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Ken Kazumata, Kikutaro Tokairin, Masaki Ito, Haruto Uchino, Taku Sugiyama, Masahito Kawabori, Toshiya Osanai, Khin Khin Tha and Kiyohiro Houkin

OBJECTIVE

The microstructural integrity of gray and white matter is decreased in adult moyamoya disease, suggesting covert ischemic injury as a mechanism of cognitive dysfunction. Establishing a microstructural brain imaging marker is critical for monitoring cognitive outcomes following surgical interventions. The authors of the present study determined the pathophysiological basis of altered microstructural brain injury in relation to advanced arterial occlusion, cerebral hypoperfusion, and cognitive function.

METHODS

The authors examined 58 patients without apparent brain lesions and 30 healthy controls by using structural MRI, as well as diffusion tensor imaging (DTI). Arterial occlusion in each hemisphere was classified as early or advanced stage based on MRA and posterior cerebral artery (PCA) involvement. Regional cerebral blood flow (rCBF) was measured with N-isopropyl-p-[123I]-iodoamphetamine SPECT. Furthermore, cognitive performance was examined using the Wechsler Adult Intelligence Scale, Third Edition and the Trail Making Test (TMT). Both voxel- and region of interest–based analyses were performed for groupwise comparisons, as well as correlation analysis, using parameters such as cognitive test scores; gray matter volume; fractional anisotropy (FA) of association fiber tracts, including the inferior frontooccipital fasciculus (IFOF) and superior longitudinal fasciculus (SLF); PCA involvement; and rCBF.

RESULTS

Compared to the early stages, advanced stages of arterial occlusion in the left hemisphere were associated with a lower Performance IQ (p = 0.031), decreased anterior cingulate volumes (p = 0.0001, uncorrected), and lower FA in the IFOF, cingulum, and forceps major (all p < 0.01, all uncorrected). There was no significant difference in rCBF between the early and the advanced stage. In patients with an advanced stage, PCA involvement was correlated with a significantly lower Full Scale IQ (p = 0.036), cingulate volume (p < 0.01, uncorrected), and FA of the left SLF (p = 0.0002, uncorrected) compared to those with an intact PCA. The rCBF was positively correlated with FA of the SLF, IFOF, and forceps major (r > 0.34, p < 0.05). Global gray matter volumes were moderately correlated with TMT part A (r = 0.40, p = 0.003). FA values in the left SLF were moderately associated with processing speed (r = 0.40, p = 0.002).

CONCLUSIONS

Although hemodynamic compensation may mask cerebral ischemia in advanced stages of adult moyamoya disease, the disease progression is detrimental to gray and white matter microstructure as well as cognition. In particular, additional PCA involvement in advanced disease stages may impair key neural substrates such as the cingulum and SLF. Thus, combined structural MRI and DTI are potentially useful for tracking the neural integrity of key neural substrates associated with cognitive function and detecting subtle anatomical changes associated with persistent ischemia, as well as disease progression.

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Erick M. Westbroek, Zach Pennington, A. Karim Ahmed, Yuanxuan Xia, Christine Boone, Philippe Gailloud and Daniel M. Sciubba

OBJECTIVE

Preoperative endovascular embolization of hypervascular spine tumors can reduce intraoperative blood loss. The extent to which subtotal embolization reduces blood loss has not been clearly established. This study aimed to elucidate a relationship between the extent of preoperative embolization and intraoperative blood loss.

METHODS

Sixty-six patients undergoing preoperative endovascular embolization and subsequent resection of hypervascular spine tumors were retrospectively reviewed. Patients were divided into 3 groups: complete embolization (n = 22), near-complete embolization (≥ 90% but < 100%; n = 22), and partial embolization (< 90%; n = 22). Intraoperative blood loss was compared between groups using one-way ANOVA with post hoc comparisons between groups.

