Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes. METHODS: A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed. RESULTS: Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation. CONCLUSIONS: A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.

Posterior spinal decompression in adults with spinal cord injury without traumatic compromise of the spinal canal: what is the data?

Background: Spinal cord injury (SCI) can be caused by a variety of factors and its severity can range from a mild concussion to a complete severing of the spinal cord. Τreatment depends on the type and severity of injury, the patient's age and overall health. Reduction of dislocated or fractured vertebrae via closed manipulation or surgical procedures, fixation and removal of bony fragments and debris that compromise the spinal canal are indicated for decompression of the spinal cord and stabilization of the spine. However, when there is no obvious traumatic obstruction of spinal canal, the question arises as to whether laminectomy is needed to be performed to improve neurological outcome. Methods: A literature review covering all indexed studies published between 2013 and 2023 was performed using keywords to identify the patient group of interest (spinal cord injury, SCI, spinal cord trauma, cervical, thoracic, lumbar, thoracolumbar),central cord syndrome (CCS) and the interventions (laminectomy, laminoplasty, decompression, duroplasty). Results: This review includes6 observational studies investigating the outcome of posterior spinal decompression in patients suffering from spinal cord injury without traumatic spinal cord stenosis. Most patients already had degenerative stenosis. From a total of 202, 151 patients (74.7%) improved neurologically by at least one grade at ASIA scale, after being treated with either laminectomy, laminoplasty, duroplasty or a combination of these techniques. Conclusion: Early decompression in SCI patients remains a reasonable practice option and can be performed safely, but no specific evidence supports the use of laminectomy alone. There is emerging evidence that intended durotomy followed by extended meningoplasty may improve the neurological outcome in patients suffering from SCI when meta-traumatic edema is apparent. However, the lack of high-quality evidence and results support the need for further research.

Radiation-induced meningiomas (RIM) in adults: A single-centre retrospective experience.

Introduction: Radiotherapy of central nervous system (CNS) is treatment against many paediatric cancers, even if it is a well-recognized risk factor for meningioma formation. An increased risk of developing secondary brain tumors like radiation-induced meningiomas (RIM) is related to irradiated patients. Research question: This retrospective study aims to present RIM cases treated in a single tertiary-hospital in Greece and compare the results with international literature and cases of sporadic meningiomas. Materials and methods: A single-centre retrospective study of all patients diagnosed between January 2012 and September 2022 with RIM after having been irradiated in CNS for paediatric cancer was undertaken through hospital's electronic record and clinical notes, identifying baseline demographics and latency period. Results: Thirteen patients were identified with RIM diagnosis after receiving irradiation for Acute Lymphoblastic Leukaemia (69.2%), Premature Neuro-Ectodermal Tumour (23.1%), and Astrocytoma (7.7%). Median age at irradiation was 5 years old and 32 years old at RIM's presentation. The latent period from irradiation to meningioma diagnosis was 26.23 â€‹± â€‹5.96 years. After surgical excision, histopathologic results showed grade I meningiomas in 12 out of thirteen cases, while only one atypical meningioma was diagnosed. Conclusion: Patients who underwent CNS-radiotherapy in childhood for any condition have an increased risk of developing secondary brain tumors such as radiation-induced meningiomas. RIMs resemble sporadic meningiomas in symptomatology, location, treatment, and histologic grade. However, long-term follow-up and regular check-ups are recommended in irradiated patients due to short latency period from irradiation to RIM development, which means younger age patients than those with sporadic meningiomas cases.

Primary Intraosseous Cavernous Hemangioma of the Cranium: A Systematic Review of the Literature.

