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Open access

Mohammad Anadani and Jonathan Lena

BACKGROUND

Spinal arteriovenous malformations (AVMs) are the most challenging spinal vascular malformations. Endovascular transarterial embolization of spinal AVM has been well described. However, transvenous embolization has not been previously reported. In this case report, the authors describe transvenous embolization of a recurrent intramedullary/conus spinal AVM that was previously deemed unamenable to endovascular therapy

OBSERVATIONS

A 30-year-old female presented with debilitating lumbar back pain and was found to have an intramedullary spinal AVM at the level of the conus medullaris. Initially, the AVM was treated with endovascular arterial embolization and subsequently with microsurgical resection. However, on follow-up angiography, the AVM had recurred. Further arterial embolization was deemed not possible because of anatomical challenges. After careful consideration, endovascular transvenous embolization was performed with successful occlusion of the AVM nidus.

LESSONS

Transvenous embolization is an alternative route for endovascular treatment of spinal AVMs that have an accessible single draining vein.

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Anna B. Lebouille-Veldman, Dylan Spenkelink, Cornelia F. Allaart, and Carmen L. A. Vleggeert-Lankamp

OBJECTIVE

The authors’ objective was to evaluate the association of the Disease Activity Score (DAS) with cervical spine deformity in rheumatoid arthritis (RA) patients during 10-year optimal treatment of systemic disease.

METHODS

The authors evaluated radiological and 10-year follow-up (FU) data of the BeSt (BehandelStrategien) trial. In 272 RA patients, atlantoaxial subluxation (AAS), presence of vertical translocation (VT), and subaxial subluxation (SAS) were evaluated. The associations of these deformities with DAS, self-assessed health (determined with the Health Assessment Questionnaire [HAQ]), and erosions of the hands and feet (Sharp–Van der Heijde score) were studied.

RESULTS

After 10 years of FU, AAS (> 2 mm neutral position) was observed in 62 patients (23%), AAS (≥ 3 mm in flexion) in 24%, AAS (≥ 5 mm in flexion) in 7%, VT did not occur, and SAS was present in 60 patients (22%). In total, 135 patients (50%) were in remission (DAS < 1.6) at 10 years of FU. No association could be established between AAS and DAS. Patients with cervical spine deformity (AAS > 2 mm and/or SAS) at 10 years had a higher HAQ score at 10 years than patients without cervical spine deformity (HAQ scores of 0.65 and 0.51, respectively, p = 0.04; 95% CI –0.29 to 0.00).

CONCLUSIONS

Even though 50% of patients were in remission after 10 years and the BeSt trial was designed to optimize treatment, 40% of patients developed at least mild RA-associated cervical spine deformity and 7% developed significant AAS. This indicates that even in this era of disease-modifying antirheumatic drugs and biologicals, cervical deformity is prevalent among patients with RA and should not be neglected in patient treatment plans and information.

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Yinqing Wang, Yongjie Ma, Zihao Song, Chengbin Yang, Tianqi Tu, Kun Yang, Chuan He, Guilin Li, Peng Hu, Liyong Sun, Ming Ye, and Hongqi Zhang

OBJECTIVE

Current knowledge about venous hypertensive myelopathy (VHM) is incomplete. This study was performed with the aim of clarifying the clinical features and outcomes of craniocervical VHM.

METHODS

This retrospective, single-center cohort study included 65 patients with craniocervical junction arteriovenous fistulas resulting in VHM treated in Xuanwu Hospital from January 1, 2002, to December 30, 2020. All patients underwent microsurgery or endovascular treatment. The primary outcome was neurological function assessment using the Japanese Orthopaedic Association (JOA) scale, modified Aminoff-Logue Scale (mALS), and Venous Hypertensive Myelopathy Scale (VHMS). The secondary outcomes were recurrences and postoperative adverse events. Pearson linear regression and receiver operating characteristic curves were used to evaluate the relationships among the three scales. Kaplan-Meier and multivariate logistic regression analyses were performed to predict outcomes.

