Tethered cord prevalence among patients with prenatal or postnatal myelomeningocele repair.

BACKGROUND: Myelomeningocele (MMC) is a severe form of spina bifida characterized by spinal cord extrusion into a cerebrospinal fluid (CSF) filled sac which may lead to lifelong disability. Repair of these lesions have classically occurred shortly after birth, but more recently, prenatal myelomeningocele repair techniques have been elucidated. This study aimed to investigate the outcome of surgery, particularly with subsequent spinal cord tethering, in patients with prenatal myelomeningocele closure and those with postnatal repair surgery. MATERIALS AND METHODS: In this retrospective study which assessed patients from April 2002 to April 2020, the data of 18 total patients with MMC were reviewed. Nine patients from each group were included, closed prenatally or postnatally, respectively. Demographic information including age and sex, birth week, infant comorbidities, presence of dermoid or lipoma, cutaneous stigmata, total number and timing of detethering procedures, presence of Chiari malformation, and need for VPS was obtained. RESULTS: Eighteen patients including nine infants closed prenatally and nine infants with myelomeningoceles closed postnatally were reviewed. The mean age was 4 ± 3 years and 6.22 ± 2.4 in prenatal and postnatal retrospectively. There was a significant relationship between the number of detethering procedures (p-value = 0.03) and the need for a ventriculoperitoneal shunt (VPS) (p-value = 0.01) between the groups, with the prenatal closure group having lower rates of each. There was no significant difference between the groups in regard to the mean age at the detethering procedure (p = 0.4), sex (p = 0.09), birth week (p = 0.8), comorbidities (p = 0.8), presence of intraspinal dermoid or lipoma (p = 0.09), presence of cutaneous stigma (p = 0.08), Chiari (p = 0.6), fatty filum (p = 0.08), syrinx (p = 0.4), bone anomaly (p = 0.4), and spina bifida neurological scale (p = 0.66). CONCLUSION: There was a significant relationship between the two groups in terms of the number of detethering procedures, and the need for VPS. Our data represents a possible difference in the need for detethering surgeries and ventriculoperitoneal shunt placements between patients with prenatal and postnatal myelomeningocele closures.

Prognostic risk factors for early outcomes of patients with myelomeningocele: a prospective study.

INTRODUCTION: Myelomeningocele (MMC) is a prevalent form of neural tube defect. Despite advancements in treatment, MMC still poses significant health risks, including complications leading to chronic disability and mortality. Identifying prognostic risk factors for early outcomes is crucial for tailored intervention strategies. METHODS: This prospective study involved newborns and infants diagnosed with MMC who underwent surgery between 2020 and 2023 at Urmia University of Medical Sciences. Demographic data and surgical outcomes were collected, and participants were followed up for six months. Statistical analyses were conducted using descriptive statistics, Chi-Square, and independent t-test. RESULTS: The study included 29 MMC cases, with an incidence rate of 1.4 per 10,000 live births. Lesions were predominantly located in the lumbar spine. Although mortality rates appeared to increase with ascending lesion sites, this trend was not statistically significant. Short-term outcomes revealed high morbidity and mortality rates, with neurological deficits being the most prevalent complication. Multivariable analysis identified head circumference as a significant predictor of adverse outcomes (IRR = 1.37, 95% CI = 1.02 to 1.86, p = 0.04). Furthermore, an increase in birth weight was associated with a reduction in the incidence of requiring a ventriculoperitoneal shunt (IRR = 0.99, 95% CI = 0.998 to 0.999, p = 0.02). CONCLUSION: This prospective study highlights prognostic risk factors for early outcomes in MMC patients, emphasizing the need for personalized intervention strategies. By addressing modifiable risk factors and implementing targeted interventions, healthcare providers can strive to improve outcomes and enhance the quality of life for MMC patients.

