NFTI-QOL

NFTI-QOL

The NFTI-QOL is a robustly constructed disease-specific QOL questionnaire for neurofibromatosis type 2. It correlates strongly and significantly with EuroQOL and all SF-36 domains (p < 0.01). It is straightforward and quick (≤3 minutes) for patients to complete and easy to score. It is suitable as a quantitative method of assessing QOL in NF2 both in a clinical setting and as an outcome measure for treatment. The NFTI-QOL has been validated for adults (>16 years) in the United Kingdom, and could be adapted for use in other countries 1).


The aim of the study of Lawson McLean et al was to produce and validate a German version of the NFTI-QOL (NFTI-QOL-D) and to correlate QOL scores with a depression score (PHQ-9) and clinical disease severity.

The original English-language NFTI-QOL was translated into German and then back-translated in order to preserve the questionnaire’s original concepts and intentions. A link to an online survey encompassing the NFTI-QOL-D and the PHQ-9 depression questionnaire was then sent to 97 patients with NF2 by email. The respondents’ scores were compared to clinician-reported disease severity scores.

77 patients completed the online survey in full. Internal consistency among NFTI-QOL-D responses was strong (Cronbach’s alpha: 0.74). Both PHQ-9 and clinician disease severity scores correlated with NFTI-QOL-D scores (Pearson correlation coefficient rho 0.63 and 0.62, respectively).

The NFTI-QOL-D is a reliable and useful tool to assess patient-reported QOL in German-speaking patients with neurofibromatosis type 2. The correlation of QOL with both psychological and physical disease parameters underlines the importance of individualized interdisciplinary patient care for NF2 patients, with attention paid to mental well-being as well as to somatic disease manifestation2).

Data were evaluated for 288 NF2 patients (n = 464 visits) attending the English national NF2 clinics from 2010 to 2012. The male-to-female ratio was equal and the mean age was 42.2 (SD 17.8) years. The analysis included NFTI-QOL eight-item score, ClinSev graded as mild, moderate, or severe, and GenSev as a rank order of the number of NF2 mutations (graded as mild, moderate, severe). The mean (SD) 8.7 (5.4) score for NFTI-QOL for either a first visit or all visits 9.2 (5.4) was similar to the published norm of 9.4 (5.5), with no significant relationships with age or gender. NFTI-QOL internal reliability was good, with a Cronbach’s alpha score of 0.85 and test re-test reliability r = 0.84. NFTI related to ClinSev (r = 0.41, p < 0.001; r = 0.46 for all visits), but weakly to GenSev (r = 0.16, p < 0.05; r = 0.15 for all visits). ClinSev related to GenSev (r = 0.41, p < 0.001; r = 0.42 for all visits). NFTI-QOL showed good reliability and ability to detect significant longitudinal changes in the QOL of individuals. The moderate relationships of NFTI-QOL with a clinician- and genetic-rated severity suggest that NFTI-QOL taps into NF2 patient experiences that are not encompassed by ClinSev rating or genotype 3)


1)

Hornigold, R. E., Golding, J. F., Leschziner, G., Obholzer, R., Gleeson, M. J., Thomas, N., Walsh, D., Saeed, S., & Ferner, R. E. (2012). The NFTI-QOL: A Disease-Specific Quality of Life Questionnaire for Neurofibromatosis 2. Journal of Neurological Surgery. Part B, Skull Base, 73(2), 104-111. https://doi.org/10.1055/s-0032-1301396
2)

Lawson McLean AC, Freier A, Lawson McLean A, Kruse J, Rosahl S. The German version of the neurofibromatosis 2 impacts on quality of life questionnaire correlates with severity of depression and physician-reported disease severity. Orphanet J Rare Dis. 2023 Jan 6;18(1):3. doi: 10.1186/s13023-022-02607-z. PMID: 36604703.
3)

Ferner RE, Shaw A, Evans DG, McAleer D, Halliday D, Parry A, Raymond FL, Durie-Gair J, Hanemann CO, Hornigold R, Axon P, Golding JF. Longitudinal evaluation of quality of life in 288 patients with neurofibromatosis 2. J Neurol. 2014 May;261(5):963-9. doi: 10.1007/s00415-014-7303-1. Epub 2014 Mar 12. PMID: 24619350; PMCID: PMC4008785.

Intracranial Aneurysm (IA)

Intracranial Aneurysm (IA)

The clinical presentation is varied, ranging from asymptomatic lesions to those presenting with major rupture

see Ruptured intracranial aneurysm.

Conflicts of interest in journals

The role of major journals publishing the results of randomized controlled trials (RCTs) is crucial. This is because, when results are published in a major journal, the study receives “…the journal’s stamp of approval”, the published results carry a kind of professional approbation, and the paper becomes more attractive to both the readers and media, who may amplify the real value of the results.


Powell et al. sought to evaluate the Financial conflicts of interest of physicians followed on Twitter by the top three neurosurgical journals.

They analysed the Financial conflicts of interest of United States (US) physicians followed by the top three neurosurgical journals (Journal of NeurosurgeryWorld NeurosurgeryNeurosurgery) on Twitter. They determined the Financial conflicts of interest of each physician using the Open Payments Search Tool located at https://openpaymentsdata.cms.gov and summed the data between 2014 and 2021.

They examined 2651 Twitter accounts followed by the top three neurosurgical journals on Twitter and determined 705 (26.6%) belonged to US physicians. Of the 705 US physicians, 577 (81.8%) received general payments between 2014 and 2021. After excluding US physicians currently in residency or fellowship (n = 157), this percentage increased to 93.2% (n = 511/548). In total, nearly $70 million in general payments were made between 2014 and 2021.

These findings raise questions regarding the interaction between neurosurgical journals and the medical community on Twitter. This study may serve as the basis for future work on best practices for medical journals navigating their affiliations on Twitter 1).


Staartjes et al. aimed to evaluate the extent and influence of conflicts of interest (COIs) in recent RCTs published in core neurosurgical journals using a cross-sectional analysis.

Through review of 6 general neurosurgical journals, all interventional RCTs published from January 2009 to January 2019 were identified. Because it is difficult to objectively assess study outcome, the authors opted for a strict rating approach based on the statistical significance of unambiguously reported primary endpoints, and the reported statistical protocol.

