Hieronymus D. Boogaarts

Prevalence of cervical spondylotic myelopathy

BackgroundPatients with signs and/or symptoms of cervical spondylotic myelopathy are frequently encountered in spinal practice. Exact numbers of prevalence or incidence are not known.MethodsA literature search was performed by an experienced librarian in Pubmed, Embase, and Scopus. After selection of articles based on titles and abstracts, a full text review was performed. The prevalence of people needing surgical treatment was also estimated in a neurosurgical practice with a population adherence of 1.7 million people and a known referral pattern of the neurologists; all patients operated upon because of cervical spondylotic myelopathy between July 2009 and July 2012 were collected and prevalence calculated.ResultsThe search of the literature did not reveal any article reporting an incidence or prevalence of cervical spondylotic myelopathy. Eighty of 5,992 patients were operated upon because of a cervical spondylotic myelopathy: 1.6 per 100,000 inhabitants.ConclusionSurprisingly, an extensive search of the literature did not reveal exact data about the incidence or prevalence of cervical spondylotic myelopathy. The prevalence of surgically treated cervical spondylotic myelopathy was estimated as 1.6 per 100,000 inhabitants. Although the population adherence to the surgical practice is reasonably fixed and referral patterns are known, this estimate will still be too low for various reasons. At best, this estimate is the minimal prevalence of cervical spondylotic myelopathy that has been operated upon. To address the exact incidence or prevalence of cervical spondylotic myelopathy in general or needing surgical treatment, other investigations are warranted.

Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas.

CONTEXT Although the endoscopic technique of transsphenoidal pituitary surgery (TS) has been widely adopted, reports on its results in Cushings disease (CD) are still scarce and no studies have investigated long-term recurrence rates. This is the largest endoscopic series published till now. OBJECTIVE To gain insight into the role of endoscopic TS as a primary treatment option for CD, especially in patients with magnetic resonance imaging (MRI)-negative CD and (invasive) macroadenomas. DESIGN Retrospective cohort study. PATIENTS AND METHODS The medical records of 86 patients with CD who underwent endoscopic TS were examined. Data on preoperative and postoperative evaluation, perioperative complications, and follow-up were collected. Remission was defined as disappearance of clinical symptoms with a fasting plasma cortisol level ≤ 50 nmol/l either basal or after 1 mg dexamethasone. RESULTS The remission rate in different adenoma subclasses varied significantly: 60% in MRI-negative CD (n=20), 83% in microadenomas (n=35), 94% in noninvasive macroadenomas (n=16), and 40% in macroadenomas that invaded the cavernous sinus (n=15). The recurrence rate was 16% after 71 ± 39 months of follow-up (mean ± S.D., range 10-165 months). CONCLUSIONS Endoscopic TS is a safe and effective treatment for all patients with CD. Recurrence rates after endoscopic TS are comparable with those reported for microscopic TS. Our data suggest that in patients with noninvasive and invasive macroadenomas, the endoscopic technique of TS should be the treatment of choice as remission rates seem to be higher than those reported for microscopic TS, although no comparative study has been performed.

Primary hypertension and neurovascular compression: a meta-analysis of magnetic resonance imaging studies

OBJECT Several studies have suggested that neurovascular compression (NVC) of the brainstem might be a cause of hypertension. Because this compression syndrome might be demonstrated by MR imaging studies, several authors have tried to assess its prevalence in small series of patients with hypertension. This article presents a meta-analysis of these studies. METHODS The studies reviewed by the authors were based on MR imaging and included the presence of left-sided NVC of the left rostral ventrolateral medulla oblongata (RVLM) and/or the cranial nerves IX and X root entry zone in patients with apparent primary hypertension compared with normotensive patients. Several studies also included patients with secondary hypertension as an additional control group, which is analyzed separately. RESULTS Meta-analysis included data from 14 studies (597 patients with primary hypertension and 609 controls). The effect size was OR 2.68 (95% CI 1.51-4.75, p = 0.001) (random effect), which is consistent with the hypothesis that NVC of the left RVLM is more frequent in patients with apparent primary hypertension compared with normotensive individuals. Stratification for the study design revealed an effect size for prospective studies of OR 1.97 (95% CI 0.74-5.30, p = 0.178) and for retrospective studies of OR 3.36 (95% CI 1.66-6.79, p = 0.001). CONCLUSIONS This meta-analysis indicates a statistically significant effect size for left-sided NVC in apparent primary hypertension. However, this effect is absent if subanalysis is confined to prospective studies.

