Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran

PURPOSE

This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI).

METHODS

The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews.

RESULTS

We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%.

CONCLUSION

Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

The Advantages of 4-rod Construct over the 2-rod Techniques in Adult Spinal Deformity Patients who Underwent Pedicle Subtraction Osteotomy: A Multicenter Retrospective Comparative Study

OBJECTIVE

In this retrospective study we compared clinicoradiologic outcomes and complication profiles of the traditional 2-rod construct versus the 4-rod construct in patients with adult spinal deformity (ASD) who underwent pedicle subtraction osteotomy (PSO).

METHODS

We performed a retrospective review of 208 ASD patients at 2 referral centers who underwent lumbar PSO and long fusion from thoracic to the pelvis. Two different techniques, including the 4-rod construct and the traditional 2-rod technique, were used at the PSO level. Clinicoradiologic outcomes and complication profiles of the patients were documented and compared statistically between the groups.

RESULTS

The 4-rod construct was associated with statistically lower rates of rod fracture (44.8% vs. 26.4%, P < 0.01), pedicular screw loosening at the PSO level (25.3% vs. 14.0%, P = 0.04), and reoperation (49.4% vs. 33.9%, P = 0.02). Radiologically, the 4-rod construct was associated with higher degree of lumbar lordosis (LL) (-37.4°vs. -26.8°; P < 0.01) and improved pelvic tilt (PT) (-17.2° vs. -9.9°; P < 0.01) and sacral vertical axis (SVA) corrections (-211.5° vs. -192.2°; P = 0.04). Overall, the 4-rod construct was associated with improved quality of life (P = 0.04) and statistically lower Oswestry Disability Index score at 12 months postoperatively (P < 0.01).

CONCLUSIONS

Our results showed that the 4-rod construct was associated with statistically lower rates of rod fracture and pedicular screw loosening at the osteotomy level, higher degree of LL correction and improved PT and SVA than the 2-rod technique. The 4-rod construct was also associated with improved quality of life and Oswestry Disability Index and lower complication profiles.

Prognostic Value of Frailty for Outcome Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Frailty is a known predictor of negative health outcomes. The role of frailty in predicting outcomes after traumatic brain injury (TBI), however, is unclear. This systematic review aimed to evaluate the association between frailty and adverse outcomes in patients with TBI. We identified relevant articles that investigated the relationship between frailty and outcomes in patients with TBI by searching PubMed/MEDLINE, Web of Science, Scopus, and EMBASE from inception until 23 March 2023. To evaluate the risk of bias in the included studies, we utilized the Newcastle-Ottawa Scale (NOS). In addition, quantitative synthesis and meta-analyses were performed. We identified 12 studies that met our inclusion criteria; three were prospective. Of included studies, eight had low risk, three had moderate risk, and one had high risk of bias. Frailty was significantly associated with death in five studies, with an increased risk of in-hospital death and complications observed in frail patients. Frailty was associated with longer hospital stays and unfavorable outcome measured by the Extended Glasgow Outcome Scale (GOSE) in four studies. The meta-analysis found that higher frailty significantly increased the odds of non-routine discharge and unfavorable outcome as measured by GOSE scores of 4 or lower. The pooled odds ratio (OR) for non-routine discharge, was 1.80, with a 95% confidence interval (CI) of 1.15-2.84; and for unfavorable outcome, it was 1.91, with a 95% CI of 1.09-3.36. The analysis, however, did not find a significant predictive role for frailty on death (30-day or in-hospital death). The OR for higher frailty and death was 1.42 with a 95% CI of 0.92-2.19. Frailty should be considered in the evaluation of patients with TBI to identify those who may be at increased risk of negative outcomes.

Correlation Between Pre-Operative Diffusion Tensor Imaging Indices and Post-Operative Outcome in Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVES

The correlation between pre-operative diffusion tensor imaging (DTI) metrics and post-operative clinical outcomes in patients with degenerative cervical myelopathy (DCM) has been widely investigated with different studies reporting varied findings. We conducted a systematic review to determine the association between DTI metric and clinical outcomes after surgery.

METHODS

We identified relevant articles that investigated the relationship between pre-operative DTI indices and post-operative outcome in DCM patients by searching PubMed/MEDLINE, Web of Science, Scopus, and EMBASE from inception until October 2023. In addition, quantitative synthesis and meta-analyses were performed.

