UW Neurological Surgery Recent PubMed Publications

Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury: A TRACK-TBI Study.

JAMA Psychiatry. 2019 03 01;76(3):249-258

Authors: Stein MB, Jain S, Giacino JT, Levin H, Dikmen S, Nelson LD, Vassar MJ, Okonkwo DO, Diaz-Arrastia R, Robertson CS, Mukherjee P, McCrea M, Mac Donald CL, Yue JK, Yuh E, Sun X, Campbell-Sills L, Temkin N, Manley GT, TRACK-TBI Investigators, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Diaz-Arrastia R, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Gaudette E, Giacino JT, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Levin H, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, McCrea M, Merchant R, Mukherjee P, Nelson LD, Noel F, Okonkwo DO, Palacios E, Perl D, Puccio A, Rabinowitz M, Robertson CS, Rosand J, Sander A, Satris G, Schnyer D, Seabury S, Sherer M, Stein MB, Taylor S, Toga A, Temkin N, Valadka A, Vassar MJ, Vespa P, Wang K, Yue JK, Yuh E, Zafonte R

Abstract
Importance: Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector.
Objective: To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI).
Design, Setting, and Participants: Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study.
Main Outcomes and Measures: Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury.
Results: Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk.
Conclusions and Relevance: After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

PMID: 30698636 [PubMed - indexed for MEDLINE]

Metabolic and Organelle Morphology Defects in Mice and Human Patients Define Spinocerebellar Ataxia Type 7 as a Mitochondrial Disease.

Cell Rep. 2019 01 29;26(5):1189-1202.e6

Authors: Ward JM, Stoyas CA, Switonski PM, Ichou F, Fan W, Collins B, Wall CE, Adanyeguh I, Niu C, Sopher BL, Kinoshita C, Morrison RS, Durr A, Muotri AR, Evans RM, Mochel F, La Spada AR

Abstract
Spinocerebellar ataxia type 7 (SCA7) is a retinal-cerebellar degenerative disorder caused by CAG-polyglutamine (polyQ) repeat expansions in the ataxin-7 gene. As many SCA7 clinical phenotypes occur in mitochondrial disorders, and magnetic resonance spectroscopy of patients revealed altered energy metabolism, we considered a role for mitochondrial dysfunction. Studies of SCA7 mice uncovered marked impairments in oxygen consumption and respiratory exchange. When we examined cerebellar Purkinje cells in mice, we observed mitochondrial network abnormalities, with enlarged mitochondria upon ultrastructural analysis. We developed stem cell models from patients and created stem cell knockout rescue systems, documenting mitochondrial morphology defects, impaired oxidative metabolism, and reduced expression of nicotinamide adenine dinucleotide (NAD+) production enzymes in SCA7 models. We observed NAD+ reductions in mitochondria of SCA7 patient NPCs using ratiometric fluorescent sensors and documented alterations in tryptophan-kynurenine metabolism in patients. Our results indicate that mitochondrial dysfunction, stemming from decreased NAD+, is a defining feature of SCA7.

PMID: 30699348 [PubMed - indexed for MEDLINE]

Autophagy modulates lipid metabolism to maintain metabolic flexibility for Lkb1-deficient Kras-driven lung tumorigenesis.

Genes Dev. 2019 02 01;33(3-4):150-165

Authors: Bhatt V, Khayati K, Hu ZS, Lee A, Kamran W, Su X, Guo JY

Abstract
Loss of tumor suppressor liver kinase B1 (LKB1) promotes cancer cell proliferation but also leads to decreased metabolic plasticity in dealing with energy crises. Autophagy is a protective process involving self-cannibalization to maintain cellular energy homeostasis during nutrient deprivation. We developed a mouse model for Lkb1-deficient lung cancer with conditional deletion of essential autophagy gene Atg7 to test whether autophagy compensates for LKB1 loss for tumor cells to survive energy crises. We found that autophagy ablation was synthetically lethal during Lkb1-deficient lung tumorigenesis in both tumor initiation and tumor growth. We further found that autophagy deficiency causes defective intracellular recycling, which limits amino acids to support mitochondrial energy production in starved cancer cells and causes autophagy-deficient cells to be more dependent on fatty acid oxidation (FAO) for energy production, leading to reduced lipid reserve and energy crisis. Our findings strongly suggest that autophagy inhibition could be a strategy for treating LKB1-deficient lung tumors.

PMID: 30692209 [PubMed - indexed for MEDLINE]

Reply to Correspondence by Calugaru and Calugaru to the Article Entitled "Ischemic retinal vein occlusion: characterizing the more severe spectrum of retinal vein occlusion" by Khayat et al.

Surv Ophthalmol. 2019 Jul - Aug;64(4):593-594

Authors: Khayat M, Williams M, Lois N

PMID: 30682402 [PubMed - indexed for MEDLINE]

The Ability of Magnetic Resonance Black Blood Vessel Wall Imaging to Evaluate Blunt Cerebrovascular Injury Following Acute Trauma.

