Surgical decompression for malignant cerebral oedema after ischaemic stroke.

BACKGROUND: Large territory middle cerebral artery (MCA) ischaemic strokes account for around 10% of all ischaemic strokes and have a particularly devastating prognosis when associated with malignant oedema. Progressive cerebral oedema starts developing in the first 24 to 48 hours of stroke ictus with an associated rise in intracranial pressure. The rise in intracranial pressure may eventually overwhelm compensatory mechanisms leading to a cascading secondary damage to surrounding unaffected parenchyma. This downward spiral can rapidly progress to death or severe neurological disability. Early decompressive craniectomy to relieve intracranial pressure and associated tissue shift can help ameliorate this secondary damage and improve outcomes. Evidence has been accumulating of the benefit of early surgical decompression in stroke patients. Earlier studies have excluded people above the age of 60 due to associated poor outcomes; however, newer trials have included this patient subgroup. This review follows a Cochrane Review published in 2012. OBJECTIVES: To assess the effectiveness of surgical decompression in people with malignant oedema after ischaemic stroke with regard to reduction in mortality and improved functional outcome. We also aimed to examine the adverse effects of surgical decompression in this patient cohort. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus databases, ClinicalTrials.gov, and the WHO ICTRP to July 2022. We also reviewed the reference lists of relevant articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing decompressive craniectomy with medical management to best medical management alone for people with malignant cerebral oedema after MCA ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results, assessed study eligibility, performed risk of bias assessment, and extracted the data. The primary outcomes were death and death or severe disability (modified Rankin Scale (mRS) > 4) at 6 to 12 months follow-up. Other outcomes included death or moderate disability (mRS > 3), severe disability (mRS = 5), and adverse events. We assessed the certainty of the evidence using the GRADE approach, categorising it as high, moderate, low, or very low. MAIN RESULTS: We included nine RCTs with a total of 513 participants included in the final analysis. Three studies included patients younger than 60 years of age; two trials accepted patients up to 80 years of age; and one trial only included patients 60 years or older. The majority of included trials (six) mandated a time from stroke ictus to treatment of < 48 hours, whilst in two of them this was < 96 hours. Surgical decompression was associated with a reduction in death (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.12 to 0.27, 9 trials, 513 participants, P < 0.001; high-certainty evidence); death or severe disability (mRS > 4, OR 0.22, 95% CI 0.15 to 0.32, 9 trials, 513 participants, P < 0.001; high-certainty evidence); and death or moderate disability (mRS > 3, OR 0.34, 95% CI 0.22 to 0.52, 9 trials, 513 participants, P < 0.001; moderate-certainty evidence). Subgroup analysis did not reveal any significant effect on treatment outcomes when analysing age (< 60 years versus ≥ 60 years); time from stroke ictus to intervention (< 48 hours versus ≥ 48 hours); or dysphasia. There was a significant subgroup effect of time at follow-up (6 versus 12 months, P = 0.02) on death as well as death or severe disability (mRS > 4); however, the validity of this finding was affected by fewer participant numbers in the six-month follow-up subgroup. There was no consistent reporting of per-participant adverse event rates in any of the included studies, which prevented further analysis. AUTHORS' CONCLUSIONS: Surgical decompression improves outcomes in the management of malignant oedema after acute ischaemic stroke, including a considerable reduction in death or severe disability (mRS > 4) and a reduction in death or moderate disability (mRS > 3). Whilst there is evidence that this positive treatment effect is present in patients > 60 years old, it is important to take into account that these patients have a poorer prospect of functional survival independent of this treatment effect. In interpreting these results it must also be considered that the data demonstrating benefit are drawn from a unique patient subset with profound neurological deficit, reduced level of consciousness, and no pre-morbid disability or severe comorbidity.

Donut sign: a unique radiological sign of cerebral metastasis in malignant mesothelioma.

A man in his 70s presented to the emergency department with a 3-day history of confusion and right-facial droop. He was diagnosed with stage IIIB (T4N2M0) malignant mesothelioma 6 months previously for which he was being given palliative chemotherapy. An MRI of the brain demonstrated a left parietal cerebral metastasis with unique radiological characteristics termed 'donut sign'. He underwent a craniotomy and complete macroscopic resection of the lesion with a good postoperative outcome. Mesothelioma cerebral metastases are a rarely reported clinical entity, with only a handful of case reports and case series available. On MRI they often demonstrate a distinctive thick-walled lesion, termed 'donut sign', that may be indicative of the diagnosis. Furthermore, case autopsy series suggest these metastases may be underdiagnosed in the clinical setting due to the dismal prognosis. With newer and more effective neoplastic treatment strategies emerging, there may be a rising incidence of central nervous system metastases in the future.

