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Young M. Lee, Mitchell J. Odom, Scott L. Zuckerman, Gary S. Solomon and Allen K. Sills

Object

Sport-related concussions (SRCs) in high school and college athletes represent a significant public health concern. Research suggests that younger athletes fare worse symptomatically than older athletes after an SRC. Using reliable change index (RCI) methodology, the authors conducted a study to determine if there are age-related differences in number, severity, and resolution of postconcussion symptoms.

Methods

Between 2009 and 2011, baseline measures of neurocognitive functions and symptoms in high school and college athletes were entered into a regional database. Seven hundred forty of these athletes later sustained an SRC. Ninety-two athletes in the 13- to 16-year-old group and 92 athletes in the 18- to 22-year-old group were matched for number of prior concussions, sex, biopsychosocial variables, and days to first postconcussion testing and symptom assessment. A nonparametric Mann-Whitney U-test was used to compare the severity of each of 22 symptoms comprising the Total Symptom Scale (TSS) at baseline and first postconcussion test. To obtain a family-wise p value of 0.05 for each test, the significance level for each symptom comparison was set at an alpha of 0.05/22 = 0.0023. The number of days to return to baseline TSS score was compared using the RCI methodology, set at the 80% confidence interval, equal to a change in raw score of 9.18 points on the TSS.

Results

There was no statistically significant difference in symptom presence, symptom severity, and total symptoms between the age groups at baseline or at postconcussion testing. There was no statistically significant difference in return to baseline symptom scores between the age groups.

Conclusions

Using RCI methodology, there was no statistically significant difference between younger and older athletes in return to baseline symptoms postconcussion.

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Scott L. Zuckerman, Young M. Lee, Mitchell J. Odom, Gary S. Solomon and Allen K. Sills

Object

Up to 16% of children in the US between the ages of 3 and 17 years have either attention deficit–spectrum disorder or a learning disability (LD). Sports-related concussions among youth athletes represent a significant public health concern, and neurocognitive testing is a method to evaluate the severity of cognitive impairment and recovery after a sports-related concussion. The goal of this study was to assess baseline neurocognitive differences between athletes with attention deficit hyperactivity disorder (ADHD) and/or LD versus those with neither disorder and to establish normative data for these special populations.

Methods

Between August 2007 and March 2012, 6636 young athletes underwent baseline neurocognitive testing performed using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery. Of these participants, 90 had self-reported LD only, 262 had self-reported ADHD only, and 55 reported both. Those with ADHD and/or LD were matched with 407 participants with no history of ADHD or LD by age, sex, and number of prior concussions. The mean scores and SDs were calculated for each group to obtain normative values. A pairwise comparison between each diagnostic group was done to assess whether LD and/or ADHD diagnostic status predicted participants' baseline neurocognitive scores.

Results

Participants with ADHD had significantly lower verbal memory, visual memory, and visual motor processing speed scores, along with significantly higher reaction time, impulse control, and symptom scores compared with those without LD or ADHD. Participants with LD had similar results, with significantly lower verbal memory, visual memory, and visual motor processing speed scores, higher reaction time and symptom score, but did not differ in their impulse control score compared with those without LD or ADHD. Participants with both LD and ADHD had a significantly lower visual motor speed score and a significantly higher reaction time and symptom score than those without LD or ADHD, but did not differ with regard to the other composite scores.

Conclusions

Athletes with ADHD and/or LD have lower baseline ImPACT neurocognitive scores compared with athletes without ADHD and LD. Preliminary normative neurocognitive data for these special populations are provided.

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Byung-Uk Kang, Sang-Ho Lee, Yong Ahn, Won-Chul Choi and Young-Geun Choi

Object

C-reactive protein (CRP) is a well-known sensitive laboratory parameter that shows an increase within 6 hours after the onset of bacterial infection. In relation to surgery, a normal CRP response is a rapid increase followed by a gradual reduction, eventually returning to the normal range. The goal of this study was to determine the diagnostic significance of CRP as a detector for early onset surgical site infection in spinal surgery and to discuss effective medical treatment through clinical interpretation and application of the measured CRP values.

