A rare encounter: Comprehensive case review of myxoid meningiomas with a representative case.

Meningiomas are the most diagnosed primary central nervous system tumor. Currently, 15 different subtypes of meningioma exist with various characteristics. One extremely rare subtype is myxoid meningioma, which is a World Health Organization grade 1 benign meningioma. These specific meningiomas have only been reported 12 times in the literature. In this representative case, we present a 46-year-old female patient with a left frontal myxoid meningioma, describe the findings on imaging, and provide the histopathological features that are needed for diagnosis. Furthermore, this report discusses the other existing myxoid meningioma case reports found throughout the literature.

Racial and socioeconomic disparities in the advanced treatment of medically intractable pediatric epilepsy.

OBJECTIVE: Racial and ethnic disparities in healthcare have gained significant importance since the Institute of Medicine published its report on disparities in healthcare. There is a lack of evidence on how race and ethnicity affect access to advanced treatment of pediatric medically intractable epilepsy. In this context, the authors analyzed the latest Kids' Inpatient Database (KID) for racial/ethnic disparities in access to surgical treatment of epilepsy. METHODS: The authors queried the KID for the years 2016 and 2019 for the diagnosis of medically intractable epilepsy. RESULTS: A total of 29,292 patients were included in the sample. Of these patients, 8.9% (n = 2610) underwent surgical treatment/invasive monitoring. The mean ages in the surgical treatment and nonsurgical treatment groups were 11.73 years (SD 5.75 years) and 9.5 years (SD 6.16 years), respectively. The most common insurance in the surgical group was private/commercial (55.9%) and Medicaid in the nonsurgical group (47.7%) (p < 0.001). White patients accounted for the most common population in both groups, followed by Hispanic patients. African American patients made up 7.9% in the surgical treatment group compared with 12.9% in the nonsurgical group. African American (41.1%) and Hispanic (29.9%) patients had higher rates of emergency department (ED) utilization compared with the White population (24.6%). After adjusting for all covariates, the odds of surgical treatment increased with increasing age (OR 1.06, 95% CI 1.053-1.067; p < 0.001). African American race (OR 0.513, 95% CI 0.443-0.605; p < 0.001), Hispanic ethnicity (OR 0.681, 95% CI 0.612-0.758; p < 0.001), and other races (OR 0.789, 95% CI 0.689-0.903; p = 0.006) had lower surgical treatment odds compared with the White population. Medicaid/Medicare was associated with lower surgical treatment odds than private/commercial insurance (OR 0.603, 0.554-0.657; p < 0.001). Interaction analysis revealed that African American (OR 0.708, 95% CI 0.569-0.880; p = 0.001) and Hispanic (OR 0.671, 95% CI 0.556-0.809; p < 0.001) populations with private insurance had lower surgical treatment odds than White populations with private insurance. Similarly, African American patients, Hispanic patients, and patients of other races with nonprivate insurance also had lower surgical treatment odds than their White counterparts after adjusting for all other covariates. CONCLUSIONS: Based on the KID, African American and Hispanic populations had lower surgical treatment rates than their White counterparts, with higher utilization of the ED for pediatric medically intractable epilepsy.

Attacked and Shaken by a Dog: A Cause of Traumatic Brain and Carotid Injury in an Infant.

BACKGROUND: Posttraumatic carotid artery dissection (PTCAD) is a common injury in motor vehicle accidents and other extension and rotation injuries, but rarely developed from being shaken vigorously. CASE DESCRIPTION: A 7-day-old infant presented to our facility after being attacked by a large dog. Initial examination revealed multiple puncture wounds and lacerations with visible dura. Head CT demonstrated subarachnoid, intraparenchymal, and epidural hemorrhages as well as left hemispheric loss of gray-white differentiation. Thus, the patient presented similarly to shaken baby syndrome (SBS). The patient was taken emergently to the operating room for hematoma evacuation and dural repair. Postoperatively, worsened left hemispheric ischemia was noted and an MRA demonstrated a Grade IV left ICA dissection. No intervention, including anticoagulation, was sought as the stroke was determined to be complete with irreversible damage. Hospital course was complicated by worsening exam, seizures, and a retinal hemorrhage. At 2 years follow-up, the patient still has notable delays but is progressing slowly through milestones. CONCLUSION: Large animal attacks are a rare cause of PTCAD but may be due to the mechanism of shaking during the attack. We propose either CTA or MRA be considered as part of the initial workup in cases where an infant is attacked by a dog or other large animals, preventing delay of treatment.

