Factors Associated with Respiratory Health and Function in Duchenne Muscular Dystrophy: A Systematic Review and Evidence Grading

BACKGROUND

Despite advances in the medical management of the disease, respiratory involvement remains a significant source of morbidity and mortality in children and adults with Duchenne muscular dystrophy (DMD).

OBJECTIVE

The objective of this systematic literature review was to synthesize and grade published evidence of factors associated with respiratory health and function in DMD.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library for records of studies published from January 1, 2000 (to ensure relevance to current care practices), up until and including December 31, 2022, reporting evidence of prognostic indicators and predictors of disease progression in DMD. The quality of evidence (i.e., very low to high) was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework.

RESULTS

The bibliographic search strategy resulted in the inclusion of 29 articles. In total, evidence of 10 factors associated with respiratory health and function in patients with DMD was identified: glucocorticoid exposure (high- to very low-quality evidence), DMD mutations (low-quality evidence), DMD genetic modifiers (low-quality evidence), other pharmacological interventions (i.e., ataluren, eteplirsen, idebenone, and tamoxifen) (moderate- to very low-quality evidence), body mass index and weight (low-quality evidence), and functional ability (low-quality evidence).

CONCLUSIONS

In conclusion, we identified a total of 10 factors associated with respiratory health in function in DMD, encompassing both pharmacological therapies, genetic mutations and modifiers, and patient clinical characteristics. Yet, more research is needed to further delineate sources of respiratory heterogeneity, in particular the genotype-phenotype association and the impact of novel DMD therapies in a real-world setting. Our synthesis and grading should be helpful to inform clinical practice and future research of this heavily burdened patient population.

Predictors of Loss of Ambulation in Duchenne Muscular Dystrophy: A Systematic Review and Meta-Analysis

Objective

The objective of this study was to describe predictors of loss of ambulation in Duchenne muscular dystrophy (DMD).

Methods

This systematic review and meta-analysis included searches of MEDLINE ALL, Embase, and the Cochrane Database of Systematic Reviews from January 1, 2000, to December 31, 2022, for predictors of loss of ambulation in DMD. Search terms included "Duchenne muscular dystrophy" as a Medical Subject Heading or free text term, in combination with variations of the term "predictor". Risk of bias was assessed using the Newcastle-Ottawa Scale. We performed meta-analysis pooling of hazard ratios of the effects of glucocorticoids (vs. no glucocorticoid therapy) by fitting a common-effect inverse-variance model.

Results

The bibliographic searches resulted in the inclusion of 45 studies of children and adults with DMD from 17 countries across Europe, Asia, and North America. Glucocorticoid therapy was associated with delayed loss of ambulation (overall meta-analysis HR deflazacort/prednisone/prednisolone: 0.44 [95% CI: 0.40-0.48]) (n = 25 studies). Earlier onset of first signs or symptoms, earlier loss of developmental milestones, lower baseline 6MWT (i.e.,<350 vs. ≥350 metres and <330 vs. ≥330 metres), and lower baseline NSAA were associated with earlier loss of ambulation (n = 5 studies). Deletion of exons 3-7, proximal mutations (upstream intron 44), single exon 45 deletions, and mutations amenable of skipping exon 8, exon 44, and exon 53, were associated with prolonged ambulation; distal mutations (intron 44 and downstream), deletion of exons 49-50, and mutations amenable of skipping exon 45, and exon 51 were associated with earlier loss of ambulation (n = 13 studies). Specific single-nucleotide polymorphisms in CD40 gene rs1883832, LTBP4 gene rs10880, SPP1 gene rs2835709 and rs11730582, and TCTEX1D1 gene rs1060575 (n = 7 studies), as well as race/ethnicity and level of family/patient deprivation (n = 3 studies), were associated with loss of ambulation. Treatment with ataluren (n = 2 studies) and eteplirsen (n = 3 studies) were associated with prolonged ambulation. Magnetic resonance biomarkers (MRI and MRS) were identified as significant predictors of loss of ambulation (n = 6 studies). In total, 33% of studies exhibited some risk of bias.

Conclusion

Our synthesis of predictors of loss of ambulation in DMD contributes to the understanding the natural history of disease and informs the design of new trials of novel therapies targeting this heavily burdened patient population.

Extracellular heat shock protein 70 levels in tumour-bearing dogs and cats treated with radiation therapy and hyperthermia

Hyperthermia is a form of a cancer treatment which is frequently applied in combination with radiotherapy (RT) to improve therapy responses and radiosensitivity. The mode of action of hyperthermia is multifactorial; the one hand by altering the amount of the blood circulation in the treated tissue, on the other hand by modulating molecular pathways involved in cell survival processes and immunogenic interactions. One of the most dominant proteins induced by hyperthermia is the major stress-inducible heat shock protein 70 (Hsp70). Hsp70 can be found in the blood either as a free-protein (free HSP70) derived from necrotic cells, or lipid-bound (liposomal Hsp70) when it is actively released in extracellular vesicles (EVs) by living cells. The aim of the study was to evaluate the levels of free and liposomal Hsp70 before and after treatment with RT alone or hyperthermia combined with radiotherapy (HTRT) in dogs and cats to evaluate therapy responses. Peripheral blood was collected from feline and canine patients before and at 2, 4, 6 and 24 h after treatment with RT or HTRT. Hsp70 enzyme-linked immunosorbent assays (ELISAs) were performed to determine the free and liposomal Hsp70 concentrations in the serum. The levels were analysed after the first fraction of radiation to study immediate effects and after all applied fractions to study cumulative effects. The levels of free and liposomal Hsp70 levels in the circulation were not affected by the first singular treatment and cumulative effects of RT in cats however, after finalizing all treatment cycles with HTRT free and liposomal Hsp70 levels significantly increased. In dogs, HTRT, but not treatment with RT alone, significantly affected liposomal Hsp70 levels during the first fraction. Free Hsp70 levels were significantly increased after RT, but not HTRT, during the first fraction in dogs. In dogs, on the other hand, RT alone resulted in a significant increase in liposomal Hsp70, but HTRT did not significantly affect the liposomal Hsp70 when cumulative effects were analysed. Free Hsp70 was significantly induced in dogs after both, RT and HTRT when cumulative effects were analysed. RT and HTRT treatments differentially affect the levels of free and liposomal Hsp70 in dogs and cats. Both forms of Hsp70 could potentially be further investigated as potential liquid biopsy markers to study responses to RT and HTRT treatment in companion animals.