Methods

A prospective study was performed in 348 consecutive cases involving patients who underwent spinal surgery under general anesthesia between February and September 2008. Blood samples were obtained preoperatively and on postoperative Days 1, 3, and 5 in patients undergoing single-level decompression surgery. An additional blood specimen was obtained at postoperative Day 7 in patients requiring more extensive surgeries. Recorded laboratory results were compared with the patients' clinical course to determine the diagnostic significance of CRP. All of the patients received intravenous prophylactic antibiotic therapy. Once an abnormal response of CRP, indicated by a tendency toward continuous elevation, was noted on Day 5 or Day 7, the prophylactic antibiotics were replaced with another regimen and administration was resumed along with careful observation for signs of surgical site infection.

Results

Monitoring of CRP revealed a characteristic increase and decrease pattern in 332 of 348 patients (95.4%) showing a normal clinical course with regard to early infectious complications. The mean measured CRP (reference range < 4 mg/L) averaged 14.9 ± 20.3 mg/L on Day 1, 15.4 ± 25.1 mg/L on Day 3, and 7.9 ± 13.3 mg/L on Day 5. In contrast, there were 16 cases (4.6%) of abnormal CRP responses resulting in the resumption of intravenous antibiotic treatment, which included a second rise (in 12 cases) and a steady rise (in 4) in the CRP value. Five (1.4%) of 16 patients experienced infectious complications related to spinal surgery. Three patients (0.9%) received long-term antibiotic therapy for 4–6 weeks; however, all patients recovered with medical treatment alone and did not experience gross wound disruption or subsequent discitis. As a predictor for early wound infection, the sensitivity, specificity, positive predictive value, and negative predictive value for abnormal CRP responses were calculated as 100%, 96.8%, 31.3%, and 100%, respectively.

Conclusions

The above results demonstrate that CRP screening is a simple and reliable test for the detection of early infectious complications after spinal surgery. Close observation and appropriate medical management should be performed in a timely fashion when abnormal CRP responses are observed at 5 or 7 days after surgery.

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Choong Jin Whang, Gi Taek Yee, Chan Young Choi, Moon-Jun Sohn and Dong Joon Lee

Object. The role of radiosurgery has become increasingly important in the treatment of intracranial lesions. In this study the authors evaluated the efficacy of the Novalis shaped beam radiosurgery system (dedicated linear accelerator) for various brain and spinal lesions.

Methods. Between November 2000 and October 2003 the authors treated 356 cases of various intracranial and extracranial lesions with Novalis shaped beam radiosurgery. Of these 356 cases, 109 cases were followed for more than a 2-year period. Fifty patients underwent fractionated stereotactic radiosurgery. Twenty patients (40%) harbored benign tumors (two acoustic neuromas, seven meningiomas, five pituitary adenomas, four optic gliomas, and two craniopharyngiomas), 18 patients (36%) harbored malignant tumors (16 glioblastoma multiforme [GBM], and two metastases), and the others included five with brainstem gliomas, one chordoma, five gliomas, and one with an arteriovenous malformation (AVM). Eighteen of 20 patients with benign tumors had good tumor control. Of 59 patients treated with single-dose stereotactic radiosurgery, 24 had benign intracranial tumors (12 acoustic neuromas, 11 meningiomas, and one pituitary adenoma), 20 had malignant tumors (two GBMs and 18 metastases), and the others were eight AVMs, two glomus jugulare tumors, three lymphomas, one pineal tumor, and one spinal tumor.

Conclusions. Stereotactic radiosurgery and fractionated stereotactic radiosurgery using the Novalis shaped beam radiosurgery system are effective and safe noninvasive treatment modalities for various intracranial and extracranial lesions.

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Scott L. Zuckerman, Rachel P. Apple, Mitchell J. Odom, Young M. Lee, Gary S. Solomon and Allen K. Sills

Object

Sport-related concussions (SRCs) among youth athletes represent a significant public health concern. Prior research suggests that females fare worse symptomatically after an SRC. The authors aimed to assess sex differences in number, severity, and resolution of postconcussive symptoms using reliable change index (RCI) methodology applied to days to return to symptom baseline.

