Trans-Spinal Theta Burst Magnetic Stimulation in Parkinson's Disease and Gait Disorders.

BACKGROUND: Gait disorders in patients with Parkinson's disease (PD) can become disabling with disease progression without effective treatment. OBJECTIVES: To investigate the efficacy of intermittent θ burst trans-spinal magnetic stimulation (TsMS) in PD patients with gait and balance disorders. METHODS: This was a randomized, parallel, double-blind, controlled trial. Active or sham TsMS was applied at third thoracic vertebra with 100% of the trans-spinal motor threshold, during 5 consecutive days. Participants were evaluated at baseline, immediately after last session, 1 and 4 weeks after last session. Primary outcome was Total Timed Up and Go (TUG) values comparing active versus sham phases 1 week after intervention. The secondary outcome measurements consisted of motor, gait and balance scales, and questionnaires for quality of life and cognition. RESULTS: Thirty-three patients were included, average age 68.5 (6.4) years in active group and 70.3 (6.3) years in sham group. In active group, Total TUG mean baseline was 107.18 (95% CI, 52.1-116.1), and 1 week after stimulation was 93.0 (95% CI, 50.7-135.3); sham group, Total TUG mean baseline was 101.2 (95% CI, 47.1-155.3) and 1 week after stimulation 75.2 (95% CI 34.0-116.4), P = 0.54. Similarly, intervention had no significant effects on secondary outcome measurements. During stimulation period, five patients presented with mild side effects (three in active group and two in sham group). DISCUSSION: TsMS did not significantly improve gait or balance analysis in patients with PD and gait disorders. The protocol was safe and well tolerated. © 2024 International Parkinson and Movement Disorder Society.

TCD assessment in fulminant hepatic failure: Improvements in cerebral autoregulation after liver transplantation.

INTRODUCTION AND OBJECTIVES: Acute liver failure, also known as fulminant hepatic failure (FHF), includes a spectrum of clinical entities characterized by acute liver injury, severe hepatocellular dysfunction and hepatic encephalopathy. The objective of this study was to assess cerebral autoregulation (CA) in 25 patients (19 female) with FHF and to follow up with seventeen of these patients before and after liver transplantation. PATIENTS AND METHODS: The mean age was 33.8 years (range 14-56, SD 13.1 years). Cerebral hemodynamics was assessed by transcranial Doppler (TCD) bilateral recordings of cerebral blood velocity (CBv) in the middle cerebral arteries (MCA). RESULTS: CA was assessed based on the static CA index (SCAI), reflecting the effects of a 20-30 mmHg increase in mean arterial blood pressure on CBv induced with norepinephrine infusion. SCAI was estimated at four time points: pretransplant and on the 1st, 2nd and 3rd posttransplant days, showing a significant difference between pre- and posttransplant SCAI (p = 0.005). SCAI peaked on the third posttransplant day (p = 0.006). Categorical analysis of SCAI showed that for most patients, CA was reestablished on the second day posttransplant (SCAI > 0.6). CONCLUSIONS: These results suggest that CA impairment pretransplant and on the 1st day posttransplant was re-established at 48-72 h after transplantation. These findings can help to improve the management of this patient group during these specific phases, thereby avoiding neurological complications, such as brain swelling and intracranial hypertension.

