Paroxismal non-kinesigenic dyskinesia and hemidystonia associated with silent celiac disease Publication date: January 2020 Source: Clinical Neurology and Neurosurgery, Volume 188 Author(s): Petra Bago Rožanković, Marjan Rožanković, Zrinka Čolak Romić, Silvio Bašić Abstract Paroxismal non-kinesigenic dyskinesia (PNKD) is a rare movement disorder manifesting as choreatic/dystonic movements, usually lasting from minutes to up to 4 h, with perserved consciousness during attacks. Primary PNKD are idiopathic or genetic disorders while secondary PNKD are associated with various neurologic and medical conditions. We present a case with PNKD and right sided hemidystonia in association with celiac disease, responsive to gluten-free diet, not previously reported in available literature. In conclusion, diagnostic tests for celiac disease should be a part of etiological investigations in patients with otherwise unexplained movement disorders including PKND. Gluten free diet could produce a favorable clinical response in those patients.

Non-operative management of spinal metastases: A prognostic model for failure Publication date: January 2020 Source: Clinical Neurology and Neurosurgery, Volume 188 Author(s): Andrew J. Schoenfeld, Joseph H. Schwab, Marco L. Ferrone, Justin A. Blucher, Tracy A. Balboni, Lauren B. Barton, John H. Chi, James D. Kang, Elena Losina, Jeffrey N. Katz Abstract Objectives To describe patient-specific characteristics associated with non-operative failure leading to surgery. Patients and methods We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications. Results We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004). Conclusion We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.

Medicaid payer status and other factors associated with hospital length of stay in patients undergoing primary lumbar spine surgery Publication date: January 2020 Source: Clinical Neurology and Neurosurgery, Volume 188 Author(s): Jose F. Dominguez, Piyush Kalakoti, Xintong Chen, Kaisen Yao, Nam K. Lee, Smit Shah, Meic Schmidt, Chad Cole, Chirag Gandhi, Fawaz Al-Mufti, Christian A. Bowers Abstract Objective The Medicaid patient population and health care costs for spine surgeries among these patients have increased since 2010. Hospital length of stay (LOS) contributes appreciably to hospital costs for patients undergoing primary lumbar spine surgery (PLSS). The aim of this study was to identify independent risk factors for increased LOS in patients undergoing PLSS. Patients and methods In a single-center retrospective study, we reviewed demographic and clinical data from electronic medical records for 181 consecutive adult patients who underwent PLSS involving 1–3 levels from July 2014 to July 2017. We performed regression analyses to identify independent risk factors for increased LOS and to quantify their effects as percent changes in LOS. Results Among 181 patients who underwent PLSS, the mean LOS was 3.57 days. Based on the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologist (ASA) classification, patients with Medicaid insurance were healthier than non-Medicaid patients (mean CCI: 0.34 versus 0.65; p = 0.041, ASA: 1.71 versus 1.91; p = 0.046) yet Medicaid patients had a longer LOS compared with non-Medicaid patients (mean LOS: 4.03 versus 3.30 days; p = 0.047). There was no significant difference in discharge disposition between Medicaid and non-Medicaid patients (Home = 82.35 % versus 79.65 %; p = 0.855). Medicaid patients also had significantly less spinal levels involved in their surgery (1.44 versus 1.67; p = 0.027). Multivariable regression modeling identified independent risk factors positively associated with increased LOS as age (+1.0 % per year; p = 0.007), Medicaid insurance status (+28.7 %; p = 0.007), and CCI (10.1 % per increment in CCI; p = 0.030). Fusion surgery also was an independent risk factor for increased LOS when compared with laminectomy (−54.1 %; p < 0.001) or discectomy (−51.3 %; p < 0.001). Conclusions Increasing age, Medicaid insurance status, higher CCI, and fusion surgery were independently associated with increased LOS after PLSS. This information is useful for preoperative patient counseling, shared decision-making, and risk stratification and may help to further ongoing discussion regarding contributors to rising health care costs. Findings of increased LOS among Medicaid patients will help direct efforts to identify factors that contribute to this health care expense.