Methods

Between 2009 and 2011, 740 youth athletes completed valid neurocognitive and symptom testing before and after an SRC using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 122 female and 122 male athletes were matched on number of prior concussions, age, and number of days to first postconcussion test. At baseline and postconcussion, the authors compared each of the individual 22 symptoms on ImPACT to calculate individual symptom severity and aggregate symptom severity, or the Total Symptom Score (TSS). When comparing individual symptoms, the significance level for the comparison of each symptom was set at 0.05/22 = 0.0023. When comparing aggregate symptom severity, or TSS, a single value was compared, requiring an alpha set to 0.05. The number of days to return to baseline TSS was compared using RCI methods set at the 80% confidence interval, equal to a raw score point value of 9.18 on the TSS.

Results

At baseline, females reported a greater severity for the symptom, “sleeping less than usual,” compared with males (0.88 ± 1.49 vs 0.31 ± 0.86, p < 0.001). However, no other individual symptom severity differences were noted before or after SRC. At baseline, females exhibited a statistically significant greater aggregate symptom severity than males (7.24 ± 10.22 vs 4.10 ± 6.52, p = 0.005). Greater aggregate symptom severity for females was also found postconcussion (21.38 ± 19.02 vs 16.80 ± 17.07, p = 0.049). Females took longer to return to baseline TSS (9.1 ± 7.1 days vs 7.0 ± 5.1 days, p = 0.013).

Conclusions

The results of this retrospective study indicate that females endorse a greater severity of symptoms at baseline and postconcussion than males without significantly different symptom profiles. Furthermore, after suffering an SRC, females take longer to return to their baseline symptom level.

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Clinton D. Morgan, Scott L. Zuckerman, Young M. Lee, Lauren King, Susan Beaird, Allen K. Sills and Gary S. Solomon

OBJECT

Sport-related concussion (SRC) is a major public health problem. Approximately 90% of SRCs in high school athletes are transient; symptoms recover to baseline within 1 week. However, a small percentage of patients remain symptomatic several months after injury, with a condition known as postconcussion syndrome (PCS). The authors aimed to identify risk factors for PCS development in a cohort of exclusively young athletes (9–18 years of age) who sustained SRCs while playing a sport.

METHODS

The authors conducted a retrospective case-control study by using the Vanderbilt Sports Concussion Clinic database. They identified 40 patients with PCS and matched them by age at injury and sex to SRC control patients (1 PCS to 2 control). PCS patients were those experiencing persistent symptoms at 3 months after an SRC. Control patients were those with documented resolution of symptoms within 3 weeks of an SRC. Data were collected in 4 categories: 1) demographic variables; 2) key medical, psychiatric, and family history; 3) acute-phase postinjury symptoms (at 0–24 hours); and 4) subacute-phase postinjury features (at 0–3 weeks). The chi-square Fisher exact test was used to assess categorical variables, and the Mann-Whitney U-test was used to evaluate continuous variables. Forward stepwise regression models (Pin = 0.05, Pout = 0.10) were used to identify variables associated with PCS.

RESULTS

PCS patients were more likely than control patients to have a concussion history (p = 0.010), premorbid mood disorders (p = 0.002), other psychiatric illness (p = 0.039), or significant life stressors (p = 0.036). Other factors that increased the likelihood of PCS development were a family history of mood disorders, other psychiatric illness, and migraine. Development of PCS was not predicted by race, insurance status, body mass index, sport, helmet use, medication use, and type of symptom endorsement. A final logistic regression analysis of candidate variables showed PCS to be predicted by a history of concussion (OR 1.8, 95% CI 1.1–2.8, p = 0.016), preinjury mood disorders (OR 17.9, 95% CI 2.9–113.0, p = 0.002), family history of mood disorders (OR 3.1, 95% CI 1.1–8.5, p = 0.026), and delayed symptom onset (OR 20.7, 95% CI 3.2–132.0, p < 0.001).

