Pilot feasibility randomised controlled trial of cognitive-behavioural therapy for functional cognitive disorder after concussion.

Background: Functional cognitive disorder (FCD) may be common after a concussion, and no evidence-based treatment options are available. The current study evaluated the feasibility of a novel cognitive-behavioural therapy (CBT) protocol tailored to FCD after concussion. Methods: Participants were randomised to CBT (n=11) or the current standard of care, cognitive rehabilitation (n=13). Both interventions consisted of eleven 50 min manualised videoconference sessions. CBT involved cognitive reappraisal and exposure-based strategies. Cognitive rehabilitation involved traditional memory compensation strategy training. Prespecified feasibility criteria were set for recruitment, perceived credibility, patient adherence, therapist protocol compliance and retention. The primary efficacy outcome was the Multifactorial Memory Questionnaire-Satisfaction (MMQ-S). The first five CBT completers completed a semistructured interview about their experience with the intervention. Results: Most feasibility benchmarks were met, as 86% of invited patients consented, 96% of participants rated their intervention as credible, participants attended 96% of sessions, therapists covered all essential content in 94% of sessions and 100% of participants completed the post-treatment evaluation. Both groups improved on the MMQ-S. Post-treatment MMQ-S scores were similar between groups (Cohen's d=-0.05 (95% CI [-0.86, 0.75])). Two themes resulted from the qualitative data analysis, which highlighted aspects of the CBT interventions that participants valued. Implications: This pilot trial supports the feasibility of CBT tailored to FCD after concussion and suggests that patients with FCD may benefit from either CBT or standard cognitive rehabilitation. A larger trial is needed to evaluate the efficacy of these interventions for FCD after concussion and potentially FCD in other clinical contexts. Trial registration number: NCT05581810.

Pre-operative spine tumour embolization: Clinical outcomes and effect of embolization completeness.

INTRODUCTION: To assess the association between the impact of the completeness of pre-operative spine tumour embolisation and clinical outcomes, including estimated blood loss (EBL), neurological status and complications. METHODS: Retrospective chart review of all preoperative spine tumour embolisation procedures performed over 11 years by a single operator (2007-2018) at Vancouver General Hospital on 44 consecutive patients (mean age 57; 77% males) with 46 embolisation procedures, of which surgery was done en bloc in 26 cases and intralesional in the remaining 20. A multivariable negative binomial regression model was fit to examine the association between EBL and surgery type, tumour characteristics, embolisation completeness and operative duration. RESULTS: Among intralesional surgeries, complete versus incomplete embolisation was associated with reduced blood loss (772 vs 1428 mL, P < 0.01). There was no statistically significant difference in neurological outcomes or complications between groups. Highly vascular tumours correlated with greater blood loss than their less vascular counterparts, but tumour location did not have a statistically significant effect. CONCLUSION: This study provides evidence in support of our hypothesis that complete as opposed to incomplete tumour embolisation correlates with reduced blood loss in intralesional surgeries. Randomised control trials with larger samples are necessary to confirm this benefit and to ascertain other potential clinical benefits.

The CT guided transoral approach: A biopsy technique for a poorly differentiated chordoma in a 5 year old.

Mass lesions presenting at the craniocervical junction often present a unique challenge due to the complex anatomic arrangement limiting access for tissue diagnosis. The transoral approach has predominantly been used for percutaneous vertebroplasty of high cervical vertebrae with limited literature describing image guided biopsy for bony lesions in this region in the pediatric patient. We describe a technique of computed tomography guided transoral biopsy of a poorly differentiated chordoma located at the C1-C2 level in a 5-year-old child, and review this diagnosis.

The evolution of pre-operative spine tumour embolization.

Pre-operative spine tumour embolization is a useful adjunct to minimize operative complications and blood loss during complex resections. While the efficacy of this procedure has been well studied, relatively little is documented regarding how to optimize technical parameters for tumour characteristics. This pictorial case series seeks to review our centre's experience over the last decade in using a range of embolization techniques. As experience with this procedure has matured, we propose an approach based on the patient's vascular anatomy and tumour angioarchitecture. This includes the use of coils as protective barriers rather than primary embolics; particle embolization to permeate fine capillary networks; consideration for liquid embolic agents in the presence of large caliber tumour vessels with associated arteriovenous shunting; and percutaneous intralesional embolization when endovascular access is insufficient to achieve the desired outcome. In many cases, a combination of these methods is needed, and close communication with the surgeon ensures the best outcome. Despite these advances, continued work is needed to determine how to optimize complete devascularization, and thus surgical benefit, while safely sparing critical neuroanatomical structures.