J Neuroradiol. 2019 Jan 21;:

Authors: Vranic JE, Huynh TJ, Fata P, Barber J, Bonow RH, Levitt MR, Temkin N, Morton R, Kelly C, Shibata DK, Mossa-Basha M

Abstract
BACKGROUND AND PURPOSE: Blunt cerebrovascular injury (BCVI) is associated with a significant risk of ischemic stroke when left untreated. Cross-sectional imaging is vital to early BCVI diagnosis and treatment; however, conventional luminal vessel imaging is limited in its ability to evaluate for vessel wall pathology. The purpose of this study is to evaluate the ability of vessel wall MRI (VWI) to detect and evaluate BCVI in acutely injured trauma patients relative to neck CTA.
MATERIALS AND METHODS: Trauma patients with suspected BCVI on initial neck CTA were prospectively recruited for VWI evaluation. Two neuroradiologists blinded to patient clinical history and CTA findings evaluated each artery independently on VWI and noted the presence and grade of BCVI. These results were subsequently compared to neck CTA findings relative to expert clinical consensus review. Interrater reliability of VWI for detecting BCVI was evaluated using a weighted Cohen k -statistic.
RESULTS: Ten trauma patients (40 cervical arteries) were prospectively evaluated using both CTA and VWI. Out of 18 vascular lesions identified as suspicious for BCVI on CTA, 6 lesions were determined to represent true BCVI by expert consensus review. There was almost perfect agreement between VWI and expert consensus regarding the presence and grade of BCVI (k = 0.82). This agreement increased when considering only low grade BCVI. There was only fair agreement between CTA and expert clinical consensus (k = 0.36). This agreement decreased when considering only low grade BCVI.
CONCLUSIONS: VWI can potentially accurately identify and evaluate BCVI in acutely injured trauma patients with excellent interrater reliability.

PMID: 30677426 [PubMed - as supplied by publisher]

Dilute bleach baths used for treatment of atopic dermatitis are not antimicrobial in vitro.

J Allergy Clin Immunol. 2019 05;143(5):1946-1948

Authors: Sawada Y, Tong Y, Barangi M, Hata T, Williams MR, Nakatsuji T, Gallo RL

PMID: 30677478 [PubMed - indexed for MEDLINE]

Emerging neural specialization of the ventral occipitotemporal cortex to characters through phonological association learning in preschool children.

Neuroimage. 2019 04 01;189:813-831

Authors: Pleisch G, Karipidis II, Brauchli C, Röthlisberger M, Hofstetter C, Stämpfli P, Walitza S, Brem S

Abstract
The ventral occipitotemporal (vOT) cortex serves as a core region for visual processing, and specific areas of this region show preferential activation for various visual categories such as faces and print. The emergence of such functional specialization in the human cortex represents a pivotal developmental process, which provides a basis for targeted and efficient information processing. For example, functional specialization to print in the left vOT is an important prerequisite for fluent reading. However, it remains unclear, which processes initiate the preferential cortical activations to characters arising in the vOT during child development. Using a multimodal neuroimaging approach with preschool children at familial risk for developmental dyslexia, we demonstrate how varying levels of expertise modulate the neural response to single characters, which represent the building blocks of print units. The level of expertise to characters was manipulated firstly through brief training of false-font speech-sound associations and secondly by comparing characters for which children differed in their level of familiarity and expertise accumulated through abundant exposure in their everyday environment. Neural correlates of character processing were tracked with simultaneous high-density electroencephalography and functional magnetic resonance imaging in a target detection task. We found training performance and expertise-dependent modulation of the visual event-related potential around 220 ms (N1) and the corresponding vOT activation. Additionally, trained false-font characters revealed stronger functional connectivity between the left fusiform gyrus (FFG) seed and left superior parietal/lateral occipital cortex regions with higher training performance. In sum, our results demonstrate that learning artificial-character speech-sound associations enhances activation to trained characters in the vOT and that the magnitude of this activation and the functional connectivity of the left FFG to the parieto-occipital cortex depends on learning performance. This pattern of results suggests emerging development of the reading network after brief training that parallels network specialization during reading acquisition.

PMID: 30677503 [PubMed - indexed for MEDLINE]

Common variants of T-cells contribute differently to phenotypic variation in sarcoidosis.