Whole brain radiation therapy resulting in radionecrosis: a possible link with radiosensitising chemoimmunotherapy

Radionecrosis describes a rare but serious complication of radiation therapy. In clinical practice, stereotactic radiosurgery (SRS) is increasingly used in combination with systemic therapy, including chemotherapy, immune checkpoint inhibitor and targeted therapy, either concurrently or sequentially. There is a paucity of literature regarding radionecrosis in patients receiving whole brain radiation therapy (WBRT) alone (without additional SRS) in combination with immunotherapy or targeted therapies. It is observed that certain combinations increase the overall radiosensitivity of the tumorous lesions. We present a rare case of symptomatic radionecrosis almost 1 year after WBRT in a patient with non-squamous non-small cell lung cancer on third-line chemoimmunotherapy. We discuss available research regarding factors that may lead to radionecrosis in these patients, including molecular and genetic profiles, specific drug therapy combinations and their timing or increased overall survival.

Woven EndoBridge Device Migration and Microsnare Retrieval Strategy: Single Institutional Case Reports with Technical Video Demonstration

The Woven EndoBridge (WEB) (MicroVention/Terumo) device is a treatment option for wideneck bifurcation aneurysms. An uncommon adverse effect is WEB device migration. While certain bailout strategies for WEB recovery have been described, there is still a paucity of information on optimal strategies to maximize both short and long-term post-operative outcomes. We add 2 cases at our institution to the existing literature of WEBectomy in the setting of complicated intracranial aneurysm treatment. We discuss the long-term imaging outcomes with additional fluoroscopy video demonstrating our technique. Our findings reflect a clear benefit for the use of the Amplatz GooseneckTM microsnare (Medtronic) device as a means of WEB recovery, coupled with potential stent-assisted WEB embolization to remove the aneurysm from the parent circulation, while minimizing recurrence and thromboembolic complications.

Plant water uptake modelling: added value of cross-disciplinary approaches

In recent years, research interest in plant water uptake strategies has rapidly increased in many disciplines, such as hydrology, plant ecology and ecophysiology. Quantitative modelling approaches to estimate plant water uptake and spatiotemporal dynamics have significantly advanced through different disciplines across scales. Despite this progress, major limitations, for example, predicting plant water uptake under drought or drought impact at large scales, remain. These are less attributed to limitations in process understanding, but rather to a lack of implementation of cross-disciplinary insights into plant water uptake model structure. The main goal of this review is to highlight how the four dominant model approaches, that is, Feddes approach, hydrodynamic approach, optimality and statistical approaches, can be and have been used to create interdisciplinary hybrid models enabling a holistic system understanding that, among other things, embeds plant water uptake plasticity into a broader conceptual view of soil-plant feedbacks of water, nutrient and carbon cycling, or reflects observed drought responses of plant-soil feedbacks and their dynamics under, that is, drought. Specifically, we provide examples of how integration of Bayesian and hydrodynamic approaches might overcome challenges in interpreting plant water uptake related to different travel and residence times of different plant water sources or trade-offs between root system optimization to forage for water and nutrients during different seasons and phenological stages.

The role of species interactions for forest resilience to drought

Increasing durations and frequencies of droughts under climate change endanger the sustainable functioning of forests worldwide. The admixture of species with complementary resource use may increase the resilience of forests towards drought; however, little is known about modifications of species interactions (i.e. facilitation and competition) by increasing drought severity in mixed forests. In particular, knowledge on the regulation of central ecohydrological processes, such as tree water fluxes, is lacking. Therefore, we conducted a literature review to assess the impact of species interactions on tree resilience (resistance + recovery) under increasing drought severity. The classification of studies into three drought classes suggested that beneficial species interactions, i.e. through improved water relations, were prevalent under mild droughts. However, with increasing drought, negative effects, such as interspecific competition, occurred. These negative interactions were prominent under extreme droughts, where even trees with complementary resource-use strategies competed for water resources. Fewer data are available on recovery of water fluxes. The limited evidence supported the patterns observed for drought resistance, with facilitation and complementarity of species in mixtures enhancing tree recovery after moderate droughts. However, after extreme droughts, competition effects and reduced recovery for some species were observed, which can strongly compromise tree resilience. While we acknowledge the importance of mixed forests for biodiversity, ecosystem services or pest resistance, we caution that beneficial species interactions may shift under extreme droughts. Thus, there is an urgent need to investigate species interaction effects on resilience in more depth to adapt forest trees to increasing drought stress.

Central European 2018 hot drought shifts scots pine forest to its tipping point

The occurrence of hot drought, i.e. low water availability and simultaneous high air temperature, represents a severe threat to ecosystems. Here, we investigated how the 2018 hot drought in Central Europe caused a tipping point in tree and ecosystem functioning in a Scots pine (Pinus sylvestris L.) forest in southwest Germany. Measurements of stress indicators, such as needle water potential, carbon assimilation and volatile organic compound (VOC) emissions, of dominant P. sylvestris trees were deployed to evaluate tree functioning during hot drought. Ecosystem impact and recovery were assessed as ecosystem carbon exchange, normalized difference vegetation index (NDVI) from satellite data and tree mortality data. During summer 2018, needle water potentials of trees dropped to minimum values of -7.5 ± 0.2 MPa, which implied severe hydraulic impairment of P. sylvestris. Likewise, carbon assimilation and VOC emissions strongly declined after mid-July. Decreasing NDVI values from August 2018 onwards were detected, along with severe defoliation in P. sylvestris, impairing ecosystem carbon flux recovery in 2019, shifting the forest into a year-round carbon source. A total of 47% of all monitored trees (n = 368) died by September 2020. NDVI recovered to pre-2018 levels in 2019, likely caused by emerging broadleaved understorey species. The 2018 hot drought had severe negative impacts on P. sylvestris. The co-occurrence of unfavourable site-specific conditions with recurrent severe droughts resulted in accelerated mortality. Thus, the 2018 hot drought pushed the P. sylvestris stand towards its tipping point, with a subsequent vegetation shift to a broadleaf-dominated forest.

