Preoperative neurocognitive function as an independent survival prognostic marker in primary glioblastoma.

Background: Aim of the present study is to investigate whether preoperative neurocognitive status is prognostically associated with overall survival (OS) in newly diagnosed glioblastoma (GBM) patients. Methods: Ninety patients with dominant-hemisphere IDH-wild-type GBM were assessed by Mini Mental Status Exam (MMSE), Trail Making Test (TMT) A and B parts, and Control Word Association Test (COWAT) phonemic and semantic subtests. Demographics, Karnofsky Performance Scale, tumor parameters, type of surgery, and adjuvant therapy data were available for patients. Results: According to Cox proportional hazards model the neurocognitive variables of TMT B (P < .01), COWAT semantic subset (P < .05), and the MMSE (P < .01) were found significantly associated with survival prediction. From all other factors, only tumor volume and operation type (debulking vs biopsy) showed a statistical association (P < .05) with survival prediction. Kaplan Meier Long rank test showed statistical significance (P < .01) between unimpaired and impaired groups for TMT B, with median survival for the unimpaired group 26 months and 10 months for the impaired group, for COWAT semantic (P < .01) with median survival 23 months and 12 months, respectively and for MMSE (P < .01) with medial survival 19 and 12 months respectively. Conclusions: Our study demonstrates that neurocognitive status at baseline-prior to treatment-is an independent prognostic factor for OS in wild-type GBM patients, adding another prognostic tool to assist physicians in selecting the best treatment plan.

Association between preoperative neurocognitive status and IDH1 mutation status in high-grade gliomas.

Background: High-grade glioma (HGG) patients present with variable impairment in neurocognitive function (NCF). Based on that, isocitrate dehydrogenase 1 (IDH1) wild-type HGGs are more aggressive than IDH1 mutant-type ones, we hypothesized that patients with IDH1 wild-type HGG would exhibit more severe NCF deficits than their IDH1 mutant counterparts. Methods: NCF was assessed by Mini Mental Status Exam (MMSE), Trail Making Test (TMT), Digit Span (DS), and Controlled Word Association Test (COWAT) tests in 147 HGG patients preoperatively. Results: Analyses between IDH1 groups revealed a significant difference on MMSE concentration component (p ≤ .01), DS (p ≤ .01), TMTB (p ≤ .01), and COWAT (p ≤ .01) scores, with the IDH1 wild group performing worse than the IDH1 mutant one. Age and tumor volume were inversely correlated with MMSE concentration component (r = -4.78, p < .01), and with MMSE concentration (r = -.401, p < .01), TMTB (r = -.328, p < .01), and COWAT phonemic scores (r = -.599, p < .01), respectively, but only for the IDH1 wild-type group. Analyses between age-matched subsamples of IDH1 groups revealed no age effect on NCF. Tumor grade showed nonsignificance on NCF (p > .05) between the 2 IDH1 mutation subgroups of grade IV tumor patients. On the contrary, grade III group showed a significant difference in TMTB (p < .01) and DS backwards (p < .01) between IDH1 subgroups, with the mutant one outperforming the IDH1 wild one. Conclusions: Our findings indicate that IDH1 wild-type HGG patients present greater NCF impairment, in executive functions particularly, compared to IDH1 mutant ones, suggesting that tumor growth kinetics may play a more profound role than other tumor and demographic parameters in clinical NCF of HGG patients.

Deciphering the frontostriatal circuitry through the fiber dissection technique: direct structural evidence on the morphology and axonal connectivity of the fronto-caudate tract.

