Utility and Prognostic Value of Intraoperative Blink Reflex in Trigeminal or Facial Nerve Monitoring in Skull Base Surgeries: A Systematic Review.

BACKGROUNDS: Blink reflex (BR) is an oligosynaptic reflex that involves the ophthalmic branch of the trigeminal nerve (TN), ipsilateral main sensory and trigeminospinal nuclei, bilateral facial nuclei, and the facial nerves (FN). Theoretically, as it tests the function of both TN and FN simultaneously, it is an ideal tool for monitoring the status of TN and FN during skull base surgeries. Nevertheless, it is only recently utilized in surgeries as the use of anesthesia limits its use. METHODS: Two authors inputted the search terms: [(Blink Reflex) AND (Intraoperative Neuromonitoring OR Neuro Intraoperative Monitoring OR Intraoperative OR NIOM OR IONM) AND (skull base surgery OR Facial Nerve OR Trigeminal Nerve OR Microvascular Decompression OR Hemifacial Spasm)] in Medline through its Pubmed interface and other search engines. Papers that fulfilled the inclusion and exclusion criteria were obtained and scrutinized. RESULTS: Only 7 observational papers with a total of 437 participants were included in the current systematic review. All studies (n=5) involving the use of BR in FN surgery noted that IOBR is beneficial, safe, sensitive, specific, and predictive of outcomes while all 2 papers involving trigeminal neuralgia patients recommended BR's use in microvascular decompression (MVD) of TN. CONCLUSION: IOBR is a sensitive, specific and safe monitoring technique that has good predictability of facial paresis and paresthesia among patients undergoing MVD for trigeminal neuralgia and primary hemifacial spasm and those who are for cerebellopontine angle tumor resection.

Usefulness of Robotic Stereotactic Assistance (ROSA®) Device for Stereoelectroencephalography Electrode Implantation: A Systematic Review and Meta-analysis.

The aim of this study was to systematically review and meta-analyze the efficiency and safety of using the Robotic Stereotactic Assistance (ROSA®) device (Zimmer Biomet; Warsaw, IN, USA) for stereoelectroencephalography (SEEG) electrode implantation in patients with drug-resistant epilepsy. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search was carried out. Overall, 855 nonduplicate relevant articles were determined, and 15 of them were selected for analysis. The benefits of the ROSA® device use in terms of electrode placement accuracy, as well as operative time length, perioperative complications, and seizure outcomes, were evaluated. Studies that were included reported on a total of 11,257 SEEG electrode implantations. The limited number of comparative studies hindered the comprehensive evaluation of the electrode implantation accuracy. Compared with frame-based or navigation-assisted techniques, ROSA®-assisted SEEG electrode implantation provided significant benefits for reduction of both overall operative time (mean difference [MD], -63.45 min; 95% confidence interval [CI] from -88.73 to -38.17 min; P < 0.00001) and operative time per implanted electrode (MD, -8.79 min; 95% CI from -14.37 to -3.21 min; P = 0.002). No significant differences existed in perioperative complications and seizure outcomes after the application of the ROSA® device and other techniques for electrode implantation. To conclude, the available evidence shows that the ROSA® device is an effective and safe surgical tool for trajectory-guided SEEG electrode implantation in patients with drug-resistant epilepsy, offering benefits for saving operative time and neither increasing the risk of perioperative complications nor negatively impacting seizure outcomes.

Miliary Tuberculosis during R-MPV Therapy in an Elderly Patient with Primary Central Nerve System Lymphoma: A Case Report.

Most elderly patients with tuberculosis (TB) have previously been infected with Mycobacterium tuberculosis, which remains dormant in the body for decades and may reactivate when their immunity declines due to underlying diseases. Elderly cancer patients are at a high risk for TB, and the treatment of TB reactivation in these patients is challenging. Among cancer patients, the incidence of TB reactivation is the highest in lymphoma patients. However, the impact of chemotherapy on TB reactivation in lymphoma patients is unknown. We report the case of an immunocompetent elderly patient with primary central nervous system lymphoma (PCNSL) having no prior history of TB, who developed miliary TB during multiagent chemotherapy consisting of rituximab, high-dose methotrexate, procarbazine, and vincristine (R-MPV therapy). Retrospectively, the chest computed tomography showed calcification of the pleura, suggesting that the patient had a latent tuberculosis infection (LTBI) and developed miliary TB from the reactivation of TB triggered by the R-MPV therapy. Our case emphasizes that when chemotherapy is administered to patients with PCNSL, interferon-gamma release assay (IGRA) should be performed if there are findings on chest examination suggestive of LTBI, such as pleural calcification, and if IGRA is positive, chemotherapy should be given concurrently with LTBI treatment.