Soil VOC emissions of a Mediterranean woodland are sensitive to shrub invasion

Many belowground processes, such as soil respiration and soil-atmosphere VOC (volatile organic compounds) exchange, are closely linked to soil microbiological processes. However, little is known about how changes in plant species cover, i.e. after plant invasion, alter these soil processes. In particular, the response of soil VOC emissions to plant invasion is not well understood. We analysed soil VOC emissions and soil respiration of a Mediterranean cork oak (Quercus suber) ecosystem, comparing soil VOC emissions from a non-invaded Q. suber woodland to one invaded by the shrub Cistus ladanifer. Soil VOC emissions were determined under controlled conditions using online proton-transfer time-of-flight mass spectrometry. Net soil VOC emissions were measured by exposing soils with or without litter to different temperature and soil moisture conditions. Soil VOC emissions were sensitive to C. ladanifer invasion. Highest net emission rates were determined for oxygenated VOC (acetaldehyde, acetone, methanol, acetic acid), and high temperatures enhanced total VOC emissions. Invasion affected the relative contribution of various VOC. Methanol and acetaldehyde were emitted exclusively from litter and were associated with the non-invaded sites. In contrast, acetone emissions increased in response to shrub presence. Interestingly, low soil moisture enhanced the effect of shrub invasion on VOC emissions. Our results indicate that shrub invasion substantially influences important belowground processes in cork oak ecosystems, in particular soil VOC emissions. High soil moisture is suggested to diminish the invasion effect through a moisture-induced increase in microbial decomposition rates of soil VOC.

Patient-reported outcome measures in spine surgery: A systematic review

Background

Steadily increasing expenditure in the United States health-care system has led to a shift toward a value-based model that focuses on quality of care and cost-effectiveness. Operations involving the spine rank among some of the most common and expensive procedures performed in operating rooms nationwide. Patient-reported outcomes measures (PROMs) are a useful tool for reporting levels of outcome and analyzing patient recovery but are both under-utilized and nonstandardized in spine surgery.

Methods

We conducted a systematic review of the literature using the PubMed database, focusing on the most commonly utilized PROMs for spine disease as well as spinal deformity. The benefits and drawbacks of these PROMs were then summarized and compared.

Results

Spine-specific PROMs were based on the class of disease. The most frequently utilized PROMs were the Neck Disability Index and the modified Japanese Orthopaedic Association scale; the Oswestry Disability Index and the Roland-Morris Disability Questionnaire; and the Scoliosis Research Society 22-item questionnaire (SRS-22) for cervicothoracic spine disease, lumbar spine disease, and spinal deformity, respectively.

Conclusion

We found limited, though effective, use of PROMs targeting specific classes of disease within spine surgery. Therefore, we advocate for increased use of PROMs in spine surgery, in both the research and clinical settings. PROM usage can help physicians assess subjective outcomes in standard ways that can be compared across patients and institutions, more uniquely tailor treatment to individual patients, and engage patients in their own medical care.

Single Level Spondylolisthesis Associated Sagittal Plane Imbalance Corrected by Pre-Psoas Interbody Fusion Using Anterior Column Release with 30° Expandable Hyperlordotic Cage

Background: Loss of lumbar lordosis caused by single level degenerative spondylolisthesis can trigger significant sagittal plane imbalance and failure to correct lumbopelvic parameters during lumbar fusion can lead to poor outcome or worsening deformity. Anterior column release (ACR) through a pre-psoas approach allows the placement of a hyperlordotic cage (HLC) to improve lumbar lordosis, but it is unclear if the amount of cage lordosis affects radiological outcomes in real-life patient conditions. Methods: Three patients were treated with ACR and 30° expandable HLC for positive sagittal imbalance secondary to single-level spondylolisthesis. Patients reported baseline and post-operative Oswestry Disability Index (ODI) and Numeric Pain Score (NRS). Radiographic parameters of sagittal balance included lumbar lordosis (LL), sagittal vertical axis (SVA) and pelvic incidence-lumbar lordosis mismatch (PI-LL). Results: Surgical indications were sagittal plane imbalance caused by L4–L5 degenerative spondylolisthesis (n = 2) and L3–L4 spondylolisthesis secondary to adjacent segmental degeneration (n = 1). Average post-operative length of stay was 3 days (range 2–4) and estimated blood loss was 266 mL (range 200–300). NRS and ODI improved in all patients. All experienced improvements in LL (x¯preop = 33°, x¯postop = 56°), SVA (x¯preop = 180 mm, x¯postop = 61 mm) and PI-LL (x¯preop = 26°, x¯postop = 5°). Conclusion: ACR with expandable HLC can restore sagittal plane balance associated with single-level spondylolisthesis. Failure to perform ACR with HLC placement during pre-psoas interbody fusion may result in under correction of lordosis and poorer outcome for these patients.

Comparison of the 2010 and 2020 World Health Organization guidelines on physical activity in patients with percutaneous coronary interventions early after hospital discharge

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swiss heart foundation

Background

Physical activity (PA) is inversely associated with mortality and adverse outcome in patients with cardiovascular disease, and can be objectively measured by accelerometry. In 2020, the World Health Organization (WHO) has updated their recommendations on PA for adults including those with chronic conditions, omitting the 10 min bout criterion.[1] The aim of this study was to determine the proportions of cardiac patients immediately after hospital discharge from percutaneous coronary interventions (PCI) who fulfil the old [2] and updated WHO PA criteria, and compare the results with established step-based cut-off values.

Methods

Patients after PCI for acute or chronic coronary syndrome with a maximal age of 80 and eligible for ambulatory cardiac rehabilitation were recruited for this observational single centre study. They were provided with a wrist-worn tri-axial accelerometer without display that recorded movement data starting from the day following hospital discharge for the subsequent 18 days. Acceleration data was analysed with the widely used free GGIR package. The proportions of patients fulfilling recommendations for moderate to vigorous PA (MVPA) were determined according to the 2010 and 2020 WHO guidelines as well as 7,500 [3] and 10,000 steps.[4]

Results

159 patients (41%) participated in this study. Data from 135 patients (85%), who had at least 7 days of ≥12 h wear-time were included in the analyses. Their median age was 62 (1st quartile 56, 3rd quartile 68), 22 (16%) were women, and 15 and 120 patients had a CCS and ACS, respectively. Their median wear time was 18 (16, 18) days. 102 (75.6%) had at least 30 min of MVPA on an average day and hence fulfilled the 2020 WHO guidelines. When MVPA was determined using the 2010 WHO guidelines, which only counted MVPA of bouts of at least 10 min, only 23 patients (17.8%) achieved at least 30 min of MVPA on an average day (Figure 1). 67.4% of our patients achieved ≥7,500 steps/d and 71 patients (52.6%) performed ≥10,000 steps/d.

