS) categories

PURPOSE

To characterize the demographics, clinical and imaging findings, and outcomes of traumatic brain injury (TBI) patients in each of NeuroImaging Radiological Interpretation System (NIRIS) categories.

MATERIAL AND METHODS

We considered all consecutive patients transported to Stanford Hospital's emergency department by ambulance or helicopter between November 2015 and April 2017. We retained adult patients (> 18 years old) for whom a trauma alert was triggered and who underwent a non-contrast head computer tomography (CT) because of suspected TBI. We reviewed the non-contrast CT scans in these patients for the NIH TBI common data elements (CDEs). We recorded, then assessed differences in terms of demographics, clinical characteristics, imaging CDEs, and outcomes in patients from the different NIRIS categories.

RESULTS

In all, 1152 patients were included in this study. Patients with NIRIS 0 imaging findings were significantly younger than patients in other NIRIS categories (P<0.001). Motor vehicle accidents and falls from height were the most common mechanisms of injury across NIRIS categories. GCS scores decreased with increasing NIRIS category imaging findings and were significantly lower in patients with NIRIS 4 imaging findings (P<0.001). Significant differences in NIRIS categories were observed for all imaging CDEs (P<0.001), in agreement with the definition of the different NIRIS categories. Mortality increased progressively with increasing NIRIS severity.

CONCLUSIONS

TBI patients in different NIRIS categories have different clinical characteristics, hospital courses and outcomes. This natural history assessment of patients from different NIRIS categories could thus serve as a reference standard for future TBI clinical trials.

Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism

There have been significant advancements in the management of intracerebral hemorrhage (ICH) stemming from new knowledge on its pathogenesis. Major clinical trials, such as Surgical Trial in Lobar Intracerebral Hemorrhage (STICH I and II), have shown only a small, albeit clinically relevant, advantage of surgical interventions in specific subsets of patients suffering from ICH. Currently, the aim is to use a minimally invasive and safe trajectory in removing significant brain hematomas with the aid of neuro-endoscopy or precise guidance through neuro-navigation, thereby avoiding a collateral damage to the surrounding normal brain tissue. A fundamental rational to such approach is to safely remove hematoma, preventing the ongoing mass effect resulting in brain herniation, and to minimize deleterious effects of iron released from hematoma to brain cells. The clot lysis process is facilitated with the adjunctive use of recombinant tissue plasminogen activator and sonolysis. Revised recommendations for the management of ICH focus on a holistic approach, with special emphasis on early patient mobilization and graded rehabilitative process. There has been a paradigm shift in the management algorithm, putting emphasis on early and safe removal of brain hematoma and then focusing on the improvement of patients' quality of life. We have made significant progress in transition from nihilism toward optimism, based on evidence-based management of such a severe global health scourge as intracranial hemorrhage.

An Exploration of the Terminology of Clinical Cognition and Reasoning

We hypothesize that the functionality of electronic health records could be improved with the addition of formal representations of clinicians' cognitive processes, including such things as the interpretation and synthesis of patient findings and the rational for diagnostic and therapeutic decisions. We carried out a four-phase analysis of clinical case studies to characterize how such processes are represented through relationships between clinical terms. The result is an terminology of 26 relationships that were validated against published clinical cases with 85.4% interrater reliability. We believe that capturing patient-specific information with these relationships can lead to improvements in clinical decision support systems, information retrieval and learning health systems.

Gestational Trophoblastic Tumors: A Timely Review of Diagnostic Pathology

CONTEXT.—

Gestational trophoblastic tumors include 3 distinct entities: gestational choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Accurate diagnosis is important for clinical management of the patient.

OBJECTIVE.—

To review clinical features and pathologic diagnosis of gestational trophoblastic tumors.

DATA SOURCES.—

Literature and personal experience are the sources for this study.

CONCLUSIONS.—

Trophoblastic tumors are rare encounters in modern medicine, as a result of clinical practice of molar surveillance programs and early chemotherapeutic intervention for persistent gestational trophoblastic neoplasia. Diagnostic recognition of these tumors requires a high index of suspicion, awareness of their histologic characteristics, and appropriate application of immunohistochemical and molecular biomarkers. Recent attention has been given to a few precursor lesions of gestational trophoblastic tumors, including early/in situ choriocarcinoma and atypical placental site nodule.

Management of hydrocephalus and subdural hygromas in pediatric patients after decompression of Chiari malformation type I: case series and review of the literature

OBJECTIVE

Hydrocephalus associated with subdural hygromas is a rare complication after decompression of Chiari malformation type I (CM-I). There is no consensus for management of this complication. The authors present a series of 5 pediatric patients who underwent CM-I decompression with placement of a dural graft complicated by posterior fossa hygromas and hydrocephalus that were successfully managed nonoperatively.