OBJECTIVE: The authors sought to investigate the very existence and map the topography, morphology, and axonal connectivity of a thus far ill-defined subcortical pathway known as the fronto-caudate tract (FCT) since there is a paucity of direct structural evidence regarding this pathway in the relevant literature. METHODS: Twenty normal adult cadaveric formalin-fixed cerebral hemispheres (10 left and 10 right) were explored through the fiber microdissection technique. Lateral to medial and medial to lateral dissections were carried out in a tandem manner in all hemispheres. Attention was focused on the prefrontal area and central core since previous diffusion tensor imaging studies have recorded the tract to reside in this territory. RESULTS: In all cases, the authors readily identified the FCT as a fan-shaped pathway lying in the most medial layer of the corona radiata and traveling across the subependymal plane before terminating on the superolateral margin of the head and anterior part of the body of the caudate nucleus. The FCT could be adequately differentiated from adjacent fiber tracts and was consistently recorded to terminate in Brodmann areas 8, 9, 10, and 11 (anterior pre-supplementary motor area and the dorsolateral, frontopolar, and fronto-orbital prefrontal cortices). The authors were also able to divide the tract into a ventral and a dorsal segment according to the respective topography and connectivity observed. Hemispheric asymmetries were not observed, but instead the authors disclosed asymmetry within the FCT, with the ventral segment always being thicker and bulkier than the dorsal one. CONCLUSIONS: By using the fiber microdissection technique, the authors provide sound structural evidence on the topography, morphology, and connectional anatomy of the FCT as a distinct part of a wider frontostriatal circuitry. The findings are in line with the tract's putative functional implications in high-order motor and behavioral processes and can potentially inform current surgical practice in the fields of neuro-oncology and functional neurosurgery.

Recent trends (2010-2018) in traumatic brain injury in Greece: Results on 2042 patients.

BACKGROUND: Recent analysis on the epidemiology of traumatic brain injury (TBI) within Europe indicates an increase in fall-related injuries and in the incidence of hospitalization among older adults as well as a decrease in contribution of road traffic accidents (RTA). Given the paucity of recent national data, we analyzed TBI-related admissions from the Athens Head Trauma Registry during the largest part of the past decade (2010-2018), a period marked by a profound national socioeconomic crisis. METHODS: Demographic and clinical data of admitted TBI patients were collected and analyzed statistically. RESULTS: The mean age of patients (N=2042, 68% men) was 59 years (median 64 years). Patient age showed an upward trend across the study period. Most cases were mild, while moderate and severe injuries were indicated in, 11% and 20%, respectively. Falls were the predominant cause of injury (46% of cases), followed by RTA (38%). An upward trend in the frequency of fall-related injury was apparent across the study period; RTA-related injury frequency displayed a downward trend during the second part of the study period. Assault-related injury accounted for 6%. Surgery took place in 11% of cases. In-hospital mortality (IHM) was 21%. Fall-related mortality contributed to 56% of total IHM; RTA-related mortality contributed to 30%. The mean length of hospital stay was 13 days (median: 5 days). CONCLUSIONS: The present findings suggest a shift in the epidemiologic profile of TBI patients in Greece with a rise in the proportion of elderly patients, a concomitant increase in fall-related injuries and a reduction in RTA-related injury. They also highlight fall-related injury as the predominant cause of IHM. Our results point towards the urgent need for the intensification of fall prevention strategies, continuing medical education as well as public information campaigns on the risks of geriatric fall-related injury.

Spinal Atypical Rhabdoid Teratoid Tumor in an Adult Woman: Case Report and Review of the Literature.

BACKGROUND: Atypical rhabdoid teratoid tumors are very rare embryonal tumors that typically affect children younger than 3 years old and are encountered intracranially. CASE DESCRIPTION: Here, we describe the case of a 19-year-old woman who presented with gait disturbances and coccydynia. Imaging revealed a cauda equina mass. The tumor was partially resected. Histology reported loss of SMARCB1/INI1 expression and therefore the diagnosis of atypical rhabdoid teratoid was established. The patient underwent radiation treatment, but within 3 months 2 relapses were manifested. CONCLUSIONS: Atypical rhabdoid teratoids are exceptionally rare in adults and are seldom found in spine; only 8 such cases have been reported in the medical literature. They are invariantly characterized by multiple relapses and dismal prognosis. The clinician must be attentive of leptomeningeal disseminations and 22q11 deletion-associated comorbidities.

Intrathecal Baclofen Therapy for Painful Muscle Spasms in a Patient with Friedreich's Ataxia.