RESULTS

FA was significantly correlated with postoperative JOA or mJOA across all age and follow up subgroups, changes observed in JOA or mJOA from preoperative to postoperative stages (Δ JOA or Δ mJOA) in subgroups aged 65 and above and in those with a follow-up period of 6 months or more, as well as recovery rate in all studies pooled together and also in the under-65 age bracket. Additionally, a significant correlation was demonstrated between recovery rate and ADC across all age groups. No other significant correlations were discovered between DTI parameters (MD, AD, and ADC) and post-operative outcomes.

CONCLUSION

DTI is a quantitative noninvasive evaluation tool that correlates with severity of DCM. However, the current evidence is still elusive regarding whether DTI metric is a validated tool for predicting the degree of post-operative recovery, which could potentially be useful in patient selection for surgery.

Does hazelnut consumption affect brain health and function against neurodegenerative diseases?

INTRODUCTION

A healthy daily diet and consuming certain nutrients, such as polyphenols, vitamins, and unsaturated fatty acids, may help neuronal health maintenance. Polyphenolic chemicals, which have antioxidant and anti-inflammatory properties, are involved in the neuroprotective pathway. Because of their nutritional value, nuts have been shown in recent research to be helpful in neuroprotection.

OBJECTIVE

Hazelnut is often consumed worldwide in various items, including processed foods, particularly in bakery, chocolate, and confectionery products. This nut is an excellent source of vitamins, amino acids, tocopherols, phytosterols, polyphenols, minerals, and unsaturated fatty acids. Consuming hazelnut may attenuate the risk of neurodegenerative disorders including Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, and Huntington's disease due to its anti-inflammatory and anti-oxidant qualities.

RESULTS

Many documents introduce hazelnut as an excellent choice to provide neuroprotection against neurodegenerative disorders and there is some direct proof of its neuroprotective effects.

DISCUSSION

So hazelnut consumption in daily diet may reduce neurodegenerative disease risk and be advantageous in reducing the imposed costs of dealing with neurodegenerative diseases.

Role of Frailty Status in Prediction of Clinical Outcomes of Traumatic Spinal Injury: A Systematic Review and Meta-Analysis

Although many frailty tools have been used to predict traumatic spinal injury (TSI) outcomes, identifying predictors of outcomes after TSI in the aged population is difficult. Frailty, age, and TSI association are interesting topics of discussion in geriatric literature. However, the association between these variables are yet to be clearly elucidated. We conducted a systematic review to investigate the association between frailty and TSI outcomes. The authors searched Medline, EMBASE, Scopus, and Web of Science for relevant studies. Studies with observational designs that assessed baseline frailty status in individuals suffering from TSI published from inception until 26th March 2023 were included. Length of hospital stay (LoS), adverse events (AEs), and mortality were the outcomes of interest. Of the 2425 citations, 16 studies involving 37,640 participants were included. The modified frailty index (mFI) was the most common tool used to assess frailty. Meta-analysis was employed only in studies that used mFI for measuring frailty. Frailty was significantly associated with increased in-hospital or 30-day mortality (pooled odds ratio [OR]: 1.93 [1.19; 3.11]), non-routine discharge (pooled OR: 2.44 [1.34; 4.44]), and AEs or complications (pooled OR: 2.00 [1.14; 3.50]). However, no significant relationship was found between frailty and LoS (pooled OR: 3.02 [0.86; 10.60]). Heterogeneity was observed across multiple factors, including age, injury level, frailty assessment tool, and spinal cord injury characteristics. In conclusion, although there is limited data concerning using frailty scales to predict short-term outcomes after TSI, the results showed that frailty status may be a predictor of in-hospital mortality, AEs, and unfavorable discharge destination.