Investigating the Safety and Efficacy of Therapeutic Hypothermia in Pediatric Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: Prior guidelines recommended maintaining normothermia following traumatic brain injury (TBI), but recent studies suggest therapeutic hypothermia as a viable option in pediatric cases. However, some others demonstrated a higher mortality rate. Hence, the impact of hypothermia on neurological symptoms and overall survival remains contentious. METHODS: We conducted a systematic review and meta-analysis to evaluate the effects of hypothermia on neurological outcomes in pediatric TBI patients. The PubMed/Medline, Scopus, and Web of Science databases were searched until 1 January 2024 and data were analyzed using appropriate statistical methods. RESULTS: A total of eight studies, comprising nine reports, were included in this analysis. Our meta-analysis did not reveal significant differences in mortality (RR = 1.58; 95% CI = 0.89-2.82, p = 0.055), infection (RR = 0.95: 95% CI = 0.79-1.1, p = 0.6), arrhythmia (RR = 2.85: 95% CI = 0.88-9.2, p = 0.08), hypotension (RR = 1.54: 95% CI = 0.91-2.6, p = 0.10), intracranial pressure (SMD = 5.07: 95% CI = -4.6-14.8, p = 0.30), hospital length of stay (SMD = 0.10; 95% CI = -0.13-0.3, p = 0.39), pediatric intensive care unit length of stay (SMD = 0.04; 95% CI = -0.19-0.28, p = 0.71), hemorrhage (RR = 0.86; 95% CI = 0.34-2.13, p = 0.75), cerebral perfusion pressure (SMD = 0.158: 95% CI = 0.11-0.13, p = 0.172), prothrombin time (SMD = 0.425; 95% CI = -0.037-0.886, p = 0.07), and partial thromboplastin time (SMD = 0.386; 95% CI = -0.074-0.847, p = 0.10) between the hypothermic and non-hypothermic groups. However, the heart rate was significantly lower in the hypothermic group (-1.523 SMD = -1.523: 95% CI = -1.81--1.22 p < 0.001). CONCLUSIONS: Our findings challenge the effectiveness of therapeutic hypothermia in pediatric TBI cases. Despite expectations, it did not significantly improve key clinical outcomes. This prompts a critical re-evaluation of hypothermia's role as a standard intervention in pediatric TBI treatment.

Perioperative Segmentation of the Posterior Fossa and the Keel of Goodrich in Surgical Outcomes of Chiari Malformations.

BACKGROUND: Chiari I malformation (CM-I) is defined as the extension of brain tissue into the spinal cord. This study aimed to refine the methodology for the acquisition of 3-dimensional measurements of the posterior fossa and introduce occipital keel size as a new marker and its impact in patients with CM. METHODS: In this retrospective study, all patients who underwent Chiari decompression surgery at Montefiore Medical Center from April 2012 to April 2022 were included. Perioperative clinical information was obtained in addition to maximal keel thickness (KT), foramen magnum area, and preoperative and postoperative posterior fossa volumes for each patient and age-matched controls. Volumetric measurements were obtained using artificial intelligence-based semiautomated segmentation. RESULTS: A total of 107 patients with CM including 37 males, and 70 females were studied with a mean age of 26.56 ± 17.31 compared with 103 controls without CM. The comparison between the CM and the general population groups demonstrated a significantly increased keel size in Chiari patients. Keel size had a significant relationship with dysphagia, paresthesia, and intraoperative blood loss, while posterior volume change had a significant relationship with sex and early symptomatic improvement. The Foramen magnum area was related to tonsillar descent and more prominent in patients with spina bifida. CONCLUSIONS: The Keel of Goodrich is a new anatomical factor that should be taken into consideration when evaluating preoperative symptoms, and intraoperative complications in patients with CM-I. Volumetric analyses demonstrated that posterior fossa volume change had a significant impact on early symptom improvement in patients with Chiari, as did the choice of operative approach. The routine use of semiautomated segmentation of the posterior fossa may help stratify Chiari patients in the future and should be implemented in routine clinical care.

Predicting the Outcome and Survival of Patients with Spinal Cord Injury Using Machine Learning Algorithms: A Systematic Review.

BACKGROUND: Spinal cord injury (SCI) is a significant public health issue, leading to physical, psychological, and social complications. Machine learning (ML) algorithms have shown potential in diagnosing and predicting the functional and neurologic outcomes of subjects with SCI. ML algorithms can predict scores for SCI classification systems and accurately predict outcomes by analyzing large amounts of data. This systematic review aimed to examine the performance of ML algorithms for diagnosing and predicting the outcomes of subjects with SCI. METHODS: The literature was comprehensively searched for the pertinent studies from inception to May 25, 2023. Therefore, electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically searched with individual search syntax. RESULTS: A total of 9424 individuals diagnosed with SCI across multiple studies were analyzed. Among the 21 studies included, 5 specifically aimed to evaluate diagnostic accuracy, while the remaining 16 focused on exploring prognostic factors or management strategies. CONCLUSIONS: ML and deep learning (DL) have shown great potential in various aspects of SCI. ML and DL algorithms have been employed multiple times in predicting and diagnosing patients with SCI. While there are studies on diagnosing acute SCI using DL algorithms, further research is required in this area.

