Evaluation of outcome measures for post-operative dysphagia after anterior cervical discectomy and fusion.

PURPOSE: The goal is to conduct a review of the current literature to determine and evaluate the current classification metrics available for quantifying post-operative dysphagia. METHODS: We surveyed the literature for the subjective and objective measures used to classify dysphagia, and further described and analyzed them in the context of post-operative dysphagia (PD) after anterior cervical spine surgery, with a focus on anterior cervical discectomy and fusion (ACDF). We searched PubMed from the years 2005-2021 using the terms "anterior cervical discectomy and fusion" and "dysphagia or postoperative dysphagia." We included papers that were meta-analyses, systemic reviews, prospective, or retrospective studies. Our selection was further consolidated via abstract and title screening. Ultimately, nineteen articles were included and had full-text reviews. RESULTS: EAT-10 tool was shown to be more valid and reliable than the commonly used Bazaz grading system. HSS-DDI was found to have a high diagnostic accuracy in stratifying mild, moderate, and severe PD. A shortened 16-item version of the original 44-item SWAL-QOL was found to be statistically and clinically significant. When compared to PROMs, objective tests more accurately diagnose PD. CONCLUSION: We found that the most valuable subjective tests were the EAT-10 and HSS-DI because they are quick, sensitive, and correlated strongly with the well-established measurements of PD. The MBS and FEES provided accurate measurements of the severity of PD, but they required more time and equipment than the surveys. In some patient populations, such as those with pre-surgical dysphagia, objective testing should always be done.

Endoscopic-Assisted Microsurgical Resection of a Recurrent Conus Medullaris Dermoid Tumor.

Surgery for intramedullary spinal cord tumors presents multiple unique challenges, including the need to operate through a very narrow myelotomy window. In this operative video, we demonstrate the use of the surgical endoscope in an operation performed on a 35-year-old woman. She has a history of conus medullaris dermoid tumor resection, and she presented to us with worsening lower extremity sensory and motor symptoms. Magnetic resonance imaging showed a 4-cm recurrence of her tumor. After consenting to surgery, she underwent reoperative posterior lumbar approach to resection of her tumor. In our video we demonstrate our use of a surgical endoscope, which allowed us to minimize the extent of our myelotomy and resect tumor rostral and caudal to our myelotomy, thus minimizing the risk of damage to normal spinal cord that is displaced by tumor (Video 1).

Acute Kidney Injury in Patients with Acute Type B Aortic Dissection.

OBJECTIVE: Acute kidney injury (AKI) is common in patients with aortic diseases; however, it has not been extensively studied in acute type B aortic dissection (TBAD). AKI is known to be associated with adverse kidney outcomes and premature death. This study investigated the incidence and impact of AKI in patients with acute TBAD. METHODS: This was a retrospective study including data from two tertiary vascular centres in the UK. Case notes and electronic records were reviewed for consecutive patients presenting with acute symptomatic TBAD. Patients were managed according to a uniform clinical protocol; both patients who underwent surgery and those managed conservatively were included in this analysis. Serum creatinine values were used to calculate the number of patients who developed AKI, based on validated Kidney Disease Improving Global Outcomes definitions. Associations between incidence of AKI, death, and Major Adverse Kidney Events (MAKE; defined as death, dialysis and/or drop in estimated glomerular filtration rate > 25%) were explored. RESULTS: Overall, 66 (42.6%) of 155 patients developed AKI within one week of presenting with TBAD. Of these, 23 patients (34.8%) had stage 1, 26 patients (39.4%) stage 2, and 17 patients (25.8%) stage 3 AKI. MAKE at 30 and 90 days occurred in 17 (11.0%) and 12 patients (7.7%), respectively. AKI was associated with significantly worse outcomes, with a 24.2% mortality rate in the AKI group compared with 7.8% among those with no AKI (p <.001); this association was also significant in adjusted analyses, both in patients who did and did not undergo surgery. CONCLUSION: AKI is very common among patients presenting with acute TBAD, even in clinically uncomplicated disease. There was a significant association with mortality and MAKE, whether patients underwent surgery or not. This warrants further investigation to better understand the underlying causes of the AKI and investigate management strategies which may improve outcomes.