Conclusion

In cardiac patients early after PCI most of the MVPA was accumulated in bouts shorter than 10 min. Applying the 2010 and 2020 WHO PA criteria to objectively measured PA led to a fourfold discrepancy. The 7,500 step cut-off corresponded with the 2020 WHO recommendations. Since achievement of intensity- or step-based cut-offs is greatly dependent on device type, wearing location, data sampling and analysis, it is currently poorly defined and not suited for patient classification and counselling. The clinical implication of this observation will be assessed in a cardiovascular outcome analysis.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Hakuba's triangle: a cadaveric study detailing its anatomy and neurovascular contents with vascular and skull base implications

Hakuba's triangle is a superior cavernous sinus triangle that allows for wide and relatively safe exposure of vascular and neoplastic lesions. This study provides cadaveric measurements of the borders of Hakuba's triangle and describes its neurovascular contents in order to enrich the available literature. The anatomical borders of the Hakuba's triangle (lateral, medial, and posterior borders) were defined based on Hakuba's description and identified. Then the triangle was dissected to reveal its morphology and relationship with adjacent neurovascular structures in Embalmed Caucasian cadaveric specimens. The oculomotor nerve occupied roughly one-third of the area of the triangle and the nerve was more or less parallel to its medial border. The mean lengths of the lateral border, posterior border, and medial border were 17 mm ± 0.5 mm, 12.2 mm ± 0.4 mm, and 10.6 mm ± 0.4 mm, respectively. The mean area of Hakuba's triangle was 63.9 mm² ± 4.4 mm². In this study, we provided cadaveric measurements of the borders of Hakuba's triangle along with descriptions of its neurovascular contents.

Atlantoaxial instability secondary to Bartonella henselae osteomyelitis managed surgically by atlantoaxial instrumentation: A case report and systematic review

Cat scratch disease (CSD), caused by Bartonella henselae, may atypically present with vertebral osteomyelitis. Antibiotic regimens are tailored to presentation, which is markedly variable and not well defined for any atypical disease. In cases of spinal instability, the use of antibiotics alone may not be sufficient. Atlantoaxial instability caused by osteomyelitis is a rare complication of CSD. In this report, we describe the rare case of vertebral osteomyelitis complicated by atlantoaxial instability, requiring both antibiotics and atlantoaxial fusion. We discuss our case, surgical technique, rationale, and outcome. In addition, we conducted a systematic review of the literature of vertebral osteomyelitis in pediatric secondary to B. henselae. A 2-year-old child presented with a 2-month history of irritability, fever, and rigid neck pain along with a recent history of feline exposure. Physical examination revealed cervical tenderness and decreased range of motion. Computed tomography (CT) showed osteolysis of the right C1 lateral mass and pars articularis; T1-weighted magnetic resonance imaging with contrast showed enhancement around the right C1 lateral mass. The titer for B. henselae was high. A diagnosis of cat scratch osteomyelitis with cervical instability was made, for which the patient underwent surgery with atlantoaxial fusion. Postoperative imaging demonstrated resolution of the contrast-enhanced lesion. At 6-year follow-up, the patient showed no signs of residual complications from surgical intervention with a solid fusion. Our review revealed 44 cases of pediatric CSD vertebral osteomyelitis. Conservative management with antibiotic employed in 86% while antibiotics with surgical intervention in 14% of the cases. Surgical intervention was most often in the form of incision for drainage and decompression without fusion. Average follow-up 10 months with 86% achieved complete resolution. Cervical instability caused by osteolysis is a rare complication of CSD. This can subsequently lead to vertebral instability, requiring definitive surgical intervention.

Practitioners' perspectives on health in Strategic Environmental Assessment of spatial planning policies in Scotland

OBJECTIVES

Local authorities in Scotland are required to produce a Local Development Plan (LDP), which allocates sites for development and sets policies to guide decisions on planning applications. As part of this, local authorities must undertake a Strategic Environmental Assessment (SEA). This is a structured assessment of likely environmental impacts, which includes human health. This study explores how SEA practitioners and SEA consultation authorities consider health.

STUDY DESIGN

Qualitative study design using eight in-depth semi-structured interviews.

METHODS

Individual interviews were carried out with SEA practitioners from six local authority areas in Scotland and two SEA consultation authorities. Interviews were recorded, transcribed and analysed thematically.

RESULTS

Respondents articulated a broad perspective on health, but this was not reflected in SEA practice. Barriers to considering health more fully in SEA included low confidence in assessing health, limited partnership working with public health professionals and the lack of a consultation authority able to cover all aspects of health. Respondents valued partnership work between public health and planning professionals.

CONCLUSION

This study suggests recent work in Scotland to increase understanding of the role of spatial planning to influence health has been successful. However, further work is required to expand this to include links between spatial planning and health inequalities. SEA in Scotland does not currently support holistic consideration of health and health inequalities. Strong partnership working between public health and other sectors can increase understanding of links with health and create healthy places.

Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature

Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.

Detethering the superficial temporal artery: Application to tension free superficial temporal artery-middle cerebral artery bypasses

Extracranial-intracranial bypass has been shown to be effective in the surgical treatment of moyamoya disease, complex aneurysms, and tumors that involve proximal vasculature in carefully selected patients. Branches of the superficial temporal artery (STA) are used commonly for the bypass surgery; however, an appropriate length of the donor vessel must be harvested to avoid failure secondary to anastomotic tension. The goal of this cadaveric study was to investigate quantitatively operative techniques that can increase the STA length available to facilitate tension-free STA-middle cerebral artery (MCA) bypass. We conducted a cadaveric study using a total of 16 sides in eight cadavers. Measurements of the STA trunk with its frontal branch (STAfb) were taken before and after skeletonization and detethering of the STA with the STAfb and mobilization of the parietal branch of the STA. A final measurement of the STA with the STAfb was taken for the free length gained toward visible proximal cortical branches of the MCA. Paired student's t-tests were used to compare the mean length before and after mobilization and unpaired t-tests to analyze according to laterality. The mean length of the STA with the STAfb was 9.0 cm prior to modification. After skeletonization and mobilization, the mean lengths increased significantly to 10.5 and 11.3 cm, respectively (p < 0.05). Especially in the cases that had the coiled and tortuous STA, skeletonization was considerably effective to increase the length of the STA with the STAfb. After simulating a bypass by bringing the STAfb to the recipient MCA site, the mean extended length of the STA with the STAfb was 3.0 cm. There were no statistically significant differences between sides in all measurements. We report a significant increase in the mean STA length available (3.0 cm) following skeletonization and mobilization. Clinical applications of the extended length of the STA with the STAfb may facilitate tension-free STA-MCA bypasses and improve outcomes. Further studies are needed in a clinical context.