METHODS

A retrospective review over the last 5 years of patients who presented with hydrocephalus and subdural hygromas following foramen magnum decompression with placement of a dural graft for CM-I was conducted at 2 pediatric institutions. Their preoperative presentation, perioperative hospital course, and postoperative re-presentation are discussed with attention to their treatment regimen and ultimate outcome. In addition to reporting these cases, the authors discuss all similar cases found in their literature review.

RESULTS

Over the last 5 years, the authors have encountered 194 pediatric cases of CM-I decompression with duraplasty equally distributed at the 2 institutions. Of those cases, 5 pediatric patients with a delayed postoperative complication involving hydrocephalus and subdural hygromas were identified. The 5 patients were managed nonoperatively with acetazolamide and high-dose dexamethasone; dosages of both drugs were adjusted to the age and weight of each patient. All patients were symptom free at follow-up and exhibited resolution of their pathology on imaging. Thirteen similar pediatric cases and 17 adult cases were identified in the literature review. Most reported cases were treated with CSF diversion or reoperation. There were a total of 4 cases previously reported with successful nonoperative management. Of these cases, only 1 case was reported in the pediatric population.

CONCLUSIONS

De novo hydrocephalus, in association with subdural hygromas following CM-I decompression, is rare. This presentation suggests that these complications after posterior fossa decompression with duraplasty can be treated with nonoperative medical management, therefore obviating the need for CSF diversion or reoperation.

Post-discharge mortality in patients with traumatic spinal cord injury in a Brazilian hospital: a retrospective cohort

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To evaluate the survival outcomes in patients with traumatic spinal cord injury (TSCI).

SETTING

A teaching hospital in Brazil.

METHODS

A total of 434 patients diagnosed with TSCI (2004-2014) were included. Overall survival, standardized mortality ratios (SMR), and causes of death were assessed by Student's t-test, χ² test, Kaplan-Meier analysis, and Cox proportional-hazards regression.

RESULTS

The mean follow-up was 4.8 years (±3.3 years). Individuals with tetraplegia had a median survival of 11 years, with participants in the paraplegia group not reaching median survival. The overall mortality rate was 37 per 1000 person-years. Age-adjusted SMR was 28.8 (95% CI: 22.8-36). There were 77 deaths with 56 defined causes, of which pneumonia was the most frequent (35.7%). Combined infectious etiologies caused 55.3% of deaths. Multivariate analysis revealed higher mortality among individuals with tetraplegia vs. paraplegia in the first 2 years post injury (HR = 8.28, 95% CI: 2.76-24.80), after 2 years post injury (HR = 2.35, 95% CI: 1.31-4.24), and in all years combined (HR = 3.36, 95% CI: 2.04-5.52).

CONCLUSION

Mortality among patients with TSCI was 28.8 times higher than in the reference population. In more than half of the cases, the cause of death was linked to infectious diseases. Pneumonia caused two times more deaths in individuals with tetraplegia than in individuals with paraplegia, with a higher impact in the first 2 years post injury. Reported findings indicate the need for a surveillance and prevention program with emphasis on vaccination and respiratory rehabilitation.

Marshall and Rotterdam Computed Tomography scores in predicting early deaths after brain trauma

Trauma is one of the most important issues of most healthcare systems accompanying with head trauma in the most cases. We sought to determine the scoring system and initial Computed Tomography (CT) findings predicting the death at hospital discharge (early death) in patients with traumatic brain injury based on Marshall and Rotterdam CT scores. This is a cross sectional study on traumatic neurosurgical patients with mild-to-severe traumatic brain injury admitted to the emergency department of Emam Reza Hospital, Birjand University of Medical Sciences. Patients≥18 years old with TBI during last 24 hours with GCS≤13 were included and exclusion criteria were multiple trauma, penetrating injuries, previous history of anticoagulant therapy, pregnancy, not willingness for participation. Their initial CT and status at hospital discharge, one and three months (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score is related to death using SPSS11 by The Mann-Whitney U at the level of p≤0.05. Overall, 98 patients were included. Mean age was 43.52±21.29. Most patients were male (63.3%). Mean Marshall and Rotterdam CT scores were 3.2±1.3 and 2.5±1. The mortality at two weeks, one moth and three months were 19.4%, 20.4%, and 20.4%. Rotterdam CT score was significantly different based on type of hematoma. Median GCS score in alive and dead patients on 2 weeks were 10 and 4 (p=0.0001), at one month were 10 and 4 (p=0.0001), and at three months were 10 and 4 (p=0.0001). The median Marshall CT score on 2 weeks were 2 and 4 (p=0.0001), at one month were 2 and 4 (p=0.0001), and at three months were 2 and 4 (p=0.0001). The median Rotterdam CT score on 2 weeks were 2 and 4 (p=0.0001), at one month were 2 and 3 (p=0.001), and at three months were 2 and 3 (p=0.001). The Rotterdam CT score was significantly correlated with mortality at two weeks, one month and three months (p=0.004, p=0.001, and p=0.001, respectively). The Marshall CT score was not significantly correlated with mortality at any time. The Rotterdam CT score was more accurate for prediction of mortality on 2 weeks (ROC80.9), at one month (ROC80.7), and at three months were (ROC80.7) than The Rotterdam CT score (ROC 76, 74.1, and 74.1, respectively). This study concluded that The Marshall CT score was more accurate for prediction of mortality on 2 weeks, at one month, and at three months were than The Marshall CT score with higher ROC. The correlation of the Rotterdam CT score with mortality was significant.