A systematic review and meta-analysis of the global epidemiology of pediatric traumatic spinal cord injuries

Despite being relatively rare, pediatric traumatic spinal cord injury (TSCI) is a debilitating event with high morbidity and long-term damage and dependency. This study aims to provide insight on the epidemiological characteristics of pediatric TSCI worldwide. The studies were included if they provided data for the pediatric population with the diagnosis of TSCI. Information sources included PubMed, Embase, Web of Science, and Scopus. All databases were searched from 1990 to April 2023. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. The results of the meta-analysis were presented as forest plots. PROSPERO Registration code: CRD42020189757. We identified 87 studies from 18 developed and 11 developing countries. Of the 87 studies evaluated, 52 studies were considered medium quality, 27 studies were considered high quality, and 8 studies were considered low quality. In developed countries, the proportion of TSCIs occurring in patients aged 0-15 years was 3% (95% CI: 2.2%; 3.9%), while in developing countries, it was 4.5% (95% CI: 2.8%; 6.4%). In developed countries, the pooled incidence of pediatric TSCI was 4.3/millions of children aged 0-15/year (95% CI: 3.1; 6.0/millions children aged 0-15/year) and boys comprised 67% (95% CI: 63%; 70%) of cases. The most prevalent level of injury was cervical (50% [95% CI: 41%; 58%]). The frequency of SCI Without Obvious Radiological Abnormality (SCIWORA) was 35% (95% CI: 18%; 54%) among children 0-17 years. The most common etiology in developed countries was transport injuries (50% [95% CI: 42%; 57%]), while in developing countries falls were the leading cause (31% [95% CI: 20%; 42%]). The most important limitation of our study was the heterogeneity of studies in reporting age subgroups that hindered us from age-specific analyses.   Conclusion: Our study provided accurate estimates for the epidemiology of pediatric TSCI. We observed a higher proportion of pediatric TSCI cases in developing countries compared to developed countries. Furthermore, we identified distinct epidemiological characteristics of pediatric TSCI when compared to adult cases and variations between developing and developed countries. Recognizing these unique features allows for the implementation of cost-effective preventive strategies aimed at reducing the incidence and burden of TSCI in children. What is Known: • Pediatric Traumatic Spinal Cord Injury (TSCI) can have profound physical and social consequences for affected children, their families, and society as a whole. • Epidemiological insights are vital for they provide the data and understanding needed to the identification of vulnerable populations, aiding in the development of targeted prevention strategies and effective resource allocation. What is New: • The estimated incidence of pediatric TSCI in developed countries is 4.3 cases per million children aged 0-15. The proportion of pediatric TSCI cases in relation to all-age TSCI cases is 3% in developed countries and 4.5% in developing countries. • The etiology of TSCI in pediatric cases differs between developing and developed countries. In developed countries, transport injuries are the most prevalent cause of pediatric TSCI, while falls are the least common cause. Conversely, in developing countries, falls are the leading cause of pediatric TSCI.

The association between multiple sclerosis and migraine: A meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a chronic progressive condition marked by the deterioration of myelin and impairment of neurological function. The global prevalence of MS is approximately 2.2 million. Migraines are common in MS patients, with inconclusive data on their relationship. Our systematic review aimed to assess the prevalence and odds of migraine in pwMS and investigate the potential factors that may influence these associations.

METHOD

Through an extensive search and meticulous study selection, we identified pertinent literature investigating the occurrence and odds of migraines among pwMS. Additionally, we explored the comparative risk of migraines in MS patients compared to healthy controls. Data were extracted, including publication details, diagnostic criteria, and migraine prevalence in MS patients.

RESULTS

A total of 35 studies were included, involving 279,620 pwMS and 279,603 healthy controls. The overall prevalence of migraine in pwMS was 0.24 (95% CI: 0.21-0.28). Subgroup analyses and meta-regression were conducted to investigate the potential impact of various factors on the relationship between migraine and MS. These factors included age, duration of MS, study design, and the Expanded Disability Status Scale (EDSS), migraine diagnosis method, study design, publication year of the study, country and continent of the study population. The results of these analyses revealed no significant influence of these factors on the relationship between migraine and MS. The meta-analysis indicated that pwMS had significantly increased odds of having migraine compared to healthy controls (OR = 1.96, 95% CI: 1.20-3.20). Sensitivity analyses supported the robustness of the findings.

CONCLUSIONS

Our study highlights that approximately 24% of pwMS experience migraine. The method of diagnosis significantly affects the reported prevalence, with questionnaires yielding higher rates. Furthermore, pwMS have a 1.96-fold increased odds of having migraine compared to healthy individuals. These findings emphasize the importance of further research and interventions to address the significant burden of migraine in the MS population.

