Indomethacin-responsive trigeminal autonomic cephalgias: a review of key characteristics and pathophysiology.

Trigeminal autonomic cephalgias (TACs) are a well-defined subset of uncommon primary headaches that share comparable onset, pathophysiology and symptom patterns. TACs are characterised by the presentation of one-sided and high-intensity trigeminal pain together with unilateral cranial autonomic signs, which can include lacrimation, rhinorrhea, and miosis. The International Classification of Headache Disorders 3rd Edition recognises four different headache entities in this group, with cluster headache as the most recognised among them. Hemicrania continua (HC) and paroxysmal hemicrania (PH) are both distinctive cephalgias of which the diagnostic criteria include an absolute response to indomethacin. Consequently, for this reason they are often referred to as 'indomethacin-responsive' TACs. The main focus of this review was to discuss the state of knowledge regarding the pathophysiology and key characteristics of PH and HC. Given the limited understanding of these conditions, and their exceptionally uncommon prevalence, a correct diagnosis can pose a clinical challenge and the search for an effective treatment may be prolonged, which frequently has a serious impact upon patients' quality of life. The information provided in this review is meant to help physicians to differentiate indomethacin-sensitive cephalgias from other distinct headache disorders with a relatively similar clinical presentation, such as cluster headache, trigeminal neuralgia, and various migraine conditions.

Differential DNA methylation associated with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review.

Recent studies suggest that differential DNA methylation could play a role in the mechanism of cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Considering the significance of this matter and a lack of effective prophylaxis against DCI, we aim to summarize the current state of knowledge regarding their associations with DNA methylation and identify the gaps for a future trial. PubMed MEDLINE, Scopus, and Web of Science were searched by two authors in three waves for relevant DNA methylation association studies in DCI after aSAH. PRISMA checklist was followed for a systematic structure. STROBE statement was used to assess the quality and risk of bias within studies. This research was funded by the National Science Centre, Poland (grant number 2021/41/N/NZ2/00844). Of 70 records, 7 peer-reviewed articles met the eligibility criteria. Five studies used a candidate gene approach, three were epigenome-wide association studies (EWAS), one utilized bioinformatics of the previous EWAS, with two studies using more than one approach. Methylation status of four cytosine-guanine dinucleotides (CpGs) related to four distinct genes (ITPR3, HAMP, INSR, CDHR5) have been found significantly or suggestively associated with DCI after aSAH. Analysis of epigenetic clocks yielded significant association of lower age acceleration with radiological CVS but not with DCI. Hub genes for hypermethylation (VHL, KIF3A, KIFAP3, RACGAP1, OPRM1) and hypomethylation (ALB, IL5) in DCI have been indicated through bioinformatics analysis. As none of the CpGs overlapped across the studies, meta-analysis was not applicable. The identified methylation sites might potentially serve as a biomarker for early diagnosis of DCI after aSAH in future. However, a lack of overlapping results prompts the need for large-scale multicenter studies. Challenges and prospects are discussed.

Long-Term Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: A Systematic Review.

BACKGROUND: The long-term outcomes after stereotactic radiosurgery (SRS) for pediatric brain arteriovenous malformations (AVMs) remain poorly understood given the paucity of longitudinal studies. A systematic review was conducted to pool cumulative incidences for all outcomes. METHODS: PubMed, Embase, and Web of Science were queried to systematically extract potential references. The articles relating to AVMs treated via SRS were required to be written in English, involve pediatric patients (<18 years of age), and include a mean follow-up period of >5 years. Individual patient data were obtained to construct a pooled Kaplan-Meier plot on obliteration rates over time. RESULTS: Among the 6 studies involving 1315 pediatric patients averaging a follow-up period of 86.6 months (range, 6-276), AVM obliteration was observed in 66.1% with cumulative probabilities of 48.28% (95% confidence interval [CI], 41.89-54.68), 76.11% (95% CI, 67.50-84.72), 77.48% (95% CI, 66.37-88.59) over 3, 5, and 10 years, respectively. The cumulative incidence of post-SRS hemorrhage, tumors, cysts, and de novo seizures was 7.2%, 0.3%, 1.6%, and 1.5%, respectively. The cumulative incidence of radiation-induced necrosis, edema, radiologic radiation-induced changes (RICs), symptomatic RICs, and permanent RICs were 8.0%, 1.4%, 28.0%, 8.7%, and 4.9%, respectively. CONCLUSIONS: Studies assessing long-term outcomes after SRS are moderate in quality and retrospective. Thus, interpretation with caution is advised given the variable degree of loss to follow-up, which suggests that complication rates may be higher than the values stated in the literature. Future prospective studies are needed to validate these findings.