RESULTS

The average blood loss in the complete embolization group was 1625 mL. The near-complete embolization group had an average blood loss of 2021 mL in surgery. Partial embolization was associated with a mean blood loss of 4009 mL. On one-way ANOVA, significant differences were seen across groups (F-ratio = 6.81, p = 0.002). Significant differences in intraoperative blood loss were also seen between patients undergoing complete and partial embolization (p = 0.001) and those undergoing near-complete and partial embolization (p = 0.006). Pairwise testing showed no significant difference between complete and near-complete embolization (p = 0.57). Analysis of a combined group of complete and near-complete embolization also showed a significantly decreased blood loss compared with partial embolization (p < 0.001). Patient age, tumor size, preoperative coagulation parameters, and preoperative platelet count were not significantly associated with blood loss.

CONCLUSIONS

Preoperative endovascular embolization is associated with decreased intraoperative blood loss. In this series, blood loss was significantly less in surgeries for tumors in which preoperative complete or near-complete embolization was achieved than in tumors in which preoperative embolization resulted in less than 90% reduction of tumor vascular blush. These findings suggest that there may be a critical threshold of efficacy that should be the goal of preoperative embolization.

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Adithya S. Reddy, Yang Liu, Joshua Cockrum, Daniel Gebrezgiabhier, Evan Davis, Yihao Zheng, Aditya S. Pandey, Albert J. Shih and Luis E. Savastano

OBJECTIVE

The development of new endovascular technologies and techniques for mechanical thrombectomy in stroke has greatly relied on benchtop simulators. This paper presents an affordable, versatile, and realistic benchtop simulation model for stroke.

METHODS

A test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with 3D-printed and commercially available cerebrovascular phantoms, a customized hydraulic system to generate physiological flow rate and pressure, and 2 types of embolus analogs (elastic and fragment-prone) capable of causing embolic occlusions under physiological flow.

RESULTS

The test bed was highly versatile and allowed realistic, radiation-free mechanical thrombectomy for stroke due to large-vessel occlusion with rapid exchange of geometries and phantom types. Of the transparent cerebrovascular phantoms tested, the 3D-printed phantom was the easiest to manufacture, the glass model offered the best visibility of the interaction between embolus and thrombectomy device, and the flexible model most accurately mimicked the endovascular system during device navigation. None of the phantoms modeled branches smaller than 1 mm or perforating arteries, and none underwent realistic deformation or luminal collapse from device manipulation or vacuum. The hydraulic system created physiological flow rate and pressure leading to iatrogenic embolization during thrombectomy in all phantoms. Embolus analogs with known fabrication technique, structure, and tensile strength were introduced and consistently occluded the middle cerebral artery bifurcation under physiological flow, and their interaction with the device was accurately visualized.

CONCLUSIONS

The test bed presented in this study is a low-cost, comprehensive, realistic, and versatile platform that enabled high-quality analysis of embolus–device interaction in multiple cerebrovascular phantoms and embolus analogs.

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Jerry Cheriyan, Thomas Cheriyan, Anterpreet Dua, Jeffrey A. Goldstein, Thomas J. Errico and Vikas Kumar

OBJECTIVE

Intraoperative cell salvage systems, or cell savers, are widely used for the management of blood loss in patients undergoing spine surgery. However, recent studies report conflicting evidence of their efficacy. The purpose of the meta-analysis was to investigate the efficacy of cell savers in reducing blood transfusion requirements in patients undergoing spine surgery.

METHODS

Both retrospective and prospective studies that investigated the efficacy of cell savers in reducing transfusion requirements in spine surgery patients when compared with control patients were identified from MEDLINE, Embase, Cochrane Collaboration Library, Google Scholar, and Scopus databases. Outcome data extracted included number of patients receiving allogenic transfusions (transfusion rate); units of allogenic transfusions; postoperative hemoglobin; costs; operative time; and complications. RevMan 5 software was used to perform statistical analyses. A random-effects model was used to calculate pooled odds ratios (with 95% CIs) and weighted mean differences (WMDs [95% CI]) for dichotomous and continuous variables, respectively.

