When the nerve keeps firing: an institutional experience and systematic review on delayed response after microvascular decompression for trigeminal neuralgia.

BACKGROUND: This study aimed to investigate the occurrence of delayed response following microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and identify potential contributing factors. Additionally, we present two cases with delayed relief observed at our institution. METHOD: Two TN patients with delayed response and clear intra-operative arterial findings are presented in this study. Furthermore, we conducted a systematic review by searching electronic bibliographic databases, including MEDLINE (PubMed), Web of Science, Scopus, and Embase, from inception to 2022. RESULTS: We identified a total of 28 full-text articles involving 322 TN patients who experienced delayed pain relief. Out of these, only 11 studies provided sufficient evidence and were included in the final analysis. Among the patients, 73.46% were female. The mean incidence rate of delayed response after MVD treatment for TN was 10.5%, with a range of 0.95 to 57.14% across different studies. The mean age of these patients was 59.86 years. The reported time to pain relief in the existing reports was at least 4 days post-surgery. In 72.88% of the reported cases, right-side dominance was observed. The majority of delayed cases experienced pain relief within 3 months, with a median time of 1 month. CONCLUSIONS: A thorough examination of the probability of delayed pain relief after MVD for TN and understanding the characteristics of this phenomenon can offer surgeons valuable post-operative guidance and aid in decision-making regarding potential immediate reoperation.

Endovascular treatment as the first-line approach for cure of low-grade brain arteriovenous malformation.

OBJECTIVE: While microsurgery has been proposed as the first-line treatment for patients with low-grade (Spetzler-Martin grade I or II) brain arteriovenous malformations (bAVMs), recent studies have shown promising results for endovascular treatment (EVT) as a single proper choice for the management of this group of bAVMs. In this study, the authors evaluated the safety and efficacy of EVT as a first-line strategy for curing low-grade bAVMs at their center. METHODS: All patients with low-grade bAVMs managed primarily by EVT between 2015 and 2021 were enrolled in this study. Patients were evaluated and treated by the same team and followed with the same protocol. The primary endpoint was the efficacy of EVT on the cure of low-grade bAVMs. The second endpoint was the safety of EVT for the treatment of low-grade bAVMs, including procedural complications and long-term clinical outcomes. RESULTS: A total of 109 patients were enrolled and represented in the study population. The mean patient age was 31.6 ± 14.8 years. Forty-eight AVMs (44%) were Spetzler-Martin grade I and 61 (56%) were grade II. Of 99 patients who completed their EVT sessions, complete exclusion was achieved in 89 patients (89.9%). Overall, complete exclusion was achieved in 59.6% of patients after a single EVT session. At the 6-month follow-up, 106 patients (97.2%) had a favorable outcome. Four patients (4.6%) experienced transient neurological deficits, and 1 patient (0.9%) had a permanent neurological deficit. CONCLUSIONS: EVT can be offered as the first choice of treatment for select patients with low-grade bAVMs, with a high cure rate and low morbidity.

Low-Profile Visualized Intraluminal Support Device for Y-Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms: A Single-Center Experience.

BACKGROUND: The Low-Profile Visualized Intraluminal Support (LVIS) device has been frequently used as an intracranial stent for treating intracranial aneurysms. However, the feasibility and efficacy of LVIS devices in Y-stent-assisted coiling (Y-SAC) have remained contentious. This study aimed to evaluate long-term angiographic and clinical outcomes of Y-SAC using LVIS devices. METHODS: We retrospectively reviewed the clinical presentation and angiography data of patients treated with Y-SAC using LVIS stents. The vascular angle geometry between the parent and the 2 branch vessels, before and after stent deployment and after coiling, were analyzed. Based on the Raymond-Roy Occlusion Classification (RROC), aneurysm occlusion status was classified. Clinical outcomes were assessed using the modified Rankin Scale. RESULTS: Forty patients with 40 aneurysms were included in this study. Immediate postprocedural angiograms showed complete/near-complete occlusion (RROC 1 and 2) in 31 aneurysms (77.5%). The long-term follow-up angiographic studies were available in 32 patients and showed RROC class 1 and 2 in 93.8% of patients. Y-SAC with LVIS devices significantly decreased the angle between the bifurcation branches from 171.90° ± 48.0° (standard deviation) to 130.21° ± 46.3° (standard deviation) (P < 0.0001). Periprocedural complications occurred in 5 patients (12.5%) including 4 in-stent thromboses (10.5%). Thirty-six patients (90.0%) had favorable clinical outcomes at the final follow-up. Univariate analysis showed that World Federation of Neurological Societies grade 3-5, thickness of subarachnoid hemorrhage on head computed tomography, intraprocedural complications, and in-stent thrombosis were predictors of poor outcome. CONCLUSIONS: Y-SAC using the LVIS device for intracranial bifurcation aneurysms is a feasible and relatively safe procedure with favorable long-term angiographic and clinical outcomes.

Intraoperative Ultrasonography in Pituitary Surgery Revisited: An Institutional Experience and Systematic Review on Applications and Considerations.