Extremely Rare Complications in Uniportal Spinal Endoscopy: A Systematic Review with Unique Case Analyses.

Background: Endoscopic spine surgery represents a significant advancement in the minimally invasive treatment of spinal disorders, promising reduced surgical invasiveness while aiming to maintain or improve clinical outcomes. This study undertakes a comprehensive review of the literature on endoscopic spine surgery, with a particular focus on cataloging and analyzing the range of complications, from common postoperative issues to more severe, casuistic outcomes like dural tears and nerve damage. Methods: Our methodology encompassed a detailed review of meta-analyses, prospective randomized trials, cohort studies, and case reports to capture a broad spectrum of complications associated with endoscopic spine techniques. The emphasis was on identifying both the frequency and severity of these complications to understand better the procedural risks. Results: The findings suggest that endoscopic spine surgery generally exhibits a lower complication rate compared to traditional surgical approaches. Nonetheless, the identification of specific, rare complications peculiar to endoscopic methods underscores the critical need for surgeons' advanced skills, continuous learning, and awareness of potential risks. Conclusions: Recognizing and preparing for the potential complications associated with the rapid adoption of endoscopic techniques is paramount to ensuring patient safety and improving surgical outcomes in minimally invasive spine surgery.

Evaluation of PHASES Score for Predicting Rupture of Intracranial Aneurysms: Significance of Aneurysm Size.

BACKGROUND: Recent data have identified that certain risk factors for rupture differ between small and larger intracranial aneurysms (IAs). Such differing risk factors make up 5 out of the 6 predictor variables used in the PHASES score, which raises the question on whether IA size has a significant effect on the score's performance. METHODS: Patients who were diagnosed with an IA incidentally or due to a subarachnoid hemorrhage between 2015 and 2023 were selected for potential inclusion. The median IA size of the cohort was chosen as the cutoff point to categorize small and large (6 mm). The PHASES score was calculated for all patients, and a receiver operating characteristic curve analysis was performed to evaluate the classification accuracy of PHASES in predicting rupture for small and large IAs. RESULTS: A total of 677 IAs were included. Among the IAs, 400 (58.9%) presented as UIAs and 279 (41.0%) as subarachnoid hemorrhage. The average PHASES score was 2.9 and 6.5 for small (n = 322) and large (n = 355) IAs, respectively. The PHASES score performed significantly lower for predicting rupture in smaller IAs (area under the curve: 0.634) compared with the larger (area under the curve: 0.741) (P = 0.00083). CONCLUSIONS: PHASES was shown to underperform on small IAs. The decision to treat small unruptured IAs remains highly controversial, and the development of a new score to estimate the annual rupture rate while accounting for IA morphology is of great need. Our findings can help encourage future researchers to develop such a score.

Gut microbiome in intracranial aneurysm growth, subarachnoid hemorrhage, and cerebral vasospasm: a systematic review with a narrative synthesis.

Intracranial aneurysms (IA) are the most common cerebral vascular pathologies. Their rupture leads to the most dangerous subtype of stroke-aneurysmal subarachnoid hemorrhage (aSAH), which may be followed by cerebral vasospasm and ischemic sequelae. Recently, an imbalance within the intestinal microbiota, referred to as dysbiosis, was suggested to play a role in the formation, progression, and rupture of IA. As no systematic review on this topic exists, considering the significance of this matter and a lack of effective prophylaxis against IA or cerebral vasospasm, we aim to sum up the current knowledge regarding their associations with intestinal microbiome, identify the gaps, and determine future prospects. Scientific databases were systematically and independently searched by two authors from inception to 1st May 2023 for original articles regarding the role of intestinal microbiota in intracranial aneurysmal growth, aSAH occurrence, as well as in cerebral vasospasm following aSAH. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was followed in an abstraction process. The STROBE tool was applied to assess the risk of bias. This research was funded by the National Science Centre, Poland (grant number 2021/41/N/NZ2/00844). Of 302 records, four studies were included that fully met eligibility criteria. Studies reported (1) that the relative abundance of Hungatella hathewayi is a protective factor against aneurysm growth and rupture, resulting from the reduced inflammation and extracellular matrix remodeling in the cerebral arterial wall and from reduced metalloproteinase-mediated degradation of smooth muscle cells in cerebral vessels. (2) Relative abundance of Campylobacter ureolyticus is associated with aSAH. (3) No article has evaluated microbiota in relation to cerebral vasospasm following aSAH although there is an ongoing study. We concluded that intestinal microbiota might be a potential target for diagnostic and therapeutic tools to improve the management of cerebral aneurysms. However, more studies of prospective design are needed.