Plasma neurofilament light chain associated with impaired regional cerebral blood flow in healthy individuals

Background: Recent findings suggest that the plasma axonal structural protein, neurofilament light (NFL) chain, may serve as a potential blood biomarker for early signs of neurodegenerative diseases, such as Alzheimer's disease (AD). Given the need for early detection of neurodegenerative disorders, the current study investigated the associations between regional cerebral blood flow (rCBF) in brain regions associated with neurodegenerative disorders and memory function with plasma NFL in AD, mild cognitive impairment (MCI), and healthy controls (HCs). Methods: We recruited 29 AD, 76 MCI, and 39 HCs from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database in the current cross-sectional study. We used Pearson's correlation models adjusted for the effect of age, sex, and APOE genotype to investigate the association between plasma NFL and rCBF. Results: We found non-significant differences in age (F(2, 141) = 1.304; P = 0.275) and years of education (F(2, 141) = 0.013; P = 0.987). Additionally, we found significant differences between groups in terms of MMSE scores (F(2, 141) = 100.953; P < 0.001). Despite the observation of significantly reduced rCBF in AD and MCI groups versus HCs, we did not detect significant differences in plasma NFL between these groups. We found significant negative associations between plasma NFL and rCBF in various AD-related regions, these findings were only observed after analyses in all participants, and were observed in HCs alone and no significant associations were observed in the AD or MCI groups. Conclusion: These outcomes add to our current understanding surrounding the use of rCBF and plasma NFL biomarkers as tools for early detection and diagnosis of neurodegenerative diseases. A conclusion might be that the association between NFL and impaired rCBF exists before the clinical symptoms appear. Further longitudinal studies with a large sample size should be performed to examine the correlation between plasma NFL and rCBF in order to understand these complex relationships.

Clinicoradiological Outcomes and Complication Profiles of Bilateral Dual Sacral-Alar-Iliac Screws versus Bilateral Single Sacral-Alar-Iliac Screws in Patients with Spinal Deformity Who Underwent Grade 3 or 4 Spinal Osteotomies: A Retrospective Comparative Study

OBJECTIVE

To compare short-term clinical and radiological outcomes and complication profiles between bilateral dual sacral-2-alar-iliac (S2AI) screw and bilateral single S2AI screw fixation techniques in patients who underwent grade 3 or 4 spinal osteotomies.

METHODS

A retrospective review of 83 patients treated with bilateral dual S2AI screws and 32 patients treated with bilateral single S2AI screws was conducted between 2018 and 2020 with a minimum 1-year follow-up. Clinical and radiological outcomes of patients and incidence of perioperative complications, including rod breakage, screw dislodgment, proximal junctional kyphosis, proximal junctional failure, need for reoperation, and systemic adverse effects, were collected and statistically compared between the groups.

RESULTS

With a mean follow-up of 18.2 months, rod fracture (6.0% vs. 18.7%, P = 0.03), screw dislodgment (0 vs. 12.5%, P < 0.01), and S2AI screw loosening (1.2% vs. 18.7%, P < 0.01) were significantly lower in the dual S2AI screws group than in the single S2AI screws group. However, the reoperation rate was similar between the 2 groups (24.1% vs. 34.3%, P = 0.26). No significant differences in clinical and radiological outcomes as well as proximal junctional kyphosis (10.8% vs. 18.7%, P = 0.25) and proximal junctional failure (9.6% vs. 18.7%, P = 0.18) were identified between the 2 groups.

CONCLUSIONS

The dual S2AI screw fixation technique showed more advantages over the single S2AI screw fixation technique with reduced incidence of screw dislodgment, rod fractures, and sacral-alar-iliac screw loosening.

The Predictors of Seizures in Patients with Encephalocele: An 11-Year Experience from a Tertiary Hospital

INTRODUCTION

The aim of the study was to investigate and identify the predictors associated with the incidence of seizures in patients with encephalocele (EC).

METHODS

A retrospective analysis was undertaken of patients treated for EC at a tertiary medical center in Tehran between 2010 and 2021. Data including age at presentation, gender, location, size, and content of EC, ventriculomegaly, hydrocephalus, associated anomalies, and neurodevelopmental delay (NDD) were evaluated for their prognostic value. In addition, univariate and multivariate analyses were performed to identify the correlation between independent predictors and seizure incidence.