The Effects of Head Elevation on Intracranial Pressure, Cerebral Perfusion Pressure, and Cerebral Oxygenation Among Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: Head elevation is recommended as a tier zero measure to decrease high intracranial pressure (ICP) in neurocritical patients. However, its quantitative effects on cerebral perfusion pressure (CPP), jugular bulb oxygen saturation (SjvO2), brain tissue partial pressure of oxygen (PbtO2), and arteriovenous difference of oxygen (AVDO2) are uncertain. Our objective was to evaluate the effects of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2 among patients with acute brain injury. METHODS: We conducted a systematic review and meta-analysis on PubMed, Scopus, and Cochrane Library of studies comparing the effects of different degrees of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2. RESULTS: A total of 25 articles were included in the systematic review. Of these, 16 provided quantitative data regarding outcomes of interest and underwent meta-analyses. The mean ICP of patients with acute brain injury was lower in group with 30° of head elevation than in the supine position group (mean difference [MD] - 5.58 mm Hg; 95% confidence interval [CI] - 6.74 to - 4.41 mm Hg; p < 0.00001). The only comparison in which a greater degree of head elevation did not significantly reduce the ICP was 45° vs. 30°. The mean CPP remained similar between 30° of head elevation and supine position (MD - 2.48 mm Hg; 95% CI - 5.69 to 0.73 mm Hg; p = 0.13). Similar findings were observed in all other comparisons. The mean SjvO2 was similar between the 30° of head elevation and supine position groups (MD 0.32%; 95% CI - 1.67% to 2.32%; p = 0.75), as was the mean PbtO2 (MD - 1.50 mm Hg; 95% CI - 4.62 to 1.62 mm Hg; p = 0.36), and the mean AVDO2 (MD 0.06 µmol/L; 95% CI - 0.20 to 0.32 µmol/L; p = 0.65).The mean ICP of patients with traumatic brain injury was also lower with 30° of head elevation when compared to the supine position. There was no difference in the mean values of mean arterial pressure, CPP, SjvO2, and PbtO2 between these groups. CONCLUSIONS: Increasing degrees of head elevation were associated, in general, with a lower ICP, whereas CPP and brain oxygenation parameters remained unchanged. The severe traumatic brain injury subanalysis found similar results.

Phenotypical characterization of exteroceptive sensation and pain symptoms on diabetic patients.

BACKGROUD: Diabetic neuropathy (DN) is one of the most common complications of diabetes, affecting about half of individuals with the disease. Among the various symptoms of DN, the development of chronic pain stands out and manifests as exacerbated responses to sensorial stimuli. The conventional clinical treatments used for general neuropathy and associated painful symptoms, still brings uncomplete and unsatisfactory pain relief. Patients with neuropathic pain syndromes are heterogeneous. They present with a variety of sensory symptoms and pain qualities which difficult the correct diagnosis of sensory comorbidities and consequently, the appropriate chronic pain management. AIMS: Herein, we aimed to demonstrate the existence of different sensory profiles on diabetic patients by investigating epidemiological and clinical data on the symptomatology of a group of patients with DN. METHODS: This is a longitudinal and observational study, with a sample of 57 volunteers diagnosed with diabetes from outpatient day clinic of Hospital Universitário of the University of São Paulo-Brazil. After being invited and signed the Informed Consent Form (ICF), patients were submitted to clinical evaluation and filled out pain and quality of life questionnaires. They also performed quantitative sensory test (QST) and underwent skin biopsy for correlation with cutaneous neuropathology. RESULTS: Data demonstrate that 70% of the studied sample presented some type of pain, manifesting in a neuropathic or nociceptive way, what has a negative impact on the life of patients with DM. We also demonstrated a positive association between pain and anxiety and depression, in addition to pain catastrophic thoughts. Three distinct profiles were identified in the sample, separated according to the symptoms of pain: (i) subjects without pain; (ii) with mild or moderate pain; (iii) subjects with severe pain. We also identified through skin biopsy that diabetic patients presented advanced sensory impairment, as a consequence of the degeneration of the myelinated and unmyelinated peripheral fibers. This study characterized the painful symptoms and exteroceptive sensation profile in these diabetic patients, associated to a considerable level of sensory degeneration, indicating, and reinforcing the importance of the long-term clinical monitoring of individuals diagnosed with DM, regarding their symptom profiles and exteroceptive sensitivity.

Site matters: Central neuropathic pain characteristics and somatosensory findings after brain and spinal cord lesions.

