Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery.

OBJECTIVE: The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. METHODS: A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). RESULTS: Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. CONCLUSIONS: With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

A 53-year-old woman with a rapidly progressive, non-enhancing left frontotemporal lesion.

Fifty-three-year-old woman presented with chronic, episodic headache.

Dialysis Disequilibrium Syndrome and Intracranial Pressure Fluctuations in Neurosurgical Patients Undergoing Renal Replacement Therapy: Systematic Review and Pooled Analysis.

BACKGROUND: Dialysis disequilibrium syndrome is a rare, well-known, potentially life-threatening complication of renal replacement therapy (RRT), often involving cerebral edema and increased intracranial pressure (ICP). However, the impact of RRT on ICP and rate of dialysis disequilibrium syndrome in neurosurgical patients have not been systematically assessed. METHODS: In February 2022, a systematic review following PRISMA guidelines was conducted using various combinations of 9 keywords in the MEDLINE database. Eleven papers were selected. Individual patient data were extracted, pooled, and analyzed. RESULTS: Fifty-eight patients, 44 men and 14 women with a mean age of 48 years (6-78 years), were analyzed. Neurosurgical conditions included the following: spontaneous intracranial hemorrhage (n = 27), traumatic brain injury (n = 16), ischemic stroke/anoxic brain injury (n = 6), intracranial tumor (n = 6), and others (n = 3). Neurosurgical interventions included the following: craniotomy/craniectomy (n = 23), external ventricular drain or ICP monitor placement (n = 16), and burr hole or twist drill craniostomy (n = 4). Intermittent dialysis was used in 33 patients, continuous RRT in 20, and a combination thereof in 4. During RRT, ICP increased in 35 patients (60.3%), remained unchanged in 20, and decreased in 3. Thirty-four patients (65.4%) died. Intermittent dialysis was associated with increased ICP (73% vs. 37.5%, P = 0.01) and mortality (75% vs. 39.1%, P = 0.01). CONCLUSIONS: In neurosurgical patients, ICP increases during RRT are common, affecting up to 60%, and potentially life-threatening, with mortality rates as high as 65%. The use of a continuous rather than intermittent RRT technique may reduce the risk of this complication. Prospective studies are warranted.

Bilaterally Fixed and Dilated Pupils Are Not the Kiss of Death in Patients with Transtentorial Herniation: A Single Surgeon's Experience.

BACKGROUND: Bilaterally fixed and dilated pupils in the setting of transtentorial herniation have traditionally been considered a sign of futility. Such patients are often denied life-saving surgery based on the premise that meaningful functional recovery would be extremely unlikely. We sought to determine the survival and functional outcome in a cohort of patients who underwent aggressive medical and surgical management. METHODS: Charts of all patients managed by a single surgeon over a 42-month period were retrospectively reviewed. Functional outcome was determined using modified Rankin Scale (mRS). Outcome was classified as good (mRS score 0-3), acceptable (mRS score 4), or poor (mRS score 5-6). RESULTS: Patients were 7 men and 2 women with a mean age of 36 years (range, 16-66 years). Etiologies included stroke (4 patients), traumatic brain injury (4 patients), and malignant cerebral edema (1 patient). Preoperative Glasgow Coma Scale scores ranged from 3 to 7, and midline shift was 7-16 mm. All patients received emergency osmotic therapy before decompressive surgery. Time to surgery (from pupillary changes) was <150 minutes for all patients (median 94 minutes; range, 50-148 minutes). At 3 months, 5 patients (55.6%) had recovered, achieving a good (n = 3) or acceptable (n = 2) outcome. The other 4 patients failed to recover and ultimately died of their injury. CONCLUSIONS: In well-selected patients with transtentorial herniation and bilaterally fixed and dilated pupils, aggressive and timely medical and surgical management may lead to substantial rates of survival and favorable functional outcome. Preconceived notions of a universally grim prognosis in such patients can lead to self-fulfilling prophecies.

Dural-Based Posterior Fossa Medulloblastoma Mimicking a Petrous Meningioma in Late Adulthood.