Sci Rep. 2017 07 17;7(1):5623

Authors: Rivera NV, Hagemann-Jensen M, Ferreira MAR, Kullberg S, Eklund A, Martin NG, Padyukov L, Grunewald J

Abstract
The involvement of the immune system, particularly the role of T-cells, in sarcoidosis is unclear. The existence of higher CD4+ T-cells and increased CD4/CD8 ratio may indicate a pathogenic role of T-cells in the disease. In this study, we quantified the contribution of T-cells associated variants and of CD4/CD8 ratio in sarcoidosis phenotypes, Löfgren's syndrome (LS) and non- Löfgren's syndrome (non-LS). We employed a polygenic-based approach using genome-wide association studies results on relative levels of T-cells in healthy individuals to measure the genetic contribution of T-cells in sarcoidosis entities. Results revealed that the genetic architecture of LS is highly influenced by genetic variants associated with CD8+ T-cells and CD4/CD8 ratio, explaining up to 7.94% and 6.49% of LS variation, respectively; whereas, the genetic architecture of non-LS is minimally influenced by T-cells, explaining a phenotypic variation of <1%. Moreover, pleiotropy assessment between T-cells and LS/non-LS associated-variants led to the discovery of highly scored pathway maps that shared common factors related to antigen presentation and T-cell regulatory mechanisms. Differences in significant polygenic scores, presence of pleiotropy, and distinct genetic factors provide further insights on how genetic variants and genes associated with relative levels of T-cell subtypes contribute differently to sarcoidosis phenotypes.

PMID: 28717140 [PubMed - indexed for MEDLINE]

A New Active Contours Approach for Finger Extensor Tendon Segmentation in Ultrasound Images Using Prior Knowledge and Phase Symmetry.

IEEE J Biomed Health Inform. 2018 07;22(4):1261-1268

Authors: Martins N, Sultan S, Veiga D, Ferreira M, Teixeira F, Coimbra M, Martins N, Sultan S, Veiga D, Ferreira M, Teixeira F, Coimbra M

Abstract
This work proposes a new approach for the segmentation of the extensor tendon in ultrasound images of the second metacarpophalangeal joint (MCPJ). The MCPJ is known to be frequently involved in early stages of rheumatic diseases like rheumatoid arthritis. The early detection and follow up of these diseases is important to start and adapt the treatments properly and, in that way, preventing irreversible damage of the joints. This work relies on an active contours framework, preceded by a phase symmetry preprocessing and with prior knowledge energies, to automatically identify the extensor tendon. Active contours methods are widely used in ultrasound images because of their robustness to speckle noise and ability to join unconnected smaller regions into a coherent shape. The tendon is formulated as a line so open ended active contours were used. Phase symmetry highlights the tendon, by setting a proper scale range and angle span. The distance between structures and the tendon slope were also included to enforce the model based on anatomical characteristics. And finally, the concavity measures were used because, given the anatomy of the finger, we know that the tendon line should have less than two concavities. To solve the active contours energy minimization a genetic algorithm approach was used. Several energy metric configurations were compared using the modified Hausdorff distance and results showed that this segmentation is not only possible, but exhibits errors smaller than 0.5 mm with a confidence of 95% with the phase symmetry preprocessing and energies based on the line neighborhood, area ratio, slope, and concavity measurements.

PMID: 28693000 [PubMed - indexed for MEDLINE]

Leading by Example: Web-Based Sexual Health Influencers Among Men Who Have Sex With Men Have Higher HIV and Syphilis Testing Rates in China.

J Med Internet Res. 2019 01 21;21(1):e10171

Authors: Wu D, Tang W, Lu H, Zhang TP, Cao B, Ong JJ, Lee A, Liu C, Huang W, Fu R, Li K, Pan SW, Zhang Y, Fu H, Wei C, Tucker JD

Abstract
BACKGROUND: The spread of healthy behaviors through social networks may be accelerated by influential individuals. Previous studies have used lay health influencers to prevent sexually transmitted infections (STIs) among internet-using men who have sex with men (MSM). However, there is a lack of understanding of the characteristics of this key subset of MSM.
OBJECTIVE: This study aimed to examine sociodemographic characteristics, HIV and syphilis testing, and sexual behaviors of Web-based MSM sexual health influencers (SHIs) in China, defined as individuals with relatively stronger influence on spreading HIV and STI information online.
METHODS: A Web-based survey of MSM was conducted in August 2017 as a final follow-up of a randomized controlled trial promoting HIV testing in 8 Chinese cities. Men were recruited through a gay social networking mobile phone app and were included if they were born biologically male, aged 16 years and above, ever had sex with another man, and HIV negative or with unknown HIV status. Information regarding sociodemographic characteristics, sexual behaviors, and HIV and syphilis testing was obtained. We assessed men's Web-based sexual health influence using a standardized 6-item opinion leadership scale focused on HIV and STI information. Influencers were defined as those whose mean score ranked within the top 13% (a higher score means greater influence). We used multivariable linear and logistic regression models to measure Web-based sexual health influence's association with HIV and syphilis testing, controlling for intervention trial effects, age, education, income, and marital status.
RESULTS: Overall, 1031 men completed the survey. Most men were younger than 30 years (819/1031, 79.43%) and had at least college education (667/1031, 64.69%). Influencers were more likely to get tested for HIV (73/132, 55.3% vs 337/899, 37.5%; P<.001) and syphilis (35/132, 26.5% vs 137/899, 15.2%; P=.001) in the last 3 months compared with noninfluencers. There were no significant differences in condomless sex with male partners (26/132, 19.7% vs 203/899, 22.6%; P=.46), mean number of male sex partners (1.32 vs 1.11; P=.16) in the last 3 months, and mainly meeting male sex partners online in the last 12 months (97/132, 73.5% vs 669/899, 74.4%; P=.82) between influencers and noninfluencers. Regression analyses showed that influencers had higher odds of HIV testing (adjusted odds ratio, AOR 2.16, 95% CI 1.48-3.17) and syphilis testing (AOR 1.99, 95% CI 1.28-3.10) in the last 3 months.
CONCLUSIONS: We identified Web-based SHIs who might be more likely to help promote healthy HIV and syphilis testing behaviors through MSM populations. Leveraging existing influencers may help improve HIV and syphilis testing among their networks.

