Inter-rater reliability of primitive signs in dementia Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Andrea Plutino, Sara Baldinelli, Chiara Fiori, Valentina Ranaldi, Mauro Silvestrini, Simona Luzzi Abstract Objectives The aim of the present study is to explore inter-rater reliability of primitive signs in a group of patients assessed for dementia. Patients and methods 97 patients admitted to our University Hospital for cognitive impairment were enrolled in the study. The mean age was 73.04 ± 8.68 (53 females and 44 males). All patients were examined by two cognitive neurologists in a blind fashion. The grasp reflex, the snout reflex, the glabella tap reflex and the palmomental reflex were elicited according to the current literature. Moreover, we add a stretch reflexes (the masseter reflex) to our battery. Results The most frequent primitive reflex was the palmomental reflex followed by the glabella tap, snout, and grasp. The inter-rater reliability was measured for each primitive reflex: grasp reflex (0.884) have a strong correspondence; the glabella tap (0.556), the palmomental (0.516) and the snout reflex (0.445) have otherwise a weak correspondence. The masseter reflex reaches a moderate agreement (0.662). All the measurements reached statistical significance (p < 0.005). Conclusion The results of the study show weak to substantial agreement for primitive signs and the masseter reflex as expressed by the low-to-high kappa values.

Leuprolide acetate pseudomenopause therapy as a cause of reversible cerebral vasoconstriction syndrome Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Hiroki Yamada, Ryogo Kikuchi, Akiyoshi Nakamura, Hiromichi Miyazaki

Gamma knife radiosurgery for pituitary spindle cell oncocytomas Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Göktuğ Akyoldaş, Ömer Batu Hergünsel, İnan Erdem Özdemir, Meriç Şengöz, Selçuk Peker Abstract Objectives Spindle cell oncocytomas (SCOs) are benign lesions of the posterior portion of the pituitary gland that typically come to neurosurgical attention due to compression of the sellar or parasellar structures, and headaches. Initial treatment options for SCOs include surgical resection, particularly via the transsphenoidal approach. However, given that initial resection tends to be insufficient and subsequent revision surgery carries high complication risk, adjuvant treatment modalities may appear to offer promising solutions for controlling tumor progression. This report focuses on a potential new therapeutic option for SCOs, gamma knife radiosurgery (GKRS). Patients and methods The authors identified all patients at one center who had a pituitary lesion treated with GKRS between 2005 and 2016. Five patients with histopathologically confirmed SCO who underwent GKRS were retrospectively identified and included in the present study Results The mean patient age was 52 years (range, 41–61 years). The most common presenting symptom was visual disturbance. All five patients had a history of transsphenoidal surgical resection prior to GKRS therapy. The mean tumor volume was 2.25 cm3 (range 0.7–5.38 cm3). The median tumor margin dose was 12 Gy (range, 12–14 Gy), and the median maximal dose was 24 Gy (range, 24–35 Gy). The median isodose was 50 (range, 40–50). No tumor volume progression was observed during radiological follow-up after GKRS (mean, 52 months; range, 36–84 months). At last follow-up, no neurological, endocrinological, or visual complications had been observed. Conclusion Given their highly vascular and adherent nature, SCOs can be challenging tumors to treat, in particular when they recur. In our five cases, GKRS provided excellent tumor volume control for approximately 4.3 years on average. These results suggest that GKRS is a safe and effective treatment modality for histopathologically confirmed residual SCO.