Telovelar versus transvermian approach to tumors of the fourth ventricle and their impact on postoperative neurological complications: A multicenter study.

Background: Tumors of the fourth ventricle are exceedingly rare; however, such lesions are formidable due to the severe postoperative neurological complications (pNCs) which often occur. The adoption of the telovelar approach over the transvermian was created to supposedly mitigate the pNCs; however, there is a lack of sufficient data supporting this theory. Methods: Records from six hospitals were reviewed for patients surgically treated for a single tumor within the 4th ventricle from 2016 to 2022. The pNCs which had 10 or more occurrences among the patients were individually assessed as the dependent variable in a binary logistic regression model against covariates which included the surgical approach. Results: This study of 67 patients confirms no significant differences in risk for pNCs between the transvermian and telovelar approach. Rather, multivariate analysis identified neurophysiological monitoring (IONM) as a protective factor for postoperative speech and swallowing defects (odds ratio [OR]: 0.076, 95% confidence interval [CI] 0.011-0.525). Furthermore, intraoperative external ventricular drainage (EVD) was a protective factor for postoperative gait and focal motor defects (OR: 0.075, 95% CI 0.009-0.648) and for postoperative hydrocephalus (OR: 0.020, 95% CI 0.002-0.233). A univariate meta-analysis pooling the present study's patients and an additional 304 patients from the three additional studies in the literature confirms no significant differences in risk between the transvermian and telovelar approach for pNCs. Conclusion: Intraoperative adjuncts including IONM and EVD may play a significant role in the postoperative outcome. Despite the present study's sample size being a major limitation, the findings may provide great value to neurosurgeons given the scarcity of the current literature.

External validation of the Chicago Chiari Outcome Scale in adults with Chiari malformation type I.

OBJECTIVE: The Chicago Chiari Outcome Scale (CCOS) serves as a standardized clinical outcome evaluation tool among patients with Chiari malformation type I (CM-I). While the reliability of this scale has been proven for pediatric patients, the literature lacks CCOS validation when used solely in adults. Therefore, this study aimed to determine the validity of the CCOS in an external cohort of adult patients. METHODS: The authors retrospectively analyzed the medical records of symptomatic patients with CM-I who underwent posterior fossa decompression between 2010 and 2018 in six neurosurgical departments. Each patient was clinically assessed at the latest available follow-up. Gestalt outcome was determined as improved, unchanged, or worsened compared with the preoperative clinical state. Additionally, the CCOS score was calculated for each patient based on the detailed clinical data. To verify the ability of the CCOS to determine clinical improvement, the area under the receiver operating characteristic (AUROC) curve was evaluated. A logistic regression analysis using all four components of the CCOS (pain symptoms, nonpain symptoms, functionality, and complications) was performed to establish predictors of the improved outcome. RESULTS: Seventy-five individuals with a mean age of 42 ± 15.32 years were included in the study. The mean follow-up duration was 52 ± 33.83 months. Considering gestalt outcome evaluation, 41 patients (54.7%) were classified as improved, 24 (32%) as unchanged, and 10 (13.3%) as worsened. All patients with a CCOS score of 14 or higher improved, while all those with a CCOS score of 8 or lower worsened. The AUROC was 0.986, suggesting almost perfect accuracy of the CCOS in delineating clinical improvement. A CCOS score of 13 showed high sensitivity (0.93) and specificity (0.97) for identifying patients with clinical improvement. Additionally, a meaningful correlation was found between higher CCOS scores in each component and better outcomes. Patient stratification by total CCOS score showed that those categorized as improved, unchanged, and worsened scored prevalently between 13 and 16 points, 10 and 12 points, and 4 and 9 points, respectively. CONCLUSIONS: In this adult cohort, the CCOS was found to be almost perfectly accurate in reflecting postoperative clinical improvement. Moreover, all four CCOS components (pain symptoms, nonpain symptoms, functionality, and complications) significantly correlated with patient clinical outcomes.