RESULTS

One hundred and two cases of EC were identified. Seventy-one ECs (69.6%) were posterior ECs, while 31 (30.4%) were anterior. Neural tissue was found in 43 (42.2%) of the ECs. Thirty-three patients (32.4%) had ventriculomegaly, of which 90.9% underwent shunt placement for progressive or symptomatic hydrocephalus. Seizure was found in 26 (25.5%) patients. On univariate analysis, presence of other anomalies, postoperative infections, and NDD were associated with seizures (p < 0.05). When the anomalies were categorized into intracranial and extracranial groups in univariate analysis, none was associated with statistically significant increase in seizure (p values of 0.09 and 0.61, respectively). Although according to multivariate analysis, only the association between other associated anomalies and seizure was near significant (OR: 2.0, 95% CI: 0.95-4.2, p = 0.049). Children with NDD and postoperative infection were, respectively, 3.04 and 1.3 times more at risk to experience seizures compared to other patients.

CONCLUSION

We found a rate of 25.5% risk of seizure in patients with EC. This study could not find any significant predictors of seizure in children with EC. However, pediatric patients with postoperative infections including sepsis, wound infection, and NDD require more consideration to reduce the risk of seizure.

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran

STUDY DESIGN

A retrospective study.

OBJECTIVES

The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs).

METHODS

The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase.

RESULTS

In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%).

CONCLUSION

These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

Odd presentation of shunt malfunction: a case series and review of literature

OBJECTIVE

Children with previous ventriculoperitoneal shunt (VPS) insertion due to hydrocephalus may refer to the hospital with various clinical complaints. Shunt malfunction is frequently diagnosed in these children necessitating shunt revision. Although increased head circumference, setting sun eye in younger children, and headache, nausea/vomiting, loss of consciousness, visual disturbance, and other signs of intracranial hypertension are common clinical manifestations of shunt malfunction, some patients may present with odd or unusual symptoms. Here, we present a series of patients with shunted hydrocephalus who presented with odd and unexpected clinical manifestations of shunt malfunction.

METHODS

Eight children with shunt malfunction were enrolled in this series. The age, sex, age of shunting, etiology of hydrocephalus and management, post-shunt insertion symptoms/sign, revision surgery, outcome, and follow-up were evaluated.

RESULTS

Patients were aged from 1 to 13 years (mean, 6.38 years). There were 5 males and 3 females. The odd presentation associated with shunt malfunction included facial palsy in three children, ptosis in 3 children, and torticollis and dystonia each in one child. All patients underwent shunt revision except for one patient in whom a new shunt was inserted. Follow-up showed improvement of the symptoms in all patients.

CONCLUSION

In this series, we reported eight patients with unusual signs and symptoms following shunt malfunction that were successfully diagnosed and managed.

Prophylactic cranial irradiation effect on survival in patients with small cell lung cancer: a comprehensive systematic review and meta-analysis

OBJECTIVE

Prophylactic cranial irradiation (PCI) is a companion treatment option for small cell lung cancer (SCLC) patients. However, its efficacy and associated risk factors have not been clearly defined. In this study, the authors aimed to systematically assess the effectiveness and role of PCI in the treatment plan of SCLC.

METHODS

The PubMed, Scopus, Web of Science, and Cochrane databases were searched using the following key terms and their equivalents: "brain," "radiotherapy," "metastases," "prophylactic," and "small cell lung cancer." Studies comparing overall survival (OS), progression-free survival (PFS), brain metastasis-free survival (BMFS), and incidence of brain metastases between patients receiving PCI and those not receiving it were considered eligible. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) tool. Meta-analysis was conducted on the mentioned outcomes with subgrouping based on different factors.

RESULTS

The authors identified 74 studies published between 1983 and 2022 with 31,551 SCLC patients, of whom 26.7% received PCI. The studies were a mix of prospective randomized and retrospective observational studies. Patients with limited-stage disease receiving PCI had better OS, PFS, and BMFS than those not receiving PCI. Patients receiving PCI also had significantly longer OS times and developed brain metastases significantly later. However, findings regarding extensive-stage SCLC were not as promising.

CONCLUSIONS

PCI is an effective option for limited-stage SCLC patients. It improves OS and PFS, delays brain metastases, and reduces the incidence of brain metastases. However, it might not benefit patients with extensive-stage SCLC under adequate follow-up with MRI surveillance. Finally, the heterogeneity of the included studies and publication bias were the main limitations of this study.