Clinical Features and Management of Skull Base Fractures in the Pediatric Population: A Systematic Review.

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical.

Clear cell meningiomas-case presentation, review of radiographic identifiers, and treatment approaches.

Spinal clear cell meningiomas (CCMs) are a rare histological subtype of meningiomas that pose preoperative diagnostic challenges due to their radiographic similarities with other lesions. They are also more aggressive, exhibiting higher rates of recurrence, particularly in pediatric patients. Overcoming diagnostic challenges of these tumors can improve patient outcomes. In this report, we describe a case of a pediatric patient presenting with a lumbar CCM in whom we were able to obtain gross total resection. Our report reviews previously identified predictors of CCM recurrence, including the Ki-67 proliferation index, number of spinal segments involved, and hormonal influences related to age and sex. We describe the characteristic radiographic features that differentiate spinal CCMs from other tumors to improve pre-operative diagnosis. Furthermore, we provide our rationale for adjuvant therapy for pediatric patients to refine treatment protocols for these rare tumors.

Volumetric segmentation in the context of posterior fossa-related pathologies: a systematic review.

BACKGROUND: Segmentation tools continue to advance, evolving from manual contouring to deep learning. Researchers have utilized segmentation to study a myriad of posterior fossa-related conditions, such as Chiari malformation, trigeminal neuralgia, post-operative pediatric cerebellar mutism syndrome, and Crouzon syndrome. Herein, we present a summary of the current literature on segmentation of the posterior fossa. The review highlights the various segmentation techniques, and their respective strengths and weaknesses, employed along with objectives and outcomes of the various studies reported in the literature. METHODS: A literature search was conducted in PubMed, Embase, Cochrane, and Web of Science up to November 2023 for articles on segmentation techniques of posterior fossa. The two senior authors searched through databases based on the keywords of the article separately and then enrolled joint articles that met the inclusion and exclusion criteria. RESULTS: The initial search identified 2205 articles. After applying inclusion and exclusion criteria, 77 articles were selected for full-text review after screening of titles/abstracts. 52 articles were ultimately included in the review. Segmentation techniques included manual, semi-automated, and fully automated (atlas-based, convolutional neural networks). The most common pathology investigated was Chiari malformation. CONCLUSIONS: Various forms of segmentation techniques have been used to assess posterior fossa volumes/pathologies and each has its advantages and disadvantages. We discuss these nuances and summarize the current state of literature in the context of posterior fossa-associated pathologies.

A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma.

There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.

The complex treatment paradigms for concomitant tethered cord and scoliosis: illustrative case.

BACKGROUND: Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections. OBSERVATIONS: A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3-4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved. LESSONS: Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

Can Neutrophil to Lymphocyte Ratio Predict Early Outcome in Patients with Spinal Cord Injury?

BACKGROUND: Spinal cord injury is a frequent debilitating neurologic condition with increasing prevalence and related morbidity over the last decades. The neutrophil-to-lymphocyte ratio is a promising biomarker for determining different medical conditions' disease course and outcome such as traumatic brain injury (TBI). This study aimed to investigate the predictive value of neutrophil to lymphocyte ratio (NLR) in the outcome of SCI. METHOD: In a retrospective cross-sectional study from April 2019 to April 2022, all patients 18 to 65 years old, following spinal cord injury who were referred to Imam Khomeini Hospital and met inclusion and exclusion criteria enrolled in the study. A checklist including demographic data, lab, and clinical findings at admission, 24h, 48 h, and discharge were recorded. IBM SPSS Statistics software was used to analyze the data. A P-value of less than 0.05 was considered significant. RESULTS: Six hundred patients met our inclusion criteria and enrolled in the study. The mean age of the patients was 40.93 ± 12.77, with 75% male and 25% female. There was a significant correlation between the N/L ratio at different time points (p.value=0.001), injury type, and ASIA score at admission and discharge (0.001). Furthermore, the NLR had approached significant value alone to predict outcomes in patients enrolled in the study (0.06). CONCLUSIONS: A high NLR is unequivocally linked with poor outcomes in patients suffering from acute SCI and should be considered a negative prognostic factor; however, the NLR had approached significant predicting value in patients enrolled in the study.