BACKGROUND: It is unknown if different etiologies or lesion topographies influence central neuropathic pain (CNP) clinical manifestation. METHODS: We explored the symptom-somatosensory profile relationships in CNP patients with different types of lesions to the central nervous system to gain insight into CNP mechanisms. We compared the CNP profile through pain descriptors, standardized bedside examination, and quantitative sensory test in two different etiologies with segregated lesion locations: the brain, central poststroke pain (CPSP, n = 39), and the spinal cord central pain due to spinal cord injury (CPSCI, n = 40) in neuromyelitis optica. RESULTS: Results are expressed as median (25th to 75th percentiles). CPSP presented higher evoked and paroxysmal pain scores compared to CPSCI (p < 0.001), and lower cold thermal limen (5.6°C [0.0-12.9]) compared to CPSCI (20.0°C [4.2-22.9]; p = 0.004). CPSCI also had higher mechanical pain thresholds (784.5 mN [255.0-1078.0]) compared to CPSP (235.2 mN [81.4-1078.0], p = 0.006) and higher mechanical detection threshold compared to control areas (2.7 [1.5-6.2] vs. 1.0 [1.0-3.3], p = 0.007). Evoked pain scores negatively correlated with mechanical pain thresholds (r = -0.38, p < 0.001) and wind-up ratio (r = -0.57, p < 0.001). CONCLUSIONS: CNP of different etiologies may present different pain descriptors and somatosensory profiles, which is likely due to injury site differences within the neuroaxis. This information may help better design phenotype mechanism correlations and impact trial designs for the main etiologies of CNP, namely stroke and spinal cord lesions. This study provides evidence that topography may influence pain symptoms and sensory profile. The findings suggest that CNP mechanisms might vary according to pain etiology or lesion topography, impacting future mechanism-based treatment choices.

Anatomic evaluation of the posterior temporal approach via the Heschl's gyrus to the thalamus, internal capsule, and atrium.

OBJECTIVE: Posterior temporal craniotomy allows for the exposure of the superior surface of the planum temporale. Heschl's gyrus is the most prominent structure of the planum temporale and can be an anatomical landmark to approach deep brain structures such as the internal capsule, lateral thalamus, and ventricular atrium. METHODS: Ten human cadavers' heads underwent a posterior bilateral temporal craniotomy and the microsurgical dissection of Heschl's gyrus was performed and variables were measured with a neuronavigation system and statistically analyzed. RESULTS: The mean distance between the keyhole and Heschl's gyrus was 61.7 ± 7.3 mm, the mean distance between the stephanion to Heschl's gyrus was 40.8 ± 6.0 mm, and the mean distance between the temporal lobe and Heschl's gyrus was 54.9 ± 6.9 mm. The length of Heschl's gyrus was 24 ± 7.5 mm, and the inclination angle in the axial plane was 20.0 ± 3.7° having the vertex as its deepest point as the base on the surface of the temporal plane. From Heschl's gyrus, the distance from the surface to the internal capsule was 29.1 ± 5.6 mm, the distance to the lateral thalamus was 34.8 ± 7.3 mm, and the distance to the ventricular atrium was 39.6 ± 7.2 mm. No statistical difference was found between the right and left sides. CONCLUSIONS: Through a posterior temporal craniotomy, the temporal planum is exposed by opening the Sylvian fissure, where Heschl's gyrus can be identified and used as a natural corridor to approach the internal capsule, the ventricular atrium, and the lateral thalamus.

Machine Learning Algorithms to Predict Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis.

Delayed cerebral ischemia (DCI) is a common and severe complication after subarachnoid hemorrhage (SAH). Logistic regression (LR) is the primary method to predict DCI, but it has low accuracy. This study assessed whether other machine learning (ML) models can predict DCI after SAH more accurately than conventional LR. PubMed, Embase, and Web of Science were systematically searched for studies directly comparing LR and other ML algorithms to forecast DCI in patients with SAH. Our main outcome was the accuracy measurement, represented by sensitivity, specificity, and area under the receiver operating characteristic. In the six studies included, comprising 1828 patients, about 28% (519) developed DCI. For LR models, the pooled sensitivity was 0.71 (95% confidence interval [CI] 0.57-0.84; p < 0.01) and the pooled specificity was 0.63 (95% CI 0.42-0.85; p < 0.01). For ML models, the pooled sensitivity was 0.74 (95% CI 0.61-0.86; p < 0.01) and the pooled specificity was 0.78 (95% CI 0.71-0.86; p = 0.02). Our results suggest that ML algorithms performed better than conventional LR at predicting DCI.Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews) CRD42023441586; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=441586.