PMID: 30664490 [PubMed - indexed for MEDLINE]

Metal bashing: iron deficiency and manganese overexposure impact on peripheral nerves.

J Toxicol Environ Health A. 2019;82(2):99-112

Authors: Amos-Kroohs RM, Usach V, Piñero G, Vorhees CV, Martinez Vivot R, Soto PA, Williams MT, Setton-Avruj P

Abstract
Iron (Fe) deficiency (FeD) and manganese (Mn) overexposure (MnOE) may result in several neurological alterations in the nervous system. Iron deficiency produces unique neurological deficits due to its elemental role in central nervous system (CNS) development and myelination, which might persist after normalization of Fe in the diet. Conversely, MnOE is associated with diverse neurocognitive deficits. Despite these well-known neurotoxic effects on the CNS, the influence of FeD and MnOE on the peripheral nervous system (PNS) remains poorly understood. The aim of the present investigation was to examine the effects of developmental FeD and MnOE or their combination on the sciatic nerve of young and adult rats. The parameters measured included divalent metal transporter 1 (DMT1), transferrin receptor (TfR), myelin basic protein (MBP) and peripheral myelin protein 22 (PMP22) expression, as well as Fe levels in the nerve. Our results showed that FeD produced a significant reduction in MBP and PMP22 content at P29, which persisted at P60 after Fe-sufficient diet replenishment regardless of Mn exposure levels. At P60 MnOE significantly increased sciatic nerve Fe content and DMT1 expression. However, the combination of FeD and MnOE produced no marked motor skill impairment. Evidence indicates that FeD appears to hinder developmental peripheral myelination, while MnOE may directly alter Fe homeostasis. Further studies are required to elucidate the interplay between these pathological conditions.

PMID: 30652531 [PubMed - indexed for MEDLINE]

Intracranial aneurysms at higher clinical risk for rupture demonstrate increased wall enhancement and thinning on multicontrast 3D vessel wall MRI.

Br J Radiol. 2019 Apr;92(1096):20180950

Authors: Hartman JB, Watase H, Sun J, Hippe DS, Kim L, Levitt M, Sekhar L, Balu N, Hatsukami T, Yuan C, Mossa-Basha M

Abstract
OBJECTIVE:: Identification of aneurysms at risk for rupture is important and challenging. We sought to evaluate if intracranial vessel wall (IVW) imaging characteristics of unruptured aneurysms correlate with clinical risk factors for rupture.
METHODS:: Patients with unruptured intracranial aneurysms were prospectively recruited and underwent a multi contrast 3D IVW protocol between April 6, 2016 and August 29, 2017. Two independent raters, blinded to aneurysm vulnerability, evaluated each aneurysm for wall enhancement, extent of enhancement in terms of the numbers of quadrants enhancing circumferentially, intensity of enhancement, and qualitative wall thinning. PHASES score was calculated for each aneurysm. Univariate logistic regression analysis was used to compare IVW characteristics between aneurysms at higher clinical risk for rupture (PHASES score > 3) and lower clinical risk for rupture (PHASES score ≤ 3).
RESULTS:: 45 patients with 65 unruptured aneurysms were analyzed; 38 aneurysms with PHASES score > 3 (58%) and 27 aneurysms with PHASES score ≤ 3 (42%). Aneurysms with PHASES score > 3 were more likely to demonstrate enhancement (42.1% vs 14.8%, p = 0.022), greater extent of enhancement (mean: 2.9 vs 2.2 quadrants, p = 0.063), and wall thinning (9.2% vs 0%, p = 0.044). Inter-reader agreement was moderate-to-good for the presence (κ = 0.64), extent (κ = 0.64), and intensity of enhancement (κ = 0.60) but relatively low for wall thinning (κ = 0.25).
CONCLUSION:: Aneurysms at higher risk of rupture by PHASES score are more likely to demonstrate wall enhancement, more diffuse enhancement, and wall thinning on IVW.
ADVANCES IN KNOWLEDGE:: This study prospectively compares IVW-detected wall enhancement and thinning between unruptured aneurysms stratified into high and low risk groups by clinical scores (PHASES) of vulnerability.

