Transient Neurological Deficits Research Articles

Antioxidant Therapies in Traumatic Brain Injury.

Due to a multiplicity of causes provoking traumatic brain injury (TBI), TBI is a highly heterogeneous pathology, characterized by high mortality and disability rates. TBI is an acute neurodegenerative event, potentially and unpredictably evolving into sub-chronic and chronic neurodegenerative events, with transient or permanent neurologic, cognitive, and motor deficits, for which no valid standardized therapies are available. A vast body of literature demonstrates that TBI-induced oxidative/nitrosative stress is involved in the development of both acute and chronic neurodegenerative disorders. Cellular defenses against this phenomenon are largely dependent on low molecular weight antioxidants, most of which are consumed with diet or as nutraceutical supplements. A large number of studies have evaluated the efficacy of antioxidant administration to decrease TBI-associated damage in various animal TBI models and in a limited number of clinical trials. Points of weakness of preclinical studies are represented by the large variability in the TBI model adopted, in the antioxidant tested, in the timing, dosages, and routes of administration used, and in the variety of molecular and/or neurocognitive parameters evaluated. The analysis of the very few clinical studies does not allow strong conclusions to be drawn on the real effectiveness of antioxidant administration to TBI patients. Standardizing TBI models and different experimental conditions, as well as testing the efficacy of administration of a cocktail of antioxidants rather than only one, should be mandatory. According to some promising clinical results, it appears that sports-related concussion is probably the best type of TBI to test the benefits of antioxidant administration.

In Reply to the Letter to the Editor Regarding “Brain Compression by Encephalo-Myo-Synangiosis is a Risk Factor for Transient Neurological Deficits After Surgical Revascularization in Pediatric Patients with Moyamoya Disease”

In Reply to the Letter to the Editor Regarding “Brain Compression by Encephalo-Myo-Synangiosis is a Risk Factor for Transient Neurological Deficits After Surgical Revascularization in Pediatric Patients with Moyamoya Disease”

Letter to the Editor Regarding “Brain Compression by Encephalo-Myo-Synangiosis Is a Risk Factor for Transient Neurological Deficits After Surgical Revascularization in Pediatric Patients with Moyamoya Disease”

Letter to the Editor Regarding “Brain Compression by Encephalo-Myo-Synangiosis Is a Risk Factor for Transient Neurological Deficits After Surgical Revascularization in Pediatric Patients with Moyamoya Disease”

Expanded transnasal approaches to the skull base in the Middle East: Where do we stand?

ABSTRACTBACKGROUND: Endoscopic transnasal surgery has gained rapid global acceptance over the last two decades. The growing literature and understanding of anterior skull base endoscopic anatomy, in addition to new dedicated endoscopic instruments and tools, have helped to expand the use of the transnasal route in skull base surgery.OBJECTIVE: Report our early experience in expanded endoscopic transnasal surgery (EETS) and approach to skull base neoplasms.DESIGN: Descriptive, retrospective case series.SETTING: Major tertiary care center.PATIENTS AND METHODS: A retrospective case review was conducted at King Saud University Medical City between December 2014 and August 2019. Cases with skull base neoplasms that underwent EETS were included. EETS was defined as endoscopic surgical exposure that extended beyond the sellar margins (prechiasmatic sulcus superiorly, clival recess inferiorly, cavernous carotid lines laterally). Routine transsphenoidal pituitary neoplasms, neoplasms of sinonasal origin and meningoencephaloceles were excluded.MAIN OUTCOME MEASURES: Preoperative clinical assessment, imaging results, surgical approach, and hospital course were all retrieved from the patient electronic charts. Clinical follow-up, perioperative complications, and gross residual tumor rates were documented and reviewed.SAMPLE SIZE AND CHARACTERISTICS: 45 cases of EETS, 13 males and 32 females with mean age of 39.0 (17.7) years (range 2–70 years).RESULTS: The series comprised a wide range of pathologies, including giant pituitary adenoma (8 cases), meningioma (23 cases), craniopharyngioma (4 cases), chordoma (4 cases), optic pathway glioma (2 cases), epidermoid neoplasms (2 cases), astrocytoma (1 case), and teratoma (1 case). For the entire series, gross total resection was achieved in 25/45 operations (55.5%). Postoperative cerebrospinal fluid leak was the most common complication observed in 9 patients (20%) which were all managed endoscopically. Major vascular complications occurred in 2 patients (4.4%) and are described. Other complications are outlined as well. No mortality was observed.CONCLUSIONS: EETS to the skull base can be done with results comparable to traditional approaches. More work is needed to expand our experience, improve outcomes, and educate the public and medical community in our region about the usefulness of this approach.LIMITATIONS: Sample size and study design.CONFLICT OF INTEREST: None.

Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality

Some studies suggest that celiac artery coverage during elective endovascular thoracoabdominal aortic aneurysm (TAAA) repair is safe given sufficient collateralization of visceral organ perfusion from the superior mesenteric artery. However, there is concern that celiac artery coverage may lead to increased risk of foregut or spinal cord ischemia with an attendant increased risk of mortality. We sought to investigate rates of bowel ischemia, spinal cord ischemia, and 30-day mortality associated with celiac artery coverage during TEVAR and complex EVAR. The Society for Vascular Surgery Vascular Quality Initiative database was queried for TEVAR and complex EVAR cases from 2012 to 2018. Inclusion criteria included TAAA pathology and endograft extension to aortic zone 6. Patients with aortic rupture, trauma, prior thoracic aortic surgery, known preoperative occlusion of the left subclavian superior mesenteric, or celiac arteries were excluded. Cases with intraoperative celiac artery occlusion (CAO) were compared retrospectively to cases with celiac artery preservation (CAP). Primary outcomes included 30-day mortality and a composite end point of 30-day mortality, spinal cord ischemia (transient or permanent lower extremity neurologic deficit), and bowel ischemia (colonoscopic evidence of ischemia, bloody stools in a patient who dies prior to colonoscopy or laparotomy, or other documented clinical diagnosis). Univariable comparisons were performed using chi-squared tests and Student's t-tests, as appropriate. Multivariable logistic regression analyses were employed to identify independent predictors of outcome. There were 628 cases identified for inclusion in the study. Patients undergoing CAO (n=44) were more likely to be female or to have higher rates of preoperative spinal drain use, American Society of Anesthesiologists score ≥3, low preop hemoglobin, and/or symptomatic presentation, but fewer mean number of aortic zones covered. CAO was associated with higher 30-day mortality (5 of 44, 11%) compared to CAP (23 of 584, 4%), P=0.039. The composite end point occurred at a significantly greater proportion for those who had CAO (10 of 44, 23%) compared to CAP (53 of 584, 9%, P=0.008), driven by higher rates of 30-day mortality and bowel ischemia (9% vs. 2%, P=0.026). By multivariate analysis, CAO was predictive of 30-day mortality (odds ratio [OR]=3.9, 95% confidence interval [CI]=1.1-13.8, P=0.04) and the composite endpoint (OR=3.0, 95% CI=1.1-8.5, P=0.03). Increasing procedure time was also associated with 30-day mortality (OR=1.4, 95% CI=1.1-1.7, P<0.001) and the composite end point (OR=1.4, 95% CI=1.1-1.6, P<0.001). For those treated for TAAAs, CAO was independently predictive of increased 30-day mortality and a composite end point of perioperative mortality, spinal cord ischemia, and bowel ischemia. When treating patients with extensive aortic aneurysmal disease, physicians should attempt to preserve the celiac artery, by revascularization or avoiding ostium coverage, whenever feasible.

Clinical results and functional outcomes after three-column osteotomy at L5 or the sacrum in adult spinal deformity.