A Comparative Study of Fiducial-Based and Fiducial-Less Registration Utilizing the O-Arm.

BACKGROUND: Frameless stereotactic surgery utilizing fiducial-based (FB) registration is an established tool in the armamentarium of deep brain stimulation (DBS) surgeons. Fiducial-less (FL) registration via intraoperative CT, such as the O-arm, has been routinely used in spine surgery, but its accuracy for DBS surgery has not been studied in a clinical setting. OBJECTIVE: We undertook a study to analyze the accuracy of the FL technique in DBS surgery and compare it to the FB method. METHODS: In this prospective cohort study, 97 patients underwent DBS surgery using the NexFrame and the O-arm registration stereotactic system. Patients underwent FB (n = 50) registration from 2015 to 2016 and FL (n = 47) O-arm registration from 2016 to 2017. RESULTS: The radial errors (RE) and vector/euclidean errors of FB and FL registration were not significantly different. There was no difference in additional passes between methods, but there was an increase in the number of RE ≥2.5 mm in the FL method. CONCLUSION: Although there was no statistically significant difference in RE or the need for additional passes, the increased number of errors ≥2.5 mm with the FL method (17 vs. 4% in FB) indicates the need for further study. We concluded that O-arm images of the implants should be utilized to assess and correct for this error.

Robot-assisted laser interstitial thermal therapy for drug-resistant epilepsy in hypothalamic hamartoma.

Hypothalamic hamartomas are congenital lesions of the hypothalamus, with a range of symptoms defined by lesion location. Common presenting symptoms include gelastic seizures and precocious puberty. When hamartoma-related seizures become resistant to medications, laser interstitial thermal therapy (LITT) has been shown to be an effective treatment. The authors present a case of robot-assisted LITT for a patient with an 11-year history of epilepsy due to hypothalamic hamartoma. In addition, they demonstrate the use of a stereotactic biopsy needle implemented during the procedure for possible biopsy of deep cranial lesions. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2415.

Deep Brain Stimulation of Nucleus Basalis of Meynert improves learning in rat model of dementia.

Background: Deep brain stimulation (DBS) of the nucleus basalis of Meynert (NBM) has been preliminarily investigated as a potential treatment for dementia. The degeneration of NBM cholinergic neurons is a pathological feature of many forms of dementia. Although stimulation of the NBM has been demonstrated to improve learning, the ideal parameters for NBM stimulation have not been elucidated. This study assesses the differential effects of varying stimulation patterns and duration on learning in a dementia rat model. Methods: 192-IgG-saporin (or vehicle) was injected into the NBM to produce dementia in rats. Next, all rats underwent unilateral implantation of a DBS electrode in the NBM. The experimental groups consisted of i-normal, ii-untreated demented, and iii-demented rats receiving NBM DBS. The stimulation paradigms included testing different modes (tonic and burst) and durations (1-hr, 5-hrs, and 24-hrs/day) over 10 daily sessions. Memory was assessed pre- and post-stimulation using two established learning paradigms: novel object recognition (NOR) and auditory operant chamber learning. Results: Both normal and stimulated rats demonstrated improved performance in NOR and auditory learning as compared to the unstimulated demented group. The burst stimulation groups performed better than the tonic stimulated group. Increasing the daily stimulation duration to 24-hr did not further improve cognitive performance in an auditory recognition task and degraded the results on a NOR task as compared with 5-hr. Conclusion: The present findings suggest that naturalistic NBM burst DBS may offer a potential effective therapy for treating dementia and suggests potential strategies for the reevaluation of current human NBM stimulation paradigms.

Precision targeting in the globus pallidus interna: insights from the multicenter, prospective, blinded VA/NINDS CSP 468 study.