Subdural Hygroma After Management of Ruptured Intracranial Aneurysms: Incidence, Associated Factors, Clinical Course, and Management Options.

OBJECTIVE: To evaluate the incidence, associated factors, clinical course, and management options of subdural hygroma in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). METHODS: From January 2013 until June 2022, 336 consecutive patients with aSAH underwent treatment in our center. No one patient was excluded from the study cohort. Computed tomography (CT) examinations were performed at admission, immediately after surgery and on the first postoperative day, and subsequently in case of any neurologic deterioration or, at least, once per week until discharge from the hospital. Thereafter, CT examinations were at the discretion of specialists in the rehabilitation facility, referring physicians, or neurosurgeons at the outpatient clinic. RESULTS: The length of radiologic follow-up starting from CT at admission ranged from 1 to 3286 days (mean, 673 ± 895 days; median, 150 days). Subdural hygromas developed in 84 patients (25%). An average interval until this imaging finding from the initial CT examination was 25 ± 55 days (median, 8 days; range, 0-362 days). Evaluation in the multivariate model showed that patient age ≥72 years (P < 0.0001), cerebrospinal fluid (CSF) shunting (P < 0.0001), and microsurgical clipping of ruptured intracranial aneurysm (RIA; P < 0.0001) are independently associated with the development of subdural hygroma. In 54 of 84 cases (64%), subdural hygromas required observation only. Increase of the lesion size with (5 cases) or without (10 cases) appearance of midline shift was associated with patient age <72 years (P = 0.0398), decompressive craniotomy (P = 0.0192), and CSF shunting (P = 0.0009), whereas evaluation of these factors in the multivariate model confirmed independent association of only CSF shunting (P = 0.0003). Active management of subdural hygromas included adjustment of the shunt programmable valve opening pressure, cranioplasty, external subdural drainage, or their combination. Overall, during follow-up (mean, 531 ± 824 days; median, 119 days; range, 2-3285 days) after the start of observation or applied treatment, subdural hygromas showed either decrease (50 cases) or stabilization (34 cases) of their sizes, and no one lesion showed progression again. CONCLUSIONS: The clinical course of subdural hygromas in patients treated for aSAH is generally favorable, but occasionally these lesions show progressive enlargement with or without the appearance of midline shift, which requires active management.

Efficacy and tolerability of lacosamide and controlled-release carbamazepine monotherapy in patients with newly diagnosed temporal lobe epilepsy: Post hoc analysis of a randomized, double-blind trial.

PURPOSE: Temporal lobe epilepsy (TLE) is often associated with drug-resistant seizures. We evaluated the efficacy and tolerability of lacosamide (LCM) versus controlled-release carbamazepine (CBZ-CR) monotherapy in adults with newly diagnosed TLE. METHODS: Exploratory post hoc analysis of patients with temporal focus of localization (indicated as the only localization focus) in a double-blind, noninferiority, phase 3 trial (SP0993; NCT01243177) in patients aged ≥ 16 years with newly diagnosed epilepsy randomized 1:1 to LCM or CBZ-CR monotherapy. RESULTS: Of 886 treated patients in this trial, temporal lobe focus of localization (TLE) was reported as the single focus for 287 (32.4%) patients (LCM 134, CBZ-CR 153). A similar proportion of patients with TLE on LCM (82  [61.2%]) and CBZ-CR (99  [64.7%]) completed the trial. Kaplan-Meier estimates for 6- and 12-month seizure freedom at the last evaluated dose level (stratified by number of seizures in the 3 months before screening  [≤2 or >2 seizures]) were similar with LCM and CBZ-CR (6 months overall: 88.7% and 89.7%; 12 months overall: 78.3% and 81.7%). Treatment-emergent adverse events (TEAEs) were reported by fewer patients on LCM (73.9%) than CBZ-CR (81.0%). Drug-related TEAEs (assessed by the investigator) were reported in 41.8% of patients on LCM and 52.3% of patients on CBZ-CR; 11.2% of patients on LCM and 15.0% on CBZ-CR discontinued due to TEAEs. CONCLUSION: Lacosamide was efficacious and generally well tolerated as monotherapy in patients with TLE with efficacy outcomes comparable with CBZ-CR, and fewer patients on LCM reported any TEAEs, drug-related TEAEs, or discontinued due to TEAEs.