Three-column osteotomies at L5 or the sacrum (LS3COs) are technically challenging, yet they may be needed to treat lumbosacral kyphotic deformities. We investigated radiographic and clinical outcomes after LS3CO. We analyzed 25 consecutive patients (mean age 56years) who underwent LS3CO with minimum 2-year follow-up. Standing radiographs and health-related quality-of-life scores were evaluated. A new radiographic parameter ["lumbosacral angle" (LSA)] was introduced to evaluate sagittal alignment distal to the S1 segment. From preoperatively to the final follow-up, significant improvements occurred in lumbar lordosis (from - 34° to - 49°), LSA (from 0.5° to 22°), and sagittal vertical axis (SVA) (from 18 to 7.3cm) (all, p < .01). Mean Scoliosis Research Society (SRS)-22r scores in activity, pain, self-image, and satisfaction (p < .05), and Oswestry Disability Index scores (p < .01) also improved significantly. Patients with SVA ≥ 5cm at the final follow-up experienced less improvement in SRS-22r satisfaction scores than those with SVA < 5cm. Patients with LSA < 20° at the final follow-up had significantly lower SRS-22r activity scores than those with LSA ≥ 20° (p = .014). Two patients had transient neurologic deficits, and 11 patients underwent revision for proximal junctional kyphosis (5), pseudarthrosis (3), junctional stenosis (2), or neurologic deficit (1). LS3CO produced radiographic and clinical improvements. However, patients who remained sagittally imbalanced had less improvement in SRS-22r satisfaction score than those whose sagittal imbalance was corrected, and patients who maintained kyphotic deformity in the lumbosacral spine had lower SRS-22r activity scores than those whose lumbosacral kyphosis was corrected. These slides can be retrieved under Electronic Supplementary Material.

Motor Cortex Stimulation for Facial Pain.

Motor cortex stimulation (MCS) has been used in the treatment of intractable neuropathic facial pain for nearly 30 years. While efficacy rates have been noted as high as 88% in some studies, considerable variability in treatment response remains. Additionally, MCS is often cited as providing diminishing relief over time, and there are few long-term studies on efficacy. Complications are generally mild and include infection, hardware complication, seizure, and transient neurological deficit. Despite relatively minimal use, MCS remains a viable treatment option for the appropriately selected facial pain patients that have proved refractory to conservative management.

Surgical treatment of epilepsy in children with gloneuronal brain tumors: morphology, MRI semiology and factors affecting the outcome

Glioneuronal tumors (GNT) are usually found in children (less than 1.5% of all neoplasms of the brain). With rare exceptions, they are benign and usually manifest only by epilepsy, which is quite often resistant to treatment with AE drugs. Tumor removal usually helps to cope with epileptic seizures, however, a number of issues regarding diagnosis and surgical treatment (interpretation of morphological data and classification, epileptogenesis and topography of the epileptogenic zone, the value of intraoperative invasive EEG and the optimal volume of resection) remain debatable. To describe the morphology, electro-clinical picture and MR-semiology in patients with gloneuronal brain tumors, as well as to analyse the results of their surgical treatment and the factors determining its outcome. 152 children with a median age of 8 years were treated surgically (There were 64 gangliogliomas, 73 DNT, 15 cases where the tumor classification failed - GNT NOS). In children under 2 years of age, temporal localization of the tumor prevailed. In 81 cases, ECoG was used during the operation. Surgical treatment complications: transient neurological deficit (in 15 cases); hematomas removed without consequences (in 2 cases), infectious (osteomyelitis of bone bone flap in 2 cases). We analyzed: the age of the epilepsy onset (median - 4 years 7 months) and its duration (median - 23.5 months), the type of seizures, as well as the features of MR-semiology and morphology of tumors and adjacent areas of the brain. The volume of tumor resection was verified by MRI (in 101 cases) and CT (in each case). The follow-up was collected through face-to-face meetings, with repeated video EEG and MRI, as well as telephone interviews. We studied the effect of a number of parameters characterizing the patient and features of his/her operation on the outcome of treatmen. Among 102 patients in whom the follow-up history is one year or more (median - 2 years), a favorable outcome (Engel IA) was observed in 86 of them (84%); 55 of them (54%) at the time of the last examination stopped drug AE treatment. Radical tumor removal and younger age at the time of surgery were statistically significantly associated with a favorable result. In children with gloneuronal brain tumors, removal of the tumor is effective and relatively safe in the treatment of symptomatic epilepsy. Radical tumor resection and earlier intervention are the most important prerequisites for a favorable outcome and persistent remission of seizures.