STAT5b gain-of-function disease in a child with mycobacterial osteomyelitis of the skull: rare presentation of an emerging disease entity.

PURPOSE: STAT proteins play a key role in several cellular functions related to cell development, differentiation, proliferation, and survival. Persistent STAT activation due to somatic STAT5bN642H gain-of-function mutation is a rare mechanism of STAT dysregulation that results in hypereosinophilia, frequent infections, leukemias, and pulmonary diseases. Herein, we describe a case of a child with a rare early onset STAT5b gain-of-function disease treated with targeted JAK inhibition who developed a cranial Mycobacterium avium osteomyelitis. METHODS: A 3-year-old male with a known STAT5b gain-of-function mutation presented with a 10-day history of a firm, immobile, non-painful cranial mycobacterium mass with dural infiltration located anterior to the coronal suture. Stepwise management finalized with complete resection of the lesion with calvarial reconstruction. A case-based literature review was performed evaluating all patients with this mutation who developed cranial disease. RESULTS: The patient was symptom and lesion-free at 1 year since surgical resection and initiation of triple mycobacterial pharmacotherapy. Our literature review demonstrated the rarity of this disease, as well as other presentations of this disease in other patients. CONCLUSION: Patients with STAT5b gain-of-function mutations have attenuated Th1 responses and are treated with medications, such as JAK inhibitors, which further inhibit other STAT proteins that regulate immunity against rare infectious entities, such as mycobacterium. Our case highlights the importance of considering these rare infections in patients on JAK inhibitors and with STAT protein mutations. Possessing a clear mechanistic understanding of this genetic mutation, its downstream effect, and the consequences of treatment may enhance a physician's diagnostic and clinical management of similar patients in the future.

Correlation Between Clinical Findings at Admission and Glasgow Outcome Scale Score in Children with Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury has different pathophysiology and outcomes in children and adults. This study investigated the relationship between clinical and laboratory findings at admission and Glasgow Outcome Scale (GOS) score in children with traumatic brain injury. METHODS: This prospective cross-sectional single-center study enrolled 444 children 1-16 years old admitted to the neurosurgery ward from 2016 to 2020. Clinical data and laboratory information were extracted from the records of these patients at admission, and the relationship with GOS score at discharge was investigated. RESULTS: The 444 patients include 249 (56.08%) boys and 195 (43.92%) girls with a mean age of 7.32 ± 4.4 years. There was no correlation between GOS score and sex (P = 0.12), age (P = 0.16), serum potassium level (P = 0.08), platelet level (P = 0.21), and blood glucose (P = 0.18). There was a significant relationship between GOS score and hypotension (P = 0.03), hyponatremia (P = 0.04), prothrombin time (P = 0.03), partial thromboplastin time (P = 0.03), pupil size (P = 0.02), pupil reaction to light (P = 0.04), and Glasgow Coma Scale score (P = 0.04). CONCLUSIONS: Clinical and laboratory findings such as hypotension, hyponatremia, prothrombin time, partial thromboplastin time, pupil size, pupil reaction to light, and Glasgow Coma Scale score at admission could affect GOS score at discharge and result in poor outcomes in children with traumatic brain injury.

Cochlear Implants: What the Neurosurgeon Needs to Know.