Intravenous perampanel as an alternative to the oral formulations in Japanese patients with epilepsy.

OBJECTIVE: Perampanel is an oral anti-seizure medication, which is approved in Japan for focal-onset seizures, with/without focal to bilateral tonic-clonic seizures, as monotherapy/adjunctive therapy in patients aged 4 years and older. Treatment for generalized tonic-clonic seizures as adjunctive therapy in patients aged 12 years and older is approved as well. We evaluated the feasibility of intravenous (IV) administration of perampanel as an alternative to oral administration. METHODS: Study 240 (NCT03754582) was an uncontrolled, open-label study of IV perampanel, conducted in 21 Japanese patients with epilepsy who received a stable dose of 8-12 mg/day of oral perampanel. Patients received 30-minute IV infusions at equivalent daily doses of oral perampanel for 4 days, then were switched back to oral perampanel. Safety, tolerability, plasma concentration, and maintenance of efficacy throughout the transition between IV and oral dosing of perampanel were assessed. As supportive data, a subgroup analysis was also conducted using data from healthy Japanese subjects (n = 18) who were enrolled in Study 050 (NCT03376997) investigating the pharmacokinetics and safety of IV perampanel in healthy subjects who received an IV infusion (30-, 60-, or 90-minute) of perampanel 12 mg and a single oral administration of perampanel 12-mg tablet. RESULTS: In Study 240, the transition between 30-minute IV and oral perampanel dosing was associated with a ≤1.4-fold increase in the mean change in maximum observed concentration of perampanel. Seizure outcomes demonstrated no considerable changes in efficacy before, during, or after 30-minute IV dosing of perampanel. The safety profiles were similar between IV and oral formulations. In Study 050, the pharmacokinetics of 30- or 60-minute IV infusion of perampanel further support the interchangeability between oral and IV formulations in the Japanese subjects. SIGNIFICANCE: These results support that 30-minute IV perampanel may be a potential short-term alternative to oral formulations for patients with epilepsy.

Early tumor-related hemorrhage after stereotactic radiosurgery of brain metastases: Systematic review of reported cases.

OBJECTIVE: Early (within 72 h) tumor-related hemorrhage (TRH) after stereotactic radiosurgery (SRS) of brain metastases (BM) has been reported only occasionally. Systematic review of such cases was done. METHODS: Literature search was performed through PubMed according to PRISMA guidelines using combination of the following medical subject headings: "hemorrhage," "stereotactic radiosurgery," and "brain metastasis." RESULTS: In total, 7 case reports and 8 clinical series, which noted early TRH after SRS of BM were identified. Scarce and inconsistent data precluded their precise synthesis and statistical analysis. BM of renal cell carcinoma comprised around one-third of reported cases. In 4 patients with multiple BM, TRH after SRS was noted simultaneously in several irradiated tumors. Considering 17 reported cases overall, in 3 patients TRH occurred during SRS session itself, in 4 within several minutes upon completion of treatment, in 7 within several hours thereafter, and in 3 on the third posttreatment day. Out of 11 reported cases providing detailed outcome, 6 patients died shortly after the ictus, 2 others were severely disabled at discharge, and 3 demonstrated good-to-moderate recovery. Overall, among evaluated series the median rates of early TRH after SRS for BM were 0.8% per patient (range, 0.4 - 1.9%) and 0.3% per tumor (range, 0.05 - 0.8%). CONCLUSION: Early TRH is very rare, but potentially life-threatening complication of SRS for BM; thus, its risk (while extremely low) and possible consequences should be discussed at the time of obtaining informed consent.

Appropriate treatment within 13 hours after onset may improve outcome in patients with high-grade aneurysmal subarachnoid hemorrhage.