"False" foramina and fissures of the skull: a narrative review with clinical implications

"False" foramina and fissures of the skull are described as openings formed between the adjacent edges of two or more bones and not conduits directly through a single bone. Trauma and metabolic disorders appear to affect these foramina and fissures differently when compared to the "true" foramina and fissures. Therefore, the aim of this paper is to provide a narrative review of the current literature about "false" foramina and fissures of the skull and skull base with a focus on their clinical significance.

Combined experimental drought and nitrogen loading: the role of species-dependent leaf level control of carbon and water exchange in a temperate grassland

Nitrogen (N) loading and extreme drought strongly alter biomass production, species composition and carbon and water fluxes of temperate grasslands. Such changes at the community level are often attributed to species- and functional group-specific responses in phenology and/or physiology. In a multifactorial field experiment, we studied the responses of three abundant grassland species (forb Centaurea jacea, grasses Arrhenatherum elatius and Dactylis glomerata) to N loading and extreme drought, focusing on responses of carbon and water relations at the leaf level. We analysed (1) changes in bulk leaf N (uptake efficiency of additional N), (2) adaptation of plant water status (leaf water potential) and (3) impact on leaf carbon and water fluxes. We observed more efficient N utilization in the two grasses compared to C. jacea. Naturally occurring summer drought significantly impacted the plant water status of all species, while extreme drought treatment only further affected water status during and after summer drought. C. jacea was able to maintain much lower leaf water potentials compared to the grasses during drought. Despite these clear species-specific responses to N loading and drought, the species were able to maintain homeostasis of leaf carbon and water fluxes. Thus, strong declines in the (community) carbon sequestration observed at this site during the (natural) summer drought were not related to leaf physiological responses in assimilation, but were driven by phenological adaptions of the species community: the drought-sensitive grasses, even though exhibiting higher N uptake efficiency, responded with a shortened life cycle to severe summer drought.

Effects of the COVID-19 Pandemic on Operative Volume and Residency Training at Two Academic Neurosurgery Centers in New Orleans

BACKGROUND

Medical subspecialties including neurosurgery have seen a dramatic shift in operative volume in the wake of the coronavirus disease 2019 (COVID-19) pandemic. The goal of this study was to quantify the effects of the COVID-19 pandemic on operative volume at 2 academic neurosurgery centers in New Orleans, Louisiana, USA from equivalent periods before and during the COVID-19 pandemic.

METHODS

A retrospective review was conducted analyzing neurosurgical case records for 2 tertiary academic centers from March to June 2020 and March to June 2019. The records were reviewed for variables including institution and physician coverage, operative volume by month and year, cases per subspecialty, patient demographics, mortality, and morbidity.

RESULTS

Comparison of groups showed a 34% reduction in monthly neurosurgical volume per institution during the pandemic compared with earlier time points, including a 77% decrease during April 2020. There was no change in mortality and morbidity across institutions during the pandemic.

CONCLUSIONS

The COVID-19 pandemic has had a significant impact on neurosurgical practice and will likely continue to have long-term effects on patients at a time when global gross domestic products decrease and relative health expenditures increase. Clinicians must anticipate and actively prepare for these impacts in the future.

The Global Burden of Neural Tube Defects and Disparities in Neurosurgical Care

BACKGROUND

Despite the success of folic acid fortification programs, neural tube defects (NTDs) such as spina bifida, encephalocele, and anencephaly remain among the most substantial causes of childhood morbidity and mortality worldwide. Although these are complicated conditions that require an interdisciplinary approach to care, definitive treatment of survivable NTDs is often neurosurgical.

METHODS

Using Global Burden of Disease data, we examined the global burden of NTDs as related to a nation's wealth, health care quality, and access to neurosurgical care. We abstracted data for death by cause, years lived with disability (YLD), gross domestic product (GDP), United Nations geoscheme, Food Fortification Initiative participation, and Healthcare Access and Quality Index. We compared means using 1-way analysis of variance and proportions using Fisher exact tests, with statistical significance as α = 0.05.

RESULTS

Seventeen of 20 (85%) nations with the most deaths caused by NTDs (P < 0.0001) and 15/20 (75%) nations with the highest YLD (P < 0.0001) were in the lowest GDP quartile. Deaths and YLD were negatively correlated with increasing GDP and Healthcare Access and Quality Index (P < 0.0001). The nations with the highest disease burdens also had the fewest neurosurgeons per capita.

CONCLUSIONS

Despite the success of folic acid fortification programs, greater global public health efforts should be placed on improving access to neurosurgical care in low and middle-income nations through sustainable initiatives such as surgeon exchange programs and the establishment of neurosurgery residency training programs.

The jugular nerve: A review of this enigmatic structure

The jugular nerve (JN) is described as joining the superior cervical ganglion to the vagus nerve. It has been studied extensively in many different animal species; however, there is very limited literature about humans. This review delves into various descriptions of this nerve's anatomy and animal studies aimed at deciphering its function. The goal is to shed more light on this understudied structure in humans.

Aneurysmal subarachnoid hemorrhage during pregnancy: a comprehensive and systematic review of the literature

Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent condition requiring rapid intervention and prolonged monitoring. There are few recommendations regarding the management of aSAH in pregnancy. We identified all available literature and compiled management decisions as well as reported outcomes through a systematic literature review without meta-analysis to provide recommendations for management of aSAH during pregnancy. We included a total of 23 articles containing 54 cases of pregnancy-related aSAH in our review. From these reports and other literature, we evaluated information on aSAH pathophysiology, diagnosis, and management with respect to pregnancy. Early transfer to an appropriate facility with neurocritical care, a high-risk obstetric service, and a neurosurgery team available is crucial for the management of aSAH in pregnancy. Intensive monitoring and a multidisciplinary approach remain fundamental to ensure maternal and fetal health.