PMID: 30653339 [PubMed - indexed for MEDLINE]

Loss of host-derived osteopontin creates a glioblastoma-promoting microenvironment.

Neuro Oncol. 2018 02 19;20(3):355-366

Authors: Szulzewsky F, Schwendinger N, Güneykaya D, Cimino PJ, Hambardzumyan D, Synowitz M, Holland EC, Kettenmann H

Abstract
Background: Microglia and periphery-derived monocytes infiltrate human and mouse glioblastoma and their density is positively correlated with malignancy. Using microarray and RNA sequencing, we have previously shown that glioblastoma-associated microglia/monocytes (GAMs) express osteopontin/SPP1.
Methods: We used quantitative reverse transcriptase PCR, immunofluorescence stainings, western blot, and flow cytometry to identify the various sources of osteopontin (OPN) expression in human and mouse glioblastoma. We implanted wild type GL261 glioblastoma cells, which do not express significant levels of OPN, into wild type and OPN-/- mice to investigate the role of microenvironment-derived OPN on glioblastoma progression.
Results: Our data indicate that GAMs are the predominant source of OPN in both human and mouse glioblastoma and express only the secreted form of OPN. Loss of microenvironment-derived OPN enhanced tumor progression. Staining by Ki67 and terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end labeling showed no difference in overall cell proliferation but a decreased apoptosis rate in tumors in OPN-/- mice. CD31 staining showed a significantly decreased number of microvessels in tumors in OPN-/- mice, accompanied by reduced coverage of vessels with platelet derived growth factor receptor β+ pericytes. Flow cytometry analysis revealed a significant increase of CD11b+/CD45low microglia but not of CD11b+/CD45high macrophages/monocytes in tumors in OPN-/- mice. Sorted CD11b+ cells from wild type and OPN-/- naïve brains and tumors did not show a significant difference in the expression pattern of activation marker genes.
Conclusion: Our results show that in tested human and mouse glioblastoma samples, OPN is predominantly expressed and secreted by GAMs and that, in contrast to OPN expression in the tumor cells per se, loss of stroma-derived OPN creates a glioblastoma-promoting microenvironment.

PMID: 29016864 [PubMed - indexed for MEDLINE]

Left External Carotid Artery to the Middle Cerebral Artery Bypass with Radial Artery Graft and Clip Reconstruction of a Large Middle Cerebral Artery Fusiform Aneurysm: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown). 2019 Jan 11;:

Authors: Cheng CY, Qazi Z, Sekhar LN

Abstract
This 16-yr-old boy presented with episodes of severe headaches, blurred vision, dizziness, and muffled hearing and was discovered to have a large fusiform aneurysm of the left middle cerebral artery (MCA), M1 segment, 20 × 12 mm in dimension. The lenticulostriate arteries were arising proximal and distal to the aneurysm, but the anterior temporal artery was arising from the aneurysm. The aneurysm culminated in the distal M1 segment, and M1 immediately branched into 3 M2 vessels, the lower one being the larger. Due to origin of the lenticulostriate arteries and the anterior temporal artery and patient's age, a bypass was preferred to a flow diversion stent. He underwent left frontotemporal craniotomy and orbital osteotomy, left cervical external carotid artery exposure followed by radial artery graft extraction. The Sylvian fissure was opened and intracranial ICA was exposed for proximal control. The distal M2 vessels traced back toward the aneurysm. The aneurysm was not clippable and a bypass to the larger inferior M2 branch was performed followed by aneurysm trapping. The radial artery graft bypass was placed from the left external carotid artery to the M2 segment of left MCA, followed by clip reconstruction and occlusion of the MCA aneurysm with the preservation of the anterior temporal branch and the lenticulostriate vessels. The patient had no postoperative complications. At the follow-up, one month after surgery, he was doing well, and his angiogram demonstrated patency of the bypass. This video shows the management of a complex fusiform M1 aneurysm with bypass and trapping. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

PMID: 30649501 [PubMed - as supplied by publisher]

Comparison of clinical outcomes following minimally invasive or lumbar endoscopic unilateral laminotomy for bilateral decompression.