Total Arch Replacement with Hypothermic Circulatory Arrest, Antegrade Cerebral Perfusion and the Y-graft

This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18-22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32-82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79-94%) were alive at 1 year, 78% at 5 years (95%CI: 66-86%), and 73% at 10 years (95%CI: 59-82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes.

Effectiveness of ‘Preauricular-Retroparotid' and ‘Retromandibular-Transparotid' approaches in the management of displaced and dislocated condylar head and neck fractures.

Introduction: Management of fractures of the condylar head, neck and base regions can be quite tricky, owing to differences in the morphology and location of the fracture, degree & direction of displacement, extent of comminution, and position of condylar head in relation to glenoid fossa. Hence, choosing an ideal surgical approach for each individual case, is both difficult as well as important. Aim: To assess the effectiveness of two major surgical approaches, the ‘Preauricular-Retroparotid’ and ‘Retromandibular-Transparotid’ approaches in the management of different types of displaced and dislocated condylar head and neck fractures. Patients and Methods: This retrospective study includes 56 patients operated over a period of four years from Jan 2016 to Dec 2019, of whom 14 had bilateral and 42 had unilateral displaced condylar head or neck fractures. 22 surgeries were for condylar head or high condylar neck fractures, treated using the Preauricular-Retroparotid approach. 48 surgeries were for low condylar neck fractures, managed using the Retromandibular-Transparotid approach. Intraoperative and postoperative complications, and detailed objective, subjective and functional treatment outcome assessments, were recorded over a postoperative follow up period ranging from one to three years. Results & Conclusion: Both surgical approaches were found effective in achieving good esthetic and functional results with no major complications, other than occasional transient neurological deficits and few instances of salivary fistulas and sialocoeles. Depending upon the level of the condylar fractures, a preauricular approach is ideal for the condylar head and high condylar neck fractures, providing direct and easy visualization to the region, for retrieval and repositioning of the medially displaced and dislocated proximal fracture fragment. The retromandibular approach is more suited for the lower level condylar neck fractures, providing a direct visual field and a wide, straight line access for implant fixation at this region.

Classifications in Brief: AO Thoracolumbar Classification System.

Classifications in Brief: AO Thoracolumbar Classification System.

P.157 Switching from risperidone to paliperidone palmitate in schizophrenia: Changes in prolactin levels and sexual function

The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair.A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded.There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively.The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.

The radiological outcomes of one-stage posterior-only hemivertebra resection and short segmental fusion for lumbosacral hemivertebra: a minimum of 5\xa0years of follow-up

BackgroundPrevious studies have reported favorable short-term outcomes after posterior-only hemivertebra resection and short fusion in patients with LSHV. However, there is a paucity of data evaluating the long-term outcomes following this procedure. The aim of the study is to evaluate the radiological outcomes following posterior-only hemivertebra resection and short fusion for the treatment of congenital scoliosis (CS) secondary to lumbosacral hemivertebra (LSHV) with a minimum of a 5-year follow-up.MethodsA total of 23 patients treated with one-stage posterior-only LSHV resection and short fusion with a minimum of a 5-year follow-up were reviewed. Radiographic parameters including the Cobb angles of the lumbosacral curve and compensatory curve, the upper instrumented vertebra (UIV) tilt, and trunk shift were measured. The complications were recorded accordingly.ResultsThe mean duration of follow-up was 88.6 ± 28.5 months, and the average age at surgery was 7.8 ± 3.5 years. Fusion levels averaged 3.0 ± 0.7 segments. The lumbosacral curve was corrected from 30.7 ± 10.4° to 6.7 ± 7.1° after surgery (P < 0.001), 7.3 ± 6.1° 2 years after surgery, and 8.1 ± 7.0° at the last follow-up. The compensatory curve was spontaneously corrected from 23.7 ± 9.4° before surgery to 8.3 ± 5.2° after surgery (P < 0.001). However, the angle slightly increased to 9.0 ± 4.8° 2 years after surgery and to 9.6 ± 6.4° at the last follow-up. Trunk shift was improved from 27.3 ± 8.6 mm before surgery to 11.7 ± 9.4 mm after surgery, and it decreased to 10.8 ± 8.2 mm 2 years after surgery and 10.4 ± 8.8 mm at the last follow-up. One patient experienced transient neurologic deficits after surgery. One patient was observed to have screw loosening at 1-year follow-up and received revision surgery.ConclusionOne-stage posterior-only hemivertebra resection with short fusion is an effective procedure for LSHV, and the correction can be well maintained during longitudinal follow-up. Great attention should be paid to the restoration of lumbosacral horizontalization.