Papillary tumor of the pineal region in pediatric populations: An additional case and systematic review of a rare tumor entity

Papillary tumors of the pineal region (PTPR) are a rare tumor entity first described in 2003, later codified in the 2007 WHO tumor classification system. PTPRs most commonly occur in the third and fourth decades, with exceedingly rare presentations in pediatric populations. Herein, we present an additional case of a 10-year-old female found to have PTPR in conjunction with Trisomy 21 managed successfully with cerebrospinal fluid diversion and gross total resection (GTR). Three years after resection she has returned to baseline without recurrence. We also performed a comprehensive review of the current literature discussing the diagnosis, treatment, and pathophysiologic correlations in children. Diagnosis and management of PTPRs is a topic that is increasingly garnering attention in the literature given the recent characterization of this tumor entity. However, relatively little is known about the presentation of PTPRs in pediatric populations. In adults, PTPRs have been linked with several chromosomal and genetic abnormalities; however this correlation is limited in pediatric literature. Although GTR is the mainstay for treatment, the application of adult treatment protocols may not be advisable due to age and the developmental changes of the CNS in children.

Multistage surgical repair for split notochord syndrome with neuroenteric fistula: case report

Split notochord syndrome (SNS) is a rare congenital defect of the central nervous system and has been associated with several anomalies affecting multiple organ systems. One association has been communication with the gastrointestinal tract and the spine, previously identified as a neuroenteric fistula (NEF). Here, the authors describe the unique case of a female infant with SNS and NEF treated with a multistage surgical repair. The three-stage operative plan included a two-stage repair of the defect and temporary subgaleal shunting followed by delayed ventriculoperitoneal shunt placement. The infant recovered well postsurgery and over a 5-year follow-up. A case description, surgical techniques, and rationale are reported. Additionally, a systematic review of the literature utilizing the MEDLINE database was performed.Treatment of SNS with NEF using a multidisciplinary multistaged approach to repair the intestinal defect, close the neural elements, and divert cerebrospinal fluid to the peritoneum is shown to be a safe and viable option for future cases.

Cerebellar pleomorphic xanthoastrocytoma in the setting of neurofibromatosis type-I: Does it portend a different prognosis? A case report and systematic review

BACKGROUND

Pleomorphic xanthoastrocytoma (PXA) is a rare brain tumor occurring supra- and infra-tentorially in both young adults and children. PXA is a benign tumor with a favorable prognosis. It is not traditionally considered as a neurofibromatosis type 1 (NF-1)-associated lesion, and its prognosis remains largely unknown, on the contrary to non-NF-1 PXA tumors.

OBJECTIVE

Herein, we present a rare case of cerebellar PXA in a patient with NF-1 and performed systematic review of NF-1-associated PXA.

METHOD

We present a case of NF-1-associated PXA arising in the cerebellar region. We also reviewed the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify published cases of cerebellar vs. non-cerebellar NF-1-associated PXA and NF1 vs. non-NF1 PXAs, highlighting their management paradigm, prognosis, and outcomes.

RESULT

Our systematic review yielded only four previously reported cases of NF-1-associated PXAs in the cerebellar region. Our review suggests that infratentorial PXAs have a higher recurrence and lower survival rates than non-cerebellar NF-1-associated PXAs and non-NF1 PXAs in general.

CONCLUSION

Early and precise diagnosis is important for these lesions with the aid of imaging features, histology, immunohistochemistry, and genetic markers. Surgical resection with goal of GTR remains the mainstay management strategy for PXA, with adjuvant therapy usually reserved for anaplastic or malignant lesions. The identification of BRAF-V600E mutation and role of BRAF inhibitors hold promise as a diagnostic tool and treatment modality, respectively, for PXAs, and their relationship to NF-1 is worth further exploration.

Fibrotic remodeling of left ventricle in the murine remnant kidney model of chronic kidney disease is independent of arterial hypertension

Background

Cardiac fibrosis and arterial hypertension are common in patients with chronic kidney disease (CKD). We studied the mechanisms of cardiac fibrogenesis and the role of blood pressure in mice with CKD.

Methods and results

10-week-old male C57/BL6N (BL6) and SV129 wildtype (WT) mice were underwent 5/6 nephrectomy (remnant kidney model, RKM) or sham operation for 10 weeks. RKM significantly elevated plasma creatinine and urea. RKM elicited both interstitial and replacement renal and left ventricular (LV) (BL6: SHAM 5.6±0.4%, RKM 7.3±0.7%, p=0.04; SV129: SHAM 6.0±0.5%, RKM 14±2%, p=0.001) fibrosis as assessed by picrosirius red staining. In parallel, the number of cardiac fibroblasts per mm2 (BL6: SHAM 36±4, RKM 85±13, p=0.001; SV129: SHAM 82±11, RKM 200±34, p=0.006) was increased in RKM mice. With regard to possible mechanisms, cardiac oxidative stress as shown by co-immunostaining for intracellular fibronectin and 8-hydroxyguanosine (BL6: SHAM 44±14%, RKM 60±24%, p=0.03; SV129: SHAM 51±6%, RKM 70±7%, p=0.04) and the percentage of CXCR4+ fibroblasts in the myocardium (BL6: SHAM 47±5%, RKM 62±4%, p=0.04; SV129: SHAM 63±5%, RKM 81±3%, p=0.005) were increased. Furthermore, the number of circulating CD45+ / collagen I+ fibrocytes (FACS) in the peripheral blood was increased by RKM in BL6 (SHAM 100±23%, RKM 443±252%, p=0.04) and diminished in SV129 (SHAM 100±19%, RKM 43±11%, p=0.01), while an opposite regulation was seen in the bone marrow. To further confirm the role of bone-marrow derived fibroblasts in renal and cardiac remodeling 10-week-old WT BL6 mice were subjected to transplantation of bone marrow from 10-week-old WT BL6 mice expressing green fluorescent protein (GFP)+ ubiquitously. 28 days later, RKM or SHAM-operation was performed. RKM significantly increased the number of GFP+ fibroblasts in kidney and LV-myocardium. CKD significantly decreased myocardial capillarization assessed by immunostaining for podocalyxin in both mouse lines. In parallel, myocardial protein expression of fibrosis regulators fibronectin, collagen I, CTGF and Hif1a were up-regulated and expression of the active form of eNOS (phospho-S1177) was reduced.

