Diem Kieu Tran

Stereotactic robot-assisted MRI-guided laser thermal ablation of radiation necrosis in the posterior cranial fossa: technical note

Laser interstitial thermal therapy (LITT) is a minimally invasive procedure used to treat a variety of intracranial lesions. Utilization of robotic assistance with stereotactic procedures has gained attention due to potential for advantages over conventional techniques. The authors report the first case in which robot-assisted MRI-guided LITT was used to treat radiation necrosis in the posterior fossa, specifically within the cerebellar peduncle. The use of a stereotactic robot allowed the surgeon to perform LITT using a trajectory that would be extremely difficult with conventional arc-based techniques. A 60-year-old man presented with facial weakness and brainstem symptoms consistent with radiation necrosis. He had a history of anaplastic astrocytoma that was treated with CyberKnife radiosurgery 1 year prior to presentation, and he did well for 11 months until his symptoms recurred. The location and form of the lesion precluded excision but made the patient a suitable candidate for LITT. The location and configuration of the lesion required a trajectory for LITT that was too low for arc-based stereotactic navigation, and thus the ROSA robot (Medtech) was used. Using preoperative MRI acquisitions, the lesion in the posterior fossa was targeted. Bone fiducials were used to improve accuracy in registration, and the authors obtained an intraoperative CT image that was then fused with the MR image by the ROSA robot. They placed the laser applicator and then ablated the lesion under real-time MR thermometry. There were no complications, and the patient tolerated the procedure well. Postoperative 2-month MRI showed complete resolution of the lesion, and the patient had some improvement in symptoms.

Evaluation of an iPhone Otoscope in a Neurotrauma Clinic and as an Adjunct to Neurosurgical Education

Introduction CellScope®, an iPhone-enabled otoscope, was introduced into the neurotrauma clinic at an American College of Surgeons certified Level I trauma center. CellScope is an innovative tool that digitally improves optical clarity of the tympanic membrane, providing the acquisition of HIPPA compliant images. We compared the CellScope to the traditional otoscope in teaching medical students, neurosurgery physician assistants, and neurosurgery residents. In addition, the utility of this device in a neurotrauma clinic was specifically examined because of the high frequency of otologic symptoms after head trauma. Method CellScope examination of the tympanic membranes was introduced as a standard/routine part of the exam of neurotrauma patients. We retrospectively reviewed the clinic charts of the NeuroTrauma patients during a three-month time period to determine if their otologic symptoms correlated with any CellScope visualized abnormalities. Medical students, P.A.s, residents, and attendings were surveyed before and after using CellScope to assess their comfort and skill in completing an otological exam, as well as their opinion on the utility of CellScope in their medical training. Results 18 medical professionals were surveyed before and after the use of CellScope. Surveys were graded on a 1-5 scale and indicated a greater preference for the CellScope (4.7/5.0) versus the otoscope (3.16/5.0). Similarly, there was a preference for the CellScope for medical education (4.7/5.0 versus 2.78/5.0). Finally, surveys showed a greater preference for CellScope in identifying abnormal pathology. The overall score showed a 49% increased preference for CellScope over the traditional otoscope. Six previously undiagnosed abnormalities of the tympanic membrane were identified in a total of 27 neurotrauma patients using CellScope. Conclusion The visualization of the tympanic membrane is an important part of the physical examination of the neurotrauma patient. Smartphone-enabled medical instruments like CellScope may facilitate and remove barriers to routine implementation of this part of the physical examination.

Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia

OBJECTIVE To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. METHODS A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. RESULTS Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. CONCLUSIONS Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.

Chronic Subdural Hematoma: A Historical and Clinical Perspective

BACKGROUND This review aims to highlight the clinical complexity of chronic subdural hematoma (cSDH) while presenting a brief historical discussion of cSDH. METHODS A thorough literature search of published English-language papers was performed in PubMed, Ovid, and Cochrane databases. RESULTS cSDH affects 1-5.3 per 100,000 individuals annually, with the incidence expected to rise as the U.S. population ages. The symptoms of cSDH are often nonspecific, with headaches being the most common complaint. Other symptoms include weakness, balance and gait problems, and memory problems. CONCLUSIONS A variety of clinical factors must be taken into account in the treatment of cSDH, and the multifaceted treatment paradigms continue to evolve.