Critical Closing Pressure and Cerebrovascular Resistance Responses to Intracranial Pressure Variations in Neurocritical Patients.

BACKGROUND: Critical closing pressure (CrCP) and resistance-area product (RAP) have been conceived as compasses to optimize cerebral perfusion pressure (CPP) and monitor cerebrovascular resistance, respectively. However, for patients with acute brain injury (ABI), the impact of intracranial pressure (ICP) variability on these variables is poorly understood. The present study evaluates the effects of a controlled ICP variation on CrCP and RAP among patients with ABI. METHODS: Consecutive neurocritical patients with ICP monitoring were included along with transcranial Doppler and invasive arterial blood pressure monitoring. Internal jugular veins compression was performed for 60 s for the elevation of intracranial blood volume and ICP. Patients were separated in groups according to previous intracranial hypertension severity, with either no skull opening (Sk1), neurosurgical mass lesions evacuation, or decompressive craniectomy (DC) (patients with DC [Sk3]). RESULTS: Among 98 included patients, the correlation between change (Δ) in ICP and the corresponding ΔCrCP was strong (group Sk1 r = 0.643 [p = 0.0007], group with neurosurgical mass lesions evacuation r = 0.732 [p < 0.0001], and group Sk3 r = 0.580 [p = 0.003], respectively). Patients from group Sk3 presented a significantly higher ΔRAP (p = 0.005); however, for this group, a higher response in mean arterial pressure (change in mean arterial pressure p = 0.034) was observed. Exclusively, group Sk1 disclosed reduction in ICP before internal jugular veins compression withholding. CONCLUSIONS: This study elucidates that CrCP reliably changes in accordance with ICP, being useful to indicate ideal CPP in neurocritical settings. In the early days after DC, cerebrovascular resistance seems to remain elevated, despite exacerbated arterial blood pressure responses in efforts to maintain CPP stable. Patients with ABI with no need of surgical procedures appear to remain with more effective ICP compensatory mechanisms when compared with those who underwent neurosurgical interventions.

Infrared image method for possible COVID-19 detection through febrile and subfebrile people screening.

This study proposed an infrared image-based method for febrile and subfebrile people screening to comply with the society need for alternative, quick response, and effective methods for COVID-19 contagious people screening. The methodology consisted of: (i) Developing a method based on facial infrared imaging for possible COVID-19 early detection in people with and without fever (subfebrile state); (ii) Using 1206 emergency room (ER) patients to develop an algorithm for general application of the method, and (iii) Testing the method and algorithm effectiveness in 2558 cases (RT-qPCR tested for COVID-19) from 227,261 workers evaluations in five different countries. Artificial intelligence was used through a convolutional neural network (CNN) to develop the algorithm that took facial infrared images as input and classified the tested individuals in three groups: fever (high risk), subfebrile (medium risk), and no fever (low risk). The results showed that suspicious and confirmed COVID-19 (+) cases characterized by temperatures below the 37.5 °C fever threshold were identified. Also, average forehead and eye temperatures greater than 37.5 °C were not enough to detect fever similarly to the proposed CNN algorithm. Most RT-qPCR confirmed COVID-19 (+) cases found in the 2558 cases sample (17 cases/89.5%) belonged to the CNN selected subfebrile group. The COVID-19 (+) main risk factor was to be in the subfebrile group, in comparison to age, diabetes, high blood pressure, smoking and others. In sum, the proposed method was shown to be a potentially important new tool for COVID-19 (+) people screening for air travel and public places in general.

Noninvasive intracranial pressure waveforms for estimation of intracranial hypertension and outcome prediction in acute brain-injured patients.

