Magnetic resonance imaging does not provide any additional clinically relevant information

A missed cervical spine (CS) injury can have devastating consequences. When CS injuries cannot be ruled out clinically using the National Emergency X-Radiography Utilization Study low-risk criteria because of either a neurologic deficit or pain, the optimal imaging modality for CS clearance remains controversial.

Cervical spine injury complicates the care of approximately 4% of injured patients admitted to trauma centers across the United States.

Evaluation

The initial evaluation of patients for cervical spine injury involves a detailed physical examination with careful evaluation of the criteria to determine whether radiographic evaluation of the cervical spine is necessary.

Radiographic evaluation

Once screening the cervical spine with radiography has been determined necessary, plain radiography has traditionally been the initial screening test for patients at risk of cervical spine injury.

Realization that standard cervical spine radiography fails to identify all patients with cervical spine injuries has resulted in the use of additional radiographic studies including supine oblique views, flexion-extension radiographs, or computed tomography (CT) scanning.

Cervical spine CT scanning

Computed tomography is effective in the detection of clinically significant CS injuries in adults deemed eligible for evaluation who had a neurologic deficit or CS pain.

Is being utilized with increasing frequency as a screening test for patients with potential cervical spine injury. However, the appropriate screening test to rule out cervical spine injury in the blunt trauma patient is unclear.

Magnetic resonance imaging

Magnetic resonance imaging does not provide any additional clinically relevant information 1).

1) Resnick S, Inaba K, Karamanos E, Pham M, Byerly S, Talving P, Reddy S, Linnebur M, Demetriades D. Clinical Relevance of Magnetic Resonance Imaging in Cervical Spine Clearance: A Prospective Study. JAMA Surg. 2014 Jul 30. doi: 10.1001/jamasurg.2014.867. [Epub ahead of print] PubMed PMID: 25076462.

Update: Pericallosal artery aneurysm endovascular treatment

Pericallosal artery aneurysm endovascular treatment

J.Sales-Llopis

Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

The initial results of endovascular coiling for pericallosal artery aneurysms were not satisfactory because most aneurysms in this location are small and distally located 1).

Since the recent improvements in endovascular techniques and equipment, pericallosal artery aneurysms have become accessible for endovascular coiling and the results have thus been improving with success rates to be 92.9–100% 2) 3) 4).

Intracranial hemorrhage (ICH) associated with this aneurysm location is not uncommon, and is viewed as a relative contraindication for heparinization and requires management of increased intracranial pressure. Par- ticular attention must be paid to perioperative management and coiling is still considered to be controversial. Thus, these conditions have resulted in under-utilization of endovascular therapy and un- der-representation in coiling trials.

Yamazaki et al. applied endovascular coiling for ruptured pericallosal artery aneurysms, including those associated with ICH, as the first-line treatment.

They consider to be important to refrain from bolus heparin injection during endovascular coiling for cases with concomitant dense hematoma. Otherwise, coil embolization should be postponed until 8 hours after the onset to lower the risk of hematoma enlargement 5).

Endovascular approaches for aneurysms < 3mm in size reportedly have higher risks for intraoperative rupture 6). 7).

Case series

2013

30 consecutive patients with ruptured pericallosal artery aneurysms including those with intracerebral hematoma. Twenty-seven cases of ruptured pericallosal artery aneurysms were successfully embolized with coiling whereas three failures required surgery. Four patients experienced periprocedural complications including thromboembolic event in two and hematoma enlargement after coiling in two. A maximum aneurysm diameter of <3 mm was most strongly associated with failure of endovascular coiling. Of the 27 coil-treated aneurysms, immediate angiographic results showed complete aneurysm occlusion in 19 cases, neck remnant in 6, and residual aneurysm in 2. One patient had a major aneurysm recurrence that was uneventfully reembolized. Sixteen of our 30 patients had good outcomes (modified Rankin scale [mRS] 0-2), 7 had moderate disability (mRS 3), and 4 had severe disability (mRS 4-5) at 3 months after treatment. The management strategy for coiling as the first-intention treatment for ruptured pericallosal artery aneurysms has the potential to become an acceptable alternative to surgical clipping for selected cases, although a larger study population and longer follow-up periods are needed before definitive conclusions can be drawn.