Patients with cochlear implants (CIs) commonly undergo neurosurgical interventions for concurrent pathologies. The neurosurgeon must be aware of the limitations these devices place on treating these patients and all pertinent interactions CIs have with common neurosurgical instruments and procedures. A literature search was performed utilizing the terms "cochlear implant" and "neurosurgery" or "neurosurgical" and all associated iterations. We reviewed the abstracts of 146 generated reports and eight published papers discussing the interaction and limitations of CI use in different neurosurgical procedures. Five realms were identified in which a CI may potentially interfere with standard neurosurgical care: Magnetic resonance imaging (MRI), radiotherapy, deep brain stimulation (DBS), intraventricular shunt placement, and intraoperative neuromonitoring (IONM). First, MRI use with CIs is limited due to thermal injury risk, imaging disruption, and implant damage. Secondly, high-dose >50 Gy single-fraction linear accelerator-based radiosurgery has been demonstrated to result in a loss of radio frequency link range in CIs, interfering with their function. Next, during surgery for DBS, the need for MRI and microelectrode recording requires CI magnet removal by neurotology and the surgeon must communicate with a non-hearing patient. Tunneling of shunts must accommodate CI position retroauricularly, if ipsilateral, and programmable valves must be placed >2 cm from the CI to prevent interference. Intraoperative neuromonitoring may produce voltages that interfere with CIs, and while monopolar cautery may pose the same risk, no study has proven this to date. Generally, bipolar cautery is safe and favored >1 cm from CIs. MRI use is limited in CI patients, although MRI-safer devices are in production. DBS electrodes may be successfully placed after CI magnet removal. Programmable shunt valves may be placed >2 cm away from CIs and radiosurgery <50 Gy has not demonstrated harm to these devices. IONM and monopolar cautery have not been demonstrated to directly affect CIs; however, more research is needed.

A case of hydrocephalus confounded by suprasellar arachnoid cyst and concomitant reversible cerebral vasoconstriction syndrome.

Background: Obstructive hydrocephalus is a neurologic condition that has varied clinical and imaging presentations, as well as a multitude of congenital etiologies including aqueductal stenosis and less commonly arachnoid cysts. Aqueductal stenosis is a physical limitation to cerebrospinal fluid flow along the course of the aqueduct, which results in enlargement of the third and lateral ventricles. Arachnoid cysts are thin walled and fluid filled central nervous system lesions that can result in mass effect on adjacent structures. While arachnoid cysts are mostly asymptomatic, they may present with neurological symptoms that vary depending on the location of the lesion. Suprasellar cysts in particular may cause obstructive hydrocephalus as well as endocrine dysfunction. Reversible cerebral vasoconstriction syndrome (RCVS) is an unusual condition caused by cerebral arterial vasoconstriction that often presents initially with a thunderclap headache. Frequently, there is some environmental trigger associated with this condition. RCVS more commonly affects women and can induce stroke. Case Description: A 57-year-old female presented to the emergency department with progressive headache and visual changes. Initial workup suggested the patient's symptoms where related to RCVS but subsequent surgical management of what was presumed to be long standing, compensated hydrocephalus resulted in resolution of the patient's symptoms. Conclusion: We report, to the best of our knowledge, the first case of aquedutal stenosis and suprasellar arachnoid cyst with concomitant RCVS. The presence of multiple pathologies found on radiologic imaging illustrates the challenges presented by incidental findings and subsequent anchoring bias in medical diagnosis.

Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage.

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

Neurological Sequelae of COVID-19.