Analysis of intracranial pressure waveforms (ICPW) provides information on intracranial compliance. We aimed to assess the correlation between noninvasive ICPW (NICPW) and invasively measured intracranial pressure (ICP) and to assess the NICPW prognostic value in this population. In this cohort, acute brain-injured (ABI) patients were included within 5 days from admission in six Intensive Care Units. Mean ICP (mICP) values and the P2/P1 ratio derived from NICPW were analyzed and correlated with outcome, which was defined as: (a) early death (ED); survivors on spontaneous breathing (SB) or survivors on mechanical ventilation (MV) at 7 days from inclusion. Intracranial hypertension (IHT) was defined by ICP > 20 mmHg. A total of 72 patients were included (mean age 39, 68% TBI). mICP and P2/P1 values were significantly correlated (r = 0.49, p < 0.001). P2/P1 ratio was significantly higher in patients with IHT and had an area under the receiving operator curve (AUROC) to predict IHT of 0.88 (95% CI 0.78-0.98). mICP and P2/P1 ratio was also significantly higher for ED group (n = 10) than the other groups. The AUROC of P2/P1 to predict ED was 0.71 [95% CI 0.53-0.87], and the threshold P2/P1 > 1.2 showed a sensitivity of 60% [95% CI 31-83%] and a specificity of 69% [95% CI 57-79%]. Similar results were observed when decompressive craniectomy patients were excluded. In this study, P2/P1 derived from noninvasive ICPW assessment was well correlated with IHT. This information seems to be as associated with ABI patients outcomes as ICP.Trial registration: NCT03144219, Registered 01 May 2017 Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03144219 .

Burst Transspinal Magnetic Stimulation Alleviates Nociceptive Pain in Parkinson Disease-A Pilot Phase II Double-Blind, Randomized Study.

BACKGROUND AND AIMS: Nociception is the most prevalent pain mechanism in Parkinson disease (PD). It negatively affects quality of life, and there is currently no evidence-based treatment for its control. Burst spinal cord stimulation has been used to control neuropathic pain and recently has been shown to relieve pain of nociceptive origin. In this study, we hypothesize that burst transspinal magnetic stimulation (bTsMS) reduces nociceptive pain in PD. MATERIALS AND METHODS: Twenty-six patients were included in a double-blind, sham-controlled, randomized parallel trial design, and the analgesic effect of lower-cervical bTsMS was assessed in patients with nociceptive pain in PD. Five daily induction sessions were followed by maintenance sessions delivered twice a week for seven weeks. The primary outcome was the number of responders (≥ 50% reduction of average pain intensity assessed on a numerical rating scale ranging from 0-10) during the eight weeks of treatment. Mood, quality of life, global impression of change, and adverse events were assessed throughout the study. RESULTS: Twenty-six patients (46.2% women) were included in the study. The number of responders during treatment was significantly higher after active than after sham bTsMS (p = 0.044), mainly owing to the effect of the first week of treatment, when eight patients (61.5%) responded to active and two (15.4%) responded to sham bTsMS (p = 0.006); the number needed to treat was 2.2 at week 1. Depression symptom scores were lower after active (4.0 ± 3.1) than after sham bTsMS (8.7 ± 5.3) (p = 0.011). Patients' global impressions of change were improved after active bTsMS (70.0%) compared with sham bTsMS (18.2%; p = 0.030). Minor adverse events were reported in both arms throughout treatment sessions. One major side effect unrelated to treatment occurred in the active arm (death due to pulmonary embolism). Blinding was effective. CONCLUSION: BTsMS provided significant pain relief and improved the global impression of change in PD in this phase-II trial. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT04546529.

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis.

OBJECTIVES: We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies. DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted. REVIEW METHODS: Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS. RESULTS: The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference. CONCLUSION: Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.

Safety and Outcomes of Dentate Nucleus Deep Brain Stimulation for Cerebellar Ataxia.