The Spectrum of Nontraumatic Convexity Subarachnoid Hemorrhage

Background: Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a nonaneurysmal variant that is associated with diverse etiologies. Methods: With IRB approval, we retrospectively reviewed consecutive nontraumatic cSAH from July 1, 2006 to July 1, 2016. Data were abstracted on demographics, medical history, neuroimaging, etiology, and clinical presentation. Results: We identified 94 cases of cSAH. The cases were classified according to the following etiologies: reversible cerebral vasoconstriction syndrome (RCVS) 17 (18%), cerebral amyloid angiopathy (CAA) 15 (16%), posterior reversible encephalopathy syndrome 16 (17%), cerebral venous thrombosis 10 (11%), large artery occlusion 7 (7%), endocarditis 6 (6%), and cryptogenic 25 (27%). Early rebleeding occurred in 9 (10%) patients. Time from initial imaging to CT rebleeding was 40 hours (range, 5-74). CAA was associated with the highest mean age at 75.8 and RCVS the lowest at 47.6 years (P< .0001). Among patients with RCVS, initial vascular imaging was negative in 6 (35%), and repeat imaging documented vasoconstriction at a mean delay of 5 days (range, 3-16). Conclusion: There were significant differences among the subgroups in cSAH, with CAA presenting as older men with transient neurological deficits, and RCVS presenting as younger women with thunderclap headache. Rebleeding was seen in 10% of cSAH patients. One-third of RCVS patients with cSAH required repeat vascular imaging to diagnose vasoconstriction.

ROLE OF GLYCEMIC CONTROL ON ISCHEMIC STROKE IN AF

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Diabetes is a known risk factor for thromboembolic events in patients with atrial fibrillation (AF). However there has been so many debates about the effect of glycemic control as a considerable risk factor. We conducted a study to evaluate any relation between A1c values and rate of stroke in patients with both AF and diabetes mellitus (DM). METHODS: This is a retrospective case-control study conducted at a teaching university-based hospital from December 2013 to December 2018. We evaluated inpatients and outpatients with diagnoses of AF and DM or the presence or absence of either a Transient Ischemic Attack (an acute-onset focal and localizable but transient neurological deficit) with or a stroke (an acute-onset focal and localizable neurologic deficit with infarction of an arterial territory on imaging). The HbA1c values were reviewed and propensity matched on CHA2DS2-VASc scores, anticoagulation status and age between study and control groups. Chi-squared test was used to compare categorical variables and t-test to compare continuous variables. RESULTS: Among 233 diabetic patients with AF, we were able to include 197 who had documented A1c values (mean age, 74 years; 69 [35%] women). The study group (n=31) includes DM patients with AF who had stroke. After matching the variables, there was no difference in the CHA2DS2-VASc scores (P = 0.717), the rate of stroke (P = 0.96), and the A1c value (P = 0.19) between two groups. Average A1c values were 7.2 [SD, 1.3] and 7.6 [SD, 1.5] in case and control groups, respectively. There were no differences between the rate of anticoagulation between two groups, prior to the acute event (32.3% in study group vs 36.6% in control group, P = 0.66) CONCLUSIONS: There is no correlation between magnitude of A1c elevation and risk of TIA or stroke in patients with both diabetes mellitus and atrial fibrillation. Limitations included a single-center and a small sample size. Lower Hba1c did not confer less risk of cerebrovascular events. Controlled and uncontrolled diabetics should continue to be scored equally in assessing the risk of stroke. CLINICAL IMPLICATIONS: “High Value Care” and “Choosing Wisely” are the core deciding factor for evidence-based practice among general internists. In this study, we found that the degree of glycemic control may not have a major prognostic role regarding risk of TIA or stroke in AF among patients with DM. It may be worth reevaluating the utility of obtaining A1c values at the time of stroke or TIA. An old saying, “treat the patient and not the number” might be appropriate in this context. DISCLOSURES: No relevant relationships by Ibrahim Ghobrial, source=Web Response No relevant relationships by Navneet Kaur, source=Web Response No relevant relationships by Mehrshid Kiazand, source=Web Response No relevant relationships by Evan Kudron, source=Web Response No relevant relationships by Noor-ul-huda Mehdi, source=Web Response No relevant relationships by Marie Tuft, source=Web Response No relevant relationships by Sowjanya Yenigalla, source=Web Response