BACKGROUND: Though primarily a pulmonary disease, Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus can generate devastating disease states that affect multiple organ systems including the central nervous system (CNS). The various neurological disorders associated with COVID-19 range in severity from mild symptoms such as headache, or myalgias to more severe symptoms such as stroke, psychosis, and anosmia. While some of the COVID-19 associated neurological complications are mild and reversible, a significant number of patients suffer from stroke. Studies have shown that COVID-19 infection triggers a wave of inflammatory cytokines that induce endothelial cell dysfunction and generate coagulopathy that increases the risk of stroke or thromboses. Inflammation of the endothelium following infection may also destabilize atherosclerotic plaque and induce thrombotic stroke. Although uncommon, there have also been reports of hemorrhagic stroke associated with COVID-19. The proposed mechanisms include a blood pressure increase caused by infection leading to a reduction in angiotensin converting enzyme-2 (ACE-2) levels that results in an imbalance of the renin-angiotensin system ultimately manifesting inflammation and vasoconstriction. Coagulopathy, as demonstrated by elevated prothrombin time (PT), has also been posited as a factor contributing to hemorrhagics stroke in patients with COVID-19. Other neurological conditions associated with COVID-19 include encephalopathy, anosmia, encephalitis, psychosis, brain fog, headache, depression, and anxiety. Though there are several hypotheses reported in the literature, a unifying pathophysiological mechanism of many of these disorders remains unclear. Pulmonary dysfunction leading to poor oxygenation of the brain may explain encephalopathy and other disorders in COVID-19 patients. Alternatively, a direct invasion of the CNS by the virus or breach of the blood-brain barrier by the systemic cytokines released during infection may be responsible for these conditions. Notwithstanding, the relationship between the inflammatory cytokine levels and conditions such as depression and anxiety is contradictory and perhaps the social isolation during the pandemic may in part be a contributing factor to some of the reported CNS disorders. OBJECTIVE: In this article, we review the current literature pertaining to some of the most significant and common neurological disorders such as ischemic and hemorrhagic stroke, encephalopathy, encephalitis, brain fog, Long COVID, headache, Guillain-Barre syndrome, depression, anxiety, and sleep disorders in the setting of COVID-19. We summarize some of the most relevant literature to provide a better understanding of the mechanistic details regarding these disorders in order to help physicians monitor and treat patients for significant COVID-19 associated neurologic impairments. METHODS: A literature review was carried out by the authors using PubMed with the search terms "COVID-19" and "Neurology", "Neurological Manifestations", "Neuropsychiatric Manifestations", "Stroke", "Encephalopathy", "Headache", "Guillain-Barre syndrome", "Depression", "Anxiety", "Encephalitis", "Seizure", "Spasm", and "ICUAW". Another search was carried out for "Long-COVID" and "Post-Acute COVID-19" and "Neurological Manifestations" or "Neuropsychiatric Manifestations". Articles such as case reports, case series, and cohort studies were included as references. No language restrictions were enforced. In the case of anxiety and depression, attempts were made to focus mainly on articles describing these conditions in infected patients. RESULTS: A total of 112 articles were reviewed. The incidence, clinical outcomes, and pathophysiology of selected neurological disorders are discussed below. Given the recent advent of this disease, the incidence of certain neurologic sequelae was not always available. Putative mechanisms for each condition in the setting of COVID-19 are outlined.

Nuances in detecting retained foreign bodies: a case report of a glass shard embedded in a child's scalp.

Foreign bodies (FBs) are a relatively common reason for admission to the emergency department, with subacutely embedded FBs presenting a diagnostic challenge to physicians. Retained FBs may cause the patient harm and result in litigation when missed. Diagnostic imaging is a powerful tool for localization of FBs and a physician's choice of modality should reflect its anticipated composition. This case report pertains to a 2-year-old boy with a glass shard embedded in his retro auricular scalp who presented with a painful subcutaneous lesion months after an overlying laceration repair at an outside emergency room. The attending neurosurgeon was able to identify a glass shard both on physical examination and axial T2-weighted MRI. Surgical exploration resulted in the removal of a 1-cm square glass shard. Key to the diagnostic potential of imaging is knowledge of a patient's relevant medical history and the composition of the suspected FB. Herein, we describe imaging modalities and their utility in the context of retained glass FBs.

Unexpected Binding of Tozuleristide "Tumor Paint" to Cerebral Vascular Malformations: A Potentially Novel Application of Fluorescence-Guided Surgery.

BACKGROUND: Fluorescence-guided surgery (FGS) is under investigation as a means to improve the extent of resection for primary central nervous system (CNS) tumors. Tozuleristide, known also as "Tumor Paint," is an investigational tumor-targeting agent covalently conjugated to a derivative of the fluorescent dye indocyanine green. OBJECTIVE: To report the finding of avid intraoperative fluorescence of tozuleristide on cerebral vascular malformations. METHODS: Our institution is participating in a phase 2/3 study of intraoperative near-infrared fluorescence detection of pediatric primary CNS tumors in patients receiving intravenous tozuleristide and imaged with the Canvas system. Our site enrolled 2 patients with intracranial lesions, suspected preoperatively of possibly being gliomas that proved to be cavernous vascular malformations after resection. RESULTS: Each lesion had a dark blue mulberry appearance and each fluoresced avidly with tozuleristide. Each was completely resected, and the patients recovered without deficit. Pathological assessment showed cavernous angioma for both cases. Tozuleristide fluorescence is postulated to result from binding to matrix metalloproteinase-2 and annexin A2, and literature review demonstrates expression of both these ligands on multiple cerebrovascular lesions, including cavernous malformations. CONCLUSION: This finding deserves further investigation to determine if tozuleristide "Tumor Paint" may have a wider role in the identification of non-neoplastic intracranial pathologies.