A total of 129 RCTs met the inclusion criteria. During the study period, the Journal of Neurosurgery published the largest number of RCTs (n = 40, 31%). Any potential COI was disclosed by 57%, and a mean of 12% of authors had a personal COI. Nonfinancial industry involvement was reported in 10%, while 31% and 20% received external support and sponsoring, respectively. Study registration was reported by 56%, while 51% of studies were blinded. Registration showed an increasing trend from 17% to 76% (p < 0.001). The median randomized sample size was 92 (interquartile range 50-153), and 8% were designed to investigate noninferiority or equality. Sixty-three RCTs (49%) unambiguously reported a primary endpoint, of which 13% were composite primary endpoints. In 43%, study outcome was positive, which was associated with a noninferiority design (31% vs 3%, p = 0.007) and a composite primary endpoint (46% vs 9%, p = 0.002). Potential COIs were not significantly associated with study positivity (69% vs 59%, p = 0.433). In the multivariate analysis, only a composite primary endpoint remained predictive of a positive study outcome (odds ratio 6.34, 95% confidence interval 1.51-33.61, p = 0.017).

This analysis provides an overview of COIs and their potential influence on recent trials published in core neurosurgical journals. Reporting of primary endpoints, study registration, and uniform disclosure of COIs are crucial to ensure the quality of future neurosurgical randomized trials. COIs do not appear to significantly influence the outcome of randomized neurosurgical trials 2).


An increasing amount of funding in neurosurgery research comes from industry, which may create a conflict of interest (COI) and the potential to bias results. The reporting and handling of COIs have become difficult, particularly as explicit policies themselves and definitions thereof continue to vary between medical journals. In a study, de Lotbiniere-Bassett et al. sought to evaluate the prevalence and comprehensiveness of COI policies among leading neurosurgical journals.

The authors conducted a cross-sectional study of publicly available online disclosure policies in the 20 highest-ranking neurosurgical journals, as determined by Google Scholar Metrics, in July 2016.

Overall, 89.5% of the highest-impact neurosurgical journals included COI policy statements. Ten (53%) journals requested declaration of nonfinancial conflicts, while 2 journals specifically set a time period for COIs. Sixteen journals required declaration from the corresponding author, 13 from all authors, 6 from reviewers, and 5 from editors. Four journals were included in the International Committee of Medical Journal Editors (ICMJE) list of publications that follow the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (currently known asRecommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals). Five journal policies included COI declaration verification, management, or enforcement. The neurosurgery journals with more comprehensive COI policies were significantly more likely to have higher h5-indices (p = 0.003) and higher impact factors (p = 0.01).

In 2016, the majority of, but not all, high-impact neurosurgical journals had publically available COI disclosure policies. Policy inclusiveness and comprehensiveness varied substantially across neurosurgical journals, but COI comprehensiveness was associated with other established markers of individual journals’ favorability and influence, such as impact factor and h5-index 3).


A study aimed to determine the prevalence and financial magnitude of potential conflict of interest among editorial board members of five leading spine journals. The editorial boards of: The Spine Journal; Spine; European Spine Journal; Journal of Neurosurgery: Spine; and Journal of Spinal Disorders & Techniques were extracted on January 2013 from the journals’ websites. Disclosure statements were retrieved from the 2013 disclosure index of the North American Spine Society; the program of the 20th International Meeting on Advanced Spine Techniques; the program of the 48th Annual Meeting of the Scoliosis Research Society; the program of the AOSpine global spine congress; the presentations of the 2013 Annual Eurospine meeting; and the disclosure index of the American Academy of Orthopaedic Surgeons. Names of the editorial board members were compared with the individuals who completed a disclosure for one of these indexes. Disclosures were extracted when full names matched. Two hundred and ten (29%) of the 716 identified editorial board members reported a potential conflict of interest and 154 (22%) reported nothing to disclose. The remaining 352 (49%) editorial board members had no disclosure statement listed for one of the indexes. Eighty-nine (42%) of the 210 editorial board members with a potential conflict of interest reported a financial relationship of more than $10,000 during the prior year. This finding confirms that potential conflicts of interest exist in editorial boards which might influence the peer review process and can result in bias. Academia and medical journals in particular should be aware of this and strive to improve transparency of the review process. Janssen et al. emphasize recommendations that contribute to achieving this goal 4).


Traditional peer-review processes used by journal editors to aid in deciding which papers are worth publishing is not capable of filtering some of the more sophisticated techniques of covered marketing and conflicts of interest. The incorporation of ethicists in the peer review process would likely help to raise red flags and to properly consider the routine statement that the study was accepted by the “human review board” of some prestigious university. By rejecting suspicious ethical studies, editors may not be able to help make the world a fairer place, but they will help in building a healthier scientific community and sending a clear message, to both scientists and the industry, that it is unacceptable to exploit and potentially harm a few people for the sake of many 5).

Conflicts of interest arising from ties between pharmaceutical industry and physicians are common and may bias research. The extent to which these ties exist among editorial board members of medical journals is not known.

A study aims to determine the prevalence and financial magnitude of potential conflicts of interest among editorial board members of five leading spine journals. The editorial boards of: The Spine Journal; Spine; European Spine Journal; Journal of Neurosurgery: Spine; and Journal of Spinal Disorders & Techniques were extracted on January 2013 from the journals’ websites. Disclosure statements were retrieved from the 2013 disclosure index of the North American Spine Society; the program of the 20th International Meeting on Advanced Spine Techniques; the program of the 48th Annual Meeting of the Scoliosis Research Society; the program of the AOSpine global spine congress; the presentations of the 2013 Annual Eurospine meeting; and the disclosure index of the American Academy of Orthopaedic Surgeons. Names of the editorial board members were compared with the individuals who completed a disclosure for one of these indexes. Disclosures were extracted when full names matched. Two hundred and ten (29%) of the 716 identified editorial board members reported a potential conflict of interest and 154 (22%) reported nothing to disclose. The remaining 352 (49%) editorial board members had no disclosure statement listed for one of the indexes. Eighty-nine (42%) of the 210 editorial board members with a potential conflict of interest reported a financial relationship of more than $10,000 during the prior year. This finding confirms that potential conflicts of interest exist in editorial boards which might influence the peer review process and can result in bias. Academia and medical journals in particular should be aware of this and strive to improve transparency of the review process. Janssen et al. emphasize recommendations that contribute to achieving this goal 6).