Interactive iBook-Based Patient Education in a NeuroTrauma Clinic

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Educational interventions may alleviate the burden of TBI for patients and their families. Interactive modalities that involve engagement with the educational material may enhance patient knowledge acquisition when compared to static text‐based educational material. OBJECTIVE: To determine the effects of educational interventions in the outpatient setting on self‐reported patient knowledge, with a focus on iPad‐based (Apple, Cupertino, California) interactive modules. METHODS: Patients and family members presenting to a NeuroTrauma clinic at a tertiary care academic medical center completed a presurvey assessing baseline knowledge of TBI or concussion, depending on the diagnosis. Subjects then received either an interactive iBook (Apple) on TBI or concussion, or an informative pamphlet with identical information in text format. Subjects then completed a postsurvey prior to seeing the neurosurgeon. RESULTS: All subjects (n = 152) significantly improved on self‐reported knowledge measures following administration of either an iBook (Apple) or pamphlet (P < .01, 95% confidence interval [CI]). Subjects receiving the iBook (n = 122) performed significantly better on the postsurvey (P < .01, 95% CI), despite equivalent presurvey scores, when compared to those receiving pamphlets (n = 30). Lastly, patients preferred the iBook to pamphlets (P < .01, 95% CI). CONCLUSION: Educational interventions in the outpatient NeuroTrauma setting led to significant improvement in self‐reported measures of patient and family knowledge. This improved understanding may increase compliance with the neurosurgeons recommendations and may help reduce the potential anxiety and complications that arise following a TBI.

THE EFFICACY OF INTERACTIVE IBOOKS IN EDUCATING OLDER PATIENTS ON TBI, CONCUSSION, AND NPH

tered treatment at homewith an 810 nm intranasal device (13 mW) or sham equivalent. Memory and cognition were assessed using MMSE and ADAS-cog at Baseline, at Week 12; and follow-up after 4 weeks of no treatment. Results:Mean(SD) baseline MMSE and ADAS-cog scores were 18.4(9.37) and 32.1(21.41) in the active group, (n1⁄413, 10M, 3F) compared with 25.8(4.36) and 14.8(7.91) in the sham group (n1⁄46, 5M, 1F). Since these were significantly different (p<0.1 for both), data were analyzed by baseline MMSE. In the baseline MMSE 0-24 subgroup, Week 12 scores were significantly improved for the 8 participants on active treatment: MMSE increased 2.00 points (p1⁄40.03, 2-tailed) and ADAS-cog decreased 5.00 points (p1⁄40.03). The only sham participant in this subgroup dropped out before post-baseline assessment. Slight declines in performance were noted at follow-up after 4 weeks of no treatment. In the baseline MMSE 25-30 subgroup, mean changes at Week 12 in MMSE and ADAS-cog were 1.80 and -2.27 in the active group (n1⁄45), versus 1.50 and -3.67 in the sham group (n1⁄45). None of the within-group or between-group comparisons were statistically significant for this milder group. Qualitative feedback from participants and caregivers in the active group reported better sleep, fewer angry outbursts and decreased anxiety, and wandering. No adverse events related to treatment were reported. Conclusions: The large significant improvements in cognitive functioning, QoL and lack of adverse events suggest that PBM therapy may show promise in treatment of individuals experiencing dementia/AD.

THE EFFECTS OF SUBDURAL HEMATOMA ON DEMENTIA, AND A POSSIBLE PATHOPHYSIOLOGICAL MECHANISM VIA BLOCKAGE OF DURAL LYMPHATICS

In SHSY5Y cell line vitamin D was found to protect the cells from metal stress as determined by cell death (trypan blue exclusion LDH), inhibition of ROS production and NfkB pathway(immunoblotting). Conclusions: Our results confirm that Vitamin D deficiency is associated with a substantially increased risk of probable Alzheimer disease. In addition, the association of Apa1 polymorphism on VDR in AD patients may contribute to AD pathology which needs to be explored further. Moreover, Vitamin D has been shown to protect SHSY5Y cells from metal stress through modulating NfkB pathway.

Limb Hypertrophy and Urinary Retention in Parkes Weber: A Case Report

Vascular malformations are developmental abnormalities of the vascular system, which may involve any part of the vascular tree: arteries, veins, or capillaries. Patients with Parkes Weber have been found to have large arteriovenous malformations (AVM). We present a rare case of spinal AVM in a patient was newly diagnosed Parkes Weber syndrome. A 21-year-old male presented with worsening back pain with urinary retention and hypertrophied right lower limb. He was found to have a large spinal AVM with multiple AVMs in his right lower extremity. He was treated with surgical resection of his spinal AVM. Intraoperative angiography confirmed gross total resection of AVM. The patient was discharged from an acute rehab facility postoperative day fifteen without complications. The patient had two follow up since discharge and was found to have full strength and no urinary retention. It is important to recognize this rare disorder for prompt treatment to prevent further progression of symptoms.