Endoscope-assisted far lateral craniotomy for resection of posterior fossa neurocysticercosis: illustrative case.

BACKGROUND: Neurocysticercosis is a parasitic infection that commonly affects the ventricles, subarachnoid spaces, and spinal cord of the central nervous system. The authors report an unusual manifestation of purely posterior fossa neurocysticercosis treated with endoscope-assisted open craniotomy for resection. OBSERVATIONS: A 67-year-old male presented with 2 months of progressive dizziness, gait ataxia, headaches, decreased hearing, and memory impairment. Imaging revealed an extra-axial cystic lesion occupying the foramen magnum and left cerebellopontine angle with significant mass effect and evidence of early hydrocephalus. Gross-total resection was accomplished via a left far lateral craniotomy with open endoscopic assistance, and pathological findings were consistent with neurocysticercosis. Postoperatively, he was noted to have a sixth nerve palsy, and adjuvant therapy included albendazole. By 9 months postoperatively, he exhibited complete resolution of an immediate postoperative sixth nerve palsy in addition to all preoperative symptoms. His hydrocephalus resolved and did not require permanent cerebrospinal fluid (CSF) diversion. LESSONS: When combined with traditional skull base approaches, open endoscopic techniques allow for enhanced visualization and resection of complex lesions otherwise inaccessible under the microscope alone. Recognition and obliteration of central nervous system neurocysticercosis can facilitate excellent neurological recovery without the need for CSF diversion.

Protocol for behavioral and neural recording during stimulation of the macaque monkey nucleus basalis.

We present an experimental protocol to record neuronal activity during intermittent stimulation of nucleus basalis (NB), as macaque monkeys perform cognitive tasks. This protocol includes implantation of electrodes and generator devices to deliver electrical stimulation to NB using multiple approaches in monkeys. Direct stimulation of NB avoids peripheral cholinergic side effects, optimizes timing, and activates non-cholinergic projection neurons. We describe electrode preparation, surgery, and implantation for direct evaluation of how stimulation affects monkeys' behavior and neuronal activity. For complete details on the use and execution of this profile, please refer to Qi et al. (2021).

Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review.

BACKGROUND: Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series. METHODS: The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient. RESULTS: This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up. CONCLUSIONS: This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.

Neutrophil extracellular traps exacerbate neurological deficits after traumatic brain injury.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity. Preventative measures reduce injury incidence and/or severity, yet one-third of hospitalized patients with TBI die from secondary pathological processes that develop during supervised care. Neutrophils, which orchestrate innate immune responses, worsen TBI outcomes via undefined mechanisms. We hypothesized that formation of neutrophil extracellular traps (NETs), a purported mechanism of microbial trapping, exacerbates acute neurological injury after TBI. NET formation coincided with cerebral hypoperfusion and tissue hypoxia after experimental TBI, while elevated circulating NETs correlated with reduced serum deoxyribonuclease-1 (DNase-I) activity in patients with TBI. Functionally, Toll-like receptor 4 (TLR4) and the downstream kinase peptidylarginine deiminase 4 (PAD4) mediated NET formation and cerebrovascular dysfunction after TBI. Last, recombinant human DNase-I degraded NETs and improved neurological function. Thus, therapeutically targeting NETs may provide a mechanistically innovative approach to improve TBI outcomes without the associated risks of global neutrophil depletion.

Glossopharyngeal Neuralgia/Neuropathy with Hemodynamic Instability and Associated Syncope Treated with Stereotactic Radiosurgery.