Cerebellar symptoms remain orphan of treatment options despite being prevalent and incapacitating. Investigate whether dentate nucleus deep brain stimulation (DN DBS) is safe and leads to improvements in cerebellar symptoms when compared to sham stimulation. This randomized double-blind crossover pilot trial enrolled five patients with spinocerebellar ataxia type 3 or post-lesion ataxia. Active or sham phases were randomly performed three months apart. The primary outcome was ataxia improvement as measured by the Scale for the Assessment and Rating of Ataxia (SARA) after the active compared to the sham period. Secondary outcome measures included safety and tolerability, the Fahn-Tolosa-Marin Tremor Rating Scale (FTMRS), quality of life measurements, and patients' global impression of change. The effects on ataxia were numerically better in four out of five patients after active versus sham stimulation. The composite SARA score did not change after comparing active to sham stimulation (8.6 ± 3.6 versus 10.1 ± 4.1; p = 0.223). The FTMRS showed significant improvement after active stimulation versus sham (18.0 ± 17.2 versus 22.2 ± 19.5; p = 0.039) as did patients' global impression of change (p = 0.038). The quality of life was not modified by stimulation (p = 0.337). DN DBS was well tolerated without serious adverse events. One patient had the electrode repositioned. DN DBS is a safe and well tolerated procedure that is effective in alleviating cerebellar tremor. In this small cohort of ataxic patients, DN DBS did not achieve statistical significance for ataxia improvement.

The diagnostic accuracy of MRI in determining the relations between paraclinoid aneurysms and the cavernous sinus.

PURPOSE: The location of paraclinoid aneurysms is determinant for evaluation of its intradural compartment and risk of SAH after rupture. Advanced MRI techniques have provided clear visualization of the distal dural ring (DDR) to determine whether an aneurysm is intracavernous, transitional or intradural for decision-making. We analyzed the diagnostic accuracy of MRI in predicting whether a paraclinoid aneurysm is intracavernous, transitional or intradural. METHODS: We conducted a prospective cohort between January 2014 and December 2018. Patients with paraclinoid aneurysms underwent 3D fast spin-echo MRI sequence before surgical treatment. The DDR was the landmark for MRI characterization of the aneurysms as follow: (i) Intradural; (ii) Transitional; and (iii) Intracavernous. The MRI sensitivity, specificity, positive and negative likelihood ratios were determined compared to the intraoperative findings. We also evaluated the intertechnique agreement using the Cohen's kappa coefficient (κ) for dichotomous classifications (cavernous vs non-cavernous). RESULTS: Twenty patients were included in the cohort. The accuracy of MRI showed a sensitivity of 86.7% (95%CI:59.5-98.3) and specificity of 90.0% (95%CI:55.5-99.8). Analyzing only patients without history of SAH, accuracy test improved with a sensitivity of 92.3% (95%CI:63.9-99.8) and specificity reached 100% (95%CI: 63-100). Values of Cohen's kappa (κ), intertechnique agreement was considered substantial for dichotomous classifications (κ = 0.754; p < 0.001). For patients without previous SAH, intertechnique agreement was even more coincident for the dichotomous classification (κ = 0.901; p < 0.001). CONCLUSION: 3D fast spin-echo MRI sequence is a reliable and useful technique for determining the location of paraclinoid aneurysms in relation to the cavernous sinus, particularly for patients with no history of SAH.