Pros and cons of a minimally invasive percutaneous subdural drainage system for evacuation of chronic subdural hematoma under local anesthesia Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Francesco Certo, Massimiliano Maione, Roberto Altieri, Marco Garozzo, Giada Toccaceli, Simone Peschillo, Giuseppe M.V. Barbagallo Abstract Objective Chronic subdural hematoma (CSH) is a common neurosurgical disease among elderly population with concomitant degenerative neurological disorders. This is a retrospective series-control analysis of prospectively collected data, aiming to show advantages and indications of a minimally invasive, percutaneous drainage system for CSH. Patients and methods We retrospectively analyse the clinical and radiological data of a minimally invasive, percutaneous draining system (Integra ™) used in fifteen patients (Group A; mean age: 75.7) with CSH, and compare them with those obtained from two retrospective series of patients: the first one (Group B 15 patients, mean age 77.1) treated with standard, single-burr hole technique for subdural drainage under general anaesthesia; the second one (Group C 15 patients, mean age 76.4) treated with standard, single-burr hole technique for subdural drainage under local anaesthesia and mild sedation. All The percutaneous procedures (Group A) were performed under local anaesthesia. Results Mean follow-up was 10.9 (range 3–14), 18.2 (range 10–29) and 15.2 (range 8–28) months in Group A, B and C respectively. Three of 15 and in Group B experienced a worsening of pre-existing neurodegenerative disorders after general anaesthesia. One patient in group C suffering from Parkinson’s disease experienced a worsening of gait disturbances. Post-operative CT scans were performed at 48 h and 21 days after the operation. An early post-operative CT-scan, obtained immediately after surgical procedure, was performed in all Group A patients. No differences in CSH evacuation were observed comparing the three groups. Two recurrent hematomas, one in group A and one in group B, required revision. Post-operative hospitalization was similar (5.1 vs 5.7 vs 5.6 days, respectively, in group A, B and C) but analgesics use was lower in Group A. Conclusion Pre-operative evaluation of radiological features of CSDHs is crucial in determining the right indication for a minimally invasive drainage. Minimally invasive treatments of CSH may reduce the use of anaesthetic drugs and worsening of pre-existing neurodegenerative disorders.

Relevance of calcification and contrast enhancement pattern for molecular diagnosis and survival prediction of gliomas based on the 2016 World Health Organization Classification Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Yuhei Michiwaki, Nobuhiro Hata, Masahiro Mizoguchi, Akio Hiwatashi, Daisuke Kuga, Ryusuke Hatae, Yojiro Akagi, Takeo Amemiya, Yutaka Fujioka, Osamu Togao, Satoshi O. Suzuki, Koji Yoshimoto, Toru Iwaki, Koji Iihara Abstract Objectives The significance of conventional neuroimaging features for predicting molecular diagnosis and patient survival based on the updated World Health Organization (WHO) classification remains uncertain. We assessed the relevance of neuroimaging features (ring enhancement [RE], non-ring enhancement [non-RE], overall gadolinium enhancement [GdE], and intratumoral calcification [IC]) for molecular diagnosis and survival in glioma patients. Patients and methods We evaluated 234 glioma patients according to the updated WHO classification. Isocitrate dehydrogenase (IDH), H3F3A, BRAF hotspot mutations, TERT promotor mutation, and chromosome 1p/19q co-deletion were examined. RE, non-RE, GdE, and IC were evaluated as significant neuroimaging findings. Kaplan-Meier analyses were performed to evaluate overall survival (OS) and the correlations of prognostic factors were evaluated by log-rank tests. Univariate and multivariate analyses were performed to detect prognostic factors for OS. Results A total of 207 patients were eligible. In 110 patients presenting RE, 102 (93%) were glioblastoma (GBM), IDH-wild type. In 97 patients without RE, presence of GdE or IC were not significantly different between IDH-mutant and -wild type tumors, whereas presence of GdE was a significant indicator of higher WHO grades. IC was the only significant finding for 1p/19q co-deleted tumors. TERT promoter mutation was observed in 7/17 patients with diffuse astrocytic glioma, IDH-wild type; recently-defined as “molecular GBM.” IC, RE, and GdE were observed with lower prevalence in molecular GBMs. While presence of RE, GdE, and absence of IC were significant factors of OS in overall cohort, presence of GdE was not significant in OS in cases without RE, and IDH-mutant tumors. IC was a significant predictor of favorable OS in cases without RE and IDH-wild type tumors. Multivariate analysis also validated these findings. Conclusion GdE alone is not a significant predictor of IDH mutation status, but the pattern of enhancement is a significant predictor with RE demonstrating high sensitivity and specificity for GBM, IDH-wild type. Predicting “molecular GBM” by conventional neuroimaging is difficult. Moreover, GdE is not a significant factor of survival analyzed with pattern of enhancement or molecular stratifications. IC is an important radiographic finding for predicting molecular diagnosis and survival in glioma patients.