Effects of Postoperative Intravenous Cyclosporine Treatment on the Survival and Functional Performance Status of Patients With Glioblastoma: A Randomized, Triple-Blinded, Placebo-Controlled Clinical Trial

BACKGROUND

Glioblastoma is associated with low median survival time irrespective of maximal treatment. Previous in vitro studies have revealed tumor inhibitory effect of cyclosporine A. However, whether the addition of cyclosporine could improve survival among patients with glioblastoma is unknown. This study aimed to determine the impact of postoperation treatment with cyclosporine on the survival and performance status.

METHODS

In this randomized, triple-blinded, placebo-controlled trial, 118 patients with glioblastoma who underwent surgery were treated with standard chemoradiotherapy regimen. Patients were randomized to receive intravenous cyclosporine for 3 days postoperatively or placebo during the same period. The primary endpoint was the short-term effect of intravenous cyclosporine on survival and Karnofsky performance scores. Secondary endpoints were chemoradiotherapy toxicity and neuroimaging features.

RESULTS

The overall survival (OS) in the cyclosporine (17.03 ± 5.8, 95% confidence interval: 11-17.37 months) group was statistically lower than in the placebo (30.53 ± 4.9, 95% confidence interval: 8-32.3 months) groups (P = 0.049). However, compared to the placebo group, a statistically higher percentage of patients in the cyclosporine group were alive at 12 months follow-up. Also, progression-free survival in the cyclosporine group was significantly prolonged than in the placebo group (6.3 ± 4.07 months vs. 3.4 ± 2.98 months, P < 0.001). In the multivariate analysis, age <50 years (P = 0.022) and gross total resection (P = 0.03) were significantly associated with OS.

CONCLUSIONS

Our study results demonstrated that administering postoperative cyclosporine does not improve OS and functional performance status. Notably, the survival rate was significantly dependent on the patient age and the extent of glioblastoma resection.

A prospective randomized controlled trial of the effect of the number of burr hole on chronic subdural hematoma recurrence: An institutional experience

OBJECTIVE

The purpose of this study was to compare the effect of single burr hole (SBH) versus double burr hole (DBH) drainage on the recurrence rate of chronic subdural hematoma (CSDH).

METHOD

Forty-four patients undergoing burr hole craniostomy (BHC) between July 2022 and December 2022 were enrolled in a randomized clinical trial (RCT) comparing SBH to DBH surgeries. The primary endpoint of this study was the recurrence rate of CSDH. Radiological characteristics such as midline shift, thickness, volume, density, type of hematoma, brain atrophy and so on were secondary endpoints.

RESULTS

Forty-four patients participated in this study. Twenty-two hematomas underwent SBH craniostomy, and the other 22 had DBH craniostomy. The mean age in the SBH and DBH groups were 68.59 ± 7.94 and 69.54 ± 10.58, respectively. In each group, the proportion of males (SBH=16; DBH=15) was higher than that of females (SBH=6; DBH=7). The mean surgery time in the SBH group was significantly less than in the DBH group (p = 0.001). However, the two groups had no statistically significant difference in the CSDH recurrence rate (p = 0.312).

CONCLUSION

Our findings showed that SBH craniostomy is equally effective as DBH craniostomy at draining hematomas and does not increase the recurrence rate. Contrarily, the SBH craniostomy had a shorter surgical duration than the DBH craniostomy. As a result, we recommend SBH surgeries for all patients, with emphasis on the elderly and those with severe comorbidities, as well as in situations with few surgical facilities and a high patient admission rate.

Supratentorial Meningioma Consistency Prediction Utilizing Tumor to Cerebellar Peduncle Intensity on T1 and T2-Weighted and Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Sequences

OBJECTIVE

Predicting meningioma consistency with preoperative imaging is critical for surgery planning. Preoperative T1 and T2-weighted and fluid attenuated inversion recovery magnetic resonance imaging (MRI) findings of supratentorial meningioma tumors were studied and compared with intraoperative supratentorial meningioma tumor consistency based on the Cavitron ultrasound surgical aspirator (CUSA) and ZADA grading scales in this cohort to predict the tumor consistency before surgery.