OBJECTIVE: The primary objective of this systematic review is to evaluate the effectiveness of intraoperative ultrasound (IOUS) in improving outcomes in patients undergoing pituitary surgery. METHODS: A systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic bibliographic databases from conception to 2022. RESULTS: The included studies yielded a total of 660 patients, with 488 patients undergoing IOUS. Outcome were available for 341 patients treated with IOUS and 157 patients who were treated without the IOUS application, and the remission rates following surgery were 76% and 59%, respectively. Only 2 studies reported remission rates for both groups, and meta-analysis for these studies showed significant superiority of intraoperative ultrasonography (Random effect, odds ratio 4.99, P < 0.01). Regarding extent of resection, IOUS resulted in 71% gross total resection, while absence of IOUS yielded a gross total resection rate of 44%. Among studies with available follow-up on IOUS, the recurrence rate was 3%. Pituitary dysfunction (34%), cerebrospinal fluid leak (31%), and central nervous system infection (8%) were the most common complications in the IOUS group. The mean follow-up was 19.97 months in studies reporting follow-up time. CONCLUSIONS: The application of the IOUS is both safe and effective and could improve the outcome of pituitary surgeries. IOUS can assist surgeons in the identification of pituitary tumors and their surrounding anatomy and can help minimize the risk of complications associated with this complex surgical procedure.

Therapeutical impacts of transcranial direct current stimulation on drug-resistant epilepsy in pediatric patients: A double-blind parallel-group randomized clinical trial.

BACKGROUND: Drug-resistant epilepsy is a challenging problem in pediatrics. Transcranial direct current stimulation (TDCS) is a non-invasive neurostimulation technique suggested as a promising method for treating epilepsy. This study aims to evaluate the efficacy of TDCS in focal epilepsy in children with drug-resistant epilepsy. METHOD: We conducted a randomized sham-controlled study with 18 subjects between 6 and 16 years of age, divided equally into two groups. TDCS was performed in 20-minute daily stimulation protocol for five days for both groups. The current intensity was one mA for the first three days, increasing to 1.5 mA on day four and 2 mA on the last day of stimulation. EEG was done before and after the intervention. RESULTS: There was a significant reduction in seizure duration in the case group compared with the sham group. CONCLUSION: five consecutive days of performing TDCS significantly reduced seizure duration in children with focal Drug-resistant epilepsy. However,further studies in this field are necessary to test the effectiveness and set up a coherent and comprehensive protocol.

The modulatory effects of exercise on lipopolysaccharide-induced lung inflammation and injury: A systemic review.

Recent studies have shown that proper exercise significantly restricts inflammatory responses through regulation of the immune system. This review discusses mechanisms of protective effects of exercise in lipopolysaccharide (LPS)-induced lung injury. We performed a systematic search in PubMed, Scopus, and Web of Sciences using the search components "physical exercise", "lung" and "LPS" to identify preclinical studies, which assessed physical activity effects on LPS-induced pulmonary injury. Articles (n = 1240) were screened and those that had the eligibility criteria were selected for data extraction and critical appraisal. In all of the 21 rodent-model studies included, pulmonary inflammation was induced by LPS. Exercise protocols included low and moderate intensity treadmill training and swimming. The results showed that aerobic exercise would prevent LPS-induced oxidative stress and inflammation as well as airways resistance, exhaled nitric oxide, protein leakage, increase in total WBC, macrophage and neutrophil population, levels of interleukin (IL)-6, IL-1ß, IL-17, tumor necrosis factor-α, granulocyte-macrophage colony-stimulating factor and CXCL1/KC, and improved IL-10 and IL-ra in lung tissue, bronchoalveolar lavage fluid (BALF) and serum. In addition, in trained animals, the expression of some anti-inflammatory factors such as heat shock protein72, IL-10, triggering receptor expressed on myeloid cells-2 and irisin was increased, thus ameliorating lung injury complications. Aerobic exercise was shown to alleviate the LPS-induced lung injury in rodent models by suppressing oxidative stress and lowering the ratio of pro-inflammatory to anti-inflammatory cytokines.

Recurrent Painful Ophthalmoplegic Neuropathy with Unilateral Oculomotor and Trochlear Nerve Palsy in an 8-year-old Girl.

BACKGROUND: Recurrent painful ophthalmoplegic neuropathy (RPON) is a rare disorder with a unilateral headache accompanied by ipsilateral episodes of painful ocular cranial nerve neuropathy, which typically occurs in childhood. CASE REPORT: We report an 8-year-old female with four episodes of RPON involving unilateral third and fourth cranial nerves. Right eye exotropia and complete ptosis were detected on examination. Brain MRI images revealed right third nerve enhancement where it exits from the brainstem. She completely recovered after 5 weeks with the administration of prednisolone and indomethacin. DISCUSSION AND CONCLUSION: Due to the rarity of this condition in children, recurrent painful ophthalmoplegic neuropathy should be considered as a differential diagnosis of unilateral or bilateral painful ophthalmoplegia, particularly with a history of migrainous headache. Since it is a treatable entity, and repeated attacks may lead to permanent sequela, early intervention is crucial.