Iuri Santana Neville

Clinical utility of brain stimulation modalities following traumatic brain injury: current evidence.

Traumatic brain injury (TBI) remains the main cause of disability and a major public health problem worldwide. This review focuses on the neurophysiology of TBI, and the rationale and current state of evidence of clinical application of brain stimulation to promote TBI recovery, particularly on consciousness, cognitive function, motor impairments, and psychiatric conditions. We discuss the mechanisms of different brain stimulation techniques including major noninvasive and invasive stimulations. Thus far, most noninvasive brain stimulation interventions have been nontargeted and focused on the chronic phase of recovery after TBI. In the acute stages, there is limited available evidence of the efficacy and safety of brain stimulation to improve functional outcomes. Comparing the studies across different techniques, transcranial direct current stimulation is the intervention that currently has the higher number of properly designed clinical trials, though total number is still small. We recognize the need for larger studies with target neuroplasticity modulation to fully explore the benefits of brain stimulation to effect TBI recovery during different stages of recovery.

Comprehensive cognitive and cerebral hemodynamic evaluation after cranioplasty

Decompressive craniectomy is an established procedure to lower intracranial pressure and can save patients’ lives. However, this procedure is associated with delayed cognitive decline and cerebral hemodynamics complications. Studies show the benefits of cranioplasty beyond cosmetic aspects, including brain protection, and functional and cerebrovascular aspects, but a detailed description of the concrete changes following this procedure are lacking. In this paper, the authors report a patient with trephine syndrome who underwent cranioplasty; comprehensive cognitive and cerebral hemodynamic evaluations were performed prior to and following the cranioplasty. The discussion was based on a critical literature review.

Surgical experience of minipterional craniotomy with 102 ruptured and unruptured anterior circulation aneurysms

The pterional approach was described in the 1970s and has become the most utilized cranial approach with many variations described, including the minipterional technique. Although described recently as an alternative to the pterional approach for anterior circulation aneurysms, to our knowledge a large series of cases using the minipterional approach in both ruptured and unruptured aneurysms has not been described. We present our clinical experience with the minipterional craniotomy in more than 100 ruptured and unruptured anterior circulation aneurysms. The results of 86 consecutive patients with 102 ruptured non-giant, anterior circulation aneurysms treated with early surgery utilizing the minipterional craniotomy were analyzed. Postoperative angiography was carried out in all cases. Outcome results were classified as excellent in 67 (77.9%), and good in seven (8.1%), while 16 (13.9%) patients died. The minipterional technique provides adequate surgical exposure and excellent outcomes for both ruptured and unruptured anterior circulation aneurysm clipping. It constitutes a safe and effective alternative to the pterional approach, with equivalent or potentially better aesthetic and functional outcomes.

Early Surgery Does Not Seem to Be a Pivotal Criterion to Improve Prognosis in Patients with Frontal Depressed Skull Fractures

Introduction. There has been much debate about the ideal timing of surgery of frontal depressed skull fractures (DSF). In this paper, we assess whether timing of surgery may have influenced outcome. Methods. Retrospective cohort of 40 consecutive patients with frontal DSF who underwent surgical treatment over a 36-month period. The patients were divided into early surgery group (ESG) which were operated within 24 h and delayed surgery group (DSG). Results. The population comprised 39 (97.50%) men and the mean age was 27.9 years (range, 2–81 yr). There was no difference of age (P = 0.53), gender male (P = 1.00), presence of focal lesion on head CT (P = 0.89), hypotension (P = 0.28), and hypoxia (P = 0.15). Mean Glasgow Coma Scale (GCS) was significantly lower in patients of ESG than DSG (8.75 and 11.7, resp., P = 0.02). There was no difference between the groups in relation to death (P = 0.13), unfavourable outcome (P = 0.41), late posttraumatic epilepsy (P = 0.64), and smell-and-taste disturbances (P = 1.00). Only one patient (3.5%) evolved meningitis during follow-up. Conclusion. We found no difference between the ESG and DSG in respect to death, unfavourable outcome, LPE, and STD.

Microvascular decompression of the posterior inferior cerebellar artery for intermediate nerve neuralgia

Background: Intermediate nerve neuralgia (INN) is an extremely rare craniofacial pain disorder mainly caused by neurovascular compression. Case Description: We present the case of a 48-year-old female with a 20-month history of intractable paroxysmal INN on the right side. The patient described feeling paroxysmal pain in her auditory canal, pinna, deep in the jaw, and adjacent retromastoid area on the right side. She described the pain as being like a burning sensation. Magnetic resonance imaging showed the right posterior cerebellar artery crossing the cerebellopontine cistern in close contact with the right VII and VIII nerves. Surgical exploration via retromastoid craniotomy revealed vascular compression of the intermediate nerve by the posterior cerebellar artery. We therefore performed microvascular nerve decompression to relieve pain, and the patient remained pain-free at the 6-month follow-up visit. Conclusion: INN should be considered as a differential diagnosis in cases with atypical facial neuralgia, and microvascular decompression is an effective treatment option that can provide optimal pain relief.

Monoblock external ventricular drainage system in the treatment of patients with acute hydrocephalus: A pilot study

Background Infection is a major complication in patients undergoing external ventricular drainage (EVD). Our study aimed to evaluate the incidence of infection in a series with the monoblock EVD system. Material/Methods 46 patients treated with EVD at our emergency department were analyzed prospectively to research the incidence of infections with a new EVD system. Results The average rate of infection was 8.7%. When we stratified the patients according to the exclusive use of EVD without craniotomies, we identified a reduction in the overall incidence of ventriculitis from 8.7% to 2.3%. Age, etiology, and the presence of ventricular bleeding were not statistically significant risk factors. Conclusions Despite the small sample examined in this study, we believe that the monoblock system is a simple, inexpensive device that reduces accidental disconnection of the system.