1)

Powell K, McCall K, Hooda K, Prasad V, Kakkilaya A. Financial conflicts of interest of physicians followed by neurosurgical journals on Twitter. Int J Health Plann Manage. 2023 Jan 3. doi: 10.1002/hpm.3611. Epub ahead of print. PMID: 36597174.
2)

Staartjes VE, Klukowska AM, Sorba EL, Schröder ML. Conflicts of interest in randomized controlled trials reported in neurosurgical journals. J Neurosurg. 2019 Aug 16:1-10. doi: 10.3171/2019.5.JNS183560. [Epub ahead of print] Review. PubMed PMID: 31419788.
3)

de Lotbiniere-Bassett MP, Riva-Cambrin J, McDonald PJ. Conflict of interest policies and disclosure requirements in neurosurgical journals. J Neurosurg. 2018 Aug 1:1-7. doi: 10.3171/2018.4.JNS172751. [Epub ahead of print] Review. PubMed PMID: 30117775.
4) , 6)

Janssen SJ, Bredenoord AL, Dhert W, de Kleuver M, Oner FC, Verlaan JJ. Potential Conflicts of Interest of Editorial Board Members from Five Leading Spine Journals. PLoS One. 2015 Jun 4;10(6):e0127362. doi: 10.1371/journal.pone.0127362. eCollection 2015. PubMed PMID: 26042410.
5)

Sahuquillo J, Biestro A. Is intracranial pressure monitoring still required in the management of severe traumatic brain injury? Ethical and methodological considerations on conducting clinical research in poor and low-income countries. Surg Neurol Int. 2014 Jun 5;5:86. doi: 10.4103/2152-7806.133993. eCollection 2014. PubMed PMID: 25024886; PubMed Central PMCID: PMC4093744.

Anterior sacral meningocele

Anterior sacral meningocele



Anterior sacral meningoceles are congenital lesions that consist of a spinal fluid-filled sac in the pelvis communicating by a small neck with the spinal subarachnoid space through a defect in the sacrum. They protrude into retroperitoneal and presacral space. 1) 2).

The wall of the sac consists of two layers, an inner arachnoid membrane and outer dura mater, which extends into the retroperitoneal presacral space from the sacral spinal canal 3).


Anterior sacral meningocele was first described in 1837 as a part of neural tube defect (NTD) spectrum.


It may be associated with a syndrome like Currarino syndrome 4) which includes anorectal malformations, sacral bony defect and presacral mass; and Marfan syndrome wherein the etiology may be disorder of collagen biosynthesis and structure at the dural level 5).

Associated malformations are found:

spina bifida

spinal dysraphism

bicornuate uterus

imperforate anus 6).


1)

Villarejo F, Scavone C, Blazquez MG, Pascual-Castroviejo I, Perez-Higueras A, Fernandez-Sanchez A, Garcia Bertrand C. Anterior sacral meningocele: review of the literature. Surg Neurol. 1983 Jan;19(1):57-71. doi: 10.1016/0090-3019(83)90212-4. PMID: 6828997.
2)

Sharma V, Mohanty S, Singh DR. Uncommon craniospinal dysraphism. Ann Acad Med Singap. 1996 Jul;25(4):602-8. PMID: 8893940.
3)

Somuncu S, Aritürk E, Iyigün O, Bernay F, Rizalar R, Günaydin M, Gürses N. A case of anterior sacral meningocele totally excised using the posterior sagittal approach. J Pediatr Surg. 1997 May;32(5):730-2. doi: 10.1016/s0022-3468(97)90018-x. PMID: 9165463.
4)

CALIHAN RJ. Anterior sacral meningocele. Radiology. 1952 Jan;58(1):104-8. doi: 10.1148/58.1.104. PMID: 14883380.
5)

North RB, Kidd DH, Wang H. Occult, bilateral anterior sacral and intrasacral meningeal and perineurial cysts: case report and review of the literature. Neurosurgery. 1990 Dec;27(6):981-6. doi: 10.1097/00006123-199012000-00020. PMID: 2274142.
6)

Dahan H, Arrivé L, Wendum D, Docou le Pointe H, Djouhri H, Tubiana JM. Retrorectal developmental cysts in adults: clinical and radiologic-histopathologic review, differential diagnosis, and treatment. Radiographics. 2001 May-Jun;21(3):575-84. doi: 10.1148/radiographics.21.3.g01ma13575. PMID: 11353107.

Preoperative Embolization for Brain Arteriovenous Malformation

Preoperative Embolization for Brain Arteriovenous Malformation

Preoperative embolization has traditionally been regarded as a safe and effective adjunct to cerebral arteriovenous malformation surgery. However, there is currently no high-level evidence to ascertain this presumption.

Sattari et al. from the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran. compared the outcomes of microsurgery (MS) vs microsurgery with preoperative embolization (E + MS) in patients with cerebral arteriovenous malformation through a systematic review.

They searched MEDLINEPubMed, and Embase. The primary outcome was cerebral arteriovenous malformation obliterationSecondary outcomes were intraoperative bleeding (mL), complications, worsened modified Rankin Scale (mRS), and mortality. The pooled proportions of outcomes were calculated through the logit transformation method. The odds ratio (OR) of categorical data and the mean difference of continuous data were estimated through the Mantel-Haenszel and the inverse variance methods, respectively.

Thirty-two studies met the eligibility criteria. One thousand eight hundred twenty-eight patients were treated by microsurgery alone, and 1088 were treated by microsurgery with preoperative embolization, respectively. The meta-analysis revealed no significant difference in AVM obliteration (94.1% vs 95.6%, OR = 1.15 [0.63-2.11], P = .65), mortality (1.7% vs 2%, OR = 0.88 [0.30-2.58], P = .82), procedural complications (18.2% vs 27.2%, OR = 0.47 [0.19-1.17], P = .10), worsened mRS (21.2% vs 18.5%, OR = 1.08 [0.33-3.54], P = .9), and intraoperative blood loss (mean difference = 182.89 [-87.76, 453.55], P = .19).