Brain Compression by Encephalo-Myo-Synangiosis is a Risk Factor for Transient Neurological Deficits After Surgical Revascularization in Pediatric Patients with Moyamoya Disease

In pediatric patients with moyamoya disease, the pathophysiology of transient neurological deficits and the clinical features of perioperative cerebral blood flow (CBF) changes are unclear. The purpose of this study was to investigate the risk factors of postoperative transient neurological deficits and identify predictors of perioperative CBF changes. This retrospective study included 42 surgical procedures in 28 pediatric patients who underwent surgical revascularization for moyamoya disease, including encephalo-myo-synangiosis (EMS) with or without superficial temporal artery-middle cerebral artery (MCA) anastomosis. Magnetic resonance images and single photon emission computed tomography results were obtained. Brain compression by EMS was also checked in fluid attenuated inversion recovery images. Using single photon emission computed tomography, CBF was measured at each anterior and posterior part of the MCA region. Postoperative transient neurological deficits were observed in 12 (28.6%) out of 42 surgical procedures. Brain compression by EMS was a significant risk for transient neurological deficits (P= 0.009). The postoperative CBF in the anterior region increased in 9 cases (21.4%) and decreased in 10 cases (23.8%); in the posterior region, it increased in 12 cases (28.6%) and decreased in 10 cases (23.8%). Preoperative CBF of the anterior region was significantly related to both perioperative CBF changes in the MCA regions (anterior part, P= 0.004; posterior part, P= 0.025). Brain compression by EMS is a risk factor for postoperative transient neurological deficits in pediatric patients with moyamoya disease, and preoperative CBF of the anterior MCA region could predict perioperative CBF change in the MCA regions.

Benefits of Magnetic Resonance Imaging for Patients Presenting With Low-risk Transient or Persistent Minor Neurologic Deficits

Benefits of Magnetic Resonance Imaging for Patients Presenting With Low-risk Transient or Persistent Minor Neurologic Deficits

Transcortical insular glioma resection: clinical outcome and predictors.

Insular lobe gliomas continue to challenge neurosurgeons due to their complex anatomical position. Transcortical and transsylvian corridors remain the primary approaches for reaching the insula, but the adoption of one technique over the other remains controversial. The authors analyzed the transcortical approach of resecting insular gliomas in the context of patient tumor location based on the Berger-Sinai classification, achievable extents of resection (EORs), overall survival (OS), and postsurgical neurological outcome. The authors studied 255 consecutive cases of insular gliomas that underwent transcortical tumor resection in their division. Tumor molecular pathology, location, EOR, postoperative neurological outcome for each insular zone, and the accompanying OS were incorporated into the analysis to determine the value of this surgical approach. Lower-grade insular gliomas (LGGs) were more prevalent (63.14%). Regarding location, giant tumors (involving all insular zones) were most prevalent (58.82%) followed by zone I+IV (anterior) tumors (20.39%). In LGGs, tumor location was an independent predictor of survival (p = 0.003), with giant tumors demonstrating shortest patient survival (p = 0.003). Isocitrate dehydrogenase 1 (IDH1) mutation was more likely to be associated with giant tumors (p < 0.001) than focal tumors located in a regional zone. EOR correlated with survival in both LGG (p = 0.001) and higher-grade glioma (HGG) patients (p = 0.008). The highest EORs were achieved in anterior-zone LGGs (p = 0.024). In terms of developing postoperative neurological deficits, patients with giant tumors were more susceptible (p = 0.038). Postoperative transient neurological deficit was recorded in 12.79%, and permanent deficit in 15.70% of patients. Patients who developed either transient or permanent postsurgical neurological deficits exhibited poorer survival (p < 0.001). The transcortical surgical approach can achieve maximal tumor resection in all insular zones. In addition, the incorporation of adjunct technologies such as multimodal brain imaging and mapping of cortical and subcortical eloquent brain regions into the transcortical approach favors postoperative neurological outcomes, and prolongs patient survival.

