A case of paroxysmal dystonia associated with LGI-1 antibody encephalitis Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Rahul Rahangdale, Thomas Scott, Timothy Leichliter, Susan Baser, James Valeriano

Pediatric ependymoma: GNAO1, ASAH1, IMMT and IPO7 protein expression and 5-year prognosis correlation Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Monserrat Pérez-Ramírez, Antonio García-Méndez, Alicia Georgina Siordia-Reyes, Anahí Chavarría, Celedonio Gómez, Normand García-Hernández Abstract Objective The aim of this work was to evaluate a pediatric ependymoma protein expression that may be useful as a molecular biomarker candidate for prognosis, correlated with clinical features such as age, gender, histopathological grade, ependymal tumor recurrence and patient survival. Patients and methods Immunohistochemistry assays were performed for GNAO1, ASAH1, IMMT, IPO7, Cyclin D1, P53 and Ki-67 proteins. Kaplan-Meier and Cox analysis were performed for age, gender, histopathological grade, relapse and survival correlation. Results We found that three proteins correlate with histopathological grade and relapse; two proteins correlate with survival; one protein does not correlate with any clinical feature. Conclusion Our results suggest that, out of the proteins analyzed, five may be considered suitable prognostic biomarkers and one may be considered a predictive biomarker for response to treatment of pediatric ependymoma.

Treatment allocation of ruptured anterior communicating artery aneurysms: The influence of aneurysm morphology Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Marvin Darkwah Oppong, Cornelius Deuschl, Daniela Pierscianek, Laurèl Rauschenbach, Mehdi Chihi, Alexander Radbruch, Philipp Dammann, Karsten H. Wrede, Neriman Özkan, Oliver Müller, Michael Forsting, Ulrich Sure, Ramazan Jabbarli Abstract Objectives Since publication of the ISAT study, the majority of neurovascular centers adhere to “coil first” policy for patients with subarachnoid hemorrhage (SAH). However, final allocation in favor of coiling or clipping is based on anatomic features of ruptured intracranial aneurysms with respect to clinical characteristics of SAH. In this study, we analyzed the parameters relevant for treatment allocation of ruptured anterior communicating artery aneurysms (AComAA). Patients and methods From our institutional SAH database, all cases with ruptured AComAA, which underwent diagnostic subtraction angiography (DSA) with subsequent treatment allocation, were included. The radiographic features of AComAA were collected from pre-treatment DSA. In addition, demographic, clinical and radiographic parameters of SAH were recorded. The variables selected through univariate analyses were subsequently evaluated using multivariate regression analysis. Results Of 300 SAH patients in the final analysis, the majority of the cases underwent endovascular coiling (n = 221, 73.7%). The following aneurysm features were associated with treatment modality in the univariate analysis: maximal sack size (p = 0.034), perpendicular height (p = 0.007), aspect ratio (p < 0.001) and sack/neck-ratio (p = 0.001). Accordingly, the following cutoffs for these variables were defined upon the receiver operating characteristics curves: 5 mm for sack size, 6 mm for perpendicular height, 1.6 for aspect ratio and sack/neck-ratio. In the multivariate analysis, aspect ratio of 1.6 was the only independent predictor of treatment allocation (p = 0.005; aOR = 2.57; 95% CI 1.33–4.96), which remained significant (p = 0.003; aOR = 2.77; 95% CI 1.41–5.45) after adjusting for patients’ age, WFNS & Fisher grades, as well as intracerebral hematoma volume. Conclusion Although not-routinely assessed during initial allocation treatment, our retrospective analysis proved that aspect ratio is a reliable predictor of treatment allocation of ruptured AComAA. Except for large space-occupying ICH commonly obligating the microsurgical treatment, other clinical and radiographic characteristics of SAH do not seem to be of clinical relevance for the selection of treatment modality.