The meta-analysis showed no significant difference in AVM obliteration, mortality, complications, worse mRS, and intraoperative blood loss between MS and E + MS groups. For AVMs where MS alone has acceptable results, it is reasonable to bypass unnecessary preoperative embolization given the higher postoperative complication risk 1).


In a meta-analysis, preoperative embolization appears to have substantially reduced the lesional volume with active AV shunting before AVM resection. Anecdotally, preoperative embolization facilitates safe and efficient resection; however, differences in outcomes were not significant. The decision to pursue preoperative embolization remains a nuanced decision based on individual lesion anatomy and treatment team experience 2).


Brosnan et al. performed a systematic review of randomized trials and cohort studies evaluating preoperative embolization of bAVMs published between 01 January 2000 and 31 March 2021 and appraise its role in clinical practice. A MEDLINE search was performed, and articles reporting on outcomes following preoperative embolization, as an adjunct to microsurgery, were eligible for inclusion. PRISMA reporting and Cochrane Handbook guidelines were followed. The primary outcome measure was the risk of complications associated with preoperative embolization. The study was registered with PROSPERO (CRD42021244231). Of the 1661 citations, 8 studies with 588 patients met predefined inclusion criteria. No studies specifically compared outcomes of surgical excision of bAVMs between those with and without preoperative embolization. Spetzler Martin (SM) grading was available in 301 cases. 123 of 298 (41⋅28%) patients presented with hemorrhage. Complications related to embolization occurred in 175/588 patients (29.4%, 95% CI 19.6-40.2). Permanent neurological deficits occurred in 36/541 (6%, 95% CI 3.9-8.5) and mortality in 6/588 (0.41%, 95% CI 0-1.4). This is the first systematic review evaluating the preoperative embolization of bAVMs. Existing studies assessing this intervention are of poor quality. Associated complication rates are significant. Based on published literature, there is currently insufficient evidence to recommend the preoperative embolization of AVMs. Further studies are required to ascertain if there are benefits of this procedure and if so, in which cases 3).

A study included patients with brain AVM who underwent embolization at our hospital between April 2011 and May 2021. Risk factors for peri- and postoperative complications were analyzed.

During the study period, 36 AVMs were treated during 58 embolization sessions. The goal of the embolization was preoperative in 24 (67%), pre-radiosurgical in 9 (25%), and palliative in 3 (8%) cases. The overall complication rate was 43% (25 of 58) per session and 36% (13 of 36) per patient. Ischemic and hemorrhagic complications were observed in 14 (24%) and 14 (24%) cases, respectively. n-Butyl cyanoacrylate (n-BCA) embolization was detected as the significant risk for postoperative hemorrhage in the univariate (79% vs. 36%, P = 0.012; Fisher exact test) and the multivariable analysis (odds ratio 4.90, 95% confidence interval 1.08-22.2, P = 0.039). The number of embolized feeder in a single session also tended to be higher in a hemorrhagic complication group (median 3.5 vs. 2.0, P = 0.11; Mann-Whitney U-test).

The risk of embolization in multimodality treatment for complex brain AVM was substantial. n-BCA embolization may carry a higher risk of postoperative hemorrhage. An accumulation of cases is awaited to investigate the effectiveness of minimal target embolization in the future 4).


A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm3). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months).

Preoperative AVM SPE affords a reasonable risk-to-benefit profile for appropriately selected patients 5)


Embolization of intracranial arteriovenous malformations (AVMs) is generally a preoperative adjunctive procedure in the USA.

Preoperative embolization may also be a contributing factor with the potential for recurrence of unresected but embolized portions of an AVM. Follow-up angiography at 1 to 3 years appears to be warranted 6).


A total of 107 patients were treated for cAVMs during the study period. Of those patients, 41 underwent cAVM embolizations with Onyx in 82 procedures.

Results: After the embolization, the cAVM diameter was reduced from 3.71 +/- 1.55 cm to 3.06 +/- 1.89 cm (P < .05). Median volume reduction was 75%. Complete occlusion with embolization alone was achieved in 4 (10%) cAVMs. The recurrence rate for completely occluded cAVMs was 50% (2 patients). A total of 71% of the 41 patients treated with Onyx underwent surgery, and 15% underwent radiosurgery. There were 9% who have not yet received definitive treatment of their residual cAVMs. A new permanent neurologic deficit occurred in 5 patients (6.1% per procedure or 12.2% per patient).

A considerable risk for a permanent neurologic deficit remains for cAVM embolization with Onyx. The risk has to be carefully weighted against the benefit of volume reduction in the treatment of cAVMs 7).


1)

Sattari SA, Shahbandi A, Yang W, Feghali J, Xu R, Huang J. Microsurgery versus Microsurgery With Preoperative Embolization for Brain Arteriovenous Malformation Treatment: A Systematic Review and Meta-analysis. Neurosurgery. 2023 Jan 1;92(1):27-41. doi: 10.1227/neu.0000000000002171. Epub 2022 Oct 26. PMID: 36519858.
2)

Park MT, Essibayi MA, Srinivasan VM, Catapano JS, Graffeo CS, Lawton MT. Surgical management outcomes of intracranial arteriovenous malformations after preoperative embolization: a systematic review and meta-analysis. Neurosurg Rev. 2022 Dec;45(6):3499-3510. doi: 10.1007/s10143-022-01860-x. Epub 2022 Sep 27. PMID: 36168072.
3)

Brosnan C, Amoo M, Javadpour M. Preoperative embolisation of brain arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev. 2022 Jun;45(3):2051-2063. doi: 10.1007/s10143-022-01766-8. Epub 2022 Mar 9. PMID: 35260972; PMCID: PMC9160113.
4)

Koizumi S, Shojima M, Shinya Y, Ishikawa O, Hasegawa H, Miyawaki S, Nakatomi H, Saito N. Risk Factors of Brain Arteriovenous Malformation Embolization as Adjunctive Therapy: Single-Center 10-Year Experience. World Neurosurg. 2022 Sep 18:S1878-8750(22)01346-8. doi: 10.1016/j.wneu.2022.09.069. Epub ahead of print. PMID: 36130658.
5)