Pre-operative halo-gravity traction in severe neurofibromatosis type 1 and congenital scoliosis with thoracic rotatory subluxation Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Benlong Shi, Liang Xu, Yang Li, Zhen Liu, Xu Sun, Zezhang Zhu, Yong Qiu Abstract Objectives To evaluate the efficacy and safety of pre-operative Halo-gravity traction in the treatment of severe neurofibromatosis type 1 and congenital scoliosis patients with thoracic rotatory subluxation. Patients and methods Patients with neurofibromatosis type 1 and congenital scoliosis undergoing Halo-gravity traction were reviewed. Radiographic parameters were measured at pre-, post-traction and post-operation. The forced vital capacity and forced expiratory volume in 1 s were recorded at pre- and post-traction. The neurologic function were assessed according to the Frankel score. The complications during Halo-gravity traction, operation and post-operative follow-up were recorded. Results A total of 35 patients (21M and 14F) with rotatory subluxation including 18 neurofibromatosis type 1 and 17 congenital scoliosis patients were included, of whom the average age was 14.9 ± 4.8 years. The average duration of Halo-gravity traction was 72.3 ± 11.2 days, during which the average Cobb angle improved from 105.4 ± 34.2° to 81.7 ± 32.6° (P < 0.001), and the global kyphosis decreased from 79.2 ± 22.5° to 59.7 ± 23.0° (P = 0.003). At pre-traction, the values of coronal and sagittal rotatory subluxation were 9.3 ± 5.2 mm and 7.5 ± 3.5 mm, which significantly improved to 6.7 ± 3.6 mm (P < 0.001) and 4.9 ± 2.3 mm (P < 0.001), respectively. The average improvement in forced vital capacity and forced expiratory volume in 1 s were from 43.6% to 54.2% predicted and from 40.4% to 48.8% predicted, respectively. After Halo-gravity traction, the Frankel scores improved from C to D in 3 patients, from D to E in 2 patients. Conclusion Halo-gravity traction can improve the coronal and sagittal curvature, and the rotatory subluxation in neurofibromatosis type 1 and congenital scoliosis patients. The pre-operative Halo-gravity traction is a safe option for severe neurofibromatosis type 1 and congenital scoliosis patients with rotatory subluxation.

The role of third ventricle bowing in the success of endoscopic third ventriculostomy in pediatric and adult patients Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Tomáš Krejčí, Ondřej Krejčí, Zdeněk Večeřa, Martin Chlachula, Dana Šalounová, Radim Lipina Abstract Objective Preoperative third ventricle deformation (known as ‘bowing’) is associated with higher endoscopic third ventriculostomy (ETV) success. In children, the effect of bowing has not to date been systematically studied. Aim of of this study is to determine the effect of bowing on ETV success in adult and child patients. Patients and methods In this retrospective, monocentric study were included 135 (70 adults and 65 children) of 157 patients who underwent ETV between 2008–2016, with mean follow-up 4.3 years. Presence and extent of bowing and its impact on ETV outcome were evaluated. Third ventricular anatomy was assessed on pre- and postoperative MR imaging. Results In patients > 6 months old, the ETV success rate was 91% in bowing-positive cases and 47.6% in bowing-negative cases. Among patients < 6 months old, ETV was successful in 37% of those with bowing and 36.4% of those without. Presence of bowing strongly indicates ETV success in patients older than 6 months (p < 0.000 5), including children of 7 months and older (p 0.001). This relationship was not confirmed in pediatric patients up to 6 months old (p 1.000). The extent of bowing does not influence ETV success (p 0.559). Bowing correction strongly correlates with ETV success (p < 0.000 5). Conclusion We confirmed significant correlation between bowing and ETV success in patients over 6 months old. This relationship was not determined in those younger than 6 months and therefore we do not recommend bowing in ETV indication criteria for this patient cohort.