METHODS

MRI from 78 consecutive patients who underwent supratentorial meningioma tumor resection between 2018 and 2021 were evaluated preoperatively. An intraoperative tumor consistency grade was applied to these lesions prospectively by the operating surgeon based on CUSA and ZADA grading scales. Tumor/cerebellar peduncle T2-weighted intensity, tumor/cerebellar peduncle T1-weighted intensity (TCT1I), and tumor/cerebellar peduncle fluid attenuated inversion recovery intensity (TCFI) ratios were calculated. Tumor consistency grades and MRI intensity ratios were correlated using one-way ANOVA.

RESULTS

Of the 78 patients, 52 (66.7%) were female and 26 (33.3%) were male. Tumor volume correlated with tumor consistency grades on both CUSA (P = 0.005) and ZADA (P = 0.024) grading scales. Also patients age correlated with tumor consistency according to ZADA grading scale (P = 0.024). TCT1I (P = 0.009) and TCFI (P < 0.005) ratios correlated significantly with tumor consistency grade according to CUSA. Similarly, TCT1I (P = 0.0032) and TCFI (P = 0.001) ratios was significantly associated with tumor consistency according to ZADA grading scales.

CONCLUSIONS

Our findings suggest that higher tumor/cerebellar peduncle T2-weighted intensity and TCFI ratios correlate with softer tumors, while higher TCT1I ratios reveal firmer tumors. These data can assist the surgeon predict the supratentorial meningioma consistency before surgery.

The neurodevelopmental outcomes of children with encephalocele: a series of 102 patients

OBJECTIVE

The overall prognosis of encephalocele (EC) is not well described. However, the presence of some risk factors may result in neurodevelopmental delay (NDD) and negatively affect the prognosis of affected patients. The goal of this study was to evaluate neurodevelopmental outcome, as well as the impact of a number of factors on the outcome in patients with ECs.

METHODS

This was an observational, retrospective study including 102 children with EC who were followed at the pediatric neurosurgery department of a tertiary medical center between the years 2010 and 2021. The authors evaluated NDD status according to the Centers for Disease Control and Prevention classification via clinical evaluation and parent interviews in the outpatient setting.

RESULTS

There were 52 boys and 50 girls. The median age at the time of surgery was 4 months (range 1 day-7.5 years). Seventy-one patients (69.6%) had posterior ECs, whereas 31 (30.4%) had anterior ECs. Forty-three (42.2%) of the ECs contained neural tissue. Of the 102 patients, 33 (32.4%) had ventriculomegaly. In terms of NDD, 14 (14.9%) had mild/moderate delay, whereas 17 patients (18.1%) had severe NDD. On univariate analysis, posterior location, size of sac, presence of neural tissue, ventriculomegaly, symptomatic hydrocephalus, and postoperative infection were correlated with NDD. On a multivariate logistic regression model, only neural tissue presence had a statistically significant association with NDD (OR 7.04, 95% CI 1.33-37.2, p = 0.022). Although not statistically significant, children with ventriculomegaly were 2.6 times as likely to have NDD (95% CI 0.59-11.19, p = 0.362).

CONCLUSIONS

This is a single-center study with a large sample size in which the neurodevelopmental status of patients with EC was assessed, and the authors tried to find the risk factors of NDD in these patients. The results showed that the presence of neural tissue within the EC sac was the only risk factor that had independent statistically significant association with NDD.

Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery

INTRODUCTION AND OBJECTIVES

Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery.

MATERIALS AND METHODS

We conducted a single-center, double-blind, randomized -controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone (CP-A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP-A group (n = 36, 50%) and CP+A group (n = 36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position + dose of acetazolamide 20 mg/kg/day in 3-4 divided doses for 7 days), and CP-A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide).

RESULTS

Baseline characteristics between the two groups showed no significant differences: Sex (P < .637), Age (P < .988) and previous CNS operation at other location besides the spine (P < .496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36 (11.11%) of CP-A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081-2.748; OR = 0.471; P < .402; Adjusted P < .247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P < .489) and type of operation (P < .465).

CONCLUSION

Acetazolamide has no positive effect in controlling CSF leak after dural opening/dural tear in adult patients who undergo spinal surgery, when we considered alongside the one-week prone position. Therefore, acetazolamide administration may not be essential for postoperative spinal surgery for dural tear. Prospective studies involving a larger sample size may be needed to track long-term acetazolamide complications on patients with CSF leak.