CONCLUSIONS

In this age- and sex-matched case-control study of risk factors for PCS among youth with SRC, risk for development of PCS was higher in those with a personal and/or family history of mood disorders, other psychiatric illness, and migraine. These findings highlight the unique nature of SRC in youth. For this population, providers must recognize the value of establishing the baseline health and psychiatric status of children and their primary caregivers with regard to symptom reporting and recovery expectations.

In addition, delayed symptom onset was an unexpected but strong risk factor for PCS in this cohort. Delayed symptoms could potentially result in late removal from play, rest, and care by qualified health care professionals. Taken together, these results may help practitioners identify young athletes with concussion who are at a greater danger for PCS and inform larger prospective studies for validation of risk factors from this cohort.

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Kevin M. Stanko, Young M. Lee, Jennifer Rios, Adela Wu, Giovanna W. Sobrinho, Jon D. Weingart, Eric M. Jackson, Edward S. Ahn, Kaisorn L. Chaichana and George I. Jallo

OBJECT

Chiari Type I malformation involves caudal displacement of the cerebellar tonsils below the foramen magnum, which obstructs normal cerebrospinal fluid flow and increases intracranial pressure. Certain aspects of its surgical treatment remain controversial. A retrospective study was conducted to assess the efficacy of tonsillar cautery on syrinx resolution among pediatric Chiari patients undergoing cervicomedullary decompression.

METHODS

A retrospective cohort study was performed for patients 0–18 years of age who underwent surgical correction for Chiari Type I malformation with syrinx between 1995 and 2013. Basic demographic information was collected as well as data for preoperative symptoms, prior surgical history, perioperative characteristics, and postsurgical outcomes. Descriptive statistics were performed in addition to bivariate analyses. Candidate predictor variables were identified based on an association with tonsillar cautery with p < 0.10. Forward stepwise likelihood ratio was used to select candidate predictors in a binary logistic regression model (Pin = 0.05, Pout = 0.10) most strongly associated with the outcome.

RESULTS

A total of 171 patients with Chiari Type I malformation with syrinx were identified, and 43 underwent tonsillar cautery. Patients who underwent tonsillar cautery had 6.11 times greater odds of improvement in their syrinx (95% CI 2.57–14.49, p < 0.001). There was no effect of tonsillar cautery on increased perioperative complications as well as the need for repeat decompressions.

CONCLUSIONS

Tonsillar cautery is safe and effective in the treatment of Chiari Type I malformation with syrinx and may decrease time to syrinx resolution after cervicomedullary decompression. Tonsillar cautery does not increase postoperative complications in pediatric Chiari Type I malformation patients.

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Jessica S. Haber, Kartik Kesavabhotla, Malte Ottenhausen, Imithri Bodhinayake, Marc J. Dinkin, Alan Z. Segal, Young M. Lee and John A. Boockvar

Cavernous sinus cavernous hemangiomas in pregnancy are extremely rare lesions. The precise management of these lesions remains unknown. The authors present a case of a cavernous hemangioma in pregnancy, centered within the cavernous sinus that underwent postpartum involution without surgical intervention.

A 34-year-old pregnant patient (gravida 1, para 0) presented to an otolaryngologist with persistent headache and left-sided facial pain and numbness in the V1 distribution. While being treated for sinusitis, her symptoms progressed to include a left-sided oculomotor palsy and abducens palsy. Magnetic resonance imaging without contrast revealed an expansile mass within the left cavernous sinus consistent with a cavernous hemangioma. The patient was evaluated by a neurosurgeon who recommended close follow-up and postpartum imaging without surgical intervention. Although the lesion enlarged during pregnancy, the patient was able to undergo an uncomplicated cesarean section at 37 weeks. All facial and ocular symptoms resolved by 9 months postpartum, and MRI showed a decrease in lesion size and reduced mass effect. The authors conclude that nonsurgical management may be a viable approach in patients who have an onset or exacerbation of symptoms associated with cavernous sinus cavernous hemangiomas during pregnancy because postpartum involution may negate the need for surgical intervention.