Conger JR, Ding D, Raper DM, Starke RM, Durst CR, Liu KC, Jensen ME, Evans AJ. Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes. J Cerebrovasc Endovasc Neurosurg. 2016 Jun;18(2):90-99. doi: 10.7461/jcen.2016.18.2.90. Epub 2016 Jun 30. PMID: 27790398; PMCID: PMC5081503.
6)

Ivanov AA, Alaraj A, Charbel FT, Aletich V, Amin-Hanjani S. Recurrence of Cerebral Arteriovenous Malformations Following Resection in Adults: Does Preoperative Embolization Increases the Risk? Neurosurgery. 2016 Apr;78(4):562-71. doi: 10.1227/NEU.0000000000001191. PubMed PMID: 26702837.
7)

Hauck EF, Welch BG, White JA, Purdy PD, Pride LG, Samson D. Preoperative embolization of cerebral arteriovenous malformations with onyx. AJNR Am J Neuroradiol. 2009 Mar;30(3):492-5. doi: 10.3174/ajnr.A1376. Epub 2008 Dec 26. PMID: 19112062; PMCID: PMC7051448.

1p/19q co-deletion

1p/19q co-deletion


Currently, classification of neoplasms, especially regarding gliomas, is established on molecular mutations in isocitrate dehydrogenase (IDH) genes and the presence of 1p/19q co-deletion 2)


1p/19q co-deletion should be tested whenever oligodendroglial features are present or if oligodendroglioma is suspected on other grounds. This is tested using FISH (fluorescence in situ hybridization) or PCR. It is often sent out, results typically take 3–7 days. Cost for FISH is on the order of $200 U.S., PCR is $300–500 U.S


Oligodendrocyte transcriptional factor-2 (Olig2) is an essential marker for oligodendrocytes expression. Olig2 marker cannot be used as an alternative diagnostic method for 1p 19q co-deletion to distinguish oligodendrogliomas from other glial neoplasms. Although some glial tumors showed diffuse Olig2 expression, 1p19q co-deletion testing is the best diagnostic method 3).

1p/19q co-deletion has not been reported in central neurocytoma, but it can be seen in extraventricular neurocytoma.


2)

Casili G, Paterniti I, Campolo M, Esposito E, Cuzzocrea S. The Role of Neuro-Inflammation and Innate Immunity in Pathophysiology of Brain and Spinal Cord Tumors. Adv Exp Med Biol. 2023;1394:41-49. doi: 10.1007/978-3-031-14732-6_3. PMID: 36587380.
3)

Kurdi M, Alkhatabi H, Butt N, Albayjani H, Aljhdali H, Mohamed F, Alsinani T, Baeesa S, Almuhaini E, Al-Ghafari A, Hakamy S, Faizo E, Bahakeem B. Can oligodendrocyte transcriptional factor-2 (Olig2) be used as an alternative for 1p/19q co-deletions to distinguish oligodendrogliomas from other glial neoplasms? Folia Neuropathol. 2021;59(4):350-358. doi: 10.5114/fn.2021.112562. PMID: 35114775.

Cervical Sympathetic Nerve Block for cerebral vasospasm

Cervical Sympathetic Nerve Block for cerebral vasospasm

Sympathetic perivascular nerve fibers originate from the superior cervical ganglion (SCG) to innervate the cerebral vasculature, with activation resulting in vasoconstriction. Sympathetic pathways are thought to be a significant contributor to cerebral vasospasm 1).


A simple treatment such as a cervical sympathetic nerve block may be an effective therapy but is not routinely performed as cerebral vasospasm treatment/DCI. cervical sympathetic nerve block consists of injecting local anesthetic at the level of the cervical sympathetic trunk, which temporarily blocks the innervation of the cerebral arteries to cause arterial vasodilatation. cervical sympathetic nerve block is a local, minimally invasive, low cost and safe technique that can be performed at the bedside and may offer significant advantages as a complementary treatment in combination with more conventional neurointerventional surgery interventions. Bombardieri et al. reviewed the literature that describes cervical sympathetic nerve block for vasospasm/DCI prevention or treatment in humans after aSAH. The studies outlined in this review show promising results for a cervical sympathetic nerve block as a treatment for vasospasm/DCI. Further research is required to standardize the technique, explore how to integrate a cervical sympathetic nerve block with conventional neurointerventional surgery treatments of vasospasm and DCI, and study its long-term effect on neurological outcomes 2).


SCG was surgically identified in 15 swine and were electrically stimulated to achieve sympathetic activation. CT perfusion scans were performed to assess for changes in cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum (TMax). Syngo. via software was used to determine regions of interest and quantify perfusion measures.

Results: SCG stimulation resulted in 20-30% reduction in mean ipsilateral CBF compared to its contralateral unaffected side (p < 0.001). Similar results of hypoperfusion were seen with CBV, MTT and TMax with SCG stimulation. Prior injection of lidocaine to SCG inhibited the effects of SCG stimulation and restored perfusion comparable to baseline (p > 0.05).

Conclusion: In swine, SCG stimulation resulted in significant cerebral perfusion deficit, and this was inhibited by prior local anesthetic injection into the SCG. Inhibiting sympathetic activation by targeting the SCG may be an effective treatment for sympathetic-mediated cerebral hypoperfusion 3).


Hu et al. investigated the therapeutic effects of SGB in a rat model of subarachnoid hemorrhage (SAH) complicated by delayed CVS and explore the underlying mechanisms. The SAH model was established by the double injection of autologous arterial blood into the cisterna magna. They simulated SGB by transection of the cervical sympathetic trunk (TCST), and measured changes in the diameter, perimeter, and cross-sectional area of the basilar artery (BA) and middle cerebral artery (MCA) to evaluate its vasodilatory effect. To investigate the underlying mechanisms, we determined the expression level of vasoactive molecules endothelin-1 (ET-1) and calcitonin gene-related peptide (CGRP) in the plasma, and apoptotic modulators Bcl-2 and Bax in the hippocampus. We found a significant increase in the diameter, perimeter, and cross-sectional area of the BA and right MCA in SAH rats subjected to TCST. Application of SGB significantly reduced the expression of ET-1 while increasing that of CGRP in SAH rats. We also found a significant increase in the expression of Bcl-2 and a decrease in the expression of Bax in the hippocampus of SAH rats subjected to TCST, when compared to untreated SAH rats. The mechanism of action of SGB is likely mediated through alterations in the ratio of ET-1 and CGRP, and Bax and Bcl-2. These results suggest that SGB can alleviate the severity of delayed CVS by inducing dilation of intracerebral blood vessels, and promoting anti-apoptotic signaling. Our findings provide evidence supporting the use of SGB as an effective and well-tolerated approach to the treatment of CVS in various clinical settings 4)