Neurotoxicity of antibodies in cancer therapy: A review Publication date: January 2020 Source: Clinical Neurology and Neurosurgery, Volume 188 Author(s): Erika Horta, Connie Bongiorno, Mustapha Ezzeddine, Elizabeth C. Neil Abstract The objective of this manuscript is to identify the neurological side effect profile associated with different classes of antibodies used in cancer pharmacotherapy and to estimate the frequency in which these neurotoxicity occurs. A systematic review of the literature was conducted using OVID MEDLINE and EMBASE databases for articles written between January of 2010 till August of 2018. The spectrum of neurotoxicity was searched using expanded terminology, medical subject headings, truncation, spelling variations and database specific controlled vocabulary. 2134 citations were retrieved that were narrowed down to 151 when SORT 1 or SORT 2 critical appraisal tool was applied to articles with human subjects. Meta-analysis using random effect model was done to estimate the prevalence of neurological symptoms per class of antibody described in SORT1 and SORT2 articles. It was found that the most common neurotoxicity per antibody class are as follows; Bi-specific T-cell engagers was headache 38% [35–40%; I2 0%]; anti-CD20, neuropathy, 16% [7–24%, I2 65%]; anti-CD30, neuropathy 57% [46–68%, I2 72%]; anti-CD52, neuropathy 5–15%; anti-CTL4, headache 12% [7–16%, I2 49%]; anti-EGFR, headache 25% [11–38%, I2 92%]; anti-Her2, neuropathy 33% [18–49%, I2 98%]; anti-PD1 and PDL1, headache 3% [2–5%, I2 85%]; and anti-VEGF, headache 25% [16–35%, I2 73%]. Therefore, all classes of antibodies used in cancer pharmacotherapy have associated neurotoxicity with a wide spectrum of effects afflicting the nervous system as a whole. The specific side effects and the frequency at which they occur differ per class of antibody. Broader and more severe symptoms were noted to effect patients with preexisting brain lesions.

Outcomes of therapeutic hypothermia in patients treated with decompressive craniectomy for malignant Middle cerebral artery infarction: A systematic review and meta-analysis Publication date: January 2020 Source: Clinical Neurology and Neurosurgery, Volume 188 Author(s): Zhongyun Chen, Xiaodan Zhang, Chunyan Liu Abstract Objectives The beneficial effects of therapeutic hypothermia (TH) after decompressive craniectomy (DC) for malignant middle cerebral artery (MCA) infarction are controversial. We conducted a systematic review and meta-analysis to assess the clinical efficacy of TH in aforementioned patients. Patients and Methods A systematic literature search was conducted to find articles published up to April 2019 evaluating the effect of combining TH and DC on short-term (≤30 days) and long-term (>6 months) mortality and neurological outcomes in patients with malignant MCA infarction. Pooled relative risk (RRs) with 95% confidence interval (CI) were calculated using the Mantel–Haenszel fixed-effects model or the DerSimonian-Laird random-effects. Results Patient data was analyzed for a total of 289 patients from four selected studies and two abstracts. Compared to DC alone, combining DC and TH had a tendency to reduce short-term mortality (RR = 0.52, 95% CI 0.26 to 1.05, P = 0.07, I2 = 0%) but had no significant effects on long-term mortality (RR = 1.26, 95% CI 0.58 to 2.76, P = 0.56, I2 = 68%) or neurological outcomes (RR = 0.81, 95% CI 0.53 to 1.24, P = 0.34, I2 = 30%). Conclusion Using TH in tandem with DC did not show definite short- or long-term survival benefits in our study, but may tend to reduce the short-term mortality of patients with malignant MCA infarction.

Herpes viruses in optic neuritis: Similar to Bell’s palsy Publication date: January 2020 Source: Clinical Neurology and Neurosurgery, Volume 188 Author(s): Graciela Ordoñez, Verónica Rivas, Marcos Santos, Montserrat Mondragon, Benjamín Pineda, Karla Rodríguez, Teresa Corona, José Flores, Julio Sotelo Abstract Objective Optic Neuritis (ON) might unfold either as a single intracranial neuritis or as multiple sclerosis, a widespread demyelinating disorder. Different herpes viruses have been proposed as potential participants in the etiology of multiple sclerosis (MS). To analyze the potential presence of herpes viruses in blood and subarachnoid area at the time of ON and contrast the findings according to long-term evolution either as intracranial neuritis or as progression to multiple sclerosis. Patients and methods In a prospective investigation we searched the presence of DNA from 5 herpes viruses (HSV-1, HSV-2, VZV, EBV and HHV6) in CSF and blood lymphocytes from 54 patients with ON, patients were followed 62 ± 3 months; those who developed MS were separated from those with ephemeral ON. Long-term prognosis of ON was related to DNA findings. Results As compared with controls, DNA from HSV-1 was significantly more frequent in CSF and blood from cases with ON; VZV and HSV-2 were found only in CSF; EBV was found only in blood samples (p < 0.006). Conclusions Our results point out the potential participation of HSV, VZV and EBV in ON; suggesting the intervention of various herpes viruses as triggering agents of autoimmunity. However, the number of positive cases was minor than negative cases. Also, our results suggest that the etiological mechanisms in ON could be similar to those of neuritis of the facial nerve (Bell’s palsy).