Does SARS-CoV-2 Affect Human Semen? A Systematic Review and Meta-Analysis.

Contradictory results have been reported regarding effects of the SARS-CoV-2 upon human semen. A timely and up-to-date systematic review with meta-analysis appears necessary. This study aimed to deliver pooled prevalence (PP) of SARS-CoV-2 in semen and pooled semen parameters as compared with the uninfected. The relevant databases were scanned by two authors for observational studies reporting analysis of semen in COVID-19 patients. The SARS-CoV-2-infected were assigned to group A (exposed arm), whereas the uninfected to group B (unexposed arm). Newcastle-Ottawa Scale was used to address the risk of bias. PRISMA guidelines were adopted. In case of homogenous studies, fixed-effects model was followed, whereas for heterogenous studies random-effects model was used. Of 990 studies, 24 were eligible involving 1589 subjects (947 in group A and 642 in group B). The "comparability" domain was biased the most. SARS-CoV-2 RNA was detected in three studies among 8 individuals producing the PP of 1.76% (95% CI 0.72-3.21). Sperm concentration was reduced significantly (WMD = -16.23 [95% CI -25.56 to -6.89], as well as total sperm in ejaculate (WMD = -34.84 [95% CI - 43.51 to -26.17]) and sperm volume (WMD = - 0.48 [95% CI - 0.59 to - 0.36] in group A as compared with controls. There was a non-significant effect upon progressive motility and leukocyte presence in semen. SARS-CoV-2 RNA in semen among the infected individuals is detected infrequently. By this token, sexual transmission through semen is of low probability and little concern for public health. However, significant decrease in sperm volume, sperm concentration, and total sperm in ejaculate has been noted. The current data, though, are limited, and more studies with longer follow-up are needed to evaluate the further impact.

External validation of the Ruptured Arteriovenous Malformation Grading Scale (RAGS) in a multicenter adult cohort.

PURPOSE: While Ruptured Arteriovenous Malformation Grading Scale (RAGS) has recently been validated in children, the literature lacks validation on adults exclusively. Therefore, we aimed to determine the validity of RAGS on the external multicenter adult cohort and compare its accuracy with other scales. METHODS: A retrospective analysis was performed in five neurosurgical departments to extract patients who presented with the first episode of acute brain arteriovenous malformation (bAVM) rupture between 2012 and 2019. Standard logistic regression and area under the receiver operating curve (AUROC) calculations were performed to determine the value of the following scales: intracerebral hemorrhage (ICH), AVM-associated ICH (AVICH), Spetzler-Martin (SM), Supplemented SM (Supp-SM), Hunt and Hess (HH), Glasgow Coma Scale (GCS), World Federation of Neurological Surgeons (WFNS), and RAGS to predict change in categorical and dichotomized modified Rankin Scale (mRS) across three follow-up periods: within the 6 months, 6 months to 1 year, and above 1 year. RESULTS: Sixty-one individuals with a mean age of 43.6 years were included. The RAGS outperformed other grading scales during all follow-up time frames. It showed AUROC of 0.78, 0.74, and 0.71 at the first 6 months, between 6 and 12 months, and after 12 months of follow-up, respectively, when categorized mRS was applied, while corresponding values were 0.79, 0.76, and 0.73 for dichotomized mRS, respectively. CONCLUSION: The RAGS constitutes a reliable scale predicting clinical outcomes following bAVM rupture among adults. Furthermore, the RAGS proved its generalizability across medical centers with varying treatment preferences.

Alterations in Human Semen After Infection with SARS-CoV-2: A Meta-analysis.

