Alexandros G. Brotis

Historic Evolution of Open Cingulectomy and Stereotactic Cingulotomy in the Management of Medically Intractable Psychiatric Disorders, Pain and Drug Addiction

Stereotactic cingulotomy constitutes a psychosurgical procedure nowadays advocated in the treatment of medically intractable obsessive-compulsive disorder, chronic pain and drug addiction. From its theoretical conception to the first cingulectomies performed and modern stereotactic-guided cingulotomies, various target localization methods, different surgical techniques, and numerous lesioning devices have been utilized. In the current article, the authors performed a literature review related to cingular lesion placement in an effort to identify misconceptions of the past, recapitulate existing knowledge and recognize targets for further research. The initial animal and human electrophysiologic experimental data regarding the role of the cingulate cortex in various behavioral and cognitive functions were meticulously reviewed. The clinical indications, surgical technique and the clinical results and complications of open cingulectomies were examined. The anatomic target localization methodologies, surgical technique, and the outcome of the initial stereotactic cingulotomy procedures were reviewed, and the evolution of the imaging techniques, stereotactic devices, and lesioning strategies were followed. The modern advanced surgical techniques, clinical outcome and the procedure-associated complications were analyzed with particular emphasis on the emotional, behavioral, and cognitive procedure-induced changes. Large-scale prospective studies with strict inclusion and well-defined, objective outcome criteria are necessary for defining the role of stereotactic cingulotomy in the current psychosurgical armamentarium.

Cerebral perfusion pressure, microdialysis biochemistry, and clinical outcome in patients with spontaneous intracerebral hematomas

PURPOSE The aim of our study was to investigate the roles of cerebral perfusion pressure (CPP) and microdialysis marker values on the clinical outcome of patients with spontaneous intracerebral hematoma. MATERIALS AND METHODS Twenty-seven patients (18 men; mean ± SD age, 54.17 ± 10.05 years; 9 women, mean ± SD age, 65.00 ± 4.24 years) with a GCS of 8 or less upon admission were included in this study. After a 6-month follow-up period, a linear regression model was applied to evaluate the outcomes using the Glasgow Outcome Scale (GOS). RESULTS Of the 27 patients, 16 died within the first 6 months after discharge from the hospital. Six patients had a favorable prognosis after 6 months. In the patients who had a favorable outcome (GOS = 4 or GOS = 5), the CPP was above 75.46 mm Hg, and intracranial pressure was below 14.21 mm Hg. No patient with a favorable prognosis had a lactate-pyruvate (L/P) ratio greater than 37.40. An inverse linear relationship was found among the L/P ratio, the CPP, and patient outcome. CONCLUSION The L/P ratio and CPP were found to be related to patient outcome. In addition, a CPP greater than 75.46 mm Hg and an L/P ratio lower than 37.40 mm Hg were related to a favorable outcome.

Ten Years of Clinical Experience in the Use of Fixed-Pressure Versus Programmable Valves: A Retrospective Study of 159 Patients

AIM The aim of this study was to present our 10-year experience with the use of fixed-pressure and programmable valves in the treatment of adult patients requiring cerebrospinal fluid (CSF) diversion. MATERIAL AND METHODS Patients (n = 159; 89 male and 70 female) suffering from hydrocephalus of various causes underwent CSF shunt implantation. Forty fixed-pressure and 119 programmable valves were initially implanted. RESULTS The observed revision rate was 40% in patients with fixed-pressure valves. In 20% of these patients, a revision due to valve mechanism malfunction was undertaken, and the initial valve was replaced with a programmable one. The revision rate in the adjustable-pressure valve subgroup was 20%. The infection rate for the fixed-pressure and programmable valve subgroups were 3%, and 1.7%, respectively. Similarly, subdural fluid collections were noticed in 17% and 4% of patients with fixed-pressure valves and programmable valves, respectively. CONCLUSIONS The revision and over-drainage rates were significantly lower when using programmable valves, and thus, this type of valve is preferred whenever CSF has to be diverted.

Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study

Idiopathic normal pressure hydrocephalus is a hydrodynamic disorder whose etiology remains unclear. The diagnosis is mainly clinical and the traditional treatment is cerebrospinal fluid shunt diversion. With the introduction of modern management strategies, endoscopic third ventriculostomy has become a viable alternative to shunting and constitutes a well-established method of treatment for obstructive hydrocephalus. The new hydrodynamic concept of hydrocephalus suggests that endoscopic third ventriculostomy (ETV) may be an effective treatment for communicative hydrocephalus. In our current review, the authors focus on the up-to-date knowledge regarding the consideration of endoscopic third ventriculostomy as a safe surgical option in the management of idiopathic normal pressure hydrocephalus.

A cervical ligamentum flavum cyst in an 82-year-old woman presenting with spinal cord compression: a case report and review of the literature

IntroductionWe report on a very rare case of a cervical ligamentum flavum cyst, which presented with progressive myelopathy and radiculopathy. The cyst was radically extirpated and our patient showed significant recovery. A review of the relevant literature yielded seven cases.Case presentationAn 82-year-old Greek woman presented with progressive bilateral weakness of her upper extremities and causalgia, cervical pain, episodes of upper extremity numbness and significant walking difficulties. Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Magnetic resonance imaging of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level, significantly compressing the spinal cord at this level, in close proximity to the yellow ligament and the C3 left lamina. The largest diameter of this lesion was 1.4 cm, and there was no lesion enhancement after the intravenous administration of a paramagnetic contrast. The lesion was surgically removed after a bilateral C3 laminectomy. The thick cystic wall was yellow and fibro-elastic in consistency, while its content was gelatinous and yellow-brownish. A postoperative cervical-spine magnetic resonance image was obtained before her discharge, demonstrating decompression of her spinal cord and dural expansion. Her six-month follow-up evaluation revealed complete resolution of her walking difficulties, improvement in the muscle strength of her arms (4+/5 in all the affected muscle groups), no causalgia and a significant decrease in her preoperative upper extremity numbness.ConclusionCervical ligamentum flavum cysts are rare benign lesions, which should be included in the list of differential diagnosis of spinal cystic lesions. They can be differentiated from other intracanalicular lesions by their hypointense appearance on T1-weighted and hyperintense appearance on T2-weighted magnetic resonance images, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. The outcome of these cysts is excellent with no risk of recurrence.

Vitamin B12, folate, and homocysteine levels and multiple sclerosis: A meta-analysis

BACKGROUND Multiple sclerosis (MS) is a demyelinating and disabling inflammatory disease of the central nervous system. Several factors contribute to MS pathogenesis including genetic-environmental interactions. Case-control studies suggest that there might be associations between MS and homocysteine (Hcy), vitamin B12, and folate blood levels. AIM To meta-analyze all available data describing associations between MS and serum or plasma Hcy, vitamin B12, and folate levels. METHODS The PubMed, MEDLINE, and EMBASE databases were searched for eligible case-control studies published until June 2017. After data extraction, separate analyses using mainly random-effects models were conducted to test for associations between MS and vitamin B12, Hcy, or folate blood levels. RESULTS Twelve, 12, and 9 studies met the inclusion criteria for meta-analysis of MS and Hcy, vitamin B12, and folate levels, respectively. The standardized mean difference (SMD) between MS patients and controls was statistically significant for Hcy (SMD: 0.70, 95% CI: 0.06, 1.34). Stratification according to clinical pattern did not reveal significant differences between relapsing-remitting MS patients and controls (SMD: 0.30, 95% CI: -0.93, 1.54) or between secondary progressive MS patients and controls (SMD: 0.12, 95% CI: -1.65, 1.90). There were no significant differences in SMD between MS patients and healthy individuals for vitamin B12 (SMD: -0.09, 95% CI: -0.29, 0.10) or folate (SMD: -0.06, 95% CI: -0.17, 0.05). CONCLUSION MS patients tend to have elevated Hcy blood levels compared to healthy controls. Hcy may contribute to the pathogenesis of the disease.