Long-term outcomes of ruptured saccular intracranial aneurysm clipping versus coiling: systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Previous meta-analyses comparing microsurgery and coiling that include BRAT may be inaccurate to compare the outcomes of ruptured saccular aneurysms. This study aims to evaluate 10-year efficiency, safety, and advantages of coiling compared with clipping in patients with spontaneous saccular aneurismal SAH as a primary outcome. Also analyzed secondary outcomes: no-occlusion, mortality, rebleeding, and retreatment. METHODS: A systematic search of the literature on microsurgical clipping versus coiling was done to identify RCTs with at least 10 years of follow-up published between 2000 and 2021. The primary outcome was favorable functional outcome, defined as a modified Rankin scale (mRS) score ≤ 2. Secondary outcomes were no-occlusion, mortality, rebleeding, and retreatment. Quality of the included trials was analyzed using the Risk of Bias 2.0 (RoB 2.0) tool. A random-effects meta-analysis was performed. RESULTS: Two studies reported 10-year follow-up results, and the meta-analysis did not demonstrate significant differences between groups (OR 0.9, 95%CI 0.66-1.24, I2 = 21%). No differences were observed compared clipping and coiling regarding occlusion rates (OR 5.3, 95%CI 0.8-36.3, I2 = 89%). Mortality rates did not show significant differences between treatment modalities (OR 0.97, 95%CI 0.77-1.21, I2 = 0%). Rebleeding rates were also similar between groups (OR 1.63, 95%CI 0.25-10.7, I2 = 37%); however, significantly higher retreatment rates were associated with coiling (OR 10.6, 95%CI 2.1-52.5, I2 = 80%). Overall, risk of bias was low. CONCLUSION: There are no long-term differences regarding no-occlusion, mortality, and rebleeding rates between coiling and clipping. Higher retreatment rates were associated with coiling.

Adult human neurogenesis: early studies clarify recent controversies and go further.

Evidence on adult mammalian neurogenesis and scarce studies with human brains led to the idea that adult human neurogenesis occurs in the subgranular zone (SGZ) of the dentate gyrus and in the subventricular zone (SVZ). However, findings published from 2018 rekindled controversies on adult human SGZ neurogenesis. We systematically reviewed studies published during the first decade of characterization of adult human neurogenesis (1994-2004) - when the two-neurogenic-niche concept in humans was consolidated - and compared with further studies. The synthesis of both periods is that adult human neurogenesis occurs in an intensity ranging from practically zero to a level comparable to adult mammalian neurogenesis in general, which is the prevailing conclusion. Nonetheless, Bernier and colleagues showed in 2000 intriguing indications of adult human neurogenesis in a broad area including the limbic system. Likewise, we later showed evidence that limbic and hypothalamic structures surrounding the circumventricular organs form a continuous zone expressing neurogenesis markers encompassing the SGZ and SVZ. The conclusion is that publications from 2018 on adult human neurogenesis did not bring novel findings on location of neurogenic niches. Rather, we expect that the search of neurogenesis beyond the canonical adult mammalian neurogenic niches will confirm our indications that adult human neurogenesis is orchestrated in a broad brain area. We predict that this approach may, for example, clarify that human hippocampal neurogenesis occurs mostly in the CA1-subiculum zone and that the previously identified human rostral migratory stream arising from the SVZ is indeed the column of the fornix expressing neurogenesis markers.

True neurogenic thoracic outlet syndrome: late outcomes from a surgical series.

BACKGROUND: True neurogenic thoracic outlet syndrome (TNTOS) is rare, and evaluation of surgical treatment is limited to a few studies in the literature. The purpose of this study is to present the results from a surgical series of 21 patients with TNTOS. METHODS: Retrospective analysis on 21 patients diagnosed with TNTOS who underwent surgery. Demographic data and neurological status were characterized, and patients were classified in accordance with a pre-established scale for assessing the severity of hand impairment before and after surgery. Neuropathic pain was assessed using a visual analogue scale (VAS) and functional disability was quantified using the QuickDASH questionnaire. The results from before and after surgery were compared using the Wilcoxon test, and the significance level was taken to be 5%. RESULTS: There was a significant difference in VAS values from before to after the operation (Wilcoxon test: p = 0.0001; r = 0.86). Most patients (90%) improved after surgery, and in 85% of these patients, the VAS improvement was greater than 50%. Improvement in hand function occurred in seven patients (33.3%), and in most of these cases (28.6%), this improvement was classified as mild. Most patients (93.3%) showed moderate to very severe functional disability at the end of the follow-up. CONCLUSION: After surgery, only one-third of the cases showed improvement in motor function and most patients had significant functional disability. However, the improvement regarding pain was significant. Surgery to control this symptom should be recommended, even in cases of late presentation and severe motor impairment.