Traumatic intracranial nail-gun injury of the right internal carotid artery causing pseudoaneurysm and caroticocavernous fistula.

Penetrating trauma due to nail gun is an uncommon yet important clinical entity. There are numerous case reports describing these injuries, yet few describe those resulting in cerebrovascular injury. Laceration of cerebral blood vessels may result in significant intracranial haemorrhage and cerebral ischaemia, with catastrophic consequences. In the present study, we report a female patient who was shot in the face with a nail gun in a domestic assault. The nail entered her right cavernous sinus and lacerated her right internal carotid artery causing a pseudoaneurysm and a caroticocavernous fistula. This report details the approach to, and pitfalls of, managing a cerebrovascular injury due to penetrating intracranial nail. Catheter cerebral angiography is essential in the diagnosis and treatment of these injuries. Best treatment and outcomes require clinicians with expertise in endovascular and surgical repair strategies.

Computed tomography-occult discoligamentous instability following blunt cervical spine trauma.

Plain CT is routinely ordered following blunt trauma of the cervical spine, and performs well in the exclusion of significant bony injuries. MRI is reserved for cases of suspected neural or posterior ligamentous compromise, and when other imaging modalities are contraindicated. There are patients however, with unremarkable radiology, and without suggestive clinical features, who are later found to have significant discoligamentous instability. In this report, we present two such cases. In both instances, worsening neurological symptoms prompted follow-up imaging, that demonstrated interval development of sub-axial cervical spondylolisthesis, requiring surgery and instrumentation. We identify and discuss radiological features that may be associated with occult discoligamentous injury, and highlight them as avenues for future research. These may prove useful in stratifying at-risk patients for further imaging in the acute setting.

Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures: A systematic review.

Management of patients with thoracolumbar burst fractures who do not have a neurologic injury has historically been controversial. Whilst management with an orthosis has gained popularity over surgical management, more recent evidence has suggested that even an orthosis may be unnecessary. A systematic review of the literature comparing orthosis with no orthosis in the management of thoracolumbar burst fractures in patients without neurological deficit was conducted. A risk of bias assessment was performed according to the Cochrane Collaboration Back Review Group. The quality of evidence was assessed according to the GRADE system. Two trials met the eligibility criteria. The functional outcomes, radiologic measures of kyphosis, pain scores, and quality of life scores were equivalent between the orthosis and the no orthosis groups. The level of evidence ranged from very low to moderate for the outcomes evaluated. The rate of complications and the rate of failure of treatment requiring surgery was low. Evidence from two small randomised controlled trials suggests that there are equivalent outcomes between treatment with and without an orthosis. Larger trials are needed to assess the treatment effect with greater confidence.

Pseudochoreoathetosis secondary to progressive spondylotic cervical myelopathy.

Pseudochoreoathetosis is a rare movement disorder associated with loss of proprioception. Culprit lesions may occur at any point between the cerebral cortex and the peripheral nerve. Seldom is the underlying cause reversible or prone to improvement. An elderly man presented to our tertiary centre with choreoathetoid movements secondary to spondylotic subaxial cervical myelopathy. His myelopathy fulminated and he was emergently treated with posterior decompressive neurosurgery. Unexpectedly, his choreoathetoid movements improved significantly post-operatively. There are a multitude of reports of pseudochoreoathetosis secondary to lesions of various aetiologies; however, few have reported this disorder secondary to cervical spondylosis. To our knowledge, there is only one other report in the medical literature. Herein, we report a second case, for the purposes of raising awareness of this disorder, and to highlight relevant clinical pearls for clinicians who encounter this rare pathology.

MRI predictors of revision surgery after primary lumbar discectomy.

The prognostic significance of preoperative MRI findings in patients undergoing discectomy is incompletely understood. Identifying the radiological predictors of revision surgery on pre-operative MRI can guide management decisions and potentially prevent multiple surgeries. We included 181 patients who underwent primary lumbar discectomy between 2010 and 2014. All patients were contacted via a short telephone interview to determine if they had revision surgery within 5 years of their index surgery. Preoperative MRI of the lumbosacral spine was evaluated for various radiological factors including type of disc herniation, anatomical location of herniation, direction of herniation, degree of disc degeneration, end plate changes and presence of listhesis. Other potential confounders including age, gender, smoking status and index level of surgery were also recorded. Multivariate model of all radiological predictors and confounders were developed and a step-wise approach was used to remove insignificant variables in order to develop final significant multivariate model. P value of <0.05 was considered statistically significant. Patients with retrolisthesis were found to be 2.7 times more likely than the patients without listhesis to require revision surgery (p = 0.019). Patients with foraminal disc herniation were 3.45 times more likely than the patients with paramedian disc herniation to require revision surgery (p = 0.026). Other MRI predictors failed to achieve statistical significance. Based on the data presented patients with retrolisthesis and/or foraminal disc herniation should be counselled on the relatively higher risk of revision surgery when proceeding with discectomy, or alternative options should be considered.