Friedreich's ataxia (FA) is the most frequent hereditary ataxia syndrome, while painful muscle spasms and spasticity have been reported in 11-15% of FA patients. This report describes the successful management of painful spasms in a 65-year-old woman with FA via intrathecal baclofen (ITB) therapy following unsuccessful medical treatments. To our knowledge, this is the third reported case in the literature. Unfortunately, the pathophysiological characteristics of muscle spasms in FA are not well explored and understood while the therapeutic mechanisms of the different treatments are rather vague. Taking into consideration the suggested spinal atrophy in FA, the clinical resemblance of FA and chronic spinal injury muscle spasms, together with the rapid ITB therapy effectiveness in alleviating FA muscle spasms, we attempted to suggest a putative pathophysiological mechanism acting at the spinal level and possibly explained by the presence of independent spinal locomotor systems producing muscle spasms. Specifically, overexcitement of these centers, due to loss of normal regulation from upper CNS levels, may result in the uncontrolled firing of secondary motor neurons and may be the key to producing muscle spasms. However, further research under experimental and clinical settings seems to be necessary.

Defining the relationship of the optic radiation to the roof and floor of the ventricular atrium: a focused microanatomical study.

Objective: The authors investigated the specific topographic relationship of the optic radiation fibers to the roof and floor of the ventricular atrium because the current literature is ambiguous. Methods: Thirty-five normal, adult, formalin-fixed cerebral hemispheres and 30 focused MRI slices at the level of the atrium were included in the study. The correlative anatomy of the optic radiation with regard to the atrial roof and floor was investigated in 15 specimens, each through focused fiber microdissections. The remaining 5 hemispheres were explored with particular emphasis on the trajectory of the collateral sulcus in relation to the floor of the atrium. In addition, the trajectory of the collateral sulcus was evaluated in 30 MRI scans. Results: The atrial roof was observed to be devoid of optic radiations in all studied hemispheres, whereas the atrial floor was seen to harbor optic fibers on its lateral part. Moreover, the trajectory of the intraparietal sulcus, when followed, was always seen to correspond to the roof of the atrium, thus avoiding the optic pathway, whereas that of the collateral sulcus was found to lead to either the lateral atrial floor or outside the ventricle in 88% of the cases, therefore hitting the visual pathway. Conclusions: Operative corridors accessing the ventricular atrium should be carefully tailored through detailed preoperative planning and effective use of intraoperative navigation to increase patient safety and enhance the surgeon's maneuverability. The authors strongly emphasize the significance of accurate anatomical knowledge.

Parietal association deficits in patients harboring parietal lobe gliomas: a prospective study.

OBJECTIVE: Although the parietal lobe is a common site for glioma formation, current literature is scarce, consists of retrospective studies, and lacks consistency with regard to the incidence, nature, and severity of parietal association deficits (PADs). The aim of this study was to assess the characteristics and incidence of PADs in patients suffering from parietal lobe gliomas through a prospective study and a battery of comprehensive neuropsychological tests. METHODS: Between 2012 and 2016 the authors recruited 38 patients with glioma confined in the parietal lobe. Patients were examined for primary and secondary association deficits with a dedicated battery of neuropsychological tests. The PADs were grouped into 5 categories: visuospatial attention, gnosis, praxis, upper-limb coordination, and language. For descriptive analysis tumors were divided into high- and low-grade gliomas and also according to patient age and tumor size. RESULTS: Parietal association deficits were elicited in 80% of patients, thus being more common than primary deficits (50%). Apraxia was the most common PAD (47.4%), followed by anomic aphasia and subcomponents of Gerstmann's syndrome (34.2% each). Other deficits such as hemineglect, stereoagnosia, extinction, and visuomotor ataxia were also detected, albeit at lower rates. There was a statistically nonsignificant difference between PADs and sex (72.2% males, 85% females) and age (77.8% at ≤ 60 years, 80% at age > 60 years), but a statistically significant difference between the > 4 cm and the ≤ 4 cm diameter group (p = 0.02, 94.7% vs 63.2%, respectively). There was a tendency (p = 0.094) for low-grade gliomas to present with fewer PADs (50%) than high-grade gliomas (85.7%). Tumor laterality showed a strong correlation with hemineglect (p = 0.004, predilection for right hemisphere), anomia (p = 0.001), and Gerstmann's symptoms (p = 0.01); the last 2 deficits showed a left (dominant) hemispheric preponderance. CONCLUSIONS: This is the first study to prospectively evaluate the incidence and nature of PADs in patients with parietal gliomas. It could be that the current literature may have underestimated the true incidence of deficits. Dedicated neuropsychological examination detects a high frequency of PADs, the most common being apraxia, followed by anomia and subcomponents of Gerstmann's syndrome. Nevertheless, a direct correlation between the clinical deficit and its anatomical substrate is only possible to a limited extent, highlighting the need for intraoperative cortical and subcortical functional mapping.