An introduction to the pathophysiology of aneurysmal subarachnoid hemorrhage

Pathophysiological processes following subarachnoid hemorrhage (SAH) present survivors of the initial bleeding with a high risk of morbidity and mortality during the course of the disease. As angiographic vasospasm is strongly associated with delayed cerebral ischemia (DCI) and clinical outcome, clinical trials in the last few decades focused on prevention of these angiographic spasms. Despite all efforts, no new pharmacological agents have shown to improve patient outcome. As such, it has become clear that our understanding of the pathophysiology of SAH is incomplete and we need to reevaluate our concepts on the complex pathophysiological process following SAH. Angiographic vasospasm is probably important. However, a unifying theory for the pathophysiological changes following SAH has yet not been described. Some of these changes may be causally connected or present themselves as an epiphenomenon of an associated process. A causal connection between DCI and early brain injury (EBI) would mean that future therapies should address EBI more specifically. If the mechanisms following SAH display no causal pathophysiological connection but are rather evoked by the subarachnoid blood and its degradation production, multiple treatment strategies addressing the different pathophysiological mechanisms are required. The discrepancy between experimental and clinical SAH could be one reason for unsuccessful translational results.

Recumbent Gait : Relationship to the Phenotype of Astasia-Abasia ?

Psychogenic gait disorders can present in many different ways. Among patients with a pure psychogenic gait disorder, buckling of the knee is the most common feature, followed by astasia‐abasia. Here, we describe one such patient with a very unusual gait disturbance that might be regarded as a variant of astasia‐abasia. The patient characteristics are described and discussed in a historical context.

A Meningoencephalocele Caused by a Chronic Growing Skull Fracture in a 76-Year-Old Patient

We present a case of a growing skull fracture in adult male, with an interval of 43 years after initial trauma. This finding is extremely rare, especially because growing skull fractures are mostly seen as an uncommon complication of pediatric head trauma with calvarial fracture. In our patient, this finding was incidental, existed for many years, and had no clinical consequences. Therefore, we advised a conservative treatment for our patient.

Four-Dimensional Computed Tomography Angiography Demonstrating a Ruptured Basilar Artery Aneurysm Causing Anterior Cerebral Circulation Arrest

A 61-year-old woman suffered a pronounced subarachnoid hemorrhage. Conventional computed tomography angiography (CTA) showed no enhancement of the intracranial vasculature, whereas there was normal contrast enhancement of bilateral external carotid artery branches. Subsequent four-dimensional computed tomography angiography (4D-CTA) demonstrated active contrast leakage out of a ruptured basilar tip aneurysm, whereas there was no enhancement of the anterior circulation at any time point, consistent with intracranial anterior circulation arrest. This case illustrates that 4D-CTA is superior to conventional CTA for the evaluation of intracranial flow dynamics and delayed intracranial vascular contrast filling.

Endovascular Neurosurgery in the Netherlands: Historical Developments and Achievements

The historical developments of endovascular neurosurgery in the Netherlands are described.

On the Spot: The Use of Four-Dimensional Computed Tomography Angiography to Differentiate a True Spot Sign From a Distal Intracranial Aneurysm

BACKGROUND Spontaneous intracerebral hemorrhage may arise from underlying abnormalities, including aneurysms. Computed tomography angiography (CTA) is widely used for the detection of possible underlying causes, which is important because it may have immediate therapeutic consequences. In addition, CTA is used to detect the so-called spot sign, indicating active hemorrhage, which carries a worse prognosis. However, CTA is a snapshot in time. Four-dimensional (4D) CTA is a dynamic type of imaging and has emerged as a valuable imaging technique for different neurovascular disorders. CASE DESCRIPTION Two patients with intracerebral hemorrhage both showed an assumed spot sign on CTA, suggesting active hemorrhage. Additional 4D-CTA showed true active hemorrhage in one patient and a distal intracranial aneurysm in the other. This aneurysm was initially falsely interpreted as a spot sign on conventional CTA. CONCLUSIONS Our case findings show how 4D-CTA can discern active bleeding from aneurysmal hemorrhage in cases with hemorrhagic stroke. This finding proves the additional value of this relatively new technique, because the detected underlying disorders have different therapeutic consequences in the acute setting.

The non-invasive search for the carotid-cavernous fistula: the added value of the 4D-CTA

Dear Editor-in-Chief, Caroticocavernous arteriovenous fistula (CCF) is a wellknown, often acquired, vascular malformation with an abrupt clinical presentation which can progress rapidly, possibly endangering the visual acuity of the patient. Adequate diagnostic imaging is crucial for early diagnosis and treatment planning in CCF. The optimal imaging strategy can be debated for evaluating this vascular malformation. In the following case, both MR angiography (MRA) and 4D-CTAwere used in the diagnostic work-up of a possible CCF.