Background: The purpose of the current study was to assess pooled prevalence (PP) of SARS-CoV-2 in semen and pooled estimates including weighted mean difference (WMD) and risk ratio (RR) of semen characteristics in infected cases as compared with healthy controls. Methods: Major databases were searched by two authors. SARS-CoV-2-positive cases were assigned to the exposed arm (group A), whereas the controls to the unex-posed (group B). Risk of bias was assessed with Newcastle-Ottawa Scale and PRISMA guidelines were followed. Random-effects model was employed for analyzing the heterogeneity and fixed-effects model for homogeneity of studies. Results: Of 170 studies, 14 studies were eligible involving 507 subjects (316 in group A, 191 in group B). The risk of bias was the highest for "comparability" domain. SARS-CoV-2 RNA was found in only two studies among 7 subjects (PP= 2.10%, 95%CI 0.58-4.42). There was a significant decrease in sperm concentration (WMD= -15.29, 95%CI -24.70 - -5.88) and total sperm in ejaculate (WMD= -47.58, 95%CI -86.40 - -8.75) in group A. The effect of COVID-19 upon progressive motility, ejaculate volume, and leukocyte presence in semen was not significant. Conclusion: Prevalence of SARS-CoV-2 in semen among the infected cases is low. Sexual transmission through semen is improbable and of little concern for public health. Sperm concentration and total sperm in ejaculate are significantly reduced as compared with controls. Due to limited information of the current research, longer follow-up is needed to identify delayed or progressive impact.

EuroQol-5 dimensions health-related quality of life questionnaire in craniovertebral instability treated with posterior fixation with or without occipital plating: A comparative study with matched datasets.

Objective: Health-related quality of life (HRQoL) in craniocervical instability (CCI) before and after posterior fixation is yet to be determined. This study aimed to deliver novel and clinically relevant data about HRQoL (baseline, at follow-up, predictors, and correlates) in subjects with CCI treated with posterior fixation with or without occipital plating, and to compare it with matched datasets. Methods: EuroQol-5 dimensions (EQ-5D) questionnaires were collected to evaluate HRQoL before surgery and at follow-up. Study sample size was estimated at 58. Comparison with representative datasets was done by matching on a many-to-many basis. Classic CCI parameters were measured. Strengthening the Reporting of Observational Studies in Epidemiology was followed. Results: Sixty subjects were included. The mean age was 37.2 years. The median follow-up for EQ-5D was 26.3 months with interquartile range (IQR) 10.8 to 47.3 months. The median preoperative score of the 3-level version of EQ-5D (EQ-5D-3L) was 0.254 (IQR = -0.025 to 0.504), whereas at follow-up, it increased to 0.779 (IQR = 0.387-0.864) which is still worse than the 25th percentile (0.894) of the age-matched population. Occipital plating (n = 35; 58.3%) did not influence HRQoL trajectory (P = 0.692). In multiple linear regression, HRQoL at follow-up was affected by the age (ß = -0.004; P = 0.049) and length of hospitalization (ß = -0.134; P = 0.010). Of radiologic measurements, preoperative Wackenheim line correlated with HRQoL at follow-up (rho = -0.432; P = 0 - 028). Conclusions: HRQoL is significantly reduced in CCI. Although this can be improved with posterior fixation, it is still worse than the age-matched population. Occipital plating may not influence HRQoL. HRQoL of the elderly might not increase as much as of the younger subjects. The longer hospitalization, the worse HRQoL could be expected. Preoperative Wackenheim parameter could correlate with HRQoL at follow-up.

Morphometric analysis of the lumbar vertebrae and intervertebral discs in relation to abdominal aorta: CT-based study.

PURPOSE: Although lumbar discectomy is the most common procedure in spine surgery, reports about anatomical relations between discs and prevertebral vessels are limited. Aim of this research was to investigate morphometric of the lumbar region and the relations between intervertebral discs (IVDs) and abdominal aorta. METHODS: 557 abdominal computed tomography scans were assessed. For each spinal column level from Th12/L1 down to L4/L5, we investigated: intervertebral disc's and vertebra's height, width, length, and distance from aorta or common iliac artery (CIA). Those arteries were also measured in two dimensions and classified based on location. RESULTS: 54.58% of patients were male. There was a significant difference in arterial-disc distances (ADDs) between genders at the levels: L1/L2 (1.32 ± 1.97 vs. 0.96 ± 1.78 mm; p = 0.0194), L2/L3 (1.97 ± 2.16 vs. 1.15 ± 2.01 mm; p < 0.0001), L3/L4 (2.54 ± 2.78 vs. 1.71 ± 2.61 mm; p = 0.0012), also for both CIAs (left CIA 3.64 ± 3.63 vs. 2.6 ± 3.06 mm; p = 0.0004 and right CIA: 7.96 ± 5.06 vs. 5.8 ± 4.57 mm; p < 0.001)-those ADDs were higher in men at all levels. The length and width of IVD increased alongside with disc level with the maximum at L4/L5. CONCLUSION: Bifurcations of the aorta in most cases occurred at the L4 level. Collected data suggest that at the highest lumbar levels, there is a greater possibility to cause injury of the aorta due to its close anatomical relationship with discs. Females have limited, in comparison to males, ADD at L1/L2, L2/L3, and L3/L4 levels what should be taken into consideration during preoperative planning of surgical intervention.