Radiological predictors of recurrent lumbar disc herniation: a systematic review and meta-analysis.

OBJECTIVE: Lumbar discectomy for the management of lumbar radiculopathy is a commonly performed procedure with generally excellent patient outcomes. However, recurrent lumbar disc herniation (rLDH) remains one of the most common complications of the procedure, often necessitating repeat surgery. rLDH is known to be influenced by a variety of factors, and in this systematic review the authors aimed to explore the radiological predictors of recurrence. METHODS: A systematic review and meta-analysis was conducted to identify studies analyzing radiological predictors of recurrent herniation, both ipsilateral and contralateral. A search was conducted on Medline and EMBASE. Both retrospective and prospective comparative studies were included, measuring radiological parameters of lumbar discectomy patients. All factors were considered irrespective of imaging modality, and a meta-analysis of the data was performed in which 5 or more studies were identified analyzing the same parameter. RESULTS: In total, 1626 reported studies were screened, with 23 being included in this review, of which 13 were appropriate for meta-analysis. Three factors, namely disc height index, Modic changes, and sagittal range of motion, were determined to be significantly correlated with an increased rate of rLDH. Some variables were considered in only 1 or 2 different studies, and the authors have included a narrative review of these novel findings. CONCLUSIONS: The findings of associations between the radiological parameters and rLDH implicates the role of instability in the development of recurrence. Understanding the physiological factors associated with instability is important, because although early degenerative disc changes may predispose patients to herniation recurrence, more advanced degeneration likely reduces segmental motion and concurrently risk of recurrence.

SMART (Stroke-Like Migraine Attacks After Radiation Therapy) Syndrome: A Case Study with Imaging Supporting the Theory of Vascular Dysfunction.

BACKGROUND SMART (Stroke-like Migraine Attacks after Radiation Therapy) syndrome is an uncommon delayed complication of cerebral radiotherapy. Less than 50 cases have been reported in the literature since it was first described in 1995. On average, presentation is about 20 years after radiotherapy, and patients commonly present with headaches, complex seizures, and stroke-like symptoms. The exact pathophysiology of the disease remains poorly understood, but one theory suggests radiation-induced vascular dysfunction. CASE REPORT We present one such case of a 28-year-old man who presented to our Emergency Department with a gradually progressive severe headache and right-sided weakness developing over a few hours. MRI played a central role in the diagnosis of SMART syndrome, with serial studies demonstrating and supporting the theory of vascular dysfunction. The condition is usually self-limiting, and most patients achieve complete recovery of symptoms, as did ours. Its optimal management remains unclear. CONCLUSIONS Better understanding of the imaging findings in SMART syndrome may help differentiate it from tumor recurrence, cerebral infections, or vasculitis. Because the diagnosis of this condition portends a significantly better prognosis and substantially alters patient expectation and management, it is important that clinicians are aware of the usual delayed presentation, symptomology, and imaging findings.

Os odontoideum: a rare cause of syncope.

Syncopal events are a concerning presentation and timely evaluation is warranted. Common aetiologies include cardiac and neurological pathology such as arrhythmias, vertebrobasilar arterial disease and vasovagal syncope. We describe the case of a 65-year-old man who presented to our emergency department with symptoms of vertigo and syncope. He was investigated extensively for both cardiac and neurological causes of his symptoms which returned negative results. An outpatient CT scan demonstrated the presence of Os odontoideum and dynamic instability of the atlantoaxial junction, with presumed dynamic obstruction of the vertebral arterial system. This was successfully managed with a posterior atlantoaxial lateral mass fusion with resolution of syncopal symptoms.

Pathologic Basis of Lumbar Radicular Pain.