Primary intraosseous cavernous hemangioma (PICH) is a rare, benign tumor of vascular origin, typically arising in the vertebral body. Its presence in the skull is exceedingly rare, with only a few cases being reported worldwide. We carried out the first systematic review of the literature, covering the epidemiology, clinical and imaging features, management, and prognosis of cranial PICH. The literature search revealed 51 studies with 77 patients; the mean age of the patients was 32.7 years with a female predominance of 1.4:1. The majority of cranial PICHs were located in the calvarium, primarily in the frontal and parietal regions, with only a few located in the skull base. The most common initial clinical manifestation was local growth or swelling, followed by a headache. Radiographically, PICHs represented osteolytic, intradiploic masses, which in many cases displayed trabeculations, leading to the so-called "honeycomb" or "starburst" pattern. After contrast administration, PICHs typically enhance. Tumor removal, with craniectomy or en bloc resection and subsequent skull reconstruction, was selected for calvarial PICHs, whereas a transsphenoidal approach, with only partial resection, was applied for clival/sella PICHs. Preoperative embolization, aiming to minimize intraoperative blood loss, was performed in the case of large tumors. At a mean follow-up of 39 months, no patient experienced tumor recurrence, even after subtotal resection. Owing to the benign nature of the tumor, maximal safe resection is recommended as the treatment of choice for patients with cranial PICH.

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review.

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.

Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature.

PURPOSE: Deep brain stimulation (DBS) has been established as a safe and efficient method for the treatment of various movement disorders. As the emerging applications continue to expand and more centers become eligible for the procedure, complication rates and complication avoidance become increasingly important. Our aim was to report the DBS-related complication in our department over the last 7 years, compare our rates with those reported in the literature, and highlight those practices that will aid complications avoidance. PATIENTS AND METHODS: Since 2003, 106 patients underwent DBS for various pathologies in our department. There were 38 (36%) females and 68 (64%) males with a mean age of 57 years. Preoperative diagnoses included Parkinson's disease (n = 88), dystonia (n = 12), tremor (n = 3), epilepsy (n = 1), obsessive-compulsive disorder (n = 1), and central pain syndrome (n = 1). Surgical and hardware-related complications, their treatment, and outcome were recorded and compared with those reported in the literature. RESULTS: There were 12 procedure-related complications (11.3% of patients, 5.7% of the procedures). These included death (n = 1), aborted procedure (n = 1), postoperative respiratory distress (n = 3), intracranial hemorrhage (n = 2), epilepsy (n = 1), postoperative confusion or agitation (n = 3), and malignant neuroleptic syndrome (n = 1). Hardware-related complications presented in 4.3% of the procedures and included infection (five patients, 4.7%), electrode breakage (0.94%), lead migration or misplacement (0.94%), and stricture formation (two patients, 1.9%). CONCLUSIONS: Complication rates after DBS surgery remain low, proving that DBS is not only effective but also safe. Certain strategies do exist in order to minimize complications.

Treatment of idiopathic head drop (camptocephalia) by deep brain stimulation of the globus pallidus internus.

Deep brain stimulation of the globus pallidus internus has been shown to be beneficial in a small number of patients suffering from axial dystonias. However, it has not yet been reported as an effective treatment for the alleviation of idiopathic head drop. The authors describe a 49-year-old woman with idiopathic cervical dystonia (camptocephalia) who was unable to raise her head > 30 degrees when standing or sitting; her symptoms would abate when lying down. This disabling neurological condition was treated successfully with bilateral chronic electrical stimulation of the globus pallidus internus.

Effect of constant-current pallidal deep brain stimulation for primary dystonia on cognition, mood and quality of life: Results from a prospective pilot trial.

OBJECTIVE: Knowledge on the effects of DBS on cognitive functions is limited and no data exists on the effects of constant-current DBS (CC-GPi-DBS), which appears to prevail over constant-voltage stimulation. Our aim was to prospectively assess the effect of Constant-Current-GPi-DBS, using an 8-contact lead, on cognition, mood and quality of life. PATIENTS AND METHODS: Ten patients aged 27-49 underwent prospective neuropsychological assessment using dedicated tests. Various cognitive domains (intelligence, executive functions, memory, attention, visuo-spatial perception, verbal intelligence) as well as emotional state and quality of life were examined preoperatively and 1, 6 and 12 months after continuous constant-current DBS. RESULTS: Patients performed preoperatively below average on information processing speed, phonemic verbal fluency and working memory. At 6-months there was an improvement in phonemic verbal fluency (p < .05), which was retained at 12-months postoperatively (p = .05). Results also showed marginal improvement in the Trail Making-A test (p = .051) and the Stroop colour-word test (p < .05). Despite improvement in Quality of Life (Physical and Mental Component improved by 32.42% and 29.46% respectively), patients showed no discernible change in anxiety and depression status. CONCLUSIONS: CC-GPi-DBS for primary dystonia has no discernible negative impact on cognition and mood. If anything, we noted an improvement of certain cognitive functions.