OBJECTIVE: Deep brain stimulation (DBS) targeting the globus pallidus interna (GPi) has been shown to significantly improve motor symptoms for the treatment of medication-refractory Parkinson's disease. Yet, heterogeneity in clinical outcomes persists, possibly due to suboptimal target identification within the GPi. By leveraging robust sampling of the GPi and 6-month postsurgical outcomes, this study aims to determine optimal symptom-specific GPi DBS targets. METHODS: In this study, the authors analyzed the anatomical lead location and 6-month postsurgical, double-blinded outcome measures of 86 patients who underwent bilateral GPi DBS. These patients were selected from the multicenter Veterans Affairs (VA)/National Institutes of Neurological Disorders and Stroke (NINDS) Cooperative Studies Program (CSP) 468 study to identify the optimal target zones ("sweet spots") for the control of overall motor (United Parkinson's Disease Rating Scale [UPDRS]-III), axial, tremor, rigidity, and bradykinesia symptoms. Lead coordinates were normalized to Montreal Neurological Institute space and the optimal target zones were identified and validated using a leave-one-patient-out approach. RESULTS: The authors' findings revealed statistically significant optimal target zones for UPDRS-III (R = 0.37, p < 0.001), axial (R = 0.22, p = 0.042), rigidity (R = 0.20, p = 0.021), and bradykinesia (R = 0.23, p = 0.004) symptoms. These zones were localized within the primary motor and premotor subdivisions of the GPi. Interestingly, these zones extended beyond the GPi lateral border into the GPi-globus pallidus externa (GPe) lamina and into the GPe, but they did not reach the GPi ventral border, challenging traditional surgical approaches based on pallidotomies. CONCLUSIONS: Drawing upon a robust dataset, this research effectively delineates specific optimal target zones for not only overall motor improvement but also symptom subscores. These insights hold the potential to enhance the precision of targeting in subsequent bilateral GPi DBS surgical procedures.

Deep Brain Stimulation Before Anterior Cervical Discectomy and Fusion for a Patient With Cervical Dystonia and Cervical Myelopathy: A Case Report.

Cervical dystonia with concurrent cervical myelopathy is a challenging pathology that requires thoughtful management. A 46-year-old female was referred to our center with this presentation. We elected to perform bilateral globus pallidus internus deep brain stimulation (DBS-GPi) prior to C5 to C7 anterior cervical discectomy and fusion (ACDF) to avoid the potential for dystonic movements to negatively impact cervical fusion. The patient was followed up at three months post C5 to C7 ACDF and nine months post DBS-GPi with complete control of tremor and no radiographic evidence of hardware loosening or malalignment. Though this strategy was successful in treating both our patient's cervical myelopathy and cervical dystonia, larger studies need to be conducted to optimize the treatment of patients presenting with these concurrent pathologies.

The Management of Recurrent Post-myelography Lumbar Pseudomeningocele With Epidural Blood Patch.

Pseudomeningoceles are a well-known potential postoperative complication of spinal and cranial surgeries that can occur after lumbar decompression and posterior fossa surgeries. They are often caused by incidental durotomies but may also occur as a result of dural puncture during diagnostic testing. This report describes a 59-year-old male that developed a recurrent pseudomeningocele after an L4 laminectomy for severe lumbar spinal stenosis that was ultimately treated with an epidural blood patch (EBP). His preoperative condition greatly improved, but he developed a pseudomeningocele that did not resolve after applying ice and light pressure. The patient subsequently underwent a wound exploration where no dural defect was identified. During this exploration, the dura was reinforced with dural onlays and sealant. Unfortunately, the patient developed another pseudomeningocele within a short interval. It was then suspected that the post-laminectomy site provided a space for the dural punctures from previous CT myelography to leak cerebrospinal fluid (CSF) into. The patient subsequently underwent ultrasound (US)-guided aspiration of the pseudomeningocele and EBP injections at the levels where his preoperative myelography was performed. The success of the EBP indicates that the previous CT myelography was the likely cause of the pseudomeningocele. Recurrent spinal pseudomeningoceles with no evidence of incidental durotomy may be caused by dural puncture from myelography. In such cases, EBP to the area that the previous myelography was performed can resolve the pseudomeningocele.