BACKGROUND: Lumbar radicular pain is one of the most commonly encountered clinical syndromes; however, its underlying mechanistic basis, and its relation to the natural history of the disease, are poorly understood. METHODS: We revieved the available literature to explore the pathophysiology and natural history of lumbar radicular pain. RESULTS: Experimental observations have spawned distinctive, but not mutually exclusive, pathophysiologic descriptions of radicular pain. These mechanisms include mechanical compression and inflammatory processes. In most cases, a complex interplay between these mechanisms is required to sustain the pain. However, when the dorsal root ganglion is mechanically deformed, sustained discharges causing pain can be evoked, leading to pain based on a purely mechanical basis. However, in other instances, previous sensitization of the nerve root by inflammatory processes is required. CONCLUSION: An understanding of these processes and the natural history of the syndrome is important to developing therapeutic strategies.

Spontaneous Acute Arterial Subdural Hematoma.

BACKGROUND: Spontaneous acute arterial subdural hematoma (SDH) is a rare entity caused by hemorrhage from a cortical perisylvian artery without a known precipitant. CASE DESCRIPTION: A 53-year-old man presented with a 2-day history of acute-onset headache and dysphasia. He had a generalized seizure on arrival to hospital and no history of trauma. A computed tomography demonstrated an acute left-sided SDH. A computed tomography angiogram and a digital subtraction angiogram demonstrated active contrast extravasation into the SDH. A craniotomy was performed to evacuate the hematoma; the bleeding perisylvian artery was visualized and coagulated. CONCLUSIONS: We report a rare case of acute SDH and present a review of the literature. The etiology, investigation, and management of this rare neurosurgical emergency are discussed.

Extra-skeletal Ewing sarcoma of the lumbosacral region in an adult pregnant patient: a case report.

Extra-skeletal Ewing sarcoma in pregnancy is rare. There is thus limited scientific evidence to guide clinicians in its complicated management, particularly within the context of early gestation. We therefore share our successful outcome in a 32-year-old pregnant patient, following a unique management strategy of complete aggressive surgical resection prior to neo-adjuvant therapy. The case involved a 2-month history of right-sided back and gluteal pain, with associated paraesthesia. Lumbosacral magnetic resonance imaging (MRI) revealed an approximate 40×50 mm indeterminate mass in the lower right paraspinal musculature. The mass extended into the first right sacral foramen and the central canal; and also impinged on the S2 exiting nerve. After considering the patients' rapid deterioration, pregnant status and other clinical factors, it was elected to proceed with complete surgical resection prior to any other therapeutic modality. Following surgery, the patient experienced immediate resolution of her pain and by 6 weeks was able to cease the use of all analgesics. At 32-weeks' gestation she underwent an uncomplicated vaginal delivery. At 9 months follow up, she remains disease free and has experienced complete resolution of her back pain and radiculopathy.

Integrated Genetic, Epigenetic, and Transcriptional Profiling Identifies Molecular Pathways in the Development of Laterally Spreading Tumors.

Laterally spreading tumors (LST) are colorectal adenomas that develop into extremely large lesions with predominantly slow progression to cancer, depending on lesion subtype. Comparing and contrasting the molecular profiles of LSTs and colorectal cancers offers an opportunity to delineate key molecular alterations that drive malignant transformation in the colorectum. In a discovery cohort of 11 LSTs and paired normal mucosa, we performed a comprehensive and unbiased screen of the genome, epigenome, and transcriptome followed by bioinformatics integration of these data and validation in an additional 84 large, benign colorectal lesions. Mutation rates in LSTs were comparable with microsatellite-stable colorectal cancers (2.4 vs. 2.6 mutations per megabase); however, copy number alterations were infrequent (averaging only 1.5 per LST). Frequent genetic, epigenetic, and transcriptional alterations were identified in genes not previously implicated in colorectal neoplasia (ANO5, MED12L, EPB41L4A, RGMB, SLITRK1, SLITRK5, NRXN1, ANK2). Alterations to pathways commonly mutated in colorectal cancers, namely, the p53, PI3K, and TGFß pathways, were rare. Instead, LST-altered genes converged on axonal guidance, Wnt, and actin cytoskeleton signaling. These integrated omics data identify molecular features associated with noncancerous LSTs and highlight that mutation load, which is relatively high in LSTs, is a poor predictor of invasive potential. IMPLICATIONS: The novel genetic, epigenetic, and transcriptional changes associated with LST development reveal important insights into why some adenomas do not progress to cancer. The finding that LSTs exhibit a mutational load similar to colorectal carcinomas has implications for the validity of molecular biomarkers for assessing cancer risk. Mol Cancer Res; 14(12); 1217-28. ©2016 AACR.

Does a distal perfusion cannula reduce ischaemic complications of extracorporeal membrane oxygenation?

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized. METHODS: We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables. RESULTS: There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT. CONCLUSION: Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.