Spinal synovial cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review.

This study is designed based on the retrospective analysis of patients treated in the Neurosurgical Department of two major hospitals and review of the literature. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic lumbar intraspinal synovial cysts. Spinal juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Although the relevant reports in the international literature are increasing, the controversy about conservative versus surgical treatment and the need for concomitant fusion still exists. Data from seven patients (age range 58-69 years, mean age 61 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concomitant local pathology, treatment and results of treatment were recorded. A follow-up of at least 6 months (range 6-48 months) was conducted and results were noted. All patients had back pain, while five also experienced unilateral radicular leg pain and one had bilateral leg pain. One patient had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. No fusion was performed. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. Review of the literature revealed a trend towards surgery, as this is correlated to a more favorable outcome compared with conservative treatment. Fusion should be performed on a case-by-case basis only. Surgery is a safe and effective treatment choice in this increasingly appearing ailment. A prospective, randomized trial should clarify issues under debate.

Asymptomatic massive subdural hematoma in a patient with bitemporal agenesis and bilateral temporal arachnoid cysts.

The case of a 38-year-old man with a history of chronic migraine is reported. Despite a 3 week history of changes in his migraine pattern, a normal neurologic examination led to conservative treatment. He later presented with worsening headaches and imbalance; tendon reflexes were increased on the right side, and brain computed tomography and magnetic resonance imaging revealed a massive subacute subdural hematoma over the left hemisphere, developing on the grounds of bilateral temporal agenesis. The presence of bilateral temporal arachnoid cysts along with bitemporal agenesis altered clinical findings, causing only mild symptoms where an otherwise acute and devastating neurologic deterioration would be expected.

Impact of age on complications and outcome in meningioma surgery.

BACKGROUND: Surgery for benign brain tumors in elderly patients without severe general health problems is an acceptable practice, as results are comparable with the ones of younger patients. Nevertheless, the hypothesis that operative complications and perioperative incidents could differ between the 2 age groups should be controlled; and age-specific strategies in operative technique and perioperative care may be useful. METHODS: Medical records of 348 patients were reviewed. Demographic data (age, sex), rate of excision, complications of the immediate postoperative period, neurological outcome, and mortality were recorded; and statistical evaluation comparing 2 age groups (19-64 and 65-84 years of age) was performed. RESULTS: The "young" age group consisted of 240 patients, whereas the "elderly" one had 108. Tumor removal rate was not significantly different in the 2 groups. The elderly age group included significantly more "complicated cases." Regarding each complication, postoperative hematoma, infections, and deep vein thrombosis were more frequent in elderly patients, presenting various degrees of statistical significance, whereas postoperative brain edema, hydrocephalus, and cardiorespiratory incidents presented no statistically significant difference. Finally, more elderly patients presented neurological deterioration, although mortality was not significantly different. CONCLUSIONS: Operation for intracranial meningioma in elderly patients is justified as long as detailed preoperative evaluation is performed. Planning of modified protocols including intraoperative technical aspects, careful use of steroids antibiotics, and prophylactic low molecular weight heparin, and early mobilization is necessary for optimizing operative outcome of elderly patients.

Dominant efficiency of nonregular patterns of subthalamic nucleus deep brain stimulation for Parkinson's disease and obsessive-compulsive disorder in a data-driven computational model.

