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Shane Shahrestani, Danielle Wishart, Sung Min J. Han, Ben A. Strickland, Joshua Bakhsheshian, William J. Mack, Arthur W. Toga, Nerses Sanossian, Yu-Chong Tai, and Gabriel Zada

OBJECTIVE

Stroke is a leading cause of morbidity and mortality. Current diagnostic modalities include CT and MRI. Over the last decade, novel technologies to facilitate stroke diagnosis, with the hope of shortening time to treatment and reducing rates of morbidity and mortality, have been developed. The authors conducted a systematic review to identify studies reporting on next-generation point-of-care stroke diagnostic technologies described within the last decade.

METHODS

A systematic review was performed according to PRISMA guidelines to identify studies reporting noninvasive stroke diagnostics. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool was utilized to assess risk of bias. PubMed, Web of Science, and Scopus databases were utilized. Primary outcomes assessed included accuracy and timing compared with standard imaging, potential risks or complications, potential limitations, cost of the technology, size/portability, and range/size of detection.

RESULTS

Of the 2646 reviewed articles, 19 studies met the inclusion criteria and included the following modalities of noninvasive stoke detection: microwave technology (6 studies, 31.6%), electroencephalography (EEG; 4 studies, 21.1%), ultrasonography (3 studies, 15.8%), near-infrared spectroscopy (NIRS; 2 studies, 10.5%), portable MRI devices (2 studies, 10.5%), volumetric impedance phase-shift spectroscopy (VIPS; 1 study, 5.3%), and eddy current damping (1 study, 5.3%). Notable medical devices that accurately predicted stroke in this review were EEG-based diagnosis, with a maximum sensitivity of 91.7% for predicting a stroke, microwave-based diagnosis, with an area under the receiver operating characteristic curve (AUC) of 0.88 for differentiating ischemic stroke and intracerebral hemorrhage (ICH), ultrasound with an AUC of 0.92, VIPS with an AUC of 0.93, and portable MRI with a diagnostic accuracy similar to that of traditional MRI. NIRS offers significant potential for more superficially located hemorrhage but is limited in detecting deep-seated ICH (2.5-cm scanning depth).

CONCLUSIONS

As technology and computational resources have advanced, several novel point-of-care medical devices show promise in facilitating rapid stroke diagnosis, with the potential for improving time to treatment and informing prehospital stroke triage.

Free access

Shane Shahrestani, Ben A. Strickland, Joshua Bakhsheshian, William J. Mack, Arthur W. Toga, Nerses Sanossian, Yu-Chong Tai, and Gabriel Zada

OBJECTIVE

Spontaneous intracerebral hemorrhage occurs in an estimated 10% of stroke patients, with high rates of associated mortality. Portable diagnostic technologies that can quickly and noninvasively detect hemorrhagic stroke may prevent unnecessary delay in patient care and help rapidly triage patients with ischemic versus hemorrhagic stroke. As such, the authors aimed to develop a rapid and portable eddy current damping (ECD) hemorrhagic stroke sensor for proposed in-field diagnosis of hemorrhagic stroke.

METHODS

A tricoil ECD sensor with microtesla-level magnetic field strengths was constructed. Sixteen gelatin brain models with identical electrical properties to live brain tissue were developed and placed within phantom skull replicas, and saline was diluted to the conductivity of blood and placed within the brain to simulate a hemorrhage. The ECD sensor was used to detect modeled hemorrhages on benchtop models. Data were saved and plotted as a filtered heatmap to represent the lesion location. The individuals performing the scanning were blinded to the bleed location, and sensors were tangentially rotated around the skull models to localize blood. Data were also used to create heatmap images using MATLAB software.

RESULTS

The sensor was portable (11.4-cm maximum diameter), compact, and cost roughly $100 to manufacture. Scanning time was 2.43 minutes, and heatmap images of the lesion were produced in near real time. The ECD sensor accurately predicted the location of a modeled hemorrhage in all (n = 16) benchtop experiments with excellent spatial resolution.

CONCLUSIONS

Benchtop experiments demonstrated the proof of concept of the ECD sensor for rapid transcranial hemorrhagic stroke diagnosis. Future studies with live human participants are warranted to fully establish the feasibility findings derived from this study.

Free access

Sharath Kumar Anand, William J. Benjamin IV, Arjun Rohit Adapa, Jiwon V. Park, D. Andrew Wilkinson, Badih J. Daou, James F. Burke, and Aditya S. Pandey

OBJECTIVE

The establishment of mechanical thrombectomy (MT) as a first-line treatment for select patients with acute ischemic stroke (AIS) and the expansion of stroke systems of care have been major advancements in the care of patients with AIS. In this study, the authors aimed to identify temporal trends in the usage of tissue-type plasminogen activator (tPA) and MT within the AIS population from 2012 to 2018, and the relationship to mortality.

METHODS

Using a nationwide private health insurance database, 117,834 patients who presented with a primary AIS between 2012 and 2018 in the United States were identified. The authors evaluated temporal trends in tPA and MT usage and clinical outcomes stratified by treatment and age using descriptive statistics.