RESULTS

The mean patient age was 57.4 ± 11.4 years, and 88% of patients were male. The 1-year follow-up rate was 83.1%, and the 5-year follow-up rate was 50.8%. The VHMS was correlated with the JOA (R2 = 0.6722) and mALS (R2 = 0.7399) and increased the assessment accuracy by approximately 20% when compared with the other two scales. Overall, 25.9% of patients experienced delayed neurological decline beyond the 1-year follow-up. Further logistic regression suggested that age > 65 years was an independent predictor (OR 7.831, 95% CI 1.090–56.266; p = 0.041). Embolic recanalization and new bilateral symmetry feeders were the major reasons for recurrence. Recurrence increased the risk of adverse events after the second surgery (OR 20.455, 95% CI 1.170–357.320; p = 0.039).

CONCLUSIONS

CCJ AVFs resulting in VHM are a rare but deadly complication, and providers should be cautious of age-related delayed neurological decline and strive for a one-time anatomical cure.

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Karol Wiśniewski, Marta Popęda, Benjamin Price, Michał Bieńkowski, Andreas Fahlström, Katharine Drummond, and Alexios A. Adamides

OBJECTIVE

Delayed cerebral ischemia (DCI) is a serious complication of aneurysmal subarachnoid hemorrhage (aSAH), which is responsible for significant death and disability. The dynamic balance between the production and elimination of reactive oxygen species (ROS) in patients with DCI is suspected be shifted to favor ROS formation. The authors assessed the relationship between F2-isoprostanes (F2-IsoPs), oxidative stress biomarkers, and glucose-6-phosphate dehydrogenase (G6PD), which are responsible for nicotinamide adenine dinucleotide phosphate (NADPH) production for glutathione system function, with post-aSAH DCI.

METHODS

The authors assessed 45 aSAH patients for F2-IsoP and G6PD concentration using commercial ELISA on days 2, 4, and 6 after aSAH. The authors examined the correlation between plasma F2-IsoP and G6PD concentrations and clinical factors with DCI occurrence and aSAH outcome.

RESULTS

Expectedly, the most important clinical predictors of DCI were Hunt and Hess grade and modified Fisher (mFisher) grade. Plasma F2-IsoP and G6PD concentrations were greater in aSAH patients than the control group (p < 0.01). F2-IsoP concentrations were greater and G6PD concentrations were lower in patients with DCI than those without (p < 0.01). Plasma F2-IsoP and G6PD concentrations on day 2 were correlated with DCI occurrence (p < 0.01). Plasma F2-IsoP concentrations on days 2 and 6 were correlated with outcome at 1 and 12 months (p < 0.01).

CONCLUSIONS

Decreased G6PD indirectly informs the reduced antioxidant response, especially for the glutathione system. G6PD concentration was lower in patients with DCI than those without, which may explain the increased F2-IsoP concentrations. mFisher grade, plasma F2-IsoP concentration, and G6PD concentration on day 2 after aSAH, in combination, may serve as predictors of DCI. Further research is necessary to investigate the therapeutic utility of F2-IsoPs and antioxidants in clinical practice.

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Samuel B. Kankam, Amirhosein Nejat, Amin Tavallaii, Keyvan Tayebi Meybodi, Zohreh Habibi, and Farideh Nejat

OBJECTIVE

The goal of this study was to investigate and identify the predictors associated with the incidence of hydrocephalus requiring shunt insertion in patients with encephalocele (EC), and to develop a scoring system to estimate the probability of hydrocephalus occurrence over time in these patients.

METHODS

A retrospective analysis was undertaken on data from patients treated for EC at a tertiary medical center between 2010 and 2021. Data including patient age at presentation, sex, sac location, sac size, contents, presence of ventriculomegaly/hydrocephalus, CSF leakage, and other associated intracranial/extracranial anomalies were among the variables evaluated for their predictive value. In addition, logistic regression analyses were performed to identify the independent predictors. A predictive scoring system was developed based on regression coefficients.

RESULTS

A total of 102 cases of EC were identified. The patient group consisted of 52 boys and 50 girls. Seventy-one patients (69.6%) had posterior ECs. Forty-three (42.2%) of the ECs contained neural tissue. Thirty-three patients presented with ventriculomegaly (32.4%), 30 of whom (90.9%) underwent ventriculoperitoneal shunt placement for hydrocephalus. Multivariate analysis revealed that the presence of other associated anomalies (OR 2.8, 95% CI 1.1–7.4, p = 0.027), larger EC sac size (OR 1.3, 95% CI 1.01–1.6, p = 0.042), and infections (OR 6.8, 95% CI 1.3–34.8, p = 0.034) were associated with ventriculomegaly. The logistic regression model consisted of 5 variables including the patients’ history of meningitis, their sex, sac location, sac size, and presence of other other associated anomalies; analysis resulted in the maximum accuracy of 86% for the prediction of hydrocephalus occurrence.