J Neurosurg Spine. 2019 Jan 11;:1-9

Authors: McGrath LB, White-Dzuro GA, Hofstetter CP

Abstract
OBJECTIVEMinimally invasive lumbar unilateral tubular laminotomy for bilateral decompression has gradually gained acceptance as a less destabilizing but efficacious and safe alternative to traditional open decompression techniques. The authors have further advanced the principles of minimally invasive surgery (MIS) by utilizing working-channel endoscope-based techniques. Full-endoscopic technique allows for high-resolution off-axis visualization of neural structures within the lateral recess, thereby minimizing the need for facet joint resection. The relative efficacy and safety of MIS and full-endoscopic techniques have not been directly compared.METHODSA retrospective analysis of 95 consecutive patients undergoing either MIS (n = 45) or endoscopic (n = 50) unilateral laminotomies for bilateral decompression in cases of lumbar spinal stenosis was performed. Patient demographics, operative details, clinical outcomes, and complications were reviewed.RESULTSThe patient cohort consisted of 41 female and 54 male patients whose average age was 62 years. Half of the patients had single-level, one-third had 2-level, and the remaining patients had 3- or 4-level procedures. The surgical time for endoscopic technique was significantly longer per level compared to MIS (161.8 ± 6.8 minutes vs 99.3 ± 4.6 minutes; p < 0.001). Hospital stay for MIS patients was on average 2.4 ± 0.5 days compared to 0.7 ± 0.1 days for endoscopic patients (p = 0.001). At the 1-year follow-up, endoscopic patients had a significantly lower visual analog scale score for leg pain than MIS patients (1.3 ± 0.3 vs 3.0 ± 0.5; p < 0.01). Moreover, the back pain disability index score was significantly lower in the endoscopic cohort than in the MIS cohort (20.7 ± 3.4 vs 35.9 ± 4.1; p < 0.01). Two patients in the MIS group (epidural hematoma) and one patient in the endoscopic group (disc herniation) required a return to the operating room acutely after surgery (< 14 days).CONCLUSIONSLumbar endoscopic unilateral laminotomy for bilateral decompression is a safe and effective surgical procedure with favorable complication profile and patient outcomes.

PMID: 30641853 [PubMed - as supplied by publisher]

Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study.

JAMA Netw Open. 2018 05 18;1(1):e180210

Authors: Seabury SA, Gaudette É, Goldman DP, Markowitz AJ, Brooks J, McCrea MA, Okonkwo DO, Manley GT, TRACK-TBI Investigators, Adeoye O, Badjatia N, Boase K, Bodien Y, Bullock MR, Chesnut R, Corrigan JD, Crawford K, Diaz-Arrastia R, Dikmen S, Duhaime AC, Ellenbogen R, Feeser VR, Ferguson A, Foreman B, Gardner R, Giacino J, Gonzalez L, Gopinath S, Gullapalli R, Hemphill JC, Hotz G, Jain S, Korley F, Kramer J, Kreitzer N, Levin H, Lindsell C, Machamer J, Madden C, Martin A, McAllister T, Merchant R, Mukherjee P, Nelson L, Noel F, Palacios E, Perl D, Puccio A, Rabinowitz M, Robertson C, Rosand J, Sander A, Satris G, Schnyer D, Sherer M, Stein M, Taylor S, Temkin N, Toga A, Valadka A, Vassar M, Vespa P, Wang K, Yue J, Yuh E, Zafonte R

Abstract
Importance: Mild traumatic brain injury (mTBI) affects millions of Americans each year. Lack of consistent clinical practice raises concern that many patients with mTBI may not receive adequate follow-up care.
Objective: To characterize the provision of follow-up care to patients with mTBI during the first 3 months after injury.
Design, Setting, and Participants: This cohort study used data on patients with mTBI enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study between February 26, 2014, and August 25, 2016. We examined site-specific variations in follow-up care, the types of clinicians seen by patients receiving follow-up care, and patient and injury characteristics associated with a higher likelihood of receiving follow-up care. The TRACK-TBI study is a prospective, multicenter, longitudinal observational study of patients with TBI presenting to the emergency department of 1 of 11 level I US trauma centers. Study data included patients with head trauma who underwent a computed tomography (CT) scan within 24 hours of injury, had a Glasgow Coma Scale score of 13 to 15, were aged 17 years or older, and completed follow-up care surveys at 2 weeks and 3 months after injury (N = 831).
Main Outcomes and Measures: Follow-up care was defined as hospitals providing TBI educational material at discharge, hospitals calling patients to follow up, and patients seeing a physician or other medical practitioner within 3 months after the injury. Unfavorable outcomes were assessed with the Rivermead Post Concussion Symptoms Questionnaire.
Results: Of 831 patients (289 [35%] female; 483 [58%] non-Hispanic white; mean [SD] age, 40.3 [16.9] years), less than half self-reported receiving TBI educational material at discharge (353 patients [42%]) or seeing a physician or other health care practitioner within 3 months after injury (367 patients [44%]). Follow-up care varied by study site; adjusting for patient characteristics, the provision of educational material varied from 19% to 72% across sites. Of 236 patients with a positive finding on a CT scan, 92 (39%) had not seen a medical practitioner 3 months after the injury. Adjusting for injury severity and demographics, patient admission to the hospital ward or intensive care unit, patient income, and insurance status were not associated with the probability of seeing a medical practitioner. Among the patients with 3 or more moderate to severe postconcussive symptoms, only 145 of 279 (52%) reported having seen a medical practitioner by 3 months.
Conclusions and Relevance: There are gaps in follow-up care for patients with mTBI after hospital discharge, even those with a positive finding on CT or who continue to experience postconcussive symptoms.