RESULTS

Among patients presenting with AIS in this population, the mean age was 69.1 years (SD ± 12.3 years), and 51.7% were female. Between 2012 and 2018, the use of tPA and MT increased significantly (tPA, 6.3% to 11.8%, p < 0.0001; MT, 1.6% to 5.7%, p < 0.0001). Mortality at 90 days decreased significantly in the overall AIS population (8.7% to 6.7%, p < 0.0001). The largest reduction in 90-day mortality was seen in patients treated with MT (21.4% to 14.1%, p = 0.0414) versus tPA (11.8% to 7.0%, p < 0.0001) versus no treatment (8.3% to 6.3%, p < 0.0001). Age-standardized mortality at 90 days decreased significantly only in patients aged 71–80 years (11.4% to 7.8%, p < 0.0001) and > 81 years (17.8% to 11.6%, p < 0.0001). Mortality at 90 days stagnated in patients aged 18 to 50 years (3.0% to 2.2%, p = 0.4919), 51 to 60 years (3.8% to 3.9%, p = 0.7632), and 61 to 70 years (5.5% to 5.2%, p = 0.2448).

CONCLUSIONS

From 2012 to 2018, use of tPA and MT increased significantly, irrespective of age, while mortality decreased in the entire AIS population. The most dramatic decrease in mortality was seen in the MT-treated population. Age-standardized mortality improved only in patients older than 70 years, with no change in younger patients.

Open access

Yukiko Tanaka, Hidenori Anami, Hiroyuki Kurihara, Satoru Miyao, Hidetoshi Nakamoto, Yuichi Kubota, and Takakazu Kawamata

BACKGROUND

Eagle syndrome, or elongated styloid process syndrome, is a rare cause of cerebral infarction. When the styloid process is elongated but the internal carotid artery (ICA) is morphologically normal on three-dimensional computed tomography angiography (3D-CTA), determining the causal relationship between elongation and cerebral infarction is difficult.

OBSERVATIONS

The patient was a 27-year-old man who experienced two left cerebral infarctions in 3 months. On 3D-CTA, the styloid process was elongated, but the structure of the ICA was normal. When the patient’s neck was rotated leftward, the peak systolic velocity and pulsatility index increased (shown via dynamic subtraction ultrasonography) and ICA stenosis was evident (shown via subtraction angiography). The styloid process was removed, and the cerebral infarction did not recur in the 2 years after surgery.

LESSONS

This is the first report to document that indirect compression of ICA by the styloid process can cause Eagle syndrome. The blood flow changes of the ICA on dynamic ultrasonography revealed morphological changes that were hidden on 3D-CTA or nondynamic subtraction angiography.

Open access

Wakiko Saruta, Ichiyo Shibahara, Hajime Handa, Madoka Inukai, Shunsuke Kanayama, Ryoma Yasumoto, Keizo Sakurai, Hisanao Akiyama, Hitoshi Ishikawa, Sumito Sato, Takuichiro Hide, and Toshihiro Kumabe

BACKGROUIND

Leber’s hereditary optic neuropathy (LHON) is a mitochondrial disease characterized by bilateral severe subacute central vision loss and a mutation in the mitochondrial DNA (mtDNA). The findings on cranial magnetic resonance imaging of patients with LHON vary from subtle to multiple white matter changes. However, they rarely present with diffuse infiltrative white matter changes.

OBSERVATIONS

The authors reported a case with diffuse white matter changes mimicking gliomatosis cerebri (GC). The histological findings included only mild glial hyperplasia without immunohistochemical positivity, supporting the diagnosis of glial tumors. Analysis of mtDNA obtained from the blood and brain tissue revealed mutation of m.11778G>A in the NADH dehydrogenase 4 gene, which confirmed the case as LHON. Immunohistochemistry of the brain tissue revealed 8-hydroxy-2′-deoxyguanosine positivity, suggesting the presence of oxidative stress.

LESSONS

LHON is extremely difficult to diagnose unless one suspects or knows the disease. The present case brings attention not only to LHON but also to other mtDNA-mutated diseases that need to be considered with diffuse white matter changes or GC.

Open access

Callum M. Allison, Syed Shumon, Abhijit Joshi, Annelies Quaegebeur, Georges Sinclair, and Surash Surash

BACKGROUND

Malignant peripheral nerve sheath tumors (MPNSTs) within the neuroaxis are rare, usually arising from peripheral and cranial nerves. Even more scarce are cranial subclassifications of MPNSTs termed “malignant intracerebral nerve sheath tumors” (MINSTs). These tumors are aggressive, with a strong tendency for metastasis. With this presentation, alongside resistance to adjunctive therapy, complete excision is the mainstay of treatment, although it is often insufficient, resulting in a high rate of mortality.