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

Pure word deafness revealing ischemic stroke in a Tunisian patient Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Thouraya Ben Younes, Mariem Messelmani, Malek Mansour, Jamel Zaouali, Ridha Mrissa

Treatable causes of adult-onset rapid cognitive impairment Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Shuying Wang, Jing Zhang, Junhua Liang, Haiqing Song, Xunming Ji Abstract Objectives Acute and subacute cognitive decline, defined collectively as rapid cognitive impairment (RCI), is attributed to diverse disorders and brings great challenges for differential diagnosis. In this study we investigated the RCI patients to determine the underlying causes and the cognitive outcome of the treatable RCI. Patients and Methods We reviewed medical records of consecutively hospitalized patients (n = 346) with significant and new cognitive dysfunction between January 2014 and December 2015. Based on the duration of their cognitive dysfunction, patients were divided into two groups with the RCI (< 12 months) and the chronic cognitive impairment (CCI, ≥ 12 months), respectively. Etiologies of the RCI and the CCI were analyzed; the cognitive outcomes of the RCI patients with the treatable disorders were assessed in the follow-up visits. Results Potentially treatable or reversible causes were identified in 134 (72%) of 187 RCI patients and in 34 (21%) of 159 CCI patients. The causes in the 134 (72%) RCI patients were immune/inflammation (50, 37%), infection (30, 22%), vascular diseases (29, 22%), neoplasm (16, 12%), metabolic/toxic disorders (7, 5%), and others (2, 1%). The treatable disorders found in both the RCI and the CCI patients were vascular diseases, autoimmune encephalitis, viral encephalitis, inflammatory demyelinating diseases, Hashimoto encephalopathy, neurosyphilis, hydrocephalus, and Vitamin B12 deficiency. Total 114 RCI patients with the treatable disorders were followed up for 6∼39 (median 21) months. Poor cognitive outcomes were found in 24 (21%) of the 114 followed-up patients, comprising patients with infection (1, 3%), immune/inflammation (12, 25%), vascular diseases (8, 28%), and metabolic/toxic disorders (3, 43%). Conclusions Treatable or reversible causes are common underlying RCI. Poor outcomes with severe cognitive deficits are considerably present in the treatable RCI patients and result in permanent dementia.

Intensity-modulated radiotherapy, coplanar volumetric-modulated arc, therapy, and noncoplanar volumetric-modulated arc therapy in, glioblastoma: A dosimetric comparison Publication date: December 2019 Source: Clinical Neurology and Neurosurgery, Volume 187 Author(s): Yong Hou, Yan Zhang, Zhen Liu, Lili Yv, Kun Liu, Xiufang Tian, Yajuan Lv Abstract Objective Advanced techniques such as volumetric-modulated arc therapy (VMAT) may reduce radiation damage and improve the quality of life for patients.We performed a study comparing dose distributions to the planning target volumes(PTVs) and other organs at risk (OARs) of intensity-modulated radiotherapy (IMRT),coplanar VMAT (coVMAT), and non-coplanar VMAT (ncVMAT). Patients and methods 13 patients with GBM who had undergone postoperative radiotherapy were enrolled. Three plans for each patient were created, namely, IMRT, coVMAT, and ncVMAT. Prescription doses and normal-tissue constraints were identical for these three plans. The dosimetric differences of target dose distribution, conformity index (CI), homogeneity index (HI), the gradient index (GI), dose of OARs, monitor units (MUs) and beam-on times among these three plans were investigated. Results These three techniques resulted in comparable maximum, minimum, and mean PTV doses. Small but insignificant differences were observed in GI,CI, and HI. Compared with IMRT, VMAT plans showed statistically significant reductions in the mean doses to the optic chiasm (P < 0.05). Compared with IMRT, VMAT techniques significantly reduced the number of MUs and less beam-on time than IMRT techniques (P ＜ 0.05). However, calculation times were significantly longer for ncVMAT and coVMAT plans at 12 and 12.3 min, versus 2.6 min for IMRT. Our study showed that IMRT or VMAT planning is feasible and efficient for patients with GBM.Compared to IMRT plans, ncVMAT or coVMAT plans showed similar PTV coverage and comparable OARs sparing. VMAT plans significantly reduces the mean doses to the optic chiasm than IMRT plans. Conclusion There was no obvious superiority of ncVMAT over coVMAT in target coverage and sparing of OARs.Compared with IMRT, VMAT techniques significantly reduced the number of MUs and beam-on time but extended the calculation times.