CONCLUSIONS

According to the findings, the presence of other associated anomalies, a larger sac, and infections are significant independent predictors of hydrocephalus. By considering these 3 predictors as well as sac location and the patient’s sex, it will be possible to predict hydrocephalus occurrence in patients with EC with significant accuracy.

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Ramin A. Morshed, Satvir Saggi, Daniel D. Cummins, Annette M. Molinaro, Jacob S. Young, Jennifer A. Viner, Javier E. Villanueva-Meyer, Ezequiel Goldschmidt, Lauren Boreta, Steve E. Braunstein, Edward F. Chang, Michael W. McDermott, Mitchel S. Berger, Philip V. Theodosopoulos, Shawn L. Hervey-Jumper, Manish K. Aghi, and Mariza Daras

OBJECTIVE

Resection of brain metastases (BMs) may be associated with increased risk of leptomeningeal disease (LMD). This study examined rates and predictors of LMD, including imaging subtypes, in patients who underwent resection of a BM followed by postoperative radiation.

METHODS

A retrospective, single-center study was conducted examining overall LMD, classic LMD (cLMD), and nodular LMD (nLMD) risk. Logistic regression, Cox proportional hazards, and random forest analyses were performed to identify risk factors associated with LMD.

RESULTS

Of the 217 patients in the cohort, 47 (21.7%) developed postoperative LMD, with 19 cases (8.8%) of cLMD and 28 cases (12.9%) of nLMD. Six-, 12-, and 24-month LMD-free survival rates were 92.3%, 85.6%, and 71.4%, respectively. Patients with cLMD had worse survival outcomes from the date of LMD diagnosis compared with nLMD (median 2.4 vs 6.9 months, p = 0.02, log-rank test). Cox proportional hazards analysis identified cerebellar/insular/occipital location (hazard ratio [HR] 3.25, 95% confidence interval [CI] 1.73–6.11, p = 0.0003), absence of extracranial disease (HR 2.49, 95% CI 1.27–4.88, p = 0.008), and ventricle contact (HR 2.82, 95% CI 1.5–5.3, p = 0.001) to be associated with postoperative LMD. A predictive model using random forest analysis with an area under the receiver operating characteristic curve of 0.87 in a test cohort identified tumor location, systemic disease status, and tumor volume as the most important factors associated with LMD.

CONCLUSIONS

Tumor location, absence of extracranial disease at the time of surgery, ventricle contact, and increased tumor volume were associated with LMD. Further work is needed to determine whether escalating therapies in patients at risk of LMD prevents disease dissemination.

Open access

Fred H. Geisler, Ali Moghaddamjou, Jamie R. F. Wilson, and Michael G. Fehlings

OBJECTIVE

Methylprednisolone (MP) to treat acute traumatic spinal cord injury (ATSCI) remains controversial since the release of the second National Acute Spinal Cord Injury Study (NASCIS2) in 1990. As two historical studies, NASCIS2 and Sygen in ATSCI, used identical MP dosages, it was possible to construct a new case-level pooled ATSCI data set satisfying contemporary criteria and able to clarify the effect of MP.

METHODS

The new pooled data set was first modernized by excluding patients with injury levels caudal to T10, lower-extremity American Spinal Injury Association (ASIA) motor scores (LEMSs) ≥ 46, Glasgow Coma Scale scores ≤ 11, and age < 15 or > 75 years, and then standardized to the ASIA grading and scoring format. A new updated NASCIS2 data set from this pooled data set contained 31.6% fewer patients than the 1990 NASCIS2 data set.