OBSERVATIONS

The authors report the case of an adult patient with a history of Noonan syndrome (NS) presenting with slowly progressive right-sided hemiparesis and right-sided focal motor seizures. Despite initial imaging and histology suggesting a left frontal lobe high-grade intrinsic tumor typical of a glioblastoma, subsequent molecular analysis confirmed a diagnosis of MINST. The patient’s neurological condition improved after gross-total resection and adjuvant chemo-radiation; he remains on follow-up.

LESSONS

MINSTs are rare neoplasms with a poor prognosis; management options are limited, with surgery being the cornerstone of treatment. Reports on rare tumors such as this will increase awareness of this particular pathology and disclose clinical experience. In this case, the authors were unable to establish a definite cause-and-effect relation between NS and MINST. Nevertheless, it remains the first reported case in the literature.

Open access

Ryuichi Noda, Tomohiro Inoue, Sho Tsunoda, Masafumi Segawa, Yoshio Masuda, Teppei Morikawa, and Atsuya Akabane

BACKGROUND

Eccrine porocarcinoma (EP) is a rare malignant skin neoplasm, and there are still many unknowns regarding its natural history and treatment. Due to its scarcity, associated brain metastasis is a far rarer condition.

OBSERVATIONS

A 71-year-old-woman with a history of EP was diagnosed with brain metastasis. In her clinical course, the patient underwent tumor removal surgery twice and Gamma Knife radiosurgery (GKRS) four times. The tumor showed a good response to radiotherapy. The histopathological findings of the brain tumor were consistent with those of the primary skin tumor.

LESSONS

There are only a few case reports referring to the detailed treatment, especially with GKRS, of brain metastasis from EP. Few reports have presented a detailed histopathological comparison between the primary skin lesion and the metastatic brain lesion. Herein, the authors have described the clinical course, histological features, and results of multidisciplinary treatment for brain metastasis of EP.

Open access

Terrence Ishmael, Vincent Arlet, and Harvey Smith

BACKGROUND

Circumferential fusion with or without reduction is the preferred treatment for high-grade isthmic spondylolisthesis. Reduction presents significant risk of neurological injury. The authors present one case in which the “reverse Bohlman” technique was used with the addition of a hyperlordotic interbody cage at L4–5 as a means to correct sagittal malalignment while avoiding the reduction of L5 on S1.

OBSERVATIONS

The patient was a 22-year-old woman with a long-term history of lower back pain and bilateral L5 radiculopathy secondary to high-grade isthmic lumbar spondylolisthesis. She underwent anterior lumbar interbody fusion using the reverse Bohlman technique plus a hyperlordotic interbody cage at L4–5, followed by decompression and posterior spinal instrumentation and fusion from L4 to the pelvis. At 2-year follow-up, she was found to have complete resolution of symptoms with clinical and radiographic evidence of fusion. Her spinopelvic parameters had significantly improved.

LESSONS

The reverse Bohlman technique with the addition of a hyperlordotic interbody cage at L4–5 is a potential alternative treatment method to correct sagittal malalignment while avoiding possible injury to the L5 nerve roots that can be seen in the reduction of high-grade isthmic spondylolisthesis.

Open access

Michiharu Yoshida, Takeshi Hiu, Shiro Baba, Minoru Morikawa, Nobutaka Horie, Kenta Ujifuku, Koichi Yoshida, Yuki Matsunaga, Daisuke Niino, Ang Xie, Tsuyoshi Izumo, Takeo Anda, and Takayuki Matsuo

BACKGROUND

Pituitary apoplexy associated with aneurysmal rupture is extremely rare and may be misdiagnosed as primary pituitary adenoma apoplexy. The authors present a case of a patient with pituitary apoplexy caused by rupture of an anterior cerebral artery aneurysm embedded within a giant pituitary adenoma, and they review the relevant literature.

OBSERVATIONS

A 78-year-old man experienced sudden headache with progressive vision loss. Magnetic resonance imaging (MRI) revealed a giant pituitary tumor with abnormal signal intensity. Magnetic resonance angiography immediately before surgery showed a right A1 segment aneurysm, suggesting coexisting pituitary apoplexy and ruptured aneurysm. The patient underwent urgent transsphenoidal surgery for pituitary apoplexy. The tumor was partially removed, but the perianeurysmal component was left behind. Subsequent cerebral angiography showed a 5-mm right A1 aneurysm with a bleb that was successfully embolized with coils. Retrospective review of preoperative dynamic MRI showed extravasation of contrast medium from the ruptured aneurysm into the pituitary adenoma. Histopathologic examination showed gonadotroph adenoma with hemorrhagic necrosis. Postoperatively, the patient’s visual function improved.

LESSONS

MRI identification of pituitary apoplexy caused by aneurysmal rupture has not been reported previously. Aneurysmal rupture should be considered in the differential diagnosis of pituitary apoplexy. When a ruptured aneurysm is encountered, the authors recommend treating it before addressing pituitary apoplexy.

Open access

Angelo Rusconi, Paolo Roccucci, Stefano Peron, and Roberto Stefini

BACKGROUND

Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches.

OBSERVATIONS

Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness.

LESSONS

In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.