OBJECTIVE: This retrospective study evaluated whether earlier timing of appropriate treatment of high-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as management of ruptured intracranial aneurysm (RIA) combined with required additional surgical measures for control of increased intracranial pressure (ICP), is associated with more favorable outcomes. METHODS: The study cohort comprised 253 patients with high-grade aSAH. Modified Rankin Scale score of 0-3 at 3-month follow-up after the ictus was considered as favorable outcome. RESULTS: Appropriate treatment of aSAH was completed in 205 patients (81 %), and included clipping or coiling of RIA without (64 cases) and with (141 cases) additional surgical measures for control of increased ICP (evacuation of intracranial hematoma, decompressive craniotomy, and/or cerebrospinal fluid drainage). Favorable outcome was noted significantly more often if appropriate treatment was completed within 13 h after aSAH than between 13 and 72 h (37 % vs. 17 %; adjusted P = 0.0475), which was confirmed by evaluation in the multivariate model along with other prognostic factors. Subgroup analysis revealed that completion of the appropriate treatment within 13 h was associated with more favorable outcome in those patients, who underwent management of RIA in combination with additional surgical measures for control of increased ICP (P = 0.0023), and in those, who felt into poor outcome predicting group (P = 0.0046). CONCLUSIONS: Appropriate treatment of high-grade aSAH with management of RIA in combination with required additional surgical measures for control of increased ICP, may be associated with more favorable outcomes if completed within 13 h after the ictus.

Nonconvulsive status epilepticus as sign of tumor recurrence.

Status epilepticus (SE) can be a sign of brain tumor progression or recurrence, but there are few reports of nonconvulsive status epilepticus (NCSE) being a sign of tumor progression or recurrence. Moreover, much remains to be elucidated about its clinical course, and outcome. This is the first report of NCSE associated with the progression of a metastatic brain tumor treated by surgical excision of the tumor. The patient was 74-year-old woman. She had a history of craniotomy for tumor resection and gamma knife treatment for multiple metastatic brain tumors originating from breast cancer. She suddenly developed dysarthria and right hemiparesis, followed by convulsive seizures in the right side of her body. Magnetic resonance imaging showed tumor recurrence in the left parietal lobe and worsening edematous changes around the tumor. Antiseizure medication was initiated, however her seizures did not improve; therefore, tumor resection was performed. Postoperatively, her consciousness, seizures, and electroencephalogram findings improved. NCSE caused by brain tumors may be refractory to treatment with antiseizure medications, and early surgical treatment may be useful for seizure control.

Long-term outcomes after surgery for brainstem cavernous malformations: analysis of 46 consecutive cases.

OBJECTIVE: The objective of this study was to evaluate the long-term outcomes after resection of brainstem cavernous malformations (BSCMs) and to assess the usefulness of the Lawton grading system in these cases. METHODS: This retrospective study analyzed 46 consecutive patients with BSCMs operated on between July 1990 and December 2020. Outcomes at the last follow-up were defined as favorable (modified Rankin Scale [mRS] score 0-2) or unfavorable (mRS score > 2). RESULTS: The study cohort comprised 24 men (52%) and 22 women (48%), ranging in age from 8 to 78 years old (median 37 years). In 19 patients (41%), the preoperative mRS score was > 2. All patients had hemorrhagic BSCM. There were 12 (26%) mesencephalic, 19 (41%) pontine, 7 (15%) medullary, and 8 (17%) cerebellar peduncle lesions, with a maximal diameter ranging from 5 to 40 mm (median 15 mm). In total, 24 BSCMs (52%) had bilateral extension crossing the brainstem midline. Lawton grades of 0, I, II, III, IV, V, and VI were defined in 3 (7%), 2 (4%), 10 (22%), 11 (24%), 8 (17%), 7 (15%), and 5 (11%) cases, respectively. Total resection of BSCMs was attained in 43 patients (93%). There were no perioperative deaths. Excluding the 3 most recent cases, the length of follow-up ranged from 56 to 365 months. The majority of patients demonstrated good functional recovery, but regress of the preexisting oculomotor nerve deficit was usually incomplete. No new hemorrhagic events were noted after total resection of BSCMs. In 42 patients (91%), the mRS score at the time of last follow-up was ≤ 2 (favorable outcome), and in 18 (39%), it was 0 (absence of neurological symptoms). Forty-four patients (96%) demonstrated clinical improvement and 2 (4%) had no changes compared with the preoperative period. Multivariate analysis revealed that only lower Lawton grade had a statistically significant independent association (p = 0.0280) with favorable long-term outcome. The area under the receiver operating characteristic curve for prediction of favorable outcome with 7 available Lawton grades of BSCM was 0.93. CONCLUSIONS: Resection of hemorrhagic BSCMs by an experienced neurosurgeon may be performed safely and effectively, even in severely disabled patients. In the authors' experience, preexisting oculomotor nerve palsy represents the main cause of permanent postoperative neurological morbidity. The Lawton grading system effectively predicts long-term outcome after surgery.