Background: Medulloblastoma of the posterior fossa is commonly encountered in pediatric populations but rarely reported in adults. Adult cases of medulloblastoma typically occur in younger patients, tend to arise intra-axially within the cerebellar hemisphere, and usually exhibit classic histopathologic features. Case Report: A 54-year-old male presented with headaches, dizziness, gait instability, and frequent falls that had worsened during the prior 3 months. Imaging and histopathologic analysis revealed extra-axial, dural-based posterior fossa medulloblastoma with desmoplastic/nodular histopathology, mimicking a petrous meningioma. The mass occupied the left cerebellopontine angle. The patient underwent microsurgical gross total resection of the tumor followed by proton beam radiation therapy and was disease-free at 1-year follow-up. Conclusion: Few dural-based posterior fossa medulloblastomas resembling petrous meningiomas have been reported, and to our knowledge, this is the first description of a case to be treated successfully with proton beam therapy in an older adult. Although rare, medulloblastoma can occur extra-axially in the cerebellopontine angle of older adults, potentially mimicking a petrous meningioma. This rare possibility should always be kept in mind, especially if expectant, nonsurgical management is being considered. To optimize outcome, posterior fossa medulloblastoma should be treated with aggressive microsurgical resection followed by radiation therapy. When available, proton beam therapy should be considered.

Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review.

PURPOSE: Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion. METHODS: MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines. RESULTS: Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8). CONCLUSIONS: Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.

The AAOS 2019 Clinical Practice Guidelines for the Management of Rotator Cuff Injuries Are Unbiased and Incorporate a Diverse Body of Literature.

Purpose: To analyze the scientific research that formed the basis of the 2019 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for the management of rotator cuff injuries. Methods: All studies cited in the 2019 AAOS clinical practice guidelines for the management of rotator cuff injuries were extracted and categorized. Extracted data included type of study, number of patients, level of evidence, journal of publication, impact factor, year of publication, country of origin, contributing authors, affiliated institutions, and significant findings. Data were analyzed to determine time from publication to implementation, level of evidence, and frequency of cited journals and authors. Results: The studies cited in the guideline included 15,130 patients from 140 studies published between 1994 and 2018. The overall mean time from article publication to 2019 AAOS clinical practice guidelines was 4.76 ± 2.23 years. Of articles published in 2010 to 2019, 64 studies were cited in the strong recommendation strength subcategory, and 57 articles were cited in the moderate recommendation strength subcategory. Articles published in Journal of Shoulder & Elbow Surgery and Arthroscopy were cited most frequently. The most frequent authors were J. H. Oh, R. Z. Tashjian, S. H. Kim, N. Maffulli, and J. C. Yoo. Conclusions: The 2019 AAOS CPG reference a diverse number of journals and authors, appearing to be impartial. Furthermore, prompt time from publication to implementation in the Guidelines indicates that it is possible to influence clinical guidelines with recent work. Clinical Relevance: An analysis of the scientific research that forms the basis of the AAOS Clinical Practice Guidelines for the Management of Rotator Cuff Injuries can provide valuable information about the quality of the Guidelines.

Are Bilaterally Fixed and Dilated Pupils the Kiss of Death in Patients with Transtentorial Herniation? Systematic Review and Pooled Analysis.

OBJECTIVE: Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a space-occupying lesion have traditionally been considered a sign of futility. As a result, such patients may be denied life-saving decompressive surgery, resulting in very high mortality rates. We sought to determine the survival rate and functional outcomes in patients with transtentorial herniation and BFDP following emergency decompressive surgery. METHODS: This was a systematic review of MEDLINE, Embase, Cochrane, and Google Scholar databases, using a combination of 15 prespecified keywords, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology. Individual patient data were extracted, pooled, and analyzed. RESULTS: Twenty-two studies totaling 503 patients were included. Study designs were as follows: prospective cohort (n = 1), retrospective cohort (n = 15), and case report (n = 6). Nearly two thirds of patients (67.7%) were male. The mean age was 41 years (range = 3-82). The median preoperative Glasgow coma scale was 3 (range = 3-6). Nearly two thirds (66.9%) underwent surgical decompression within 2 hours of pupillary changes. The mean follow-up was 7 months (range = 1-40). Two thirds (67%) died. Among survivors, 50.5% had severe disability (Glasgow outcome scale = 2-3), while 49.5% had a good outcome (Glasgow outcome scale 4-5), representing 17% of the whole population. Given the methodological limitations, the prognostic value of age, Glasgow coma scale, and time to surgery could not be determined. CONCLUSIONS: The literature suggests a rate of favorable recovery approaching 17% following decompressive surgery in patients with transtentorial herniation and BFDP, secondary to space-occupying lesions. In the setting of stroke or trauma, the clinical finding of BFDP should not be solely relied on as an indicator of futility. Prospective studies are warranted.