Transient neurologic deficit with complete recovery due to cervical spinal cord infarction after preoperative embolization for metastatic lesion of malignant pheochromocytoma at proximal thoracic spine

Spinal cord infarction after preoperative transarterial embolization for metastatic spinal lesions is uncommon and usually leads to complete paralysis. Transient neurologic deficit due to spinal cord infarction after preoperative embolization for spinal metastases has never been reported in the literature. A 30-year-old female patient was diseased with malignant pheochromocytoma and multiple metastases to lung and bones. She suffered from refractory pain at upper back and numbness at her body below xiphoid process but no motor deficit was noted at extremities. Magnetic resonance imaging (MRI) revealed paraspinal and epidural lesions originating from T2 to T4 vertebrae with compression to spinal cord. Preoperative embolization was executed to the spinal metastases with the intent to reduce intraoperative bleeding. Embolization procedure was performed to bilateral costocervical trunk, 3rd and 4th intercostal arteries with 400 μm Embozene® microsphere under local anesthesia. The procedure was discontinued immediately after development of severe hypertension that might be related to the pheochromocytoma and was treated with intravenous antihypertensive drug. There was no neurologic deficit until 6.5 hours after the procedure when weakness at right lower extremity and hypesthesia at left arm developed. Emergent MRI showed focal infarcts in spinal cord at right aspect of C5 and left C4 levels. With adequate hydration but no administration of steroid, muscle power gradually recovered in a few hours. Posterior instrumentation, neural decompression and tumor debulking were performed 2 days after embolization as scheduled. One week after the event of spinal cord infarction, she could stand up and walk without aid. Even though it is rare, spinal cord infarction is an important differential diagnosis for sudden decrease of muscle power after preoperative embolization for spinal metastases. Although complete paralysis is more common, transient neurologic deficit with complete recovery could happen in patients with minor infarcts in the spinal cord.

Transient neurologic deficit with complete recovery due to cervical spinal cord infarction after preoperative embolization for metastatic lesion of malignant pheochromocytoma at proximal thoracic spine

Spinal cord infarction after preoperative transarterial embolization for metastatic spinal lesions is uncommon and usually leads to complete paralysis. Transient neurologic deficit due to spinal cord infarction after preoperative embolization for spinal metastases has never been reported in the literature. A 30-year-old female patient was diseased with malignant pheochromocytoma and multiple metastases to lung and bones. She suffered from refractory pain at upper back and numbness at her body below xiphoid process but no motor deficit was noted at extremities. Magnetic resonance imaging (MRI) revealed paraspinal and epidural lesions originating from T2-4 vertebrae with compression to spinal cord. Preoperative embolization was executed to the spinal metastases with the intent to reduce intraoperative bleeding. Embolization procedure was performed to bilateral costocervical trunk, 3rd and 4th intercostal arteries with 400 μm Embozene® microsphere under local anesthesia. The procedure was discontinued immediately after development of severe hypertension that might be related to the pheochromocytoma and was treated with intravenous antihypertensive drug. There was no neurologic deficit until 6.5 hours after the procedure when weakness at right lower extremity and hypesthesia at left arm developed. Emergent MRI showed focal infarcts in spinal cord at right aspect of C5 and left C4 levels. With adequate hydration but no administration of steroid, muscle power gradually recovered in a few hours. Posterior instrumentation, neural decompression and tumor debulking were performed 2 days after embolization as scheduled. One week after the event of spinal cord infarction, she could stand up and walk without aid. Even though it is rare, spinal cord infarction is an important differential diagnosis for sudden decrease of muscle power after preoperative embolization for spinal metastases. Although complete paralysis is more common, transient neurologic deficit with complete recovery could happen in patients with minor infarcts in the spinal cord.