The maximum diameters of our failed cases were < 3 mm while all 22 aneurysms with a maximum diameter ≥ 3 mm were successfully embolized. Therefore, morphologically, they consider the lower limit on pericallosal artery aneurysm diameters difficult to treat by endovascular coiling to be < 3mm since the failure rate was significantly higher than for larger aneurysms.

The overall complication rate was 13.3% (4/30 cases) and independent activities of daily living (mRS 0–2) were achieved in 53.3% (16/30). Two cases experienced thromboembolic complications with one resulting in a moderate permanent deficit and the other in a minor neurological deficit from which the patient fully recovered. Two patients developed hematoma enlargement probably because coil embolization was performed within 8 hours of onset under systemic heparinization. It is, therefore, important to intentionally postpone endovascular coiling in patients with associated ICH until 8 hours after the onset, or to minimize heparinization for patients requiring coil embolization within 8 hours. This may lower the risk of hemorrhagic complications 8).


Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms reported in 3 cases 9).

2012

4 cases treating wide-neck pericallosal artery aneurysms at the bifurcation with Y-configuration stent placement is feasible and effective. This technique may be considered as a therapeutic option for wide-neck aneurysms that pose a difficult technical challenge 10).

2011

32 patients presenting with SAH due to pericallosal aneurysm treated with an endovascular approach were more likely to have a good modified Rankin scale (mRS) (mRS 0-2 vs 3-6) (p=0.028), to make a complete recovery (mRS=0) (p=0.017) and were less likely to die (mRS=6) (p=0.026). Patients with electively treated pericallosal aneurysms did not have statistically significant differences in outcome between surgical and endovascular cohorts. Differences in secondary endpoints did not reach significance. Patients with ruptured pericallosal aneurysms fare better with endovascular therapy, with better chance of complete recovery. Surgical and endovascular treatments of unruptured pericallosal aneurysms have similar results and outcome 11).

2007

Nguyen et al., examined data of 25 patients that were stored in a prospectively collected database for pericallosal artery aneurysms in patients who underwent coil placement between 1992 and 2005. Hemorrhagic and thromboembolic complications as well as clinical and angiographic outcomes were reviewed. Angiographically documented recurrences were classified as minor or major. These lesions were compared with a historical cohort of non-pericallosal artery aneurysms in patients who underwent coil therapy between 1992 and 2002. The known risk factors for recurrence and procedure-related hemorrhagic complications were evaluated in both groups to assess baseline imbalances.

During a 13-year period, 25 pericallosal artery aneurysms were treated with coils in 25 patients. The non-pericallosal artery lesion group included 488 aneurysms of which 344 underwent follow-up imaging. Procedure-related perforations were more frequent for pericallosal artery aneurysms than those in other intradural locations (three of 25 compared with eight of 476, respectively; risk ratio 7.1, 95% confidence interval [CI] 2.1-22.5, p = 0.03). Follow-up imaging studies (obtained at a mean 28 months) were available for 19 patients with pericallosal artery aneurysms. The recurrence rate was not significantly higher in these patients (22.9/100 person-years of observation) than in those with non-pericallosal artery aneurysms (17.9/100 person-years of observation) (incidence rate ratio 1.3, 95% CI 0.6-2.4, p = 0.46).

Pericallosal artery aneurysms were associated with significantly higher periprocedural rupture than non-pericallosal artery lesions. No significant intergroup difference was found for aneurysm recurrence 12).

Case reports

2014

A rare unique case of ruptured fusiform proximal pericallosal artery aneurysm. Endovascular treatment of this type of aneurysm is a feasible method and can be considered as an effective alternative to surgical technique 13).