A supratentorial primitive neuroectodermal tumor presenting with intracranial hemorrhage in a 42-year-old man: a case report and review of the literature

IntroductionWe report on a very rare case of a supratentorial primitive neuroectodermal tumor in an adult, which presented with intracerebral hemorrhage, and review the relevant medical literature.Case presentationA 42-year-old Caucasian man complained of a sudden headache and nausea-vomiting. The patient rapidly deteriorated to coma. An emergency computed tomography scan showed an extensive intraparenchymal hemorrhage that caused significant mass effect and tonsilar herniation. During surgery, an increased intracranial pressure was recorded and extensive bilateral decompressive craniectomies were performed. A cherry-like intraparenchymal lesion was found in his right frontal lobe and resected. The patient died in the intensive care unit after approximately 48 hours. The resected lesion was identified as a central nervous system primitive neuroectodermal tumor.ConclusionSupratentorial primitive neuroectodermal tumors must be considered in the differential diagnosis of space-occupying lesions in adults. Spontaneous supratentorial hemorrhage due to primitive neuroectodermal tumors is an extremely rare but potentially lethal event.

Variants of the elastin (ELN) gene and susceptibility to intracranial aneurysm: a synthesis of genetic association studies using a genetic model-free approach.

Background: The presence of an intracranial aneurysm (IA) is thought to have a genetic origin. The genetic association studies (GAS) that investigated the association between IA and elastin gene (ELN) variants have produced contradictory or inconclusive results. Materials and methods: In order to decrease the uncertainty of estimated genetic risk effects, a meta-analysis of published GAS-related variants in the ELN gene (ELN INT20 1315T > C, EX20 1264G > A, INT23 1501 + 24T > C and INT4 196 + 71G > A) with susceptibility to IA was conducted using a genetic model-free approach. The risk effects were estimated using the generalized odds ratio (ORG) metric. Results: The analysis showed significant association for the INT20 1315T > C variant [ORG = 0.66 (0.45–0.95)], indicating a protection effect. For the variants EX20 1264G > A, INT23 1501 + 24T > C and INT4 196 + 71G > A, no statistically significant association with IAs was found. Conclusion: There is evidence that the ELN variant INT20 1315T > C is implicated in the development of IA; however, the results should be interpreted with caution since the number of published studies is limited.

An evidence-based approach towards the cranio-cervical junction injury classifications

PurposeThe cranio-cervical junction (CCJ) is an anatomically, functionally and biomechanically complex region. It is commonly involved in trauma of varying severity that can be managed with a multitude of treatment options and carry diverse prognosis. Our objective is to evaluate the quality of currently used CCJ injury classifications in an evidence-based approach.MethodsWe performed two consecutive literature reviews. In the first, we tried to find which classifications are currently used in CCJ injuries. In the second, we scrutinized the gathered classifications in terms of validity, reliability, severity grading, treatment guidance and prognosis assessment.ResultsTwenty classifications are currently used to describe the CCJ injuries and 72 individual injury patterns have been recognized. Almost a third of them can grade severity, guide treatment and assess prognosis. Only two classifications have been tested for validity and reliability.ConclusionsCCJ injuries are poorly described by the current classifications according to evidence-based criteria. There is an obvious need for a simple and reliable classification tool to guide patient management in the evidence-based medicine era.

Acute Schmorl's Node during Strenuous Monofin Swimming: A Case Report and Review of the Literature

Study Design This case report describes an acute Schmorls node (SN) in an elite monofin athlete during exercise. The patient presented with severe back pain and leg numbness and was managed successfully with conservative treatment. Objective The aim of our communication was to describe a rare presentation of a common pathological condition during an intense sport. Background Swimming is not generally considered to be a sport activity that leads to spinal injuries. SNs are usually asymptomatic lesions, incidentally found on imaging studies. There is no correlation between swimming and symptomatic SN formation. Case Report A 16-year-old monofin elite athlete suffered from an acute nonradiating back pain during extreme exercise. His back pain was associated with a fracture of the superior L5 end plate and an acute SN at the L5 vertebral body with perilesional bone marrow edema. The pain resolved with nonsteroidal anti-inflammatory drugs and bed rest. The athlete had an excellent outcome and returned to his training activities 6 months after his incident. Conclusion SN should be considered in the differential diagnosis of severe back pain, especially in sport-related injuries. SNs present with characteristic imaging findings. Due to the benign nature of these lesions, surveillance-only management may be the best course of action.