A giant pseudoaneurysm of the occipital artery.

BACKGROUND: Pseudoaneurysms of the occipital artery (OA) are extremely rare and can occur following head trauma or iatrogenic injury; OA anatomy seems to play a crucial role in their pathogenesis. CASE DESCRIPTION: This report describes the case of a 76-year-old patient with a giant OA pseudoaneurysm secondary to a head injury the patient had sustained 1 month earlier. After radiological confirmation via ultrasonography (US) and computed tomography angiography (CTA), the patient underwent surgery for resection of the lesion. An uneventful postoperative course with no recurrence was confirmed at 1 and 2-month follow-up visits. CONCLUSIONS: Despite their rarity, pseudoaneurysms of the OA should be considered in the differential diagnosis of patients presenting with an occipital pulsatile mass. Prompt management reduces the risk of a serious hemorrhage. In our case, considering the size of the lesion, surgical resection seemed to be the only reasonable option.

The Superior Frontal Transsulcal Approach to the Anterior Ventricular System: Exploring the Sulcal and Subcortical Anatomy Using Anatomic Dissections and Diffusion Tensor Imaging Tractography.

OBJECTIVE: To explore the superior frontal sulcus (SFS) morphology, trajectory of the applied surgical corridor, and white matter bundles that are traversed during the superior frontal transsulcal transventricular approach. METHODS: Twenty normal, adult, formalin-fixed cerebral hemispheres and 2 cadaveric heads were included in the study. The topography, morphology, and dimensions of the SFS were recorded in all specimens. Fourteen hemispheres were investigated through the fiber dissection technique whereas the remaining 6 were explored using coronal cuts. The cadaveric heads were used to perform the superior frontal transsulcal transventricular approach. In addition, 2 healthy volunteers underwent diffusion tensor imaging and tractography reconstruction studies. RESULTS: The SFS was interrupted in 40% of the specimens studied and was always parallel to the interhemispheric fissure. The proximal 5 cm of the SFS (starting from the SFS precentral sulcus meeting point) were found to overlie the anterior ventricular system in all hemispheres. Five discrete white matter layers were identified en route to the anterior ventricular system (i.e., the arcuate fibers, the frontal aslant tract, the external capsule, internal capsule, and the callosal radiations). Diffusion tensor imaging studies confirmed the fiber tract architecture. CONCLUSIONS: When feasible, the superior frontal transsulcal transventricular approach offers a safe and effective corridor to the anterior part of the lateral ventricle because it minimizes brain retraction and transgression and offers a wide and straightforward working corridor. Meticulous preoperative planning coupled with a sound microneurosurgical technique are prerequisites to perform the approach successfully.

Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature.

BACKGROUND: To define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life. METHODS: A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews. RESULTS: Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost. CONCLUSIONS: No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.

Interventions for idiopathic intracranial hypertension.