BACKGROUND: Glossopharyngeal neuralgia/neuropathy is rare, and less than 3% of cases involve cardiac arrhythmias of syncope due to activated vagal reflex pathways. Most of these cases are successfully treated with medical management with or without pacemaker placement. We present the first reported case of glossopharyngeal neuralgia/neuropathy with cardiac symptoms refractory to medical management including pacemaker placement but successfully treated with Gamma Knife Radiosurgery. CASE DESCRIPTION: A 70-year-old Caucasian man with recurrent squamous cell carcinoma of the tongue base treated with multiple surgeries, lymph node excision, chemotherapy, and external beam radiation, developed episodes of severe right ear and throat pain. These episodes would be followed by syncopal episodes associated with hypotension and bradycardia. Aggressive medical management including pacemaker could not stabilize the patient's hemodynamic instability. After extensive workup, the patient was diagnosed with glossopharyngeal neuralgia/neuropathy with associated carotid sinus instability. The patient was not a strong surgical candidate, thus the patient underwent Gamma Knife Radiosurgery. The target was set as the glossopharyngeal meatus. Within days of treatment, the patient had no further clinically significant syncope or hemodynamic instability for the remaining 6 months of his life. CONCLUSIONS: To our knowledge, we present the first case of glossopharyngeal neuralgia/neuropathy with medically refractory cardiac dysfunction successfully treated with Gamma Knife Radiosurgery. We advocate that Gamma Knife be considered for similar subsets of patients.

Rapidly Resolving Nonalcoholic Marchiafava-Bignami Disease in the Setting of Malnourishment After Gastric Bypass Surgery.

Objectives. We describe a rare case of nonalcoholic Marchiafava-Bignami disease (MBD) in the setting of malnourishment after gastric bypass. Methods. A 44-year-old nonalcoholic Caucasian woman with malnutrition after gastric bypass presented with 2 weeks of weakness. The patient acutely became stuporous. Brain magnetic resonance imaging showed lesions in the corpus callosum and internal capsules consistent with MBD. After 10 days of treatment, the patient had resolution of her encephalopathy with return to baseline mental function, with radiological improvement. Results. MBD is a rare neurological disorder seen in alcoholics and can rapidly progress to coma or death. Our patient was successfully treated with a regimen typically used in alcoholics. We discuss the relevant literature supporting this regimen. Conclusions. This case demonstrates that since the pathophysiological etiology of the disease is malnutrition, MBD patients can be effectively treated with this regimen regardless of the underlying cause.

Acute spontaneous intracranial epidural haematoma and disseminated intravascular coagulation in a paediatric sickle cell patient.

An African American teenage boy during an acute sickle cell crisis spontaneously developed acute bifrontal epidural haematomas (EDHs) in addition to disseminated intravascular coagulation (DIC). The successfully evacuated EDH reaccumulated postoperatively. After multiple transfusions, the patient underwent repeat surgery. Subsequent maximal medical therapy was unable to significantly improve the patient's neurological status, and due to family wishes, care was withdrawn. EDH are the most common emergent neurosurgical complication of sickle cell disease (SCD). Twenty-two such cases have been previously reported. We present one further complicated by DIC leading to reaccumulation of the patient's EDH. An understanding of the mechanisms of EDH formation in SCD and their associated radiological findings could help clinicians identify when a patient is at high risk of EDH formation and thus offer the potential for early intervention prior to the development of an emergency.

The role of magnetic resonance-guided laser ablation in neurooncology.

INTRODUCTION: The use of magnetic resonance-guided laser-induced thermal therapy (MR-LITT) as a minimally invasive method of treating intra-cranial pathology is a rapidly growing field. The use of MR-LITT in neurooncology has shown promising results; however, there has been no review to date of the current literature. METHODS: A review of the published literature regarding MR-LITT in neurooncology was performed. Studies on PubMed were included if at least one patient with a cerebral tumour or radiation necrosis was treated using quantitative MR thermography-guided LITT, as well as if either safety or outcomes were discussed. RESULTS: In treating recurrent Grade-III and -IV gliomas, we found improved median overall survival of 20.9 months from diagnosis of recurrence, which is comparable with that of 18.9 months for high-dose-rate brachytherapy and 24.4 months for repeated open surgery. Median progression-free survival (PFS) of recurrent glioma is noted to be 4.5 months. For metastatic lesions, we found a median overall survival (OS) to vary between 9.0 and 19.8 months with a PFS between 3.8 and 8.5 months. Current literature reports median OS in similar patients to lie between 7.0 and 28.6 months. Severe complication rates (with permanent deficits) are found to be between 12 and 16.7%, comparable with 11% found in literature for open surgery. CONCLUSIONS: The current literature shows that MR-LITT is safe and shows promising local tumour control rates. Larger randomised studies are warranted to further investigate this adjuvant therapy in the treatment of recurrent high-grade gliomas and metastases.