The effectiveness of reducing endotracheal cuff pressure after retractor placement to decrease postoperative laryngeal dysfunction in anterior cervical surgery: a meta-analysis.

OBJECTIVE: The authors sought to determine if a consensus could be reached regarding the effectiveness of endotracheal tube cuff pressure (ETTCP) reduction after retractor placement in reducing postoperative laryngeal dysfunction after anterior cervical fusion surgery. METHODS: A literature search of MEDLINE (PubMed), EMBASE, Cochrane Central, Google Scholar, and Scopus databases was performed. Quantitative analysis was performed on data from articles comparing groups of patients with either reduced or unadjusted ETTCP after retractor placement in the context of anterior cervical surgery. The incidence and severity of postoperative recurrent laryngeal nerve palsy (RLNP), dysphagia, and dysphonia were compared at several postsurgical time points, ranging from 24 hours to 3 months. Heterogeneity was assessed using the chi-square test, I2 statistics, and inverted funnel plots. A random-effects model was used to provide a conservative estimate of the level of effect. RESULTS: Nine studies (7 randomized, 1 prospective, and 1 retrospective) were included in the analysis. A total of 1671 patients were included (1073 [64.2%] in the reduced ETTCP group and 598 [35.8%] in the unadjusted ETTCP group). In the reduced ETTCP group, the severity of dysphagia, measured by the Bazaz-Yoo system in 3 randomized studies at 24 hours and at 4-8 weeks, was significantly lower (24 hours [standardized mean difference: -1.83, p = 0.04] and 4-8 weeks [standardized mean difference: -0.40, p = 0.05]). At 24 hours, the odds of developing dysphonia were significantly lower (OR 0.51, p = 0.002). The odds of dysphagia (24 hours: OR 0.77, p = 0.24; 1 week: OR 0.70, p = 0.47; 12 weeks: OR 0.58, p = 0.20) were lower, although not significantly, in the reduced ETTCP group. The odds of a patient having RLNP were significantly lower at all time points (24 hours: OR 0.38, p = 0.01; 12 weeks: OR 0.26, p = 0.03) when 3 randomized and 2 observational studies were analyzed. A subgroup analysis using only randomized studies demonstrated a similar trend in odds of having RLNP, yet without statistical significance (24 hours: OR 0.79, p = 0.60). All other statistically significant findings persisted with removal of any observational data. CONCLUSIONS: Based on the current best available evidence, reduction of ETTCP after retractor placement in anterior cervical surgery may be a protective measure to decrease the severity of dysphagia and the odds of developing RLNP or dysphonia.

Beach Breaking Waves and Related Cervical Spine Injuries: A Level One Trauma Center Experience and Systematic Review.

OBJECTIVE: To analyze cervical spine injuries resulting from recreational activity in shallow ocean water amid high-energy breaking waves. METHODS: Single-center 10-year review of patients who sustained cervical injuries at the beach in Long Island, New York, USA. A systematic review following the PRISMA guidelines was also performed. RESULTS: Nineteen patients (age 17-79 years) sustained cervical injury from high-energy breaking waves while in shallow beach water. Six patients dived into a wave; 6 patients were struck by a large wave while standing upright; and 7 tumbled in the waves while engaged in nonspecified recreational activity. All 7 patients with subaxial cervical AO Spine Injury Score (AO-SIS) >10 had cervical spine injury with cord signal change and required operative management. Diving mechanism, AO-SIS >10, and cord signal change all predicted significant disability or death at 12 months (P < 0.01). The present study and 7 additional studies reporting on 534 patients (mean age, 45.4 years) were analyzed. Within the reported literature, most patients (94.2%) sustained a spinal cord injury. On long-term follow-up, an estimated 64.8% of patients had permanent neurologic injury and 12.5% had permanent quadriplegia. CONCLUSIONS: We offer the first description of cervical injuries sustained in water-related recreational activity using the AO-SIS. The morphology of injuries varied significantly and seemed to depend on body position and wave kinetic energy. Patients presenting with cervical injury in this setting and yielding AO-SIS >10 are likely to have poor functional recovery.