Correlation Between Oligometastatic Tumor in Two Other Visceral Organs and Prognosis in Patients With Brain Metastases.

Background and Objective: A recent report indicated that metastases to other body organs commonly develop after stereotactic body radiation treatment for cure in patients with oligometastases (OGM) confined to one organ. This study was undertaken to determine if the presence of metastatic disease in two other visceral organs (TVO) in patients with conventionally treated brain metastases (BRM) was associated with poorer prognosis. Methods: This retrospective clinical investigation included 26 patients treated for palliation of OGM-BRM between May 1996 and February 2020. These individuals were classified according to the presence (13 patients) or absence (13 patients) of metastases in TVO. Results: With an overall mean follow-up of 16 months, 20 patients were deceased, and 6 patients were alive. The median survivals for the OGM-BRM-TVO and non-OGM-BRM-TVO subsets were 4 and 12 months, respectively; the corresponding crude survival rates at 12 months were 0% and 46% (p < 0.01). Subgroup analysis correlating prognosis to the number of BRM (single vs. multiple) and OGM-BRM categories (synchronous vs. metachronous) failed to reveal a survival advantage favoring a certain subgroup. Conclusion: Although the evidence is speculative, we believe that an aggressive disease condition is more likely present in patients with OGM-BRM-TVO. With the notion of an overall poor survival, we suggest a more tailored, less or nonharmful management approach (i.e., palliative therapy or hospice) for this particular patient cohort.

Healthy and pathological pallidal regulation of thalamic burst versus tonic mode firing: a computational simulation.

The mechanisms by which the basal ganglia influence the pallidal-receiving thalamus remain to be adequately defined. Our prior in vivo recordings in fully alert normal and dystonic rats revealed that normally fast tonic discharging entopeduncular [EP, rodent equivalent of the globus pallidus internus (GPi)] neurons are pathologically slow, highly irregular, and bursty under dystonic conditions. This, in turn, induces pallidal-receiving thalamic movement-related neurons to change from a healthy burst predominant to a pathological tonic-predominant resting firing mode. This study aims to understand the pallidal influence on thalamic firing modes using computational simulations. We inputted various combinations of healthy and pathological (dystonic) in vivo neuronal recordings to the Rubin and Terman's computational model of low threshold spiking pallidothalamic neurons. The input sets consist of representative tonic, burst, irregular tonic and irregular burst inputs collected from EP/GPi in our animal lab. Initial test combinations of EP/ GPi input to the model were identical to the neuronal population distributions observed in vivo. The thalamic neuron model outputted similar firing rate and mode as observed in corresponding in-vivo thalamus. Further influence of each individual patterns was also delineated. By simulating the firing properties of encountered neurons, the basal ganglia output is suggested to critically act as firing mode selector for thalamic motor relay neurons. By selecting and determining the timing and extent of opening of thalamic T-type calcium channels via GABAergic hyperpolarizing input, GPi neurons are in position to precisely orchestrate thalamocortical burst motor signaling.

Health inequities and socioeconomic factors predicting the access to treatment for unruptured intracranial aneurysms in the USA in the last 20 years: interaction effect of race, gender, and insurance.

BACKGROUND: The literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed over time. METHODS: A cross-sectional study using the National Inpatient Sample database covering 97% of the USA population was carried out. RESULTS: A total of 213 350 treated patients with UIA were included in the final analysis and compared with 173 375 treated patients with aneurysmal subarachnoid hemorrhage (aSAH) over the years 2000-2019. The mean (SD) age of the UIA and aSAH groups was 56.8 (12.6) years and 54.3 (14.1) years, respectively. In the UIA group, 60.7% were white patients, 10.2% were black patients, 8.6% were Hispanic, 2% were Asian or Pacific Islander, 0.5% were Native Americans, and 2.8% were others. The aSAH group comprised 48.5% white patients, 13.6% black patients, 11.2% Hispanics, 3.6% Asian or Pacific Islanders, 0.4% Native Americans, and 3.7% others. After adjusting for covariates, black patients (OR 0.637, 95% CI 0.625 to 0.648) and Hispanic patients (OR 0.654, 95% CI 0.641 to 0.667) had lower odds of treatment compared with white patients. Medicare patients had higher odds of treatment than private patients, while Medicaid and uninsured patients had lower odds. Interaction analysis showed that non-white/Hispanic patients with any insurance/no insurance had lower treatment odds than white patients. Multivariable regression analysis showed that the treatment odds of black patients has improved slightly over time, while the odds for Hispanic patients and other minorities have remained the same over time. CONCLUSION: This study from 2000 to 2019 shows that disparities in the treatment of UIA have persisted but have slightly improved over time for black patients while remaining constant for Hispanic patients and other minority groups.