Cavernous carotid artery aneurysms on a single institution: An epidemiological study with 201 patients Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Jefferson Rosi Junior, Louise Makarem Oliveira, Antonio Luiz Boechat, Manoel Jacobsen Teixeira, Eberval Gadelha Figueiredo Abstract Objectives Cavernous carotid aneurysms (CCA) represent 2–9% of all intracranial aneurysms. For long considered benign lesions, these entities are unique when it comes to clinical presentation and management. Usually asymptomatic, CCAs can grow and rupture causing different manifestations. The lack of a long-term assessment of both treated and untreated CCAs' natural history justifies why there is no consensus regarding what are the recommended therapeutic measures. While some advocate that an intervention is always necessary, others consider that patients deserve an individualized evaluation. Patients and Methods We describe our single-institution experience in diagnosis, follow-up, and management of 201 CCAs. In addition, we evaluate the association of giant CCAs with aneurysms in other locations using a Chi-square test. Results 201 patients had 245 CCAs. 92% of the patients were women. The mean age at diagnosis was 61 years. Concomitant aneurysms were observed in 53.2% of the patients, and the middle cerebral artery was the most affected artery. 66 (30.6%) CCAs were considered "giant", and the follow-up period ranged from 1 to 23 years.The presence of a giant CCA seemed to hinder other aneurysms' formation - RR 0.47 (IC 95% 0.31–0.67), p < 0.0001. Conclusions CCAs should be individually assessed. A conservative approach ought to be adopted for asymptomatic and oligosymptomatic lesions. Finally, a multidisciplinary team must evaluate the other situations, in order to define whether the microsurgical or the endovascular treatment is better option. Presence of a giant lesion within the cavernous sinus is associated with less occurrence of other aneurysms.

Intraoperative neuromonitoring during microsurgical clipping for unruptured anterior choroidal artery aneurysm Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Hyoung Soo Byoun, Chang Wan Oh, O-Ki Kwon, Si Un Lee, Seung Pil Ban, Sung Hoon Kim, Tackeun Kim, Jae Seung Bang, Sung Un Kim, Jongsuk Choi, Kyung Seok Park Abstract Objective To investigate the safety and unexpected finding of the intraoperative neuromonitoring (IONM) including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during microsurgical clipping of an unruptured anterior choroidal artery (AChA) aneurysm. Patients and methods From January 2011 to March 2018, the neurophysiological, clinical, and radiological data of 115 patients who underwent microsurgical clipping for an unruptured AChA aneurysm under IONM were retrospectively analyzed. The incidence of ischemic complications after microsurgical clipping of unruptured AChA aneurysms as well as the false-negative rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IONM during surgery were calculated. Results Ischemic complications after the microsurgical clipping of an AChA aneurysm under IONM occurred in 7 of 115 patients (6.08%). Among them, 3 were symptomatic (2.6%). The false-negative rate of IONM for ischemic complications was 6.08% (7 patients). High specificity; 100% (95% confidence interval [95% CI] = 0.972–1.000), PPVs; 100% (95% CI = 0.055–1.000), and NPVs; 93% (95% CI = 0.945–0.973) with low sensitivity; 11.1% (95% CI = 0.006–0.111) were calculated. Conclusions IONM including transcranial MEP during microsurgical clipping of unruptured AChA aneurysm might have limited usefulness. Therefore, other MEP monitoring using direct cortical stimulation or modified transcranial methodology should be considered to compensate for it.

Conservative versus operative treatment in supratentorial intracerebral hemorrhage - A survey among neurosurgeons and neurologists in Germany Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Christian Roth, Merdhad Salehi, Wolfgang Deinsberger, Stefanie Kaestner, Holger Engel Abstract Objectives Decision making for surgical therapy in patients with intracerebral hemorrhage is still controversial among neurologists and neurosurgeons. Whereas neurologists may favor conservative treatments, surgeons may opt for operations. This might lead to different therapy decisions. Patients and methods Between 2017 and 2018, we conducted a survey among the neurological and neurosurgical societies in Germany. An online questionnaire consisting of 10 fictive patients with spontaneous supratentorial intracerebral hemorrhage (including CT scans and brief case descriptions) was administered to the members of the societies. The participants were asked to decide whether conservative or surgical treatment would be preferred. Furthermore, the results from the neurosurgeons were compared to the results of our previous surveys in 1999 and 2009. Results A total of 157 answers were collected (response rate of 16.2%). Nineteen had to be excluded, leaving 138 for analysis (84 neurosurgeons and 54 neurologists). There were no significant differences in therapy decisions between neurologists and neurosurgeons in all ten cases. Comparing the answers from neurosurgeons with our previous results, there were no significant differences between the results from 1999, 2009 and 2017. Conclusions Against common prejudices, the process of decision making for or against surgery in patients with spontaneous intracerebral hemorrhage is comparable among conservative physicians (neurologists) and neurosurgeons in Germany. This might be the result of joint efforts in spontaneous intracerebral hemorrhage (ICH) therapy, such as joint guidelines or a society of neurointensive care medicine.

Intracranial aspergillosis amongst immunocompetent patients: An experience with combined surgical and medical management of 18 patients Publication date: November 2019 Source: Clinical Neurology and Neurosurgery, Volume 186 Author(s): Santanu Bora, Amandeep Kumar, Shashwat Mishra, Guru D. Satyarthee, Pankaj K. Singh, Dattaraj Sawarkar, Satish Verma, Sachin Borkar, Rajeev Sharma, Sarat P. Chandra, Shashank S. Kale Abstract Objective Fungal infections of central nervous system (CNS) commonly affect immunocompromised patients, however, recently such cases have been reported even amongst immunocompetent patients. Patients & methods In this study, we retrospectively analyzed outcome of 18 immunocompetent patients with histopathologically proven intracranial Aspergillosis undergoing combined surgical and medical management. Results The age of patients ranged from 5-65 years. Fourteen out of 18 patients had well defined lesions while 4 had diffuse disease. Paranasal sinuses were involved in 8 & cavernous sinus in 3 patients. Six patients had hydrocephalus. Four patients developed infarcts during their clinical course. Surgical interventions included gross (n = 4) or subtotal excision (n = 8), decompressive craniectomy & biopsy of lesion (n = 4), biopsy only (n = 2) and ventriculoperitoneal shunt placement (n = 6). All patients received postoperative antifungal therapy. The duration of follow up ranged from 10-60 months. Overall mortality was 44.4%. Mortality amongst patients undergoing gross total and subtotal excision was 25% & 50% respectively. Patients undergoing DC had a mortality of 25%. Both patients undergoing only biopsy died. Hydrocephalus was associated with a very high mortality (83.3%). Amongst surviving patients (n = 10), 6 patients became disease free & rest 4 had stable disease at last follow up. Conclusions Intracranial aspergillosis is associated with high morbidity & mortality even amongst immunocompetent patients. An aggressive multidisciplinary management is thus needed to improve outcome. Our study shows that a combination of surgical excision or decompressive craniectomy and antifungal therapy can be helpful in improving prognosis of these patients.

Unilateral posterior reversible encephalopathy syndrome: A case report Publication date: October 2019 Source: Clinical Neurology and Neurosurgery, Volume 185 Author(s): Tadashi Ozawa, Ryota Tanaka, Risa Nagaoka, Yuhei Anan, Younhee Kim, Kosuke Matsuzono, Takafumi Mashiko, Reiji Koide, Haruo Shimazaki, Keisuke Ohtani, Yusuke Amano, Kensuke Kawai, Shigeru Fujimoto

Akinetic mutism and status epilepticus due to Epstein Barr virus encephalitis Publication date: October 2019 Source: Clinical Neurology and Neurosurgery, Volume 185 Author(s): Patricia Rodrigo-Armenteros, Solange Kapetanovic-García, Lander Antón-Méndez, Juan José Gómez-Muga, Edurne Bedia-Del Río, María Ángeles Fernández-Cuesta, Juan Carlos García-Moncó Abstract Neurological complications of Epstein Barr virus (EBV) infection are infrequent and may include occasionally encephalitis, usually with a benign evolution. We here report on an aggressive case of EBV encephalitis in a 14-year-old boy with extensive basal ganglia involvement, and to a lesser degree of brain cortex who presented atypically with akinetic mutism and non-convulsive status epilepticus, requiring intensive care but showed a favorable outcome. EBV encephalitis is uncommon and its best management is unclear. Its pathophysiology is not well understood but could include autoimmunity. Onconeuronal and synaptic antibodies were negative in serum and cerebrospinal fluid, including the dopamine D2 receptor. To the best of our knowledge, this is the first report to evaluate antibodies to D2 receptors in EBV encephalitis. Corticosteroid therapy is usually recommended but the use of acyclovir is controversial. Intensive care is required in severe cases to assure a favorable outcome.

HSV-2 radiculitis: An unusual presentation mere days after genital infection Publication date: October 2019 Source: Clinical Neurology and Neurosurgery, Volume 185 Author(s): Ali Adel Ne’ma Abdullah, Emma Tallantyre