As a possible confounder, tail-cuff blood pressure was moderately enhanced (Ø 30mmHg) 9 weeks after nephrectomy. In a control experiment using the vasodilator hydralazine (250 mg/L/day), peripheral blood pressure was equalized in all 4 experimental groups, but the extent of LV fibrosis and expression of the above-mentioned fibrosis markers remained unchanged.

Conclusions

Chronic kidney disease in the RKM model elicits left ventricle fibrosis by increasing myocardial protein expression of fibrosis regulators, reduction of myocardial capillarization and mobilization / recruitment of circulating fibroblasts, independently of blood pressure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft

A comprehensive review of the great auricular nerve graft

The great auricular nerve (GAN) is a superficial branch of the cervical plexus that innervates parts of the mandible, auricle, and earlobe. Over the past 30 years, the GAN has become the nerve graft donor of choice for many surgeons for reconstructing injured facial nerves. In this review, we discuss the anatomy and function of the GAN, while focusing on surgical landmarks and the characteristics that make it a suitable nerve graft donor. In addition, we present and summarize published case reports on use of the GAN for grafting. We hope that this review will provide surgeons with an up-to-date and concise reference.

Multiple flow-related intracranial aneurysms in the setting of contralateral carotid occlusion: Coincidence or association?

The prevalence of intracranial aneurysms (IAs) is higher in patients with internal carotid artery (ICA) stenosis, likely due to alterations in intracranial hemodynamics. Severe stenosis or occlusion of one ICA may result in increased demand and altered hemodynamics in the contralateral ICA, thus increasing the risk of contralateral IA formation. In this article, we discuss a relevant case and a comprehensive literature review as it pertains to the association of ICA stenosis and IA. Our patient was a 50-year-old female with a chronic asymptomatic right ICA occlusion who presented with diffuse subarachnoid hemorrhage. Emergent angiography revealed left-sided A1-A2 junction, paraclinoid, left middle cerebral artery (MCA) bifurcation, and left anterior temporal artery aneurysms. Brisk filling of the right anterior circulation through the anterior communicating artery was also identified, signifying increased demand on the left ICA circulation. Complete obliteration of all aneurysms was achieved with coil embolization and clipping. For our literature review, we searched the PubMed and EMBASE databases for case reports and case series, as well as references in previously published review articles that described patients with concurrent aneurysms and ICA stenosis. We selected articles that provided adequate information about the case presentations to compare aneurysm and patient characteristics. Our review revealed a higher number of patients with multiple aneurysms contralateral (25%) to rather than ipsilateral to (6%), the ICA stenosis. We discuss the pathogenesis and management of multiple flow-related IA in the context of the existing literature related to concurrent ICA stenosis and IA.

[Management of Primary Ciliary Dyskinesia]

Die Primäre Ciliäre Dyskinesie (PCD, MIM 242650) ist eine seltene hereditäre Multisystemerkrankung mit klinisch heterogenem Phänotyp. Leitsymptom ist eine chronische Sekretretention der oberen und unteren Atemwege, welche durch die Dysfunktion motiler respiratorischer Zilien entsteht. In der Folge kommt es zur Ausbildung von Bronchiektasen, häufig zu einer Infektion durch Pseudomonas aeruginosa sowie einer abnehmenden Lungenfunktion bis hin zum Lungenversagen.

Bislang gibt es kaum evidenzbasierte Therapieempfehlungen, da randomisierte Langzeitstudien zur Behandlung der PCD fehlten. In diesem Jahr wurden die Daten einer ersten placebokontrollierten Medikamentenstudie bei PCD veröffentlicht. Anlässlich dieses Meilensteins im Management der PCD wurde der vorliegende Übersichtsartikel als Konsens von Patientenvertretern sowie Klinikern, die langjährige Erfahrung in der Behandlung der PCD haben, verfasst. Diese Arbeit bietet eine Zusammenfassung aktuell eingesetzter Behandlungsverfahren, die überwiegend auf persönlichen Erfahrungen und Expertenmeinungen beruhen oder von anderen Atemwegserkrankungen wie der Cystischen Fibrose (CF), COPD oder Bronchiektasen-Erkrankung abgeleitet werden. Da es derzeit keine kurative Therapie für PCD gibt, stehen symptomatische Maßnahmen wie die regelmäßige Reinigung der Atemwege und die Behandlung von rezidivierenden Atemwegsinfektionen im Fokus. Nicht respiratorische Manifestationen werden organspezifisch behandelt. Um neben der ersten Medikamentenstudie mehr evidenzbasiertes Wissen zu generieren, werden weitere Projekte etabliert, u. a. ein internationales PCD-Register. Hierüber wird Patienten der Zugang zu klinischen und wissenschaftlichen Studien erleichtert und die Vernetzung behandelnder Zentren gefördert. Des Weiteren können Erkenntnisse über eine Genotyp-spezifische Erkrankungsschwere erlangt werden, um folglich die therapeutische Versorgung der Patienten zu verbessern und somit zu individualisieren.

Effects of Medical Comorbidities on the Surgical Outcomes of Deep Brain Stimulation for Parkinson Disease: A Retrospective, Single-Institution Study

OBJECTIVE

Advancing age and greater number of medical comorbidities are well-known risk factors for higher rates of surgical complications and undesirable outcomes. We sought to determine the risk of increasing medical comorbidities on surgical outcomes for patients with Parkinson disease undergoing deep brain stimulation (DBS) surgery.

METHODS

We retrospectively reviewed 107 consecutive patients who underwent DBS for Parkinson disease at Ochsner Medical Center in 2008-2018. Patients were stratified into 3 groups based on Elixhauser comorbidity index (ECI) at the time of surgery: 0, 1, or ≥2. Outcome measures were changes in Unified Parkinson's Disease Rating Scale III scores, changes in medications, and surgical complications. Analysis of variance, paired t test, and nonparametric equivalents were used for statistical analysis.

RESULTS

Of patients, 31 (29.0%) had ECI score 0, 44 (41.1%) had ECI score 1, and 32 (29.9%) had ECI score ≥2. For all groups, Unified Parkinson's Disease Rating Scale III scores decreased significantly postoperatively (P = 0.0014, P < 0.0001, P < 0.0001). All groups had a reduction in mean levodopa equivalent daily dose after surgery; however, only the group with ≥2 comorbidities achieved statistical significance (P = 0.0026). The rate of postoperative complications was significantly correlated with comorbidity score on univariate logistic regression analysis (P = 0.0425).