After successful modeling of cervical sympathetic block, 18 healthy male white rabbits were randomly divided into three groups (n=6), ie, sham operation group (Group A), SAH group (Group B) and SAH with cervical sympathetic block group (Group C). Models of delayed CVS were established by puncturing cisterna magna twice with an injection of autologous arterial blood in Groups B and C. A sham injection of blood through cisterna magna was made in Group A. 0.5 ml saline was injected each time through a catheter for cervical sympathetic block after the first injection of blood three times a day for 3 d in Group B (bilateral alternating). 0.5 ml of 0.25% bupivacaine was injected each time through a catheter for cervical sympathetic block after the first injection of blood three times a day for 7 d in Group B. 2 ml venous blood and cerebrospinal fluid were obtained before (T1), 30 min (T2) and 7 d (T3) after the first injection of blood, respectively, and conserved in a low temperature refrigerator. Basilar artery value at T1, T2 and T3 was measured via cerebral angiography. The degree of damage to nervous system at T1 and T3 was recorded.

Results: There was no significant difference in diameter of basilar artery at T1 among three groups. The diameters of basilar artery at T2 and T3 of Groups B and C were all smaller than that in Group A, which was smaller than Group C, with a significant difference. There was no significant difference in NO and NOS in plasma and cerebrospinal fluid among three groups. The NO and NOS contents at T2 and T3 of Groups B and C were all lower than Group A; Group C was higher than Group B, with a significant difference. The nerve function at T3 of Groups B and C were all lower than Group A and that of Group C higher than Group B, with a significant difference.

Cervical sympathetic block can relieve cerebral vasospasm after subarachnoid hemorrhage and increase NO content and NOS activity in plasma and cerebrospinal fluid to promote neural functional recovery 5)


1) , 3)

Kim WJ, Dacey M, Samarage HM, Zarrin D, Goel K, Chan C, Qi X, Wang AC, Shivkumar K, Ardell J, Colby GP. Sympathetic nervous system hyperactivity results in potent cerebral hypoperfusion in swine. Auton Neurosci. 2022 Sep;241:102987. doi: 10.1016/j.autneu.2022.102987. Epub 2022 May 6. PMID: 35567916; PMCID: PMC9659432.
2)

Bombardieri AM, Albers GW, Rodriguez S, Pileggi M, Steinberg GK, Heit JJ. Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence. J Neurointerv Surg. 2022 Dec 6:jnis-2022-019838. doi: 10.1136/jnis-2022-019838. Epub ahead of print. PMID: 36597947.
4)

Hu N, Wu Y, Chen BZ, Han JF, Zhou MT. Protective effect of stellate ganglion block on delayed cerebral vasospasm in an experimental rat model of subarachnoid hemorrhage. Brain Res. 2014 Oct 17;1585:63-71. doi: 10.1016/j.brainres.2014.08.012. Epub 2014 Aug 13. PMID: 25128600.
5)

Chun-jing H, Shan O, Guo-dong L, Hao-xiong N, Yi-ran L, Ya-ping F. Effect of cervical sympathetic block on cerebral vasospasm after subarachnoid hemorrhage in rabbits. Acta Cir Bras. 2013 Feb;28(2):89-93. doi: 10.1590/s0102-86502013000200001. PMID: 23370920.

Delirium Diagnosis

Delirium Diagnosis


Unlike dementiadelirium has an acute onset, motor signs (tremormyoclonusasterixis), slurred speech, altered consciousness (hyperalert/agitated or lethargic, or fluctuations), hallucinations may be florid.

Consultation-liaison psychiatry could improve the recognition rate of postoperative delirium in elderly patients, and shorten hospitalization time. The training of mental health knowledge for non-psychiatrists could improve the ability of early identify and treatment of delirium 1).


It is a corollary of the criteria that a diagnosis of delirium usually cannot be made without a previous assessment, or knowledge, of the affected person’s baseline level of cognitive function. In other words, a mentally disabled person who is suffering from this will be operating at their own baseline level of mental ability and would be expected to appear delirious without a baseline mental functional status against which to compare.

Early detection is crucial because the longer a patient experiences delirium the worse it becomes and the harder it is to treat. Currently, identification is through intermittent clinical assessment using standardized tools, like the Confusion Assessment Method for the Intensive Care Unit. Such tools work well in clinical research but do not translate well into clinical practice because they are subjective, intermittent, and have low sensitivity. As such, healthcare providers using these tools fail to recognize delirium symptoms as much as 80% of the time.

EEG shows pronounced diffuse slowing.

Delirium-related biochemical derangement leads to electrical changes in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. However, continuous EEG monitoring is not feasible due to the cost and the need for skilled interpretation. Studies using limited-lead EEG show large differences between patients with and without delirium while discriminating delirium from other causes. The Ceribell is a limited-lead device that analyzes EEG. If it is capable of detecting delirium, it would provide an objective physiological monitor to identify delirium before symptom onset. This pilot study was designed to explore relationships between Ceribell and delirium status. Completion of this study will provide a foundation for further research regarding delirium status using the Ceribell data 2).


Hut SC, Dijkstra-Kersten SM, Numan T, Henriquez NR, Teunissen NW, van den Boogaard M, Leijten FS, Slooter AJ. EEG and clinical assessment in delirium and acute encephalopathy. Psychiatry Clin Neurosci. 2021 May 16. doi: 10.1111/pcn.13225. Epub ahead of print. PMID: 33993579.


Early neutrophil-to-lymphocyte ratio (NLR) elevation may also predict delayed-onset delirium, potentially implicating systemic inflammation as a contributory delirium mechanism 3).