OBJECTIVE: Almost 30 years after the start of the modern era of deep brain stimulation (DBS), the subthalamic nucleus (STN) still constitutes a standard stimulation target for advanced Parkinson's disease (PD), but the use of STN-DBS is also now supported by level I clinical evidence for treatment-refractory obsessive-compulsive disorder (OCD). Disruption of neural synchronization in the STN has been suggested as one of the possible mechanisms of action of standard and alternative patterns of STN-DBS at a local level. Meanwhile, recent experimental and computational modeling evidence has signified the efficiency of alternative patterns of stimulation; however, no indications exist for treatment-refractory OCD. Here, we comparatively simulate the desynchronizing effect of standard (regular at 130 Hz) versus temporally alternative (in terms of frequency, temporal variability and the existence of bursts or pauses) patterns of STN-DBS for PD and OCD, by means of a stochastic dynamical model and two microelectrode recording (MER) datasets. APPROACH: The stochastic model is fitted to subthalamic MERs acquired during eight surgical interventions for PD and eight surgical interventions for OCD. For each dynamical system simulated, we comparatively assess the invariant density (steady-state phase distribution) as a measure inversely related to the desynchronizing effect yielded by the applied patterns of stimulation. MAIN RESULTS: We demonstrate that high (130 Hz)-and low (80 Hz)-frequency irregular patterns of stimulation, and low-frequency periodic stimulation interrupted by bursts of pulses, yield in both pathologic conditions a significantly stronger desynchronizing effect compared with standard STN-DBS, and distinct alternative patterns of stimulation. In PD, values of the invariant density measure are proven to be optimal at the dorsolateral oscillatory region of the STN including sites with the optimal therapeutic window. SIGNIFICANCE: In addition to providing novel insights into the efficiency of low-frequency nonregular patterns of STN-DBS for advanced PD and treatment-refractory OCD, this work points to a possible correlation of a model-based outcome measure with clinical effectiveness of stimulation and may have significant implications for an energy- and therapeutically-efficient configuration of a closed-loop neuromodulation system.

Functional outcome of intrathecal baclofen administration for severe spasticity.

PURPOSE: To estimate the functional benefit in patients with severe spasticity treated with intrathecal baclofen infusion through an implantable pump and to stress the need for functional assessment of these patients with a functional scale. PATIENTS AND METHODS: Between 1999 and 2003, 22 patients with a long history of severe and disabling pharmaceutically intractable spasticity, underwent implantation of a pump for continuous intrathecal baclofen infusion. The patients were subdivided into two categories according to the aetiology of spasticity: 15 had Multiple Sclerosis and seven had suffered a Spinal Cord Injury at different levels (from C4 to T11). Clinical status was assessed with the Ashworth and Penn spasm scales. Functional benefits were evaluated with the Barthel index score and pain relief with a self-reported visual analogue pain scale. RESULTS: Postoperatively, all patients presented improvement in spasticity, reduction of spasm frequency, significant improvement in functional status, enhancement of life comfort and reduction of pain. CONCLUSION: Reduction of spasticity and spasms achieved with intrathecally delivered baclofen, leads to functional improvement and pain relief.

Multiple hemorrhagic brain infarcts after viper envenomation.

We report the case of a 65-year-old woman who presented with severe neurologic complications after envenomation by a viper snake. A computed tomography (CE) scan revealed multiple brain hemorrhagic infarcts. Conservative treatment in this case proved to be sufficient and repetitive CT scans displayed a complete resolution of the radiologic findings. Possible mechanisms for the cerebral infarctions are discussed. The mechanism of infarctions in this case was believed to be the vasomotor and coagulation disorders caused by the toxins present in the snake's venom and was one of the reasons that led to conservative treatment.

Silent radiological imaging time in patients with brain metastasis.