Prevalence of high-riding vertebral arteries and narrow C2 pedicles among Central-European population: a computed tomography-based study.

High-riding vertebral artery (HRVA) and narrow C2 pedicles (C2P) pose a great risk of injuring the vessel during C2 pedicle or transarticular screw placement. Recent meta-analysis revealed a paucity of European studies regarding measurements and prevalence of these anatomical variants. Three hundred eighty-three consecutive cervical spine CT scans with 766 potential screw insertion sites were analyzed independently by two trained observers. C2 internal height (C2InH), C2 isthmus height (C2IsH), and C2P width were measured. Kappa statistics for inter- and intraobserver reliability as well as for inter-software agreement were calculated. HRVA was defined as C2IsH of ≤ 5 mm and/or C2InH of ≤ 2 mm. Narrow C2P was defined as C2P width ≤ 4 mm. STROBE checklist was followed. At least 1 HRVA was found in 25,3% (95% CI 21,1-29,8) of patients (16,7% of potential sites). At least 1 narrow C2P was seen in 36,8% (95% CI 32,1-41,7) of patients (23,8% of potential sites). Among those with HRVA, unilateral HRVA was present in 68,0% (95% CI 58,4-77,0), whereas bilateral HRVA in 32,0% (95% CI 23,0-41,6). No difference in terms of laterality (right or left) was seen neither for HRVA nor narrow C2P. Significant differences were found between females and males for all measurements. Each parameter showed either good or excellent inter- or intraobserver, and inter-software agreement coefficients. HRVA and narrow C2P are common findings in Central-European population and should be appreciated at the planning stage before craniocervical instrumentation. Measurements can be consistently reproduced by various observers at varying intervals using different software.

Global incidence of spinal perineural Tarlov's cysts and their morphological characteristics: a meta-analysis of 13,266 subjects.

BACKGROUND: Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and symptoms. Purpose of this meta-analysis is to deliver global incidence and characteristics (location, size, and shape) of TCs. METHODS: Following PRISMA checklist, all major databases were searched by two authors for radiologic studies reporting incidence and morphologic features (location, size, and shape) of TCs. Anatomical Quality Assessment tool was applied for risk of bias evaluation. Meta-analysis of random-effects model was employed. Subgroup analysis for regional distribution, gender, sacral levels, age, correspondence with symptoms, and persistent genital arousal disorder (PGAD) were planned ahead. RESULTS: 22 radiologic studies of level 3 evidence involving 13,266 subjects were included. Global pooled prevalence of TCs was 4.18% (95% CI 2.47-6.30). Mean pooled sagittal diameter was 11.86 mm (95% CI 10.78-12.93). Sacral cysts strongly prevailed over the other segments. Of the sacral, S2 level was the most common (46.7% [95% CI 29.4-60.5]). Geographically, the highest incidence was found in Europe (6.07% [95% CI 1.49-13.00]), followed by North America (3.82% [95% CI 0.49-9.44]), and Asia (3.33% [95% CI 1.52-5.75]). TCs were more common in women than in men (5.84% vs 3.03%, p < 0.001, test of homogeneity, χ2). Subjects with PGAD had incidence of 37.87% (95% CI 2.45-81.75). TCs in pediatric population are rare-0.53% (95% CI 0.02-1.51). 15.59% of TCs corresponded with symptoms. CONCLUSIONS: Spinal perineural (Tarlov) cysts are found in a minority of population. S2 level of the sacral bone is affected most frequently. There is female predominance. Correspondence with symptoms is seen in less than one-fifth of TCs. Studies with stronger evidence level are needed to corroborate the results. The purported high incidence in PGAD requires confirmation in case-control studies for the risk-ratio calculation.