RESULTS

In the new pooled data set, recovery of LEMSs from baseline to 26 weeks, the primary outcome variable, was separated statistically into five different injury severity cohorts (p < 0.0001). The severity cohorts contained groups with severe floor (62.9%) and ceiling (10.7%) effects, which do not contribute to drug effects. The new NASCIS2 data set duplicated the p value for MP versus placebo in the sub-subgroup analysis of MP initiated ≤ 8 hours (the subgroup) and recovery of motor function on only the right side of the body (a further subgroup within the ≤ 8-hour subgroup), presented as the positive MP effect in the original NASCIS2 reporting. However, current statistical interpretation considers results seen only in post hoc sub-subgroups, without multi-test corrections, to be random effects without clinical significance. The combined case-level pooled data set from the NASCIS2 and Sygen studies increased the MP group from 106 to 431 patients, creating a new MP combined group. This new data set served as a surrogate for a contemporary MP study and found that administration of MP did not enhance ASIA motor score improvement in the lower extremities at 26 weeks. Secondary analysis of descending ASIA motor and sensory cervical neurological levels in cervical ATSCI patients at 26 weeks also found no MP drug effect.

CONCLUSIONS

Analysis of both the new updated NASCIS2 data set and the new case-matched pooled data set from two historical ATSCI studies revealed that administration of MP after spinal cord injury did not demonstrate any enhancement in neurological recovery at 26 weeks. The results of this analysis warrant review by clinical guideline groups.

Open access

Mohammed Ghazal, Marcus Fager, Amir Samadi, Michael Gubanski, and Hamza Benmakhlouf

OBJECTIVE

The authors’ objective was to investigate the stability of the newly introduced Vantage stereotactic frame fixation in single-fraction Gamma Knife radiosurgery.

METHODS

A total of 255 patients were included in this work and treated with the Vantage frame and Leksell Gamma Knife (LGK) Icon equipped with cone-beam computed tomography (CBCT) imaging. After the frame was mounted on the patient’s head, a CT scan was acquired. After the patient was positioned on the couch of LGK, CBCT was acquired to verify the target position before treatment delivery. A second CBCT examination was acquired after treatment delivery to assess intrafractional motion. During treatment delivery, the High Definition Motion Management (HDMM) system was enabled to track a marker on the nose tip of the patient as a surrogate of intracranial motion. The stability of the Vantage frame was deconstructed into two parts: 1) motion between CT and the first CBCT prior to treatment delivery (CT-CBCT1), and 2) motion between CBCT procedures during treatment delivery (CBCT1-CBCT2). Transformation between CT and CBCT1 was given by Leksell GammaPlan, whereas transformation between CBCT1 and CBCT2 required mathematical processing of the transformation and coregistration matrices in the source files.

RESULTS

The average CT-CBCT1 displacement vector was 0.31 mm, with a range as great as 1.09 mm, and 89% and 97% of cases were within 0.5 mm and 0.7 mm, respectively. The CBCT1-CBCT2 displacement vectors averaged at 0.09 mm, with 97% of cases being within 0.2 mm. Spatial shift in the posterior direction was evident, with 94% of cases demonstrating this trend and averaging 0.05 mm. This was attributed to increased pressure on the posterior fixation pins. The HDMM displacement vectors presented larger values with an average of 0.4 mm and a range as great as 1.6 mm, and 98% of cases were within 1.0 mm. The correlation between CBCT1-CBCT2 and HDMM displacements was weak, which was attributed to the high stability of the Vantage frame and consequently small target displacements coupled with the sensitivity of HDMM to face mimics.

CONCLUSIONS

This work demonstrated that the Vantage frame possess the same degree of submillimeter stability as the well-established Leksell Coordinate Frame G (G-frame). Displacements between CT and CBCT1 were 3 times higher than between CBCT1 and CBCT2. A suggested HDMM threshold of 1.2 mm ensures a target accuracy within 0.2 mm in Vantage frame treatments.

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Andreas Leidinger, Scott L. Zuckerman, Yueqi Feng, Yitian He, Xinrui Chen, Beverly Cheserem, Linda M. Gerber, Noah L. Lessing, Hamisi K. Shabani, Roger Härtl, and Halinder S. Mangat

OBJECTIVE

The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings.

METHODS

This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated.

RESULTS

Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26–43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1–6) days; surgery was performed after a further median delay of 22 (IQR 13–39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively.

CONCLUSIONS

Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors’ results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.