The evolving neurosurgical perspective on Enhanced Recovery After Surgery (ERAS): a systematic review.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs may be implemented to minimize the body's stress response to surgery and enable a safe and timely discharge. Successful implementation involves a multifaceted approach from surgeons, anesthesiologists, nurses, nutritionists, and nonclinical staff. EVIDENCE ACQUISITION: National databases (MEDLINE (PubMed), Cochrane Central, and Google Scholar databases) were searched to identify studies on the clinical implementation of ERAS protocols in neurosurgery. A systematic review was chosen to select studies and pooled data analysis was performed. EVIDENCE SYNTHESIS: Thirty-five studies reported the use of enhanced recovery after surgery (ERAS), with 13 studies on cranial surgery and 22 on spinal surgery. Overall, 27 studies reported length of stay, 10 studies reported differences in opioid use, 21 studies reported either complications, readmission rate, or long term (>30 day) follow-up, 14 studies reported patient feedback, and 10 studies reported cost reduction of ERAS implementation. Findings supported significant reduction in length of stay, opioid use, and costs associated with ERAS regimens. Complications, readmission rates, and follow-up pain scores remained similar in ERAS and control groups. CONCLUSIONS: Our review finds that ERAS regimen implementation can serve an important role in facilitating clinical quality improvement and cost-effective care in all applications related to neurosurgical care and recovery. While application of ERAS in neurological surgery may have an important role in facilitating patient beneficial and cost-effective care, the findings of this review confirm that several challenges remain in select settings and prevent widespread implementation.

Comparison of Minimally Invasive Procedures to Treat Knee Pain Secondary to Osteoarthritis: A Systematic Review and Meta-Analysis.

PURPOSE: To review and indirectly compare the outcomes of genicular artery embolization (GAE), radiofrequency (RF) ablation, and intra-articular (IA) injection for the treatment of knee pain secondary to osteoarthritis (OA). MATERIALS AND METHODS: A literature review of the MEDLINE and Cochrane databases was conducted with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement in June 2020. The visual analog scale (VAS) was recorded at baseline and at all available time points for each therapy. Standard mean differences were calculated at each time point and compared between treatments to assess the magnitude of the treatment effect. RESULTS: All 3 treatments demonstrated significant differences in VAS scores after therapy. RF ablation produced the greatest significant mean reduction in relative VAS score from baseline at 1 year of follow-up (mean, 0.49; 95% confidence interval, 0.4-0.59; P = .03). GAE reported the most significant reductions in VAS scores across all measured time points. Overall, the comparison did not demonstrate a significant difference in VAS scores among patients receiving IA injections, RF ablation, and GAE. CONCLUSIONS: The current evidence does not suggest a significant difference in outcomes among IA injection, RF ablation, and GAE for knee pain secondary to OA.

Quantitative Prediction of the Location of Carotid Bifurcation and Neurovascular Structures in the Carotid Region: A Cross-Sectional Cadaveric Study.

INTRODUCTION: The carotid region is encountered in vascular and neurological surgery and carries a potential for vascular and cranial nerve trauma. The carotid bifurcation is an especially important landmark and difficult to predict based on currently established landmarks. This study is a detailed analysis of the carotid region and proposes a novel methodology to predict the height of the bifurcation. MATERIALS AND METHODS: Superficial and deep dissections were performed on the anterior triangle of the neck to expose the carotid region in twenty-one formalin-fixed donor cadavers. Musculoskeletal and neurovascular structures were assessed in relation to the carotid bifurcation and the medial border of the clavicle (MBC). RESULTS: The carotid bifurcation occurred, on average, 11.4 mm higher on the left (p < 0.001; 95% CI: 9.28, 13.54). The superior thyroid artery (p < 0.001), facial vein (p < 0.001), and cranial nerve XII (p < 0.001) were all more distal on the left side when measured from the MBC while the angle of the mandible and stylohyoid muscle remained symmetric. Left- and right-sided vascular structures were symmetric when measured from the carotid bifurcation. CONCLUSIONS: Neurovascular structures within the carotid region are likely to be anatomically superior on the left side while vessels are likely to remain symmetric in relation to the carotid bifurcation. When measured from the MBC, the bifurcation height can be predicted by multiplying the distance between the MBC and mastoid process by 0.65 (right side) or 0.74 (left side). This novel methodological estimation may be easily learned and directly implemented in clinical practice.

Herniation Through Defects in the Broad Ligament.