A role for protein arginine methyltransferase 7 in repetitive and mild traumatic brain injury.

Mild traumatic brain injury affects the largest proportion of individuals in the United States and world-wide. Pre-clinical studies of repetitive and mild traumatic brain injury (rmTBI) have been limited in their ability to recapitulate human pathology (i.e. diffuse rotational injury). We used the closed-head impact model of engineered rotation acceleration (CHIMERA) to simulate rotational injury observed in patients and to study the pathological outcomes post-rmTBI using C57BL/6J mice. Enhanced cytokine production was observed in both the cortex and hippocampus to suggest neuroinflammation. Furthermore, microglia were assessed via enhanced iba1 protein levels and morphological changes using immunofluorescence. In addition, LC/MS analyses revealed excess glutamate production, as well as diffuse axonal injury via Bielschowsky's silver stain kit. Moreover, the heterogeneous nature of rmTBI has made it challenging to identify drug therapies that address rmTBI, therefore we sought to identify novel targets in the concurrent rmTBI pathology. The pathophysiological findings correlated with a time-dependent decrease in protein arginine methyltransferase 7 (PRMT7) protein expression and activity post-rmTBI along with dysregulation of PRMT upstream mediators s-adenosylmethionine and methionine adenosyltransferase 2 (MAT2) in vivo. In addition, inhibition of the upstream mediator MAT2A using the HT22 hippocampal neuronal cell line suggest a mechanistic role for PRMT7 via MAT2A in vitro. Collectively, we have identified PRMT7 as a novel target in rmTBI pathology in vivo and a mechanistic link between PRMT7 and upstream mediator MAT2A in vitro.

PRMT7 can prevent neurovascular uncoupling, blood-brain barrier permeability, and mitochondrial dysfunction in repetitive and mild traumatic brain injury.

Mild traumatic brain injury (TBI) comprises the largest percentage of TBI-related injuries, with pathophysiological and functional deficits that persist in a subset of TBI patients. In our three-hit paradigm of repetitive and mild traumatic brain injury (rmTBI), we observed neurovascular uncoupling via decreased red blood cell velocity, microvessel diameter, and leukocyte rolling velocity 3 days post-rmTBI via intra-vital two-photon laser scanning microscopy. Furthermore, our data suggest increased blood-brain barrier (BBB) permeability (leakage), with corresponding decrease in junctional protein expression post-rmTBI. Mitochondrial oxygen consumption rates (measured via Seahorse XFe24) were also altered 3 days post-rmTBI, along with disrupted mitochondrial dynamics of fission and fusion. Overall, these pathophysiological findings correlated with decreased protein arginine methyltransferase 7 (PRMT7) protein levels and activity post-rmTBI. Here, we increased PRMT7 levels in vivo to assess the role of the neurovasculature and mitochondria post-rmTBI. In vivo overexpression of PRMT7 using a neuronal specific AAV vector led to restoration of neurovascular coupling, prevented BBB leakage, and promoted mitochondrial respiration, altogether to suggest a protective and functional role of PRMT7 in rmTBI.

Angioplasty and stenting of a jugular-carotid fistula resulting from the inadvertent placement of a hemodialysis catheter: case report and review of literature.

Hemodialysis catheterization through the right internal jugular vein (IJV) is widely used for mid- to long-term hemodialysis for patients with renal failure. The purpose of this report is to address a serious complication in conjunction with this procedure. This is a case report of an iatrogenic jugular-carotid fistula (JCF) and a method for rectifying such a vascular conundrum, using endovascular techniques. We describe the technique used to achieve closure of the fistula as well a review of the literature. An 82-year-old woman with history of congestive heart failure, chronic renal failure, and diabetes mellitus developed an iatrogenic arteriovenous fistula, following an attempt of canalizing the right IJV. The patient was treated using three different stents, which achieved closure of the fistula. Venous catheter misplacement into an artery is a serious complication. Early endovascular treatment should be considered for a JCF.