Older age, headache, coagulopathy, decreased level of consciousness, seizures, and history of falls. Conversely, infection was associated with a reduced yield.

In higher-risk patients and settings, there should be a push toward earlier neuroimaging as indicated by clinical examinations and individual risk factors. In the meta-analysis, the yield of head CT was higher in ICU patients and those who had focal neurological deficits in addition to altered mental status and was especially high in neuro ICU settings 4)

Neuroimaging should not replace a clinical exam, even in ICU settings; ICU patients should have their sedation reduced to properly test for delirium 5).

Delirium has a complex and fluctuating course with underlying causes that are often multifactorial; identifying a CNS lesion does not necessarily exclude other causes, and vice-versa 6).

The risks of neuroimaging need to be considered in the decision-making process 7).

The use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS 8).


1)

Xie Q, Liu XB, Jing GW, Jiang X, Liu H, Zhong BL, Li Y. The Effect of Consultation-Liaison Psychiatry on Postoperative Delirium in Elderly Hip Fracture Patients in the General Hospital. Orthop Surg. 2023 Jan 3. doi: 10.1111/os.13501. Epub ahead of print. PMID: 36597675.
2)

Mulkey MA, Hardin SR, Munro CL, Everhart DE, Kim S, Schoemann AM, Olson DM. Methods of identifying delirium: A research protocol. Res Nurs Health. 2019 May 30. doi: 10.1002/nur.21953. [Epub ahead of print] PubMed PMID: 31148216.
3)

Reznik ME, Kalagara R, Moody S, Drake J, Margolis SA, Cizginer S, Mahta A, Rao SS, Stretz C, Wendell LC, Thompson BB, Asaad WF, Furie KL, Jones RN, Daiello LA. Common biomarkers of physiologic stress and associations with delirium in patients with intracerebral hemorrhage. J Crit Care. 2021 Mar 23;64:62-67. doi: 10.1016/j.jcrc.2021.03.009. Epub ahead of print. PMID: 33794468.
4)

MadsenTE, KhouryJ, Cadena R, et al. Potentially missed diagnosis of ischemic stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky stroke study.Acad Emerg Med. 2016;23(10):1128-1135. doi:10.1111/acem.13029
5)

Venkat A, Cappelen-Smith C, Askar S, et al. Factors associated with stroke misdiagnosis in the emergency department: a retrospective case-control study. Neuroepidemiology. 2018;51(3–4):123-127. doi:10.1159/000491635
6)

The 2019 American Geriatrics Society Beers Criteria®UpdateExpert Panel. American Geriatrics Society 2019 updated AGSbeers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767
7)

Reznik ME, Rudolph JL. “Yield” to the time-brain dilemma: The case for neuroimaging in delirium. J Am Geriatr Soc. 2023 Jan 6. doi: 10.1111/jgs.18206. Epub ahead of print. PMID: 36606371.
8)

Akhtar H, Chaudhry SH, Bortolussi-Courval É, Hanula R, Akhtar A, Nauche B, McDonald EG. Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis. J Am Geriatr Soc. 2022 Nov 26. doi: 10.1111/jgs.18134. Epub ahead of print. PMID: 36434820.

Spinal cord injury epidemiology

Spinal cord injury epidemiology


see also Cervical spine fracture epidemiology.


Thoracolumbar spine fracture epidemiology


Pediatric cervical spine injury epidemiology.


Spinal cord injury epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. With decompressive surgery and proactive interventions to improve spinal cord perfusion, early treatment has become more intensive. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries.


Traumatic spinal cord injuries (TSCIs) affect up to 500,000 people worldwide each year, and their high morbidity is associated with substantial individual and societal burden and socioeconomic impact 1) 2).

TSCIs most commonly affect young males and result from road traffic accidents, but recent reports also highlight their increasing incidence in older adults as a result of low-energy falls 3) 4) 5).


Kelly-Hedrick et al. reviewed four registry networks, The NACTN Spinal Cord Injury RegistryThe Spinal Cord Injury Model Systems (SCIMS) Database, The Rick Hansen Spinal Cord Injury Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury Study (EMSCI). They compared the registries’ focuses, data platforms, advanced analytics use, and impacts. They also describe how registries’ data can be combined with EHR or shared using federated analysis to protect registrants’ identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes like early decompression. They’ve also revealed latent disease-modifying factors, helped develop clinical trial stratification models and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science 6).


1)

WHO. Spinal Cord Injury, Fact Sheet. Available at 2013 http://www.who.int/mediacentre/factsheets/fs384/en/
2)

Singh A., Tetreault L., Kalsi-Ryan S., Nouri A., Fehlings M.G. (2014). Global prevalence and incidence of traumatic spinal cord injury. Clin. Epidemiol. 6, 309–331
3)

Noonan V.K., Fingas M., Farry A., Baxter D., Singh A., Fehlings M.G., Dvorak M.F. (2012). Incidence and prevalence of spinal cord injury in Canada: a national perspective. Neuroepidemiology 38, 219–226
4)

Selvarajah S., Hammond E.R., Haider A.H., Abularrage C.J., Becker D., Dhiman N., Hyder O., Gupta D., Black J.H., 3rd, Schneider E.B. (2014). The burden of acute traumatic spinal cord injury among adults in the United States: an update. J. Neurotrauma 31, 228–238
5)

Wyndaele M., Wyndaele J.J. (2006). Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord 44, 523–529
6)

Kelly-Hedrick M, Abd-El-Barr M, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan VK, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest J. The Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma. 2022 Dec 28. doi: 10.1089/neu.2022.0450. Epub ahead of print. PMID: 36576020.

Brain abscess

Brain abscess

J.Sales-Llopis

Neurosurgery Service, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL – FISABIO Foundation), Alicante, Spain.


A brain abscess is a focal area of necrosis starting in an area of cerebritis surrounded by a membrane.

Brain abscesses are suppurative infections of the brain parenchyma surrounded by a vascularized capsule.

see also Intracranial abscess.

It is a potentially life-threatening condition requiring prompt radiological identification and rapid treatment.

The most frequent intracranial locations (in descending order of frequency) are: frontal-temporal, frontal-parietal, parietal, cerebellar, and occipital lobes.