PMID: 30646055 [PubMed - indexed for MEDLINE]

Association Between 5-Year Clinical Outcome in Patients With Nonmedically Evacuated Mild Blast Traumatic Brain Injury and Clinical Measures Collected Within 7 Days Postinjury in Combat.

JAMA Netw Open. 2019 01 04;2(1):e186676

Authors: Mac Donald CL, Barber J, Patterson J, Johnson AM, Dikmen S, Fann JR, Temkin N

Abstract
Importance: Although previous work has examined clinical outcomes in combat-deployed veterans, questions remain regarding how symptoms evolve or resolve following mild blast traumatic brain injury (TBI) treated in theater and their association with long-term outcomes.
Objective: To characterize 5-year outcome in patients with nonmedically evacuated blast concussion compared with combat-deployed controls and understand what clinical measures collected acutely in theater are associated with 5-year outcome.
Design, Setting, and Participants: A prospective, longitudinal cohort study including 45 service members with mild blast TBI within 7 days of injury (mean 4 days) and 45 combat deployed nonconcussed controls was carried out. Enrollment occurred in Afghanistan at the point of injury with evaluation of 5-year outcome in the United States. The enrollment occurred from March to September 2012 with 5-year follow up completed from April 2017 to May 2018. Data analysis was completed from June to July 2018.
Exposures: Concussive blast TBI. All patients were treated in theater, and none required medical evacuation.
Main Outcomes and Measures: Clinical measures collected in theater included measures for concussion symptoms, posttraumatic stress disorder (PTSD) symptoms, depression symptoms, balance performance, combat exposure intensity, cognitive performance, and demographics. Five-year outcome evaluation included measures for global disability, neurobehavioral impairment, PTSD symptoms, depression symptoms, and 10 domains of cognitive function. Forward selection multivariate regression was used to determine predictors of 5-year outcome for global disability, neurobehavior impairment, PTSD, and cognitive function.
Results: Nonmedically evacuated patients with concussive blast injury (n = 45; 44 men, mean [SD] age, 31 [5] years) fared poorly at 5-year follow-up compared with combat-deployed controls (n = 45; 35 men; mean [SD] age, 34 [7] years) on global disability, neurobehavioral impairment, and psychiatric symptoms, whereas cognitive changes were unremarkable. Acute predictors of 5-year outcome consistently identified TBI diagnosis with contribution from acute concussion and mental health symptoms and select measures of cognitive performance depending on the model for 5-year global disability (area under the curve following bootstrap validation [AUCBV] = 0.79), neurobehavioral impairment (correlation following bootstrap validation [RBV] = 0.60), PTSD severity (RBV = 0.36), or cognitive performance (RBV = 0.34).
Conclusions and Relevance: Service members with concussive blast injuries fared poorly at 5-year outcome. The results support a more focused acute screening of mental health following TBI diagnosis as strong indicators of poor long-term outcome. This extends prior work examining outcome in patients with concussive blast injury to the larger nonmedically evacuated population.

PMID: 30646193 [PubMed - indexed for MEDLINE]

Intranasal Sufentanil Versus Intravenous Morphine for Acute Pain in the Emergency Department: A Randomized Pilot Trial.

J Emerg Med. 2019 Mar;56(3):301-307

Authors: Sin B, Jeffrey I, Halpern Z, Adebayo A, Wing T, Lee AS, Ruiz J, Persaud K, Davenport L, de Souza S, Williams M

Abstract
BACKGROUND: Patients in the United States frequently seek medical attention in the emergency department (ED) to address their pain. The intranasal (i.n.) route provides a safe, effective, and painless alternative method of drug administration. Sufentanil is an inexpensive synthetic opioid with a high therapeutic index and rapid onset of action, making it an attractive agent for management of acute pain in the ED.
OBJECTIVE: The objective of our study was to evaluate the safety and efficacy of i.n. sufentanil as the primary analgesic for acute pain in the ED.
METHODS: This was a single-center, prospective, randomized, double-blind, double-dummy, controlled trial that evaluated the use of i.n. sufentanil 0.7 μg/kg via mucosal atomizer device vs. intravenous morphine 0.1 mg/kg in adult patients who presented to the ED with acute pain. The primary outcome was patient's pain score at 10 min after administration of intervention. Secondary outcomes were adverse events, the need for rescue analgesia, and patient satisfaction after treatment.
RESULTS: Thirty patients were enrolled in each group. There was no significant difference in pain scores at 10 min after administration of intervention (sufentanil: 2.0, interquartile range = 2.0-3.3 vs. morphine: 3.0, interquartile range = 2.0-5.3, p = 0.198). No serious adverse events were reported. Rescue analgesia was not requested in either group. No significant difference in median satisfaction scores was found.
CONCLUSION: The use of i.n. sufentanil at 0.7 μg/kg/dose resulted in rapid and safe analgesia with comparable efficacy to i.v. morphine for up to 30 min in patients who presented with acute pain in the ED.