Management challenges of traumatic spondylolisthesis of the Axis with an unusual C2-C3 posterior subluxation in a paediatric patient: case report and literature review

Introduction

Paediatric cervical spine injuries are uncommon. Traumatic spondylolisthesis of the axis (TSA) is commonly encountered in the trauma setting. The management of TSA may be surgical or non-surgical. Decision making is quite challenging depending on patient presentation and nature of injury, and even more so in the paediatric age group.

Objectives

To present a case report highlighting the challenges in the management of TSA.

Methods

We present an 8 year old male, who sustained a bilateral C2 pars fracture with associated unusual C2-C3 posterior subluxation.

Results

Neuroradiological studies identified the fracture/subluxation of C2-C3 and revealed an intact but posteriorly displaced C2-C3 disc causing cord compression. An Extension Halter traction was initially commenced. This seemed to have worsened the patient's neck pains, and caused motor weakness and autonomic dysfunction. An anterior cervical discectomy and fusion was finally decided on and performed after evaluation and brainstorming by our spinal Unit. Intra-operative findings revealed separation of the C2-C3 disc from the C3 superior end plate which probably explains the unusual nature of the subluxation.

Conclusion

The case shows that surgical intervention as a primary management for TSA even in the paediatric age group is safe and also avoids risks inherent in conservative management.

Feasibility of Modified Anterior Odontoid Screw Fixation: Analysis of a New Trajectory Using 3-Dimensional Simulation Software

BACKGROUND

Anterior odontoid screw fixation (AOSF) has been suggested as the optimal treatment for type II and some shallow type III odontoid fractures. However, only the classical surgical trajectory is available; no newer entry points or trajectories have been reported.

METHODS

We evaluated the anatomic feasibility of a new trajectory for AOSF using 3-dimensional (3D) screw insertion simulation software (Mimics). Computed tomography (CT) scans of patients (65 males and 59 females) with normal cervical structures were obtained consecutively, and the axes were reconstructed in 3 dimensions by Mimics software. Then simulated operations were performed using 2 new entry points below the superior articular process using bilateral screws of different diameters (group 1: 4 mm and 4 mm; group 2: 4 mm and 3.5 mm; group 3: 3.5 mm and 3.5 mm). The success rates and the required screw lengths were recorded and analyzed.

RESULTS

The success rates were 79.03% for group 1, 95.16% for group 2, and 98.39% for group 3. The success rates for groups 2 and 3 did not differ significantly, and both were significantly better than the rate for group 1. The success rate was much higher in males than in females in group 1, but the success rate was similar in males and females in the other 2 groups. Screw lengths did not differ significantly among the 3 groups, but an effect of sex was apparent.

CONCLUSIONS

Our modified trajectory is anatomically feasible for fixation of anterior odontoid fractures, but further anatomic experiments and clinical research are needed.

Metastatic Nongestational Choriocarcinoma to the Brain: Case Report and Proposed Treatment Recommendations

BACKGROUND

Nongestational choriocarcinoma (NGC) is a rare germ cell tumor, accounting for <0.6% of all gestational tumors, and has a poor prognosis when metastasized. NGC with metastasis to the brain is reported even less frequently. Gestational choriocarcinoma (GC) when metastasized to the brain has a higher morbidity and mortality but has been known to be a chemosensitive and radiosensitive lesion, and NGC is chemoresistant with an even worse prognosis. Currently, there is no consensus for treatment for metastatic NGC to the brain.

CASE DESCRIPTION

This 66-year-old postmenopausal female presented with left upper extremity weakness more pronounced in her hand and a workup demonstrating a hemorrhagic lesion over the right frontal parietal lobe. Her metastatic workup was negative, leading to a craniotomy for resection of the mass. The pathology was consistent with metastatic GC of nongestational origin.

CONCLUSIONS

Because of its chemosensitive nature, reports of optimal metastatic GC treatment include radiation alone, chemotherapy without radiation, surgical resection, or combined multimodal therapy. No recommendations for NGC metastasized to the brain have been reported. We propose a systematic workup for hemorrhagic brain lesions to include the proposed imaging modalities and serum markers, including β-human chorionic gonadotropin, to aid early diagnosis. Based on a review of the literature, we recommend surgical resection with adjuvant therapy for accessible symptomatic metastatic GC and NGC to the brain for optimal patient outcomes. Chemotherapy and radiation alone without surgical resection can be considered for asymptomatic GC metastasis to the brain.