BACKGROUND: Idiopathic intracranial hypertension (IIH) has an estimated incidence of one to three people per 100,000 people per year, and occurs most commonly in obese, young women. IIH is associated with severe morbidity, notably due to a significant threat to sight and severe headache. Several different management options have been proposed. Conservative measures centre on weight loss. Pharmacological therapy includes use of diuretics. Refractory and sight-threatening cases demand surgical intervention, most often in the form of cerebrospinal fluid (CSF) diversion or optic nerve sheath fenestration. Other treatments include venous sinus stenting and bariatric surgery. OBJECTIVES: To assess the effects of any intervention for IIH in any patient group. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015 Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2015), EMBASE (January 1980 to July 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 22 July 2015. SELECTION CRITERIA: We included only randomised controlled trials (RCTs) in which any intervention was compared to placebo, or to another form of treatment, for people with a clinical diagnosis of IIH. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the search results for trials to be included in the review. We resolved any discrepancies by third party decision. MAIN RESULTS: We identified two completed RCTs (enrolling a total of 211 participants and conducted in the UK and US) and two ongoing trials that met the inclusion criteria. Both completed trials compared acetazolamide to placebo, in conjunction with a weight loss intervention in both groups. Attrition bias was a problem in both trials with high loss to follow-up, in one study this loss to follow-up occurred particularly in the acetazolamide arm. One trial was unmasked and we judged it to be at risk of performance and detection bias.In these studies, change in visual acuity was similar in the treatment and control groups as measured by logMAR acuity. In one study people in the acetalomazide group had a similar change in logMAR acuity compared to the placebo group between baseline and 12 months in the right eye (MD 0.04 logMAR, 95% CI -0.08 to 0.16) and left eye (MD 0.03 logMAR, 95% CI -0.09 to 0.15). In the other study people in the acetalomazide group had a similar change in vision over six months compared with people in the placebo group (mean difference in change in letters read was 0.01 (95% CI -1.45 to 1.46). One study reported no cases of visual loss in 21 people treated with acetalomazide compared to 2/20 cases in the placebo group (odds ratio 0.17, 95% CI 0.01, 3.82).The prespecified outcome for this review was reduction in CSF pressure to normal levels which was not reported by the two trials. One trial reported that, in a subsample of 85 participants who agreed to lumbar puncture at 6 months, people in the acetalomazide group on average had a greater reduction in CSF pressure (MD -59.9 mmH(2)O, 95% CI -96.4, -23.4).In one study, people in the acetalozamide group on average experienced a greater reduction in papilloedema as assessed by fundus photographs MD -0.70 (95% CI -1.00 to -0.40) and by clinical grading MD -0.91 (95% CI -1.27 to -0.54) between baseline and six months in the study eye.Headache was recorded as present/absent in one study at 12 months (OR 0.42, 95% CI 0.12,1.41, 41 participants). Both studies reported headache on visual analogue scales (different ones) but results were inconclusive (MD for change in headache score measured on 10-point visual analogue scale at 12 months was 1.0 (-1.80, 3.70, 41 participants) and MD for change in headache score on a 6 point scale measured at 6 months was -0.45 (-3.5,2.6, number of participants unclear).In one study, a similar proportion of people in the acetalomazide group were in remission (however, the trial authors did not state their definition of this term) at 12 months compared to the placebo group. However, the 95% CIs were wide and there is considerable uncertainty as to the effect (OR 1.13 (95% CI 0.32 to 3.90, 41 participants).In one study of 185 participants, people in the acetalomazide group had an increased risk of decreased CO2, diarrhoea, dysgeusia, fatigue, nausea, paresthesia, tinnitus and vomiting compared to people in the placebo group. In general, the estimates of effect were uncertain with wide 95% CIs. Adverse effects were not reported in the other study.One study reported that quality of life was better in acetazolamide-treated patients based on the visual quality of life (VFQ-25) (MD 6.35, 95% CI 2.22 to 10.47) and the physical (MD 3.02, 95% CI 0.34 to 5.70) and mental (MD 3.45, 95% CI 0.35 to 6.55) components of the 36-Item Short Form Health Survey tool at six months. Costs were not reported in either study.We judged the evidence to be low certainty (GRADE) downgrading for imprecision and risk of bias. AUTHORS' CONCLUSIONS: Although the two included RCTs showed modest benefits for acetazolamide for some outcomes, there is insufficient evidence to recommend or reject the efficacy of this intervention, or any other treatments currently available, for treating people with IIH. Further high-quality RCTs are required in order to adequately assess the effect of acetazolamide therapy in people with IIH.

Bariatric surgery as metabolic surgery for diabetic patients.

The recent increase in the prevalence of obesity seems to be responsible for the increase in T2 Diabetes Mellitus (T2DM). At present around 50 % of T2DM patients are obese and this percentage appears set to increase in the near future. Successful management of T2DM in obese patients is a complicated task, as many parameters such as blood pressure, LDL-cholesterol levels have to be adequately controlled along with HbA1c levels. There is a substantial amount of evidence showing that bariatric surgery achieves long term remission of diabetes in the majority of obese patients and improves significantly comorbidities associated with DM such as dyslipidemia, hypertension, and obstructive sleep apnea. It seems that early surgical intervention before irreversible b-cell damage has occurred, increases the chances of long term T2DM resolution. However, at present a very small percentage (< 2%) of obese patients with T2DM is treated surgically. The present review focuses on the efficacy and safety of the main bariatric procedures. It also emphasizes the mechanism with which bariatric surgery exerts its therapeutic effect and on the long term results on T2DM remission.