A 35-year-old with bacterial endocarditis from Streptococcus mitis was diagnosed with a ruptured 3 mm MIA of the pericallosal anterior cerebral artery after episodic diplopia. The MIA was successfully treated with stent-assisted coil embolization utilizing a Neuroform EZ stent (Stryker Neuroendovascular, Kalamazoo, MI, USA). Follow-up magnetic resonance angiography at 3months demonstrated complete aneurysm obliteration, and the patient was neurologically intact. In the literature, a M1 segment middle cerebral artery MIA, bilateral cavernous carotid MIA, and a unilateral cavernous carotid MIA were also successfully treated with Neuroform, Helistent (Hexacath, Rueil-Malmaison, France), and SILK (BALT Extrusion, Montmorency, France) stents, respectively. We present the first patient with a pericallosal MIA treated with stent-assisted coil embolization. Proper treatment of the causative organism with antibiotics minimizes the risk of infectious seeding of the stent. Intracranial stenting may be safely and effectively utilized to treat select cases of MIA 14).

2013

Endovascular treatment of traumatic pericallosal artery aneurysms. A case report 15).

2010

A 54-year-old woman who underwent endovascular treatment in the setting of a massive subarachnoid haemorrhage due to rupture of a dissecting basilar trunk aneurysm treated with stent implantation and coiling. A further saccular aneurysm in the left pericallosal artery disclosed by four-vessel angiography was treated with coiling during the same procedure. Follow-up DSA performed after six months confirmed complete occlusion of both aneurysms and patency of the stent 16).

1) Pierot L, Boulin A, Cataings L, Rey A, Moret J: Endovascular treatment of pericallosal artery aneurysms. Neurol Res 18: 49–53, 1996
2) , 12) Nguyen TN, Raymond J, Roy D, Chagnon M, Weill A, Iancu-Gontard D, Guilbert F. Endovascular treatment of pericallosal aneurysms. J Neurosurg. 2007 Nov;107(5):973-6. PubMed PMID: 17977269.
3) Vora N, Thomas AJ, Gupta R, Gologorsky Y, Panapitiya N, Jovin T, Jankowitz B, Kassam A, Horowitz M. Endovascular treatment of distal anterior cerebral artery aneurysms: technical results and review of the literature. J Neuroimaging. 2010 Jan;20(1):70-3. doi: 10.1111/j.1552-6569.2008.00324.x. Review. PubMed PMID: 19018950.
4) Waldenberger P, Petersen J, Chemelli A, Schenk C, Gruber I, Strasak A, Eisner W, Beer R, Glodny B. Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option. Surg Neurol. 2008 Oct;70(4):368-77. doi:10.1016/j.surneu.2007.07.058. Epub 2008 Mar 4. PubMed PMID: 18291498.
5) , 8) Yamazaki T, Sonobe M, Kato N, Kasuya H, Ikeda G, Nakamura K, Ito Y, Tsuruta W, Nakai Y, Matsumura A. Endovascular coiling as the first treatment strategy for ruptured pericallosal artery aneurysms: results, complications, and follow up. Neurol Med Chir (Tokyo). 2013;53(6):409-17. PubMed PMID: 23803620.
6) Brinjikji W, Lanzino G, Cloft HJ, Rabinstein A, Kallmes DF: Endovascular treatment of very small (3 mm or smaller) intracranial aneurysms: report of a consecutive series and a meta-analysis. Stroke 41: 116–121, 2010
7) skandar A, Nepper-Rasmussen J: Endovascular treatment of very small intracranial aneurysms. Interv Neuroradiol 17: 299–305, 2011
9) Chalouhi N, Tjoumakaris S, Gonzalez LF, Hasan D, Alkhalili K, Dumont AS, Rosenwasser R, Jabbour P. Endovascular treatment of distal intracranial aneurysms with Onyx 18/34. Clin Neurol Neurosurg. 2013 Dec;115(12):2528-32. doi: 10.1016/j.clineuro.2013.10.018. Epub 2013 Nov 1. PubMed PMID: 24239516.
10) Darkhabani ZM, Lazzaro MA, Zaidat OO. Pericallosal artery aneurysm treatment using Y-configuration stent-assisted coil embolization: a report of four cases. J Neurointerv Surg. 2012 Nov;4(6):459-62. doi: 10.1136/neurintsurg-2011-010086. Epub 2012 Jan 12. PubMed PMID: 22247235.
11) Hui FK, Schuette AJ, Moskowitz SI, Spiotta AM, Lieber ML, Rasmussen PA, Dion JE, Barrow DL, Cawley CM. Microsurgical and endovascular management of pericallosal aneurysms. J Neurointerv Surg. 2011 Dec 1;3(4):319-23. doi: 10.1136/jnis.2011.004770. Epub 2011 Mar 1. PubMed PMID: 21990472.
13) Alurkar A, Karanam LS, Oak S, Nayak S. Endovascular treatment of fusiform A2 aneurysm with parent artery occlusion. Surg Neurol Int. 2014 Jul 30;5(Suppl 4):S199-202. doi: 10.4103/2152-7806.137752. eCollection 2014. PubMed PMID: 25184100; PubMed Central PMCID: PMC4138823.
14) Ding D, Raper DM, Carswell AJ, Liu KC. Endovascular stenting for treatment of mycotic intracranial aneurysms. J Clin Neurosci. 2014 Jul;21(7):1163-8. doi: 10.1016/j.jocn.2013.11.013. Epub 2013 Dec 14. Review. PubMed PMID: 24518267.
15) Van Rooij WJ, Van Rooij SB. Endovascular treatment of traumatic pericallosal artery aneurysms. A case report. Interv Neuroradiol. 2013 Mar;19(1):56-9. Epub 2013 Mar 4. PubMed PMID: 23472724; PubMed Central PMCID: PMC3601618.
16) Lazzarotti GA, Cosottini M, Puglioli M. Stenting and coil embolization of a ruptured dissecting basilar artery aneurysm associated with coil embolization of a pericallosal artery aneurysm. A case report. Neuroradiol J. 2010 Apr;23(2):205-11. Epub 2010 Apr 20. PubMed PMID: 24148540.