Rescue Subthalamic Deep Brain Stimulation for Refractory Meige Syndrome.

Meige syndrome is a segmental form of dystonia. It is a disabling disease, especially when refractory to treatment with botulinum toxin. A well-established therapeutic option is deep brain stimulation (DBS), and the target in bilateral globus pallidus internus (GPi DBS) demonstrated satisfactory short- and long-term efficacy. However, some patients present minor or suboptimal responses after GPi DBS, and in those cases, rescue DBS may be appropriate. The present case illustrates a good outcome after subthalamic nucleus (STN) and not after GPi DBS (considering that both were well positioned and had adequate programming). The larger dimension of the GPi and its somatotopic organization, with the stimulation outside the "face region," could explain our outcomes.

Routine postoperative computed tomography scan after craniotomy: systematic review and evidence-based recommendations.

Over the last few years, the role of early postoperative computed tomography (EPOCT) after cranial surgery has been repeatedly questioned, but there is yet no consensus on the practice. We conducted a systematic review to address the usefulness of EPOCT in association with neurological examination after elective craniotomies compared to the neurological examination alone. Studies were eligible if they provided information about the number of patients scanned, how many were asymptomatic or presented neurological deterioration before the scan and how many of each of those groups had their management changed due to imaging findings. CTs had to be performed in the first 48 h following surgery to be considered early. Eight studies were included. The retrospective studies enrolled a total of 3639 patients, with 3737 imaging examinations. Out of the 3696 CT scans performed in asymptomatic patients, less than 0.8% prompted an intervention, while 100% of patients with neurological deterioration were submitted to emergency surgery. Positive predictive values of altered scans were 0.584 for symptomatic patients and 0.125 for the asymptomatic. The number of altered scans necessary to predict (NNP) one change in management for the asymptomatic patients was 8, while for the clinically evident cases, it was 1.71. The number of scans needed to diagnose one clinically silent alteration is 134.75, and postoperative imaging of neurologically intact patients is 132 times less likely to issue an emergency intervention than an altered neurological examination alone. EPOCT following elective craniotomy in neurologically preserved patients is not supported by current evidence, and CT scanning should be performed only in particular conditions. The authors have developed an algorithm to help the judgment of each patient by the surgeon in a resource-limited context.

Anatomic, qualitative, and quantitative evaluation of the variants of the infratentorial supracerebellar approach to the posteroinferior thalamus.

The posteroinferior region of the thalamus is formed by the pulvinar, and it is surgically accessed through the infratentorial supracerebellar approach, between the midline and the retromastoid region. This study aimed to compare the paramedian, lateral, extreme lateral, and contralateral paramedian corridors with the posteroinferior thalamus through a suboccipital craniotomy and an infratentorial supracerebellar access. Ten cadavers were studied, and the microsurgical dissections were accompanied by the measurement of the variables using a neuronavigation system. Statistical analysis was performed using analysis of variance (ANOVA). The distance between the access midpoint at the cranial surface and pulvinar varied between 53.3 and 53.9 mm, the contralateral access being an exception (59.9 mm). The vertical angle ranged from 20.6° in the contralateral access to 23.5° in the lateral access. There was a gradual increase in the horizontal angle between the paramedian (17.4°), lateral (31.3°), and extreme lateral (43.7°) accesses. But, this angle in the contralateral access was 14.6°, similar to that of the paramedian access. The exposed area of the thalamus was 125.1 mm2 in the paramedian access, 141.8 mm2 in the lateral access, and 165.9 mm2 in the extreme lateral access, which was similar to that of the contralateral access (164.9 mm2). The horizontal view angle increased with lateralization of the access, which facilitated microscopic visualization. With regard to the exposure of the microsurgical anatomy, the extreme lateral and contralateral accesses circumvent the neural and vascular obstacles at the midline, allowing a larger area of anatomical exposure.