PMID: 30638644 [PubMed - indexed for MEDLINE]

A Pilot Study Identifying Brain-Targeting Adaptive Immunity in Pediatric Extracorporeal Membrane Oxygenation Patients With Acquired Brain Injury.

Crit Care Med. 2019 03;47(3):e206-e213

Authors: Ortega SB, Pandiyan P, Windsor J, Torres VO, Selvaraj UM, Lee A, Morriss M, Tian F, Raman L, Stowe AM

Abstract
OBJECTIVES: Extracorporeal membrane oxygenation provides short-term cardiopulmonary life support, but is associated with peripheral innate inflammation, disruptions in cerebral autoregulation, and acquired brain injury. We tested the hypothesis that extracorporeal membrane oxygenation also induces CNS-directed adaptive immune responses which may exacerbate extracorporeal membrane oxygenation-associated brain injury.
DESIGN: A single center prospective observational study.
SETTING: Pediatric and cardiac ICUs at a single tertiary care, academic center.
PATIENTS: Twenty pediatric extracorporeal membrane oxygenation patients (0-14 yr; 13 females, 7 males) and five nonextracorporeal membrane oxygenation Pediatric Logistic Organ Dysfunction score matched patients INTERVENTIONS:: None.
MEASUREMENTS AND MAIN RESULTS: Venous blood samples were collected from the extracorporeal membrane oxygenation circuit at day 1 (10-23 hr), day 3, and day 7 of extracorporeal membrane oxygenation. Flow cytometry quantified circulating innate and adaptive immune cells, and CNS-directed autoreactivity was detected using an in vitro recall response assay. Disruption of cerebral autoregulation was determined using continuous bedside near-infrared spectroscopy and acquired brain injury confirmed by MRI. Extracorporeal membrane oxygenation patients with acquired brain injury (n = 9) presented with a 10-fold increase in interleukin-8 over extracorporeal membrane oxygenation patients without brain injury (p < 0.01). Furthermore, brain injury within extracorporeal membrane oxygenation patients potentiated an inflammatory phenotype in adaptive immune cells and selective autoreactivity to brain peptides in circulating B cell and cytotoxic T cell populations. Correlation analysis revealed a significant relationship between adaptive immune responses of extracorporeal membrane oxygenation patients with acquired brain injury and loss of cerebral autoregulation.
CONCLUSIONS: We show that pediatric extracorporeal membrane oxygenation patients with acquired brain injury exhibit an induction of pro-inflammatory cell signaling, a robust activation of adaptive immune cells, and CNS-targeting adaptive immune responses. As these patients experience developmental delays for years after extracorporeal membrane oxygenation, it is critical to identify and characterize adaptive immune cell mechanisms that target the developing CNS.

PMID: 30640221 [PubMed - indexed for MEDLINE]

Creation across culture: Children's tool innovation is influenced by cultural and developmental factors.

Dev Psychol. 2019 Apr;55(4):877-889

Authors: Neldner K, Redshaw J, Murphy S, Tomaselli K, Davis J, Dixson B, Nielsen M

Abstract
Prior research suggests that human children lack an aptitude for tool innovation. However, children's tool making must be explored across a broader range of tasks and across diverse cultural contexts before we can conclude that they are genuinely poor tool innovators. To this end, we investigated children's ability to independently construct 3 new tools using distinct actions: adding, subtracting, and reshaping. We tested 422 children across a broad age range from 5 geographic locations across South Africa (N = 126), Vanuatu (N = 190), and Australia (N = 106), which varied in their levels of exposure to Westernized culture. Children were shown a horizontal, transparent tube that had a sticker in its middle. Children were sequentially given each incomplete tool, which when accurately constructed could be used to push the sticker out of the tube. As predicted, older children were better at performing the innovation tasks than younger children across all cultures and innovation actions. We also found evidence for cultural variation: While all non-Western groups performed similarly, the Western group of children innovated at higher rates. However, children who did not innovate often adopted alternate methods when using the tools that also led to success. This suggests that children's innovation levels are influenced by the cultural environment, and highlights the flexibility inherent in human children's tool use. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

PMID: 30640502 [PubMed - indexed for MEDLINE]