Adult spinal deformity

Adult spinal deformity (ASD) surgery is increasing in the spinal neurosurgeon’s practice.

A survey of neurosurgeon AANS membership assessed the deformity knowledge base and impact of current training, education, and practice experience to identify opportunities for improved education. Eleven questions developed and agreed upon by experienced spinal deformity surgeons tested ASD knowledge and were subgrouped into 5 categories: 1) radiology/spinopelvic alignment, 2) health-related quality of life, 3) surgical indications, 4) operative technique, and 5) clinical evaluation. Chi-square analysis was used to compare differences based on participant demographic characteristics (years of practice, spinal surgery fellowship training, percentage of practice comprising spinal surgery). Results Responses were received from 1456 neurosurgeons. Of these respondents, 57% had practiced less than 10 years, 20% had completed a spine fellowship, and 32% devoted more than 75% of their practice to spine. The overall correct answer percentage was 42%. Radiology/spinal pelvic alignment questions had the lowest percentage of correct answers (38%), while clinical evaluation and surgical indications questions had the highest percentage (44%). More than 10 years in practice, completion of a spine fellowship, and more than 75% spine practice were associated with greater overall percentage correct (p < 0.001). More than 10 years in practice was significantly associated with increased percentage of correct answers in 4 of 5 categories. Spine fellowship and more than 75% spine practice were significantly associated with increased percentage correct in all categories. Interestingly, the highest error was seen in risk for postoperative coronal imbalance, with a very low rate of correct responses (15%) and not significantly improved with fellowship (18%, p = 0.08).

The results of this survey suggest that ASD knowledge could be improved in neurosurgery. Knowledge may be augmented with neurosurgical experience, spinal surgery fellowships, and spinal specialization. Neurosurgical education should particularly focus on radiology/spinal pelvic alignment, especially pelvic obliquity and coronal imbalance and operative techniques for ASD 1).