Intraventricular CNS aspergillosis in a patient with prior history of COVID-19: Case report and review of literature

Introduction and importance

Although some immunocompetent patients have developed invasive aspergillosis, the vast majority of cases are seen in immunocompromised patients. COVID-19 infection has been proposed to cause immune dysfunction or suppression, which predisposes patients to fungal co-infections such as mucormycosis and aspergillosis.

Case presentation

A 58-year-old woman was admitted to the hospital with confusion, dysarthria, and loss of consciousness. The patient had a 1-month prior history of severe COVID-19 infection. A computerized tomography (CT) scan and a magnetic resonance imaging (MRI) revealed an intraventricular lesion with perilesional edema and a significant midline shift, which was initially thought to be an intraventricular tumor. Following a posterior parietal craniotomy, the lesion was resected via a transcortical approach from the posterior parietal region to the right lateral ventricle. Histopathological findings confirmed intraventricular aspergillosis (IVA). The patient was treated with intravenous amphotericin B for two months and discharged with oral variconazole for 4 months.

Discussion

Covid-19 infections can result in- dissemination of fungal diseases such as aspergillosis. As a minor component of cerebral aspergillosis with a poor prognosis, intraventricular aspergillosis necessitates prompt treatment, which includes surgical resection and the administration of anti-fungal medications.

Conclusion

Infection with COVID-19 causes immune dysfunction, which leads to fungal co-infection, including CNS aspergillosis. As a result, all COVID-19 patients who present with acute neurologic symptoms should have CNS aspergillosis considered in their differential diagnosis.

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Infection with COVID-19 can cause immune dysfunction, which may lead to fungal co-infection, including CNS aspergillosis.

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Workup of COVID-19 patients with acute neurologic symptoms should be broad and include fungal infectious.

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Patients with CNS aspergillosis should receive prompt treatment because these cases have poor prognosis and can be fatal.

Metformin use and brain atrophy in nondemented elderly individuals with diabetes

OBJECTIVE

There is a shred of growing evidence demonstrating that diabetic patients are at higher risk of developing Alzheimer's disease compared to the general population. The previous investigation showed the protective effect of metformin for delaying dementia in diabetic patients. However, there are limited data on the effect of metformin on structural changes. This study aims to investigate the effect of metformin on hippocampal and cortical volumes in non-demented diabetic individuals.

METHOD

We entered 157 non-demented diabetic subjects including 89 mild cognitive impairment (MCI), and 68 cognitively healthy individuals from Alzheimer's disease Neuroimaging Initiative (ADNI) which were then categorized as metformin users and non-users. We used the ANCOVA model for measuring the association between metformin use and hippocampal and cortical volumes.

RESULTS

Among 157 subjects with a mean age of 71.8 (±7.7) included in this study, 76 individuals were stratified as metformin users. Results of the univariate model indicate that metformin users had a higher right (p = 0.003) and left parietal lobe volume (p = 0.004). Moreover, the volume of left cingulate was higher in those who used metformin compared to those not used it (p = 0.027). Our results were also significant for the right frontal lobe and indicated that metformin users had higher volume (p = 0.035). There were no significant differences in the hippocampus, occipital, and temporal regions.

CONCLUSION

Our findings showed the protective effects of metformin on brain volumes in non-demented elderly individuals with diabetes. Comparing the groups show strong enough results regarding the lower atrophy in metformin users.

Isolated primary spinal epidural hydatid cyst in a child with progressive paraparesis

BACKGROUND

Primary spinal hydatid cyst is a rare but serious condition which occurs in about 1% of patients with hydatid disease. This disease may result in severe spinal cord compression presenting with various neurological deficits.

CASE REPORT

A 3-year-old boy was referred to our center with progressive weakness of lower limbs, frequency, and urinary incontinence. His parents did not report back pain during child's illness. Lumbar magnetic resonance imaging (MRI) revealed an extradural well-defined thin-walled cystic lesion at L4 to S3 vertebral levels without enhancement. The cyst had compressed the thecal sac associated with bone scalloping of vertebral bodies and posterior elements. Osteoplastic laminectomy of L4-L5 and laminectomy of S1-S3 was done. Intraoperative and histopathological findings indicated an epidural hydatid cyst.

CONCLUSION

Although spinal hydatid cysts are rare but might be considered in the differential diagnosis of any patient with signs and symptoms of spinal cord compression. The pathophysiology, clinical manifestations, epidemiology, diagnosis, and surgical treatment of extradural hydatid cyst are discussed.