Computed Tomography Angiography for Detection of Middle Meningeal Artery Lesions Associated with Acute Epidural Hematomas

Background. The natural history of traumatic aneurysms of the middle meningeal artery (MMA) is not well known, but patients with these lesions are more likely to have delayed bleeds. In this paper, we described a series of patients with epidural hematoma who underwent angiotomography (CTA) for MMA vascular lesion diagnosis. Methods. Eleven patients admitted to our emergency unit with small acute epidural hematoma were prospectively studied. All patients with temporal acute epidural hematomas underwent CTA and cerebral angiogram at our institution for diagnosis of posttraumatic lesions of middle meningeal artery. The findings of angiotomography and digital angiography were reviewed by radiologist and angiographers, respectively, to ensure that the lesions were readily diagnosed without knowing the results of angiotomography and to compare CTA findings with standard angiogram. Results. The causes of head injury were traffic accidents, falls, and aggression. Three of these patients presented traumatic MMA pseudoaneurysm. CT angiography was able to diagnose all of them, with dimensions ranging from 1.5 to 2.8 mm. Conventional angiography confirmed the findings of CT angiography, and the lesions presented with similar dimensions at both methods. Conclusions. We believe that angiotomography can be a useful technique for diagnosis of vascular lesion associated with small epidural hematoma.

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

IntroductionTraumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.Case summaryWe present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.DiscussionMost of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.ConclusionIt is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.

Caudal Zona Incerta/VOP Radiofrequency Lesioning Guided by Combined Stereotactic MRI and Microelectrode Recording for Posttraumatic Midbrain Resting-Kinetic Tremor.

OBJECTIVE Reporting the outcome of two patients who underwent unilateral ablative stereotactic surgery to treat pharmacologic resistant posttraumatic tremor (PTT). METHODS We present two patients (31 and 47 years old) with refractory PTT severely affecting their quality of life. Under stereotactic guidance, refined by T2-weighted magnetic resonance imaging and double-channel multiunit microelectrode recording (MER), three sequential radiofrequency lesions were performed in the caudal zona incerta (cZi) up to the base of thalamus (VOP). Effects of cZi/VOP lesion were prospectively rated with a tremor rating scale. RESULTS Both patients demonstrated intraoperative tremor suppression with sustained results up to 18 months follow-up, with improvement of 92% and 84%, respectively, on the tremor rating scale. Tremor improvement was associated with enhancement functionality and quality of life for the patients. The patients returned to their work after the procedure. No adverse effects were observed up to the last follow-up. CONCLUSION Radiofrequency lesion of the cZi/VOP target was effective for posttraumatic tremor in both cases. The use of T2-weighted images and MER was found helpful in increasing the precision and safety of the procedure, because it leads the RF probe by relying on neighbor structures based on thalamus and subthalamic nucleus.

Is transcranial magnetic stimulation useful in posttraumatic disorders

Dear editor, We have read with great interest the recent paper by Herrold et al. (2014) published in Neural Regeneration Research. There is evidence that approximately 20–90% of patients with mild traumatic brain injury develop posttraumatic symptoms, and 40% of these patients have persistent symptoms after trauma (Bazarian et al., 1999; Koski et al., 2015). Therefore, mild traumatic brain injury becomes an important cause of temporary disability. Indeed, posttraumatic disorders have a significant epidemiological relevance, even though it is still undervalued in most of the trauma centers (Bazarian et al., 1999) and there is no specific treatment method (Koski et al., 2015). Recently, many neurological and posttraumatic stress disorders had been treated with noninvasive brain stimulation (Boggio et al., 2010; Fox et al., 2012). Since repetitive transcranial magnetic stimulation (rTMS) was approved by the United States Food and Drug Administration for use in the treatment of resistant major depressive disorder (Herrold et al., 2014), it provided a strong basis to apply rTMS in the treatment of posttraumatic stress disorder. Herrold et al. (2014) described interventions for alcohol use disorder, mild traumatic brain injury, and posttraumatic stress disorder using rTMS. TMS seems to be a well-suited intervention for the treatment of co-occurring neurological and psychiatric disorders (Bazarian et al., 1999). A strong point of the paper from Herrold et al. (2014) is the detailed description of pathways (neural regions and networks) involved in neuromodulation mechanism in patients with alcohol use disorder, mild traumatic brain injury and posttraumatic stress disorder. Herrold et al. (2014) described that there existed substantial gaps in the understanding of the precise neurophysiological mechanisms of rTMS from the perspective of behavior, but they presented interesting explanations about the neurophysiological response to rTMS applied to the dorsolateral prefrontal cortex. The rationale in choosing the dorsolateral prefrontal cortex is usually based on previous results (Boggio et al., 2010; Van Dijk et al., 2010) regarding the treatment of depression by stimulating the same target with rTMS. Our group has a particular interest in the role of rTMS in patients with mild traumatic brain injury. Chen et al. (2007) reported that mild traumatic brain injury is a specific pattern of deficient activation of the dorsolateral prefrontal cortex in work memory task, which is correlated to the severity of patients symptoms. However, we cannot conclude whether this is the target that should be chosen in future studies because in most recently studies (Koski et al., 2015), headache was the most responsive symptom as compared to mood symptoms. Indeed, stimulation of other targets, such as the primary motor cortex given its connectivity with thalamic areas (Van Dijk et al., 2010; Fox et al., 2012), may show better results in posttraumatic stress disorders. In another interesting paper cited by Herrold et al. (