Bilateral cerebral infarction in the setting of pituitary apoplexy: a case presentation and literature review.

BACKGROUND: Pituitary tumor apoplexy (PTA) is a potentially fatal condition caused by hemorrhage and rapid expansion of a pituitary tumor. One rare consequence of PTA is occlusion of the intracavernous carotid arteries, very rarely leading to cerebral infarction. PURPOSE: To describe a case of PTA leading to bilateral cerebral infarction and provide an extensive literature review of all previously reported cases of PTA leading to cerebral infarction. We discuss how these cases contribute to our understanding of the management of PTA, and we also discuss the differences between cases associated with the reported mechanism of carotid occlusion (compression vs. vasospasm). CASE PRESENTATION: A 56-year-old previously healthy woman complained of severe headache and visual loss one day after sustaining a fall from standing. Computed tomography demonstrated an enlarged sellar and suprasellar mass displacing both cavernous ICAs laterally, with multiple bilateral hypodense areas in the ICA distribution consistent with infarction. She clinically deteriorated and underwent endoscopic transsphenoidal gross total resection for suspected PTA within 48 hours after falling. Her prognosis remained poor after 5 days, and support was withdrawn. CONCLUSION: Twenty-four cases of PTA leading to cerebral infarction have been previously documented-four bilateral, our case being the fifth. Based on our review, the presence of infarction itself does not seem to warrant surgical management in the absence of previously established indications for surgery (such as a deteriorating visual field), despite a 3-5 times mortality increase. No conclusion regarding the role of the mechanism of occlusion can be made at this time.

The Drosophila transcription factor Adf-1 (nalyot) regulates dendrite growth by controlling FasII and Staufen expression downstream of CaMKII and neural activity.

Memory deficits in Drosophila nalyot mutants suggest that the Myb family transcription factor Adf-1 is an important regulator of developmental plasticity in the brain. However, the cellular functions for this transcription factor in neurons or molecular mechanisms by which it regulates plasticity remain unknown. Here, we use in vivo 3D reconstruction of identifiable larval motor neuron dendrites to show that Adf-1 is required cell autonomously for dendritic development and activity-dependent plasticity of motor neurons downstream of CaMKII. Adf-1 inhibition reduces dendrite growth and neuronal excitability, and results in motor deficits and altered transcriptional profiles. Surprisingly, analysis by comparative chromatin immunoprecipitation followed by sequencing (ChIP-Seq) of Adf-1, RNA Polymerase II (Pol II), and histone modifications in Kc cells shows that Adf-1 binding correlates positively with high Pol II-pausing indices and negatively with active chromatin marks such as H3K4me3 and H3K27ac. Consistently, the expression of Adf-1 targets Staufen and Fasciclin II (FasII), identified through larval brain ChIP-Seq for Adf-1, is negatively regulated by Adf-1, and manipulations of these genes predictably modify dendrite growth. Our results imply mechanistic interactions between transcriptional and local translational machinery in neurons as well as conserved neuronal growth mechanisms mediated by cell adhesion molecules, and suggest that CaMKII, Adf-1, FasII, and Staufen influence crucial aspects of dendrite development and plasticity with potential implications for memory formation. Further, our experiments reveal molecular details underlying transcriptional regulation by Adf-1, and indicate active interaction between Adf-1 and epigenetic regulators of gene expression during activity-dependent neuronal plasticity.