RESULTS

Eighteen studies with 2815 patients in total were included in the meta-analysis. During spine surgery, the use of intraoperative cell salvage did not reduce the intraoperative (OR 0.66 [95% CI 0.30, 1.41]), postoperative (OR −0.57 [95% CI 0.20, 1.59]), or total transfusion (OR 0.92 [95% CI 0.43, 1.98]) rate. There was a reduction in the number of allogenic units transfused intraoperatively by a mean of 0.81 (95% CI −1.15, −0.48). However, there were no differences in the number of units transfused postoperatively (WMD −0.02 [95% CI −0.41, 0.38]) or the total units transfused (WMD 0.08 [95% CI −1.06, 1.22]). There were also no differences in operative time (WMD 19.36 [95% CI −2.43, 42.15]) or complications reported (OR 0.79 [95% CI 0.46, 1.37]) between groups. A difference in postoperative hemoglobin (WMD 0.54 [95% CI 0.11, 0.98]) between both groups was observed.

CONCLUSIONS

Cell saver is efficacious at reducing intraoperative allogenic units transfused. There is no difference in transfusion rates, postoperative units transfused, and the total number of units transfused. Further cost analysis studies are necessary to evaluate the cost-effectiveness of this method of blood conservation.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: meta-analysis; strength of recommendation: low.

Open access

Elin Tønne, Bernt J. Due-Tønnessen, Ulrikke Wiig, Barbro F. Stadheim, Torstein R. Meling, Eirik Helseth and Ketil R. Heimdal

OBJECTIVE

The authors present population-based epidemiological data for craniosynostosis regarding incidence, age at diagnosis, sex differences, and frequency of syndromic and familial cases.

METHODS

The prospective registry of the Norwegian National Unit for Craniofacial Surgery was used to retrieve data on all individuals with craniosynostosis treated between 2003 and 2017. The cohort was divided into three 5-year groups based on year of birth: 2003–2007, 2008–2012, and 2013–2017.

RESULTS

The authors identified 386 individuals with craniosynostosis. Of these, 328 (85%) consented to be registered with further information. The incidence increased significantly during the study period and was 5.5 per 10,000 live births (1/1800) in the last 5-year period. The increase was seen almost exclusively in the nonsyndromic group. Syndromic craniosynostosis accounted for 27% of the cases, and the incidence remained stable throughout the three 5-year periods. Both syndromic and nonsyndromic craniosynostosis were highly suture specific. There was a male preponderance (male/female ratio 2:1), and males accounted for 75% of the individuals with midline synostosis. Overall, 9.5% were index individuals in families with more than one affected member; of these, 73% were nonsyndromic cases.

CONCLUSIONS

The incidence of craniosynostosis increased during the study period, and the observed incidence is among the highest reported. The authors attribute this to increasing awareness among healthcare professionals. The number of syndromic cases was high, likely due to a broader definition compared to the majority of earlier reports. The study revealed a high number of familial cases in both syndromic and nonsyndromic craniosynostosis, thus highlighting the importance of genetics as an underlying cause of craniosynostosis.

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Cyrus Elahi, Theresa Williamson, Charis A. Spears, Sarah Williams, Josephine Nambi Najjuma, Catherine A. Staton, João Ricardo Nickenig Vissoci, Anthony Fuller, David Kitya and Michael M. Haglund

OBJECTIVE

Traumatic brain injury (TBI), a burgeoning global health concern, is one condition that could benefit from prognostic modeling. Risk stratification of TBI patients on presentation to a health facility can support the prudent use of limited resources. The CRASH (Corticosteroid Randomisation After Significant Head Injury) model is a well-established prognostic model developed to augment complex decision-making. The authors’ current study objective was to better understand in-hospital decision-making for TBI patients and determine whether data from the CRASH risk calculator influenced provider assessment of prognosis.

METHODS

The authors performed a choice experiment using a simulated TBI case. All participant doctors received the same case, which included a patient history, vitals, and physical examination findings. Half the participants also received the CRASH risk score. Participants were asked to estimate the patient prognosis and decide the best next treatment step. The authors recruited a convenience sample of 28 doctors involved in TBI care at both a regional and a national referral hospital in Uganda.

RESULTS

For the simulated case, the CRASH risk scores for 14-day mortality and an unfavorable outcome at 6 months were 51.4% (95% CI 42.8%, 59.8%) and 89.8% (95% CI 86.0%, 92.6%), respectively. Overall, participants were overoptimistic when estimating the patient prognosis. Risk estimates by doctors provided with the CRASH risk score were closer to that score than estimates made by doctors in the control group; this effect was more pronounced for inexperienced doctors. Surgery was selected as the best next step by 86% of respondents.