BACKGROUND: We sought to assess hernia characteristics and classification through comprehensive review of the literature involving broad ligament herniation. METHODS: A literature search via MEDLINE and Embase databases was conducted to identify and select broad ligament herniation studies published between January 1, 2000 and September 30, 2020. Extracted data included previous surgical history, previous obstetric history, diagnostic imaging, herniated organ, hernia classification, and repair performed. The reported data has been compared to a unique case of broad ligament herniation that presented to our institution. RESULTS: A total of 44 articles with 49 cases were identified for the study. Eighteen (36.7%) patients had a history of previous abdominal surgery while 29 (59.2%) had a history of previous childbirth. Type I (51.0%) and Type II (18.4%) defects were most commonly reported with most patients reporting only one defect (85.7%) using the Cilley classification. Twenty-nine patients underwent primary laparoscopic repair of the defect while 19 patients underwent exploratory laparotomy. CONCLUSIONS: The analysis of previously reported cases adds to the limited literature on broad ligament hernias and highlights the surgical management of this uncommon pathology. It also highlights the need for a broad differential diagnosis when female patients present with pelvic pain or symptoms of small bowel obstruction. The broad ligament should be fully inspected when mesenteric defects are suspected as multiple defects can be present as evidenced by the attached case study.

The Role of 3D Exoscope Systems in Neurosurgery: An Optical Innovation.

The development of the three-dimensional (3D) exoscope is a marvel of technological innovation in modern surgical practice. While its predecessor, the operating microscope (OM), has long been the gold-standard surgical visualization modality, its particular limitations in terms of accessibility and ergonomic demand have led to the development of a more sophisticated, 3D model. Specifically, the 3D exoscope allows for an enhanced image quality of the surgical field, while also being more ergonomically favorable. Moreover, this device's ability to handle delicate microsensitve procedures, along with its alleviation of surgeon fatigue, indicates great potential for neurosurgical application. For this narrative review, the authors queried PubMed database using the keyword "exoscope" to identify relevant studies involving the specialty of neurosurgery that were published in English language full text. The search yielded full-text English language-related articles regarding neurosurgical exoscope, its applications and limitations. The 3D exoscope uniquely allows for enhanced surgeon comfort and superior imaging of the patient's real-time anatomy. However, the OM was described to having a slight image favorability with fusion and decompression surgery. Cost analysis is highlighted for its potential disparity. 3D exoscopes will potentially be incorporated with intelligent carriers and robotic surgical systems. Ultimately, with further studies highlighting its use, the 3D exoscope is expected to continue to imprint its status as one of the most efficient technological visualization tools in the future of neurosurgical practice.

Diffuse Paget's Disease of the Skull with Intense Uptake of Technetium-99m-Labeled Diphosphonate Tracer in Bone Scintigraphy.

Imaging in patients with Paget's disease of bone is very important clinically to show the presence of Pagetic abnormalities, assess disease progression, and identify adversely affected structures throughout disease course. Abnormalities and progression may be seen on radiographs, computed tomography, magnetic resonance imaging, and nuclear imaging. Herein, we report a case Paget's disease of bone showing diffuse characteristic pathology using technetium-99m-labelled diphosphonate tracer in bone scintigraphy (nuclear imaging). This case emphasizes the ability of nuclear imaging to rapidly visualize and assess progressive distribution of Pagetic involvement in a patient previously diagnosed with pituitary adenoma and mild Paget's disease of the skull.

BIIB093 (intravenous glibenclamide) for the prevention of severe cerebral edema.

BACKGROUND: Vasogenic edema in the setting of acute ischemic stroke can be attributed to the opening of transient receptor potential 4 channels, which are expressed in the setting of injury and regulated by sulfonylurea receptor 1 (SUR1) proteins. Glibenclamide, also known as glyburide, RP-1127, Cirara, and BIIB093, is a second-generation sulfonylurea that binds SUR1 at potassium channels and may significantly reduce cerebral edema following stroke, as evidenced by recent clinical trials. This review provides a comprehensive analysis of clinical considerations of glibenclamide use and current patient outcomes when administered in the setting of acute ischemic stroke to reduce severe edema. METHODS: National databases (MEDLINE, EMBASE, Cochrane, and Google scholar databases) were searched to identify studies that reported on the clinical outcomes of glibenclamide administered immediately following acute ischemic stroke. RESULTS: The pharmacological mechanism of glibenclamide was reviewed in depth as well as the known indications and contraindications to receiving treatment. Eight studies were identified as having meaningful clinical outcome data, finding statistically significant differences in glibenclamide treatment groups ranging from matrix metalloproteinase-9 serum levels, midline shift, modified Rankin Scores, National Institute of Health Stroke Score, and mortality endpoints. CONCLUSION: Studies analyzing the GAMES-Pilot and GAMES-PR trials suggest that glibenclamide has a moderate, however, measurable effect on intermediate biomarkers and clinical endpoints. Meaningful conclusions are limited by the small sample size of patients studied.