Risk of the high-riding variant of vertebral arteries at C2 is increased over twofold in rheumatoid arthritis: a meta-analysis.

Rheumatoid arthritis (RA) might lead to atlantoaxial instability requiring transpedicular or transarticular fusion. High-riding vertebral artery (HRVA) puts patients at risk of injuring the vessel. RA is hypothesized to increase a risk of HRVA. However, to date, no relative risk (RR) has been calculated in order to quantitatively determine a true impact of RA as its risk factor. To the best of our knowledge, this is the first attempt to do so. All major databases were scanned for cohort studies combining words "rheumatoid arthritis" and "high-riding vertebral artery" or synonyms. RA patients were qualified into the exposed group (group A), whereas non-RA subjects into the unexposed group (group B). Risk of bias was explored by means of Newcastle-Ottawa Scale. MOOSE checklist was followed to ensure correct structure. Fixed-effects model (inverse variance) was employed. Four studies with a total of 308 subjects were included in meta-analysis. One hundred twenty-five subjects were in group A; 183 subjects were in group B. Mean age in group A was 62,1 years, whereas in group B 59,9 years. The highest risk of bias regarded "comparability" domain, whereas the lowest pertained to "selection" domain. The mean relative risk of HRVA in group A (RA) as compared with group B (non-RA) was as follows: RR = 2,11 (95% CI 1,47-3,05), I2 = 15,19%, Cochrane Q = 3,54 with overall estimate significance of p < 0,001. Rheumatoid arthritis is associated with over twofold risk of developing HRVA, and therefore, vertebral arteries should be meticulously examined preoperatively before performing craniocervical fusion in every RA patient.

Management of post-traumatic craniovertebral junction dislocation: A PRISMA-compliant systematic review and meta-analysis of casereports.

Although historically considered fatal, with the advent of improved pre-hospital care, traumatic dislocation of the craniovertebral junction (CVJ) has been increasing in prevalence in neurosurgical centers. As more survivors are reported each year, a timely review with meta-analysis of their management seems necessary. PRISMA checklist was followed step by step. PubMed and Web of Science databases were searched using words "craniovertebral junction dislocation" and their corresponding synonyms. Study eligibility criteria included research studies from 2015 onwards that delineated adult and pediatric patients with confirmed post-traumatic atlantooccipital dislocation (AOD) or atlantoaxial dislocation (AAD) who survived until proper treatment. Of 1475 initial records, 46 articles met eligibility criteria with a total of 141 patients with traumatic CVJ dislocation. Of the patients, 90 were male (63.8%). Mean age of the cohort was 33.3 years (range 1-99 years). Trauma that most often led to this injury was road traffic accident (70.9%) followed by falls (24.6%). The majority of authors support posterior instrumentation of C1-C2 (45.2%) especially by means of Goel-Harms method. At mean follow-up of 15.4 months (range 0.5-60 months), 27.2% of treated patients remained neurologically intact. Of initially symptomatic, 59% improved, 37% were stable, and 4% deteriorated. Instrumenting the occiput in cases of pure AAD was associated with lower chance of neurological improvement in chi-square test (p = 0.0013) as well as in multiple linear regression (ß = - 0.3; p = 0.023). The Goel-Harms C1-C2 fusion is currently the most frequently employed treatment. Many survivors remain with no deficits or improve, rarely deteriorate. Involving the occiput in stabilization in cases of AAD without AOD might be related with worse neurological prognosis.

Prevalence of High-Riding Vertebral Artery: A Meta-Analysis of the Anatomical Variant Affecting Choice of Craniocervical Fusion Method and Its Outcome.