Acute subdural hematoma associated with disruption of tumor vessels due to rapid growth of falx meningioma: A case report and literature review.

Background: Meningiomas associated with acute subdural hematoma (ASDH) are rare. The rapid growth of meningiomas has been shown to be one of the mechanisms underlying bleeding. We report the first case of ASDH during an imaging follow-up for the rapid growth of a falx meningioma. Case Description: A 77-year-old woman was diagnosed with an incidental tumor along the right falx cerebri 3 years before bleeding. The follow-up magnetic resonance imaging (MRI) after 3 years showed that the tumor volume had rapidly increased from 4.31 cm3 to 22.27 cm3. The blood vessels around the tumor were stretched. The patient was scheduled to undergo tumor removal surgery. However, the patient experienced a sudden onset of disturbance of consciousness and was transferred to our hospital. On arrival, her Glasgow Coma Scale (GCS) score was 6 (E1V1M4) and right hemiplegia was observed. The patient had no history of traumatic events. Computed tomography (CT) showed left hemispheric and interhemispheric ASDH. Digital subtraction angiography revealed neither tumor staining nor abnormal vessels. Gross total tumor removal and hematoma evacuation were performed. There were no obvious active intraoperative bleeding points. The pathologic diagnosis was meningioma, the World Health Organization Grade I. Postoperative course revealed a GCS score of 10 (E4V1M5) and she was transferred to a rehabilitation hospital. Conclusion: The disruption of tumor vessels due to the rapid growth of meningiomas may be a cause of bleeding. Incidental falx meningiomas with stretched tumor vessels due to rapid growth could indicate the need for early surgery.

Clinical features of herpes simplex virus reactivation after microvascular decompression for trigeminal neuralgia: Experience of 200 patients and a literature review.

Background: Herpes simplex virus (HSV) reactivation occasionally develops in the early postoperative period after microvascular decompression (MVD) for trigeminal neuralgia (TN). Therefore, the present study investigated the clinical features of this phenomenon. Methods: The study cohort comprised 200 patients with 125 women aged between 17 and 90 years (median age, 66 years) who underwent MVD for TN between January 2010 and December 2020. Characteristics were compared between patients with and without HSV reactivation and clinical features were analyzed. Results: Twenty patients had HSV reactivation: herpes labialis in 18 and herpes zoster (final diagnosis) in 2. A multivariate analysis revealed independent correlations between postoperative HV reactivation and a previous history of herpes labialis (odds ratios [OR]: 6.32, P = 0.0003) and reoperation for recurrent or persistent pain (OR: 5.06, P = 0.0211). No significant differences were observed in pain relief, postoperative facial numbness, or Barrow Neurological Institute Pain Intensity/Facial Numbness Scores in the past follow-up between patients with and without HSV reactivation. HSV reactivation manifested at a median of the 4th postoperative day (1-10 days) and its location was not related to the preoperative distribution of facial pain. All patients were treated with local acyclovir and were completely cured within 1-2 weeks. Conclusion: HSV reactivation occurred in 10% of patients after MVD including 1% of herpes zoster. A previous history of herpes labialis and reoperation was identified as risk factors for reactivation. Symptoms were completely cured by antiviral drugs within 1-2 weeks. It is important to note that cases of herpes zoster may be confused with cases of HSV after MVD.

Venous Flow Conversion Technique for Sacrificing the Superior Petrosal Vein During Microvascular Decompression for Trigeminal Neuralgia.

BACKGROUND: Microvascular decompression for trigeminal neuralgia (TN) may require sacrifice of the superior petrosal vein (SPV), with potential risks of ischemia and hemorrhagic complications due to impaired venous return. OBJECTIVE: To investigate methods for safely sacrificing the SPV. METHODS: We retrospectively reviewed 21 cases in 346 consecutive microvascular decompression surgeries for TN. They were intraoperatively identified as SPV and its tributaries being the offending vessels causing TN and were intentionally sacrificed. RESULTS: The transverse pontine vein (TPV) was sacrificed in 10 patients. The main trunk of the SPV was sacrificed using the TPV as a collateral flow pathway in 10 patients. No complications occurred related to impaired venous return. CONCLUSION: The venous flow conversion technique can be applied to safely sacrificing the SPV and its tributaries with the TPV acting as a collateral blood flow pathway to prevent postoperative impaired venous return.