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Jason P. Sheehan, Robert M. Starke, David Mathieu, Byron Young, Penny K. Sneed, Veronica L. Chiang, John Y. K. Lee, Hideyuki Kano, Kyung-Jae Park, Ajay Niranjan, Douglas Kondziolka, Gene H. Barnett, Stephen Rush, John G. Golfinos and L. Dade Lunsford

Object

Pituitary adenomas are fairly common intracranial neoplasms, and nonfunctioning ones constitute a large subgroup of these adenomas. Complete resection is often difficult and may pose undue risk to neurological and endocrine function. Stereotactic radiosurgery has come to play an important role in the management of patients with nonfunctioning pituitary adenomas. This study examines the outcomes after radiosurgery in a large, multicenter patient population.

Methods

Under the auspices of the North American Gamma Knife Consortium, 9 Gamma Knife surgery (GKS) centers retrospectively combined their outcome data obtained in 512 patients with nonfunctional pituitary adenomas. Prior resection was performed in 479 patients (93.6%) and prior fractionated external-beam radiotherapy was performed in 34 patients (6.6%). The median age at the time of radiosurgery was 53 years. Fifty-eight percent of patients had some degree of hypopituitarism prior to radiosurgery. Patients received a median dose of 16 Gy to the tumor margin. The median follow-up was 36 months (range 1–223 months).

Results

Overall tumor control was achieved in 93.4% of patients at last follow-up; actuarial tumor control was 98%, 95%, 91%, and 85% at 3, 5, 8, and 10 years postradiosurgery, respectively. Smaller adenoma volume (OR 1.08 [95% CI 1.02–1.13], p = 0.006) and absence of suprasellar extension (OR 2.10 [95% CI 0.96–4.61], p = 0.064) were associated with progression-free tumor survival. New or worsened hypopituitarism after radiosurgery was noted in 21% of patients, with thyroid and cortisol deficiencies reported as the most common postradiosurgery endocrinopathies. History of prior radiation therapy and greater tumor margin doses were predictive of new or worsening endocrinopathy after GKS. New or progressive cranial nerve deficits were noted in 9% of patients; 6.6% had worsening or new onset optic nerve dysfunction. In multivariate analysis, decreasing age, increasing volume, history of prior radiation therapy, and history of prior pituitary axis deficiency were predictive of new or worsening cranial nerve dysfunction. No patient died as a result of tumor progression. Favorable outcomes of tumor control and neurological preservation were reflected in a 4-point radiosurgical pituitary score.

Conclusions

Gamma Knife surgery is an effective and well-tolerated management strategy for the vast majority of patients with recurrent or residual nonfunctional pituitary adenomas. Delayed hypopituitarism is the most common complication after radiosurgery. Neurological and cranial nerve function were preserved in more than 90% of patients after radiosurgery. The radiosurgical pituitary score may predict outcomes for future patients who undergo GKS for a nonfunctioning adenoma.

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Zang-Hee Cho, Hoon-Ki Min, Se-Hong Oh, Jae-Yong Han, Chan-Woong Park, Je-Geun Chi, Young-Bo Kim, Sun Ha Paek, Andres M. Lozano and Kendall H. Lee

Object

A challenge associated with deep brain stimulation (DBS) in treating advanced Parkinson disease (PD) is the direct visualization of brain nuclei, which often involves indirect approximations of stereotactic targets. In the present study, the authors compared T2*-weighted images obtained using 7-T MR imaging with those obtained using 1.5- and 3-T MR imaging to ascertain whether 7-T imaging enables better visualization of targets for DBS in PD.

Methods

The authors compared 1.5-, 3-, and 7-T MR images obtained in 11 healthy volunteers and 1 patient with PD.

Results

With 7-T imaging, distinct images of the brain were obtained, including the subthalamic nucleus (STN) and internal globus pallidus (GPi). Compared with the 1.5- and 3-T MR images of the STN and GPi, the 7-T MR images showed marked improvements in spatial resolution, tissue contrast, and signal-to-noise ratio.

Conclusions

Data in this study reveal the superiority of 7-T MR imaging for visualizing structures targeted for DBS in the management of PD. This finding suggests that by enabling the direct visualization of neural structures of interest, 7-T MR imaging could be a valuable aid in neurosurgical procedures.