OBJECTIVE: A high-riding vertebral artery (HRVA) has been defined as a C2 isthmus height of ≤5 mm and/or internal height of ≤2 mm measured 3 mm lateral to the border of the spinal canal. Its reported prevalence has varied widely. If overlooked during the approach for craniocervical fusion, injury to the vertebral arteries can occur, affecting the outcome. The present meta-analysis aimed to provide the pooled prevalence of HRVAs. METHODS: A comprehensive database search was conducted by 3 of us. Peer-reviewed studies that had followed the strict definition for HRVAs and had reported its prevalence were included. The risk of bias was assessed using the anatomical quality assessment tool. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The pooled prevalence was calculated using a random effects model. RESULTS: The data from 20 studies with 3126 subjects (7496 sides) were analyzed. The overall pooled prevalence of ≥1 HRVA was 25.3% (95% confidence interval [CI], 19.6%-31.5%). The prevalence in those without the most important confounding factor, rheumatoid arthritis (RA), was 20.9% (95% CI, 16.5%-25.8%). Patients with RA had a prevalence of 42.9% (95% CI, 23.8%-63.1%). The difference between the non-RA and RA groups was statistically significant (P < 0.001, test of homogeneity, χ2). No geographical differences were noted (P = 0.20, test of homogeneity, χ2). Among those with HRVA, unilateral HRVA was present in 70.3% (95% CI, 65.2%-75.2%) and bilateral in 29.7% (95% CI, 24.8%-34.8%). No left or right side predilection was found (left, 50.8%; 95% CI, 33.8%-67.6%; right, 49.2%; 95% CI, 32.4%-66.2%). CONCLUSIONS: Craniocervical fusion should be preceded by examination of the vertebral arteries at the level of C2 because the presence of HRVAs is common and might preclude the safe insertion of transarticular or transpedicular screws.

Acute-on-Chronic Vertex Epidural Hematoma with Diastasis of the Sagittal Suture in an Adult.

BACKGROUND: Vertex epidural hematoma (VEDH) is a rare intracranial mass constituting roughly 2.5% of all epidural hematomas. Bleeding usually derives from the superior sagittal sinus, and presentation is often acute-seldom chronic. Fractures are common, but diastasis of the sagittal suture in adults is unique. We hereby present a case combining these rare features along with diagnostic pitfalls and management. CASE DESCRIPTION: A 43-year-old male with a history of hitting his head against the roll cage of the racing car 3 weeks before admission presented with unbearable headache of 9 Numeric Rating Scale intensity and decreased muscular strength in the right upper limb down to 4/5 of the Lovett scale. The initial Glasgow Outcome Scale was 4. His axial computed tomography scan mimicked convexity hyperostosis, meningioma, or lymphoma. Coronal reconstruction revealed a 102-mL large biconcave mass of mixed hyperdensity and hypodensity at the vertex. Bone window showed sagittal suture diastasis. Contrast-enhanced magnetic resonance imaging gave evidence of superior sagittal sinus detachment. Parietofrontal craniotomy crossing the midline was performed in order to evacuate the hematoma. On 2-week follow-up his pain decreased, his right arm strength recovered, and he had a Glasgow Outcome Scale score of 5. CONCLUSIONS: VEDH can present as an intensifying headache even weeks after purported trauma. Axial computed tomography scans can be tricky because of the blind spot. Even large VEDH may be seen only in the very last few axial slices and may mimic other entities. Coronal reconstructions or additional magnetic resonance imaging come in handy. One-piece parietofrontal craniotomy is an option to approach this hematoma.

The Far Lateral Approach to the Craniovertebral Junction: An Update.

INTRODUCTION: Since 1972, when Hammon first described the far lateral approach (FLA) for treatment of vertebral artery aneurysms, it has undergone numerous modifications, including drilling of the occipital condyle, removal of the laminas of upper cervical vertebrae and so on. Also, the range of indications has increased exponentially. OBJECTIVE: In this paper we discuss state-of-the-art advances in the FLA, such as promising minimally invasive variants where an endoscope is used, and many others. METHODS: We reviewed all articles touching upon the FLA in the modern era (from the year 2000 onward) and selected those that presented a significant contribution to the development of the relevant approach. The database used was PubMed. RESULTS AND CONCLUSION: We found several new caveats not mentioned in other reviews or book chapters. The FLA is an ever-changing field of battle where the common and ultimate goals are to minimize the risk of injuring the major vessel in the region-the vertebral artery-and to provide such an angle of attack upon the tumours in the anterior and anterolateral foramen magnum that it is feasible to ensure gross total resection. This paper is an update on the knowledge about this approach, which we feel is necessary.