The effects of antiepileptic drugs on bone health: A systematic review.

PURPOSE: Epilepsy may be treated with antiepileptic drugs (AEDs), which have been reported to decrease bone mineral density (BMD). Current data is conflicting and variable, and little is known with regard to how duration of AED use or specific AEDs, such as CYP-450 enzyme-inducing (EIAEDs) versus non-enzyme inducing (NEIAEDs) drugs affect BMD. We sought to systematically review BMD changes due to AED use to identify trends in reporting. METHODS: A literature search via Medline (PubMed), EMBASE, and Cochrane databases was performed. Peer-reviewed articles were identified that reported on BMD measurements in conjunction with AEDs. RESULTS: Twenty-six studies met inclusion criteria. Long-term therapy was shown across multiple, well-controlled studies to have the most significant BMD loss. Carbamazepine had the most frequent reporting of unfavorable effects on bone health and Lamotrigine seemed to show the most bone-protective qualities. Serum biochemical markers of bone turnover did not significantly correlate with measured BMD changes. CONCLUSION: The present study provides evidence that long-term AED therapy is the most significant risk factor for BMD loss. Furthermore, there was little compelling evidence to support that EIAEDs, as a class, were more harmful to bone than NEIAEDs, which has been previously suggested in multiple studies. Early clinical concern for significant loss of BMD may not be warranted as lower BMD was less likely to be observed during the initial years of AED therapy. Furthermore, serum markers of bone turnover are not clinically reliable in assessing BMD changes in patients taking AEDs.

Adnexal carcinoma of the scalp: aggressive sebaceous differentiation with invasion of the orbital wall and thoracic vertebra.

Tumors of the scalp are characterized by a heterogeneous clinical spectrum with site-specific features. A wide variety of tumors that arise in the scalp include neoplasms, hamartomas, malformations, and both benign and malignant cysts. Most scalp tumors are benign (98-99%) with only an estimated 1-2% of diagnosed cases reported as being malignant. Of these, adnexal carcinoma is reported in less than 1% of cases. Herein, we report a 65-year-old woman who presented with pain and numbness in her hands with past medical history significant only for a chronic posterior head mass that had never received workup. Computerized topography (CT), magnetic resonance imaging (MRI), and local biopsy demonstrated a large, pedunculated malignant occipital mass that had metastasized to the orbital walls and cervical spine. To our knowledge, this is the largest sebaceous carcinoma to be reported occurring in the scalp. The present case emphasizes the need for older patients with benign scalp lesions to be closely monitored with frequent CT scans for signs of malignant transformation. Furthermore, it is important to diagnose malignant scalp tumors early as they tend to metastasize and cause diffuse symptomatology, which may ultimately result in increased patient mortality.

Minimally Invasive Microsurgical Technique for Evacuation of Deep Intracerebral Hematomas.

Despite the lack of conclusive outcome data, surgical evacuation of large, symptomatic intracerebral hematomas (ICH) may be offered to patients on a case-by-case basis, aiming to prevent brain herniation, control intracranial pressure, relieve symptoms, and possibly facilitate or accelerate recovery.1-3 For deep ICH, minimally invasive techniques, which limit operative damage to healthy brain tissue, are generally preferred. Although new tube and endoscope-based techniques are currently being studied,4-7 those elaborate techniques are not widely available and often require special equipment and/or expensive disposable material. In this operative video (Video 1), we demonstrate a minimally invasive microsurgical approach for the evacuation of deep ICH, which relies on the use of careful preoperative planning, frameless stereotactic neuronavigation, and meticulous microsurgical technique. This technique involves small craniotomies, infracentimetric corticotomies, and physiologic subcortical white matter dissection, leading to very limited disruption of healthy brain tissue, akin to tube and endoscope-based procedures. We acknowledge that this technique or a modification thereof may currently be in use by other neurosurgeons in their practice.8 However, to the best of our knowledge, a step-by-step microsurgical video illustration of this technique has not been previously published. Although this technique can be broadly used by neurosurgeons, irrespective of the hospital setting, it would be particularly valuable in settings where expensive cutting-edge technology is not readily available.