Cerebral metastasis is a common finding in patients with systemic carcinoma and is an indication for progress of the disease. When brain metastases occur, they lead to a considerable decrease in both survival and the quality of life, in patients who otherwise might be functional. Furthermore, the location, size and number of such lesions, play a decisive role in management and prognosis. Even though early diagnosis and treatment is curative in rare cases, it may lead to a useful remission of the central nervous system (CNS) symptoms, enhance the patient's quality of life and prolong survival. The radiological exams established in the diagnosis of this condition, include computed tomography (CT) scan or magnetic resonance imaging (MRI). In cases of "micrometastatic" disease though, these exams may be pronounced as normal. This retrospective study was performed in patients with advanced systemic disease, who presented with neurological findings of intracranial mass lesion, in the absence of radiological evidence. Early-occurring symptoms were evaluated in accordance to location of the primary disease and follow-up with repetitive MRI scans was performed, in an attempt to confirm the diagnosis and facilitate prompt and appropriate treatment.

Supporting clinical decision making during deep brain stimulation surgery by means of a stochastic dynamical model.

OBJECTIVE: During deep brain stimulation (DBS) surgery for the treatment of advanced Parkinson's disease (PD), microelectrode recording (MER) in conjunction with functional stimulation techniques are commonly applied for accurate electrode implantation. However, the development of automatic methods for clinical decision making has to date been characterized by the absence of a robust single-biomarker approach. Moreover, it has only been restricted to the framework of MER without encompassing intraoperative macrostimulation. Here, we propose an integrated series of novel single-biomarker approaches applicable to the entire electrophysiological procedure by means of a stochastic dynamical model. APPROACH: The methods are applied to MER data pertinent to ten DBS procedures. Considering the presence of measurement noise, we initially employ a multivariate phase synchronization index for automatic delineation of the functional boundaries of the subthalamic nucleus (STN) and determination of the acceptable MER trajectories. By introducing the index into a nonlinear stochastic model, appropriately fitted to pre-selected MERs, we simulate the neuronal response to periodic stimuli (130 Hz), and examine the Lyapunov exponent as an indirect indicator of the clinical effectiveness yielded by stimulation at the corresponding sites. MAIN RESULTS: Compared with the gold-standard dataset of annotations made intraoperatively by clinical experts, the STN detection methodology demonstrates a false negative rate of 4.8% and a false positive rate of 0%, across all trajectories. Site eligibility for implantation of the DBS electrode, as implicitly determined through the Lyapunov exponent of the proposed stochastic model, displays a sensitivity of 71.43%. SIGNIFICANCE: The suggested comprehensive method exhibits remarkable performance in automatically determining both the acceptable MER trajectories and the optimal stimulation sites, thereby having the potential to accelerate precise target finalization during DBS surgery for PD.

Prognostic value of time-related Glasgow coma scale components in severe traumatic brain injury: a prospective evaluation with respect to 1-year survival and functional outcome.

The severity of traumatic brain injury (TBI) is determined by many variables, the complexity of which has made prediction of functional outcome an elusive target. To evaluate whether the three components of the Glasgow Coma Scale (GCS) and their alterations over time can serve as predictors of functional outcome after a severe TBI at 12 months after the TBI insult, we carried out a prospective study of patients with severe TBI. Seventy patients were initially enrolled. Data were retrieved from the emergency department records and the patients' intensive care unit, neurosurgical, and rehabilitation unit records. All patients underwent follow-up at 3, 6, and 12 months after injury. GCS components were evaluated on the day of injury and 2 weeks after injury. Functional outcome was estimated using the Glasgow Outcome Scale and the Functional Independence Measure motor scale. It was evaluated during rehabilitation and at 12 months after injury. Fifty-one patients were alive and followed up until 12 months. Logistic regression and receiver-operator characteristic curve analyses were carried out. In terms of functional outcome at 12 months, only GCS on day 15 was found to be a prognostic factor, with all its subscales being related to outcome 12 months later, whereas a higher GCS score on day 15 was also related to survival. A higher motor and verbal response on day 15 was strongly associated with a patient's functional independence, whereby the motor response was a better predictor. The GCS motor score 2 weeks after injury was statistically significantly associated with the 12-month functional outcome in TBI survivors. Motor response was the most useful predictor among the GCS components with respect to the long-term functional outcome in patients with severe TBI.