Non-lesional late-onset epilepsy in the elderly Japanese patients: Presenting characteristics and seizure outcomes with regard to comorbid dementia.

The objective of the present retrospective study was analysis of clinical, radiological, and electrophysiological characteristics of the non-lesional late-onset epilepsy (NLLOE) in the elderly Japanese patients, and comparison of the seizure outcomes in this population with regard to presence of comorbid dementia. The study cohort comprised 89 consecutive patients with NLLOE aged ≥ 65 years. In 49 cases (55%), NLLOE manifested with a single type of seizure. Focal impaired awareness seizures (FIAS) were encountered most often (in 69 patients; 78%). Ten patients (11%) had a history of the status epilepticus. Comorbid dementia was diagnosed in 31 patients (35%). Localized or diffuse white matter hyperintensity was the most common imaging finding (66 cases). Epileptiform discharges in the temporal area represented the most frequent abnormality on interictal EEG (24 cases). Seizure-free status for ≥ 12 months was attained in 46 out of 64 patients (72%), who were followed for ≥ 12 months (range, 12 - 110 months), and 42 of them received monotherapy, mainly with levetiracetam (21 patients), carbamazepine (10 patients), or lacosamide (8 patients). In comparison to their counterparts, the rate of seizure-free status for ≥ 12 months was significantly lower in patients with comorbid dementia (81% vs. 52%; P = 0.0205). In conclusion, the NLLOE among Japanese patients aged ≥ 65 years has variable presenting characteristics, and comorbid dementia is diagnosed in one-third of cases. Seizure-free status for ≥ 12 months may be attained in more than two-thirds of treated patients, but comorbid dementia is associated with significantly worse response to antiseizure therapy.

Effective physical therapy activities to improve the supine-to-seated transfer time in stroke patients: an observational pilot study.

[Purpose] This study aimed to examine the effective time allocation for physical therapy activities in patients with stroke. The primary outcome measure was the improvement in the time required to transition from the supine to the sitting position. [Participants and Methods] This study enrolled 19 inpatients with stroke. The activities performed during physical therapy were classified as nontherapeutic activities, minimal therapeutic activities, moderate therapeutic activities, high therapeutic activities, and other activities. We determined the relationship between the activities and the relative shortening ratio of the time required to sit up from the supine position for up to 13 weeks of physical therapy. We also considered the following background factors: patient information, functional independence measure, and Brunnstrom recovery stage. [Results] The Brunnstrom recovery stage for the lower extremity was identified as the confounding factor, and the participants were stratified into the Brunnstrom recovery stage 6 group, in which moderate therapeutic activities and other activities were significantly related to the relative shortening ratio. [Conclusion] The results suggested that other activities exerted a similar effect as moderate therapeutic activities in the Brunnstrom recovery stage 6 group and were more effective than high therapeutic activities in reducing the time required to sit up from the supine position.

Preoperative plasma D-dimer level may be predictive for success of cerebral reperfusion and outcome after emergency mechanical thrombectomy for intracranial large vessel occlusion.

Presented retrospective analysis evaluated whether preoperative plasma D-dimer level may predict the success of cerebral reperfusion and outcome after emergency mechanical thrombectomy (MT) for intracranial large vessel occlusion (ILVO). Study cohort comprised 121 patients (mean age, 76 ± 12 years) from two participating centers. ILVO mostly affected the M1 segment (48 cases) and internal carotid artery (ICA; 37 cases). Mean preoperative National Institutes of Health Stroke Scale (NIHSS) score was 18 ± 8. Mean preoperative plasma D-dimer level was 4.4 ± 6.6 µg/ml. In 88 patients (73%) MT resulted in successful cerebral reperfusion. Multivariate analysis revealed independent associations of non-successful cerebral reperfusion with preoperative plasma D-dimer level > 6.7 µg/ml (P = 0.0021), location of ILVO other than ICA (P = 0.0056), and prolonged antiplatelet or anticoagulant therapy before stroke onset (P = 0.0172). Plasma D-dimer level ≤ 6.7 µg/ml predicted successful cerebral reperfusion with 0.91 sensitivity and 0.36 specificity. In 39 patients (32%) treatment resulted in favorable outcome. Multivariate analysis revealed independent associations of the unfavorable outcome with non-successful cerebral reperfusion after MT (P = 0.0005), preoperative plasma D-dimer level > 1.9 µg/ml (P = 0.0131), higher preoperative NIHSS score (P = 0.0171), and chronic arterial hypertension before stroke onset (P = 0.0254). Plasma D-dimer level ≤ 1.9 µg/ml predicted favorable outcome with 0.64 sensitivity and 0.62 specificity. In conclusion, preoperative plasma D-dimer level may be predictive for success of cerebral reperfusion and outcome after emergency MT for ILVO, which may be potentially helpful for prediction of prognosis in selected treatment candidates.