CONCLUSIONS

This study was a novel assessment of a TBI prognostic model’s influence on provider estimation of risk in a low-resource setting. Exposure to CRASH risk score data reduced overoptimistic prognostication by doctors, particularly among inexperienced providers.

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William C. Newman, Max Vaynrub, Mark H. Bilsky, Ilya Laufer and Ori Barzilai

Osteoblastomas are a rare, benign primary bone tumor accounting for 1% of all primary bone tumors, with 40% occurring within the spine. Gross-total resection (GTR) is curative, although depending on location, this can require destabilization of the spine and necessitate instrumented fixation. Through the use of minimally invasive, muscle-sparing approaches, these lesions can be resected while maintaining structural integrity of the spine. The authors present a case report and technical note of a single patient describing the use of a purely endoscopic technique to resect a right L5 superior articulating process osteoblastoma in a 45-year-old woman. The patient underwent an image-guided endoscopic resection of her superior articulating facet osteoblastoma. Intraoperative CT demonstrated GTR. On postoperative examination, she remained neurologically intact with resolution of her pain. At follow-up, she remained pain free. Resection of lumbar osteoblastoma through a fully endoscopic approach was a safe and effective technique in this patient. This technique allowed for GTR without compromising spinal structural integrity, thus eliminating the need for instrumented fixation.

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Anthony T. Lee, Claire Faltermeier, Ramin A. Morshed, Jacob S. Young, Sofia Kakaizada, Claudia Valdivia, Anne M. Findlay, Phiroz E. Tarapore, Srikantan S. Nagarajan, Shawn L. Hervey-Jumper and Mitchel S. Berger

OBJECTIVE

Gliomas are intrinsic brain tumors with the hallmark of diffuse white matter infiltration, resulting in short- and long-range network dysfunction. Preoperative magnetoencephalography (MEG) can assist in maximizing the extent of resection while minimizing morbidity. While MEG has been validated in motor mapping, its role in speech mapping remains less well studied. The authors assessed how the resection of intraoperative electrical stimulation (IES)–negative, high functional connectivity (HFC) network sites, as identified by MEG, impacts language performance.

METHODS

Resting-state, whole-brain MEG recordings were obtained from 26 patients who underwent perioperative language evaluation and glioma resection that was guided by awake language and IES mapping. The functional connectivity of an individual voxel was determined by the imaginary coherence between the index voxel and the rest of the brain, referenced to its contralesional pair. The percentage of resected HFC voxels was correlated with postoperative language outcomes in tasks of increasing complexity: text reading, 4-syllable repetition, picture naming, syntax (SYN), and auditory stimulus naming (AN).

RESULTS

Overall, 70% of patients (14/20) in whom any HFC tissue was resected developed an early postoperative language deficit (mean 2.3 days, range 1–8 days), compared to 33% of patients (2/6) in whom no HFC tissue was resected (p = 0.16). When bifurcated by the amount of HFC tissue that was resected, 100% of patients (3/3) with an HFC resection > 25% displayed deficits in AN, compared to 30% of patients (6/20) with an HFC resection < 25% (p = 0.04). Furthermore, there was a linear correlation between the severity of AN and SYN decline with percentage of HFC sites resected (p = 0.02 and p = 0.04, respectively). By 2.2 months postoperatively (range 1–6 months), the correlation between HFC resection and both AN and SYN decline had resolved (p = 0.94 and p = 1.00, respectively) in all patients (9/9) except two who experienced early postoperative tumor progression or stroke involving inferior frontooccipital fasciculus.

CONCLUSIONS

Imaginary coherence measures of functional connectivity using MEG are able to identify HFC network sites within and around low- and high-grade gliomas. Removal of IES-negative HFC sites results in early transient postoperative decline in AN and SYN, which resolved by 3 months in all patients without stroke or early tumor progression. Measures of functional connectivity may therefore be a useful means of counseling patients about postoperative risk and assist with preoperative surgical planning.

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Lesheng Wang and Jincao Chen