1) Clark AJ, Garcia RM, Keefe MK, Koski TR, Rosner MK, Smith JS, Cheng JS, Shaffrey CI, McCormick PC, Ames CP; , and the International Spine Study Group. Results of the AANS membership survey of adult spinal deformity knowledge: impact of training, practice experience, and assessment of potential areas for improved education. J Neurosurg Spine. 2014 Jul 18:1-8. [Epub ahead of print] PubMed PMID: 25036219.

Radiotherapy versus Observation following surgical resection of Atypical Meningioma (the ROAM trial).

Atypical meningioma

Atypical (WHO Grade IImeningiomas comprise a heterogeneous group of tumors, with histopathology delineated under the guidance of the WHOand a spectrum of clinical outcomes.

Approximately 15-20% of meningiomas are atypical, meaning that the tumor cells do not appear typical or normal. Atypical meningiomas are neither malignant (cancerous) nor benign, but may become malignant. Grade II atypical meningiomas also tend to recur and grow faster.

Treatment

The role of postoperative radiotherapy for patients with atypical meningiomas who have undergone gross-total resection (GTR) remains unclear.

retrospective series supports the observation that postoperative radiotherapy likely results in lower recurrence rates of gross totally resected atypical meningiomas. Although a multicenter prospective trial will ultimately be needed to fully define the role of radiotherapy in managing gross totally resected atypical meningiomas 1)

1) Komotar RJ, Iorgulescu JB, Raper DM, Holland EC, Beal K, Bilsky MH, Brennan CW, Tabar V, Sherman JH, Yamada Y, Gutin PH. The role of radiotherapy following gross-total resection of atypical meningiomas. J Neurosurg. 2012 Oct;117(4):679-86. doi: 10.3171/2012.7.JNS112113. Epub 2012 Aug 24. PubMed PMID: 22920955.

Jenkinson MD, Weber DC, Haylock BJ, Mallucci CL, Zakaria R, Javadpour M.Radiotherapy versus Observation following surgical resection of Atypical Meningioma (the ROAM trial). Neuro Oncol. 2014 Jul 19. pii: nou149. [Epub ahead of print] PubMed PMID: 25038504.

XVI Simposium Internacional de Neuromonitorización y Tratamiento del Paciente Neurocrítico Barcelona, 18 – 22 de noviembre de 2014

 

Fecha: 21/11/2014 al 22/11/2014 

Horario: Viernes: 09:00 – 14:00; 15:30 – 20 y sábado: 09:00 – 14:00
Sede: Hotel Alimara, Barcelona

Ponentes:
Pedro Amorim, Mercedes Arribas, Alberto Biestro, Francisco José Cambra, Victoria Cañas, José M. Domínguez-Roldan, Pedro Enríquez, Lourdes Expósito, Alfredo García, S. Ramon Leal-Noval, Francisca Munar, M. Antònia Poca, Andreea Radoi, Marilyn Riveiro, Romy Rossich, Juan Sahuquillo, Oliver W. Sakowitz, Douglas H. Smith, Francisco Javier Tercero

TEMARIO

Viernes 21 de noviembre de 2014

08:00
Últimas inscripciones y acreditación
09:00
Presentación del Simposium
Juan Sahuquillo
09:20
Conferencia inaugural: Diffuse axonal damage after traumatic brain injury
Douglas H. Smith  
10:00
Inauguración oficial del Simposium
A. Garnacho, M. Báguena
10:30
Conferencia invitada: Multimodal monitoring in neurointensive care medicine: state or the art
Oliver W. Sakowitz  
11:00
Preguntas y discusión
Moderación: Juan Sahuquillo
11:30
Descanso – café
12:00
Conferencia invitada: Integrating biomarkers in the management of traumatic brain injury. Exploring new frontiers in precision medicine
Douglas H. Smith  
12:40
Mesa redonda (expositiva): From bench to bedside. Updates on the pathophysiology and treatment of the neurocritical patient
Moderación: Pedro Amorim  

Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: from vasospam to cortical spreading depolarizations
Oliver W. Sakowitz  

Anemia, transfusion and brain function in neurocritical care
S. Ramon Leal-Noval  

Brain energy metabolism after traumatic brain injry. What can we learn from cancer?
Juan Sahuquillo  

13:45
Preguntas y discusión
14:00
Descanso para comer
15:30
Mesa redonda (debate): Controversias en las indicaciones de la craniectomía descompresiva en el paciente neurocrítico
Moderación: Juan Sahuquillo

Craniectomía descompresiva en el paciente con traumatismo craneoencefálico grave. ¿Existe alguna indicación después del estudio DECRA?
Juan Sahuquillo

Indicaciones de la craniectomía descompresiva en el infarto maligno. Justificación del protocolo del HUVH
Marilyn Riveiro

¿Existe alguna indicación en la hemicraniectomía en pacientes mayores de 60 años? Aportaciones del estudio DESTINY-II
Pedro Enríquez

Complicaciones de las técnicas descompresivas. Reflexiones desde Medicina Intensiva
Alberto Biestro

¿Quién y cuándo debe decidir limitar el esfuerzo terapéutico en el paciente neurocrítico
José M. Domínguez-Roldan

17:00
Discusión
17:30
Descanso y café
18:00
Mesa redonda (debate): Paciente neurocrítico pediátrico. Actualizaciones y controversias
Moderación: M. Antònia Poca

Medidas terapéuticas de primer y segundo nivel en el TCE grave pediátrico. Análisis crítico de las guías de la Brain Trauma Foundation
M. Antònia Poca

Neuromonitorización no invasiva. Doppler transcraneal y saturación cerebral por espectroscopia de reflectancia (NIRS) en el paciente pediátrico
Francisco José Cambra

Monitorización contunua del EEG de superficie: ¿una herramienta útil en cuidados intensivos?
Romy Rossich

Actualizaciones en la fluidoterapia en el paciente pediátrico con lesiones cerebrales agudas
Francisca Munar

Valoración de las secuelas neurológicas y de su impacto en la calidad de vida en el paciente pediátrico
Victoria CañasAndreea Radoi

19:30
Preguntas y discusión
20:00
Fin de la sesiones del viernes

Sábado 22 de noviembre de 2014

09:00
Conferencias invitadas 
Moderación: Francisco Javier Tercero

De la medicina basada en la evidencia a la medicina de precisión en el manejo del paciente con un traumatismo craneoencefálico
Alberto Biestro

Anestesia en el paciente crítico. ¿Son los anestésicos agentes neuroprotectores o neurotóxicos?
Pedro Amorim

Diagnóstico y manejo terapéutico del delirio en el paciente neurocrítico
Francisco Javier Tercero

10:25
Discusión
10:40
Investigación básica y traslacional en el paciente neurocrítico
En esta sesión se presentarán en forma de comunicación oral de 10 minutos los tres mejores pósters seleccionados por el comité científico

Pedro EnríquezJosé M. Domínguez-Roldan
11:15
Preguntas y discusión
11:30
Descanso y café
12:00
Mesa redonda (expositiva): Hipotermia en el manejo del paciente neurocrítico
Moderación: Juan Sahuquillo

Actulaización y reflexiones históricas sobre la hipotermia inducida en el paciente con traumatismo craneoencefálico
Juan Sahuquillo

Fisiología de la termorregulación. ¿Cuál es el método óptimo para inducir hipotermia en el paciente neurocrítico?
Alberto Biestro

Aspectos prácticos en el manejo de enfermería del paciente en hipotermia
Mercedes ArribasLourdes Expósito

Hipotermia en la encefalopatía anóxica del recién nacido
Alfredo García

Hipotermia combinada con cirugía descompresiva en el infarto maligno
M. Antònia Poca

13:30
Discusión
14:00
Clausura del Simposium
M. Antònia Poca