Variable histopathology features of neuronal dyslamination in the cerebral neocortex adjacent to epilepsy-associated vascular malformations suggest complex pathogenesis of focal cortical dysplasia ILAE type IIIc.

Focal cortical dysplasia type IIIc (FCD-IIIc) is histopathologically defined by the International League Against Epilepsy's classification scheme as abnormal cortical organization adjacent to epilepsy-associated vascular malformations (VM). However, the incidence of FCD-IIIc, its pathogenesis, or association with the epileptogenic condition remains to be clarified. We reviewed a retrospective series of surgical brain specimens from 14 epilepsy patients with leptomeningeal angiomatosis of Sturge-Weber syndrome (LMA-SWS; n = 6), cerebral cavernous malformations (CCM; n = 7), and an arteriovenous malformation (AVM; n = 1) to assess the histopathological spectrum of FCD-IIIc patterns in VM. FCD-IIIc was observed in all cases of LMA-SWS and was designated as cortical pseudolaminar sclerosis (CPLS). CPLS showed a common pattern of horizontally organized layer abnormalities, including neuronal cell loss and astrogliosis, either manifesting predominantly in cortical layer (L) 3 extending variably to deeper areas with or without further extension to L2 and/or L4. Another pattern was more localized, targeting mainly L4 with extension to L3 and/or L5. Abnormal cortical layering characterized by a fusion of L2 and L3 or L4-L6 was also noted in two LMA-SWS cases and the AVM case. No horizontal or vertical lamination abnormalities were observed in the specimens adjacent to the CCM, despite the presence of vascular congestion and dilated parenchymal veins in all VM. These findings suggest that FCD-IIIc depends on the type of the VM and developmental timing. We further conclude that FCD-IIIc represents a secondary lesion acquired during pre- and/or perinatal development rather than following a pathomechanism independent of LMA-SWS. Further studies will be necessary to address the selective vulnerability of the developing cerebral neocortex in LMA-SWS, including genetic, encephaloclastic, hemodynamic, or metabolic events.

Focal atonic seizures originated in the posterior temporoparietal area: A case report.

Atonic seizures are typically observed in younger children with Lennox-Gastaut syndrome and have been rarely described in adults. Herein we present a case of the adolescent-onset drug-resistant focal epilepsy in a 31-year-old woman with focal atonic seizures originating in the left posterior temporoparietal area and manifesting without aura with abrupt impairment of consciousness and slow falling down. According to the video-EEG monitoring, the seizure began with the medium amplitude spikes principally at T5 area evolving onto the left centroparietal area, which was immediately followed by the diffuse suppression of the background EEG activity. The underlying mechanism might be related to high-frequency electrical stimulation of the negative motor areas within the inferior frontal gyrus or anterior to the supplementary sensorimotor area.

[A case of cardiac arrest due to the appearance of Brugada-type electrocardiogram during epilepsy treatment].

The appearance of arrhythmias in epilepsy practice can lead to sudden death. This time, we experienced a case of cardiac arrest caused by lethal arrhythmia and resuscitation, and captured changes in the electrocardiogram over time from outpatient, before and after sudden change, after resuscitation, to convalescent period. QT prolongation and Brugada-type waveforms were confirmed in the changes over time in the electrocardiogram. Focusing on the importance of recognizing the pharmacological and pharmacokinetic interactions with Na channel blockers and psychotropic drugs that may induce electrocardiographic changes, we emphasized the importance of electrocardiogram in epilepsy treatment.

Resolution of the large middle fossa arachnoid cyst without any identifiable cause: Case report.

Although the possibility of spontaneous regression of intracranial arachnoid cysts (AC) during observational follow-up is widely recognized, the number of reports documenting such clinical course, often associated with the mild head trauma, is rather limited. We present a case of nearly complete resolution of the large middle fossa AC in a 5-year-old boy without any identifiable cause in 2.3 years after the initial diagnosis. It once again justifies observational strategy for AC not accompanying by mass effect and manifesting with minimal symptoms or diagnosed incidentally.