Meningioma with holo-sagittal sinus involvement treated successfully with intrinsic sinus surgery: illustrative case.

BACKGROUND: This report describes an unusual meningioma with a large left frontal component and extensive growth within the sagittal sinus and its successful treatment with a staged approach: left frontal craniotomy followed by a sagittal craniotomy and intrinsic removal of the tumor from the sagittal sinus. OBSERVATIONS: A previously healthy 27-year-old presented with 6 months of progressively worsening bilateral headaches, visual changes, and nausea. On examination she had a left cranial nerve VI palsy and severe papilledema. Magnetic resonance imaging revealed a 5.1 × 3.8 × 4.1 cm homogenously enhancing left superior frontal parafalcine extra-axial mass with surrounding vasogenic edema and growth through the sagittal sinus extending just short of the torcula. LESSONS: This case report describes a fast-growing meningioma with a unique pattern of spread, growing through the sagittal sinus as if it were a conduit and resulting in complete occlusion of flow in the sinus. An important recognition in this case was that a robust parasagittal venous plexus had developed on either side of the falx cerebri with drainage to the inferior sagittal sinus. This collateral drainage pattern allowed for an extradural opening of the sagittal sinus from front to back and intrinsic resection of the tumor from the sinus with preservation of the lateral walls of the sinus.

Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review.

BACKGROUND: Neurologic complications are common complications encountered by patients with left ventricular assist devices (LVADs). This single-center retrospective study aims to identify the incidence and risk factors of neurologic complications and interventions in patients supported with LVADs and define the associated anticoagulation management. METHODS: Between August 2009 and August 2017, 244 patients underwent LVAD implantation. Twenty-one patients were excluded for having neurologic complications before LVAD placement or for having previously undergone heart transplantation. RESULTS: Fifty-six patients (25%) suffered 61 complications, and 11 (19.6%) died as a result. Gender, type of LVAD, or chronic medical comorbidities evaluated did not contribute to a difference in complication rate; in contrast, length of LVAD implantation was directly related to risk of neurologic complication. Eleven patients (19.6%) underwent 13 surgical interventions including 5 mechanical thrombectomies. Anticoagulation was reversed in 16 patients and held without complication. Anticoagulation was not held for ischemic complications, and no clinically significant hemorrhagic transformation occurred. Intravenous tissue plasminogen activator was also successfully administered to 3 patients without complication. CONCLUSIONS: Neurologic complications were observed in 25% of patients supported with LVADs, of which 20% required neurosurgical intervention. Anticoagulation can be safely withheld in patients with hemorrhagic complications. Patients with ischemic complications can continue to be anticoagulated with no significant risk of hemorrhagic transformation. Length of LVAD implantation was directly related to the risk of neurologic complication. Finally, our study adds to existing literature that mechanical thrombectomy and even intravenous tissue plasminogen activator are options for LVAD patients with ischemic complications.

Gram-negative Cranial Bone Flap Infection Treated with Continuous Gentamicin Irrigation: A Case Report.

A 57-year-old male presented with severely altered mental status in the setting of diabetic ketoacidosis. Neuroimaging revealed two intracranial masses. Days following surgical resection of an olfactory groove meningioma, the patient developed Serratia marcescens bacteremia along with an enlarging epidural and subgaleal fluid collection. Subgaleal fluid aspiration was also positive. The patient later returned to the operating room for wound washout where purulent collections were discovered in the subgaleal, epidural, and left subdural spaces. The wound was evacuated and the bone flap was thoroughly cleansed with betadine and soaked in peroxide prior to replacement. Four drains were placed (two subgaleal and two epidural) with two serving as inlets and two as outlets. Continuous irrigation of the subgaleal and epidural spaces with gentamicin solution was performed for five days. The bone flap was successfully salvaged and the patient was discharged from inpatient rehab three weeks following washout.