CONCLUSIONS

Our findings indicate that DBS is efficacious in patients with multiple medical comorbidities. However, patients with ≥1 medical comorbidities may be more likely to have complications. The most common observed complication was wound infection. Patients with medical comorbidities may still benefit significantly from DBS when performed at experienced centers.

Symptomatic xanthogranuloma of the lateral ventricle in a pregnant patient treated with delayed resection: A case report and systematic review

Intracranial xanthogranulomas (XG) are a rare benign histiocytic neoplasm and most often within the choroid. The majority are asymptomatic and are found incidentally on imaging or post-mortem examination or autopsy. We present a case of symptomatic XG in a pregnant patient who underwent a delayed transcortical, transventricular approach for lateral ventricle XG resection following the completion of her pregnancy. Four years post-operatively, the patient is neurologically intact and without recurrence. Our review of the literature showed differences among XG depending on location. The clinical and radiological features of XG are often indistinguishable from tumors arising from the choroid plexus and should be considered as a rare etiology in the differential of newly diagnosed intraventricular lesions.

Adult Pineal Region Atypical Teratoid Rhabdoid Tumor: A Case for Aggressive Surgical and Chemoradiation Management with Comprehensive Literature Review

BACKGROUND

Atypical teratoid rhabdoid tumor (ATRT) is a rare, highly malignant central nervous system neoplasm classified as an embryonal grade IV neoplasm by the World Health Organization. ATRT generally occurs in children younger than 3 years, with 85 pathologically confirmed cases reported in adults. It is most commonly supratentorial, with only 9 confirmed adult cases localized to the pineal region.

CASE DESCRIPTION

The case is described of a 29-year-old man with a history of chronic migraines and a previously negative computed tomography scan of the head presenting with worsening headaches and new-onset diplopia with upward gaze palsy. Computed tomography and magnetic resonance imaging showed a hemorrhagic pineal mass with extension into the right thalamus. After resection, the immunohistochemical staining and cytogenetic profile proved consistent with ATRT, making it the ninth reported case of pineal ATRT in an adult, which was treated aggressively with good outcome.

CONCLUSIONS

Adult ATRT is rare, especially in the pineal region, with only 9 cases reported. Because of the aggressiveness, ATRT must be considered in the differential diagnosis of pineal region lesions because early diagnosis and aggressive treatment are key to prolonged survival.

Neurological Impact of Coronavirus Disease of 2019: Practical Considerations for the Neuroscience Community

BACKGROUND

The coronavirus disease of 2019 (COVID-19), which is caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has recently been designated a pandemic by the World Health Organization, affecting 2.7 million individuals globally as of April 25, 2020, with more than 187,000 deaths. An increasing body of evidence has supported central nervous system involvement.

METHODS

We conducted a review of the reported data for studies concerning COVID-19 pathophysiology, neurological manifestations, and neuroscience provider recommendations and guidelines.

RESULTS

Central nervous system manifestations range from vague nonfocal complaints to severe neurological impairment associated with encephalitis. It is unclear whether the neurological dysfunction results from direct viral injury or systemic disease. The virus could affect brainstem pathways that lead to indirect respiratory dysfunction, in addition to direct pulmonary injury. Necessary adaptations in patient management, triage, and diagnosis are evolving in light of the ongoing scientific and clinical findings.

CONCLUSIONS

The present review has consolidated the current body of data regarding the neurological impact of coronaviruses, discussed the reported neurological manifestations of COVID-19, and highlighted the recommendations for patient management. Specific recommendations pertaining to clinical practice for neurologists and neurosurgeons have also been provided.

Recurrent arachnoid cysts secondary to spinal adhesive arachnoiditis successfully treated with a ventriculoperitoneal shunt

Spinal adhesive arachnoiditis (SAA) with cyst formation secondary to infectious meningitis is a rare clinical entity. These cysts can compress the spinal cord and cause neurologic decline. We present a case of a patient who underwent resection for an intradural schwannoma which was complicated post-operatively by bacterial meningitis and development of several recurrent thoracic arachnoid cysts. After two separate thoracic decompressions with lysis of intradural adhesions, a permanent ventriculoperitoneal shunt (VPS) was eventually placed with complete recovery of his symptoms. Our review of the literature showed that CSF shunts have previously been successfully used to treat spinal fluid collections. Although there are many factors to consider when treating these patients, CSF diversion may be beneficial for similar SAA presentations in order to simultaneously treat and prevent recurrence of symptoms.

Recurring Primary Xanthomatous Hypophysitis Behaving Like Pituitary Adenoma: Additional Case and Literature Review

BACKGROUND

Xanthomatous hypophysitis (XH) is the rarest histologic type of primary hypophysitis. It is nonlymphocytic and characterized by an infiltration of the pituitary gland by lipid-laden histiocytes and macrophages. The clinical and radiologic features overlap heavily with pituitary adenomas and are prone to misdiagnosis. We describe a rare case of XH recurrence at 1 year, treated surgically. Moreover, we provide an updated review of the literature to further elucidate useful management and detection strategies.

CASE DESCRIPTION

A 45-year-old woman presented with a history of menstrual irregularity for 9 months, amenorrhea, galactorrhea, and headache for 2 months duration. Preoperative endocrinologic studies showed increased prolactin levels. Magnetic resonance imaging of the sella showed a cystic lesion with suprasellar extension suggestive of a pituitary adenoma. The patient underwent transsphenoidal resection, showing a thick yellowish colloidal material. Histopathology showed necrotic tissue with no definitive diagnosis and no identified microorganisms. At 2 months after surgery, prolactin levels and menstrual cycle normalized. At 1 year after surgery, her menstrual cycle again became irregular. Repeat magnetic resonance imaging showed a recurrent mass and a second transsphenoidal resection was undertaken. Repeat histopathology was consistent with XH. The patient is 9 years postoperative and is doing well without evidence of recurrence.

CONCLUSIONS

XH presents similarly to nonfunctional adenomas and diagnosis remains difficult without surgical pathology, requiring meticulous immunohistochemistry to prevent misdiagnosis. Thus, XH should be considered as a rare cause in the differential of disease of the sellar region. Management can parallel that of pituitary neoplasm, with a focus on radiosurgery, re-resection, and high-dose steroids.