In a article, Chen review the literature to find out how the epidemiology of this disease has changed through the years and re-visit the basic pathological process of abscess evolution and highlight the new research in the biochemical pathways that initiate and regulate this process 1).

The epidemiology of brain abscess has changed with the increasing incidence of this infection in immunocompromised patients, particularly solid organ and bone marrow transplant recipients, and the decreasing incidence of brain abscess related to sinusitis and otitis 2).

There have been several trends in the epidemiology of brain abscess over recent decades. One trend is that there appears to be a trend toward a decreasing incidence of brain abscess. In a population-based study of residents of Olmstead County, Minnesota, the incidence rate was 1.3 per 100,000 patient-years from 1935 to 1944 compared with 0.9 per 100,000 patient-years from 1965 to 1981 3).

Clinical presentation is non-specific, with many cases having no convincing inflammatory or septic symptoms.

Abscess formation should be considered in case of clinical deteriorationheadache, and any neurological deficit after febrile episodes.

Similar to any other mass lesion but tend to progress rapidly.

Symptoms of raised intracranial pressure, seizures and focal neurological deficits are the most common forms of presentation

Eventually, many abscesses rupture into the ventricular system, which results in a sudden and dramatic worsening of the clinical presentation and often heralds a poor outcome.

Cerebral abscesses result from pathogens growing within the brain parenchyma. Initial parenchymal infection is known as cerebritis, which may progress into a cerebral abscess.

Cerebral infection is commonly divided into four stages with distinct imaging and histopathologic features:

early cerebritis (a focal infection without a capsule or pus formation,can resolve or develop into frank abscess) late cerebritis

early abscess/encapsulation – may occur 10 days after infection

late abscess/encapsulation – may occur >14 days after infection

Significant advances in the diagnosis and management of bacterial brain abscess over the past several decades have improved the expected outcome of a disease once regarded as invariably fatal. Despite this, intraparenchymal abscess continues to present a serious and potentially life-threatening condition 4).

There has been a gradual improvement in the outcome of patients with brain abscess over the past 50 years, which might be driven by improved brain imaging techniques, minimally invasive neurosurgical procedures, and protocoled antibiotic treatment. Multicenter prospective studies and randomized clinical trials are needed to further advance treatment and prognosis in brain abscess patients.

Our understanding of brain abscesses has increased by meta-analysis on clinical characteristics, ancillary investigations, and treatment modalities. Prognosis has improved over time, likely due to improved brain imaging techniques, minimally invasive neurosurgical procedures, and protocoled antibiotic treatment 5).


Current evidences suggest that for encapsulated brain abscess in superficial non-eloquent area, abscess resection compared to abscess aspiration had lower post-operative residual abscess rate; lower re-operation rate; higher rate of improvement in neurological status within 1 month after surgery, shorter duration of post-operative antibiotics and average length of hospital stay. There was no statistically significant difference in the rate of improvement in neurological status at 3 months post-operative and the mortality 6).

Intraventricular rupture of brain abscess (IVROBA)

Strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology 7).

Known space-occupying lesion, centered in the right frontal anterior white matter, with estimated diameters of 3.5 x 3 x 3.5 cm. It shows well-defined contours and a practically spherical shape. A predominantly hypointense signal on T1 and homogeneously hyperintense on T2, with a wall with hypointense behavior on T2-weighted sequences. After contrast administration, only enhancement of its wall was observed, in a fine and linear way, without identifying solid poles. The lesion shows diffusion sequence restriction and low values ​​of rVSC in perfusion. Marked surrounding vasogenic edema, which causes a mass effect on the neighboring sulci, as well as mild subfalcian herniation, with a deviation from the midline of approximately 6 mm (significant improvement compared to previous CT control). The discrete mass effect is also on the knee of the corpus callosum and the frontal horn of the right ventricle. The findings are compatible with a brain abscess. A small solution of continuity is observed in its anterior wall, in contact with the meninge, which is thickened in a laminar manner in relation to inflammatory involvement, without clearly identifying empyema. Extensive occupation of the frontal sinus bilaterally, with an enhancement of its wall. Retrospectively, the CT study showed slight permeation on the posterior wall of one of the loculations of the frontal sinus close to the abscess. Small hyperintense foci in subcortical and periventricular white matter with a chronic ischemic profile of a small vessel, to a mild degree. Diagnostic impression: Findings compatible with a right frontal parenchymal abscess, 3.5 cm in diameter, with inflammatory changes and thickening of the adjacent pachymeninge, although without clear associated empyema.


1)

Chen M, Low DCY, Low SYY, Muzumdar D, Seow WT. Management of brain abscesses: where are we now? Childs Nerv Syst. 2018 Oct;34(10):1871-1880. doi: 10.1007/s00381-018-3886-7. Epub 2018 Jul 3. PubMed PMID: 29968000.
2)

Calfee DP, Wispelwey B. Brain abscess. Semin Neurol. 2000;20(3):353-60. Review. PubMed PMID: 11051299.
3)

Nicolosi A, Hauser WA, Musicco M, Kurland LT: Incidence and prognosis of brain abscess in a defined population: Olmsted County, Minnesota, 1935-1981. Neuroepidemiology 1991;10:122-131.
4)

atel K, Clifford DB. Bacterial brain abscess. Neurohospitalist. 2014 Oct;4(4):196-204. doi: 10.1177/1941874414540684. PubMed PMID: 25360205; PubMed Central PMCID: PMC4212419.
5)

Brouwer MC, van de Beek D. Epidemiology, diagnosis, and treatment of brain abscesses. Curr Opin Infect Dis. 2016 Nov 8. [Epub ahead of print] PubMed PMID: 27828809.
6)

Zhai Y, Wei X, Chen R, Guo Z, Raj Singh R, Zhang Y. Surgical outcome of encapsulated brain abscess in superficial non-eloquent area: A systematic review. Br J Neurosurg. 2015 Nov 16:1-6. [Epub ahead of print] PubMed PMID: 26569628.
7)

Takeshita M, Kagawa M, Yato S, Izawa M, Onda H, Takakura K, Momma K. Current treatment of brain abscess in patients with congenital cyanotic heart disease. Neurosurgery. 1997 Dec;41(6):1270-8; discussion 1278-9. PubMed PMID: 9402578.