Application of Radiomics in Central Nervous System Diseases: a Systematic literature review Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Yanghua Fan, Ming Feng, Renzhi Wang Abstract Central nervous system (CNS) diseases are associated with complexity and diversity; as a result, it is urgent to search for a simple approach for effectively improving the clinical decision-making ability and precise treatment currently. Radiomics can collect plenty of quantitative features based on the massive medical image data; meanwhile, related diagnosis and prediction can be performed through quantitative analysis. The main steps of radiomics analysis include image collection as well as reconstruction, segmentation of the region of interest (ROI), feature extraction as well as quantification, and establishment of the predictive as well as prognostic models. Compared with traditional imaging features, radiomics allows to transform the visual image data to the in-depth features, so as to carry out quantitative research. Our findings suggest that radiomics has broad application prospects in the early screening, accurate diagnosis, grading and staging, treatment and prognosis, and molecular characteristics of CNS diseases, which can improve the capacities to diagnose and predict CNS diseases prognosis through complementing and combining with traditional imaging.

The effects of vitamin D supplementation on expanded disability status scale in people with multiple sclerosis: A critical, systematic review and metaanalysis of randomized controlled trials Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Amin Doosti-Irani, Omid Reza Tamtaji, Mohammad Ali Mansournia, Majid Ghayour- Mobarhan, Gordon Ferns, Reza Daneshvar Kakhaki, Arash Rezaei Shahmirzadi, Zatollah Asemi Abstract In this meta-analysis of randomized controlled trials (RCTs), the effects of vitamin D supplementation on the scores for the expanded disability status scale (EDSS) in people with multiple sclerosis (MS) are assessed. The following databases were search up to January 2018: MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. The quality of the relevant extracted data was assessed according to the Cochrane risk of bias tool. Data were pooled by the use of the inverse variance method and expressed as mean difference with 95% Confidence Intervals (95% CI). Six studies were included in this meta-analysis. The findings demonstrated that supplementation with vitamin D alone and vitamin D plus calcium did not affect the EDSS score (WMD -0.11 (-0.33, 0.11); P = 0.32). In addition, subgroup analysis showed that vitamin D supplementation alone, when compared to the use of a placebo, and vitamin D plus calcium supplementation compared with the control did not affect EDSS (WMD -0.13 (-0.30, 0.11); P = 0.29) and (WMD -0.08 (-0.57, 0.41); P = 0.29), respectively. Overall, this meta-analysis indicated that taking vitamin D in people with MS had no significant effect on EDSS.

Non-traumatic cervical artery dissection and ischemic stroke: A narrative review of recent research Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Michał Marciniec, Klaudia Sapko, Marcin Kulczyński, Sylwia Popek-Marciniec, Anna Szczepańska-Szerej, Konrad Rejdak Abstract Cervical artery dissection (CAD) is a leading cause of ischaemic stroke (IS) in young and middle-aged adults. Despite well characterized clinical presentation, the diagnosis of CAD can be quite challenging due to a wide variety of symptoms ranging from minor neck pain to severe neurological symptoms. Invasive diagnostic procedures such as DSA are nowadays being replaced by the sensitive and CAD-specific sequences of MR. The most recent studies confirmed the overall efficacy of antiplatelet and anticoagulant therapies for CAD patients is equivalent, although patients should be qualified for concrete treatment on the basis of recently characterized clinical features. The use of NOAC in CAD-related IS prevention cannot yet be recommended due to the lack of evidences from randomized controlled trials. Endovascular therapies should be considered as the treatment of CAD, especially in the cases of large occlusion or antithrombotic treatment failure. Further research is needed to evaluate the efficacy of new imaging modalities and treatment options. This review summarize the last 5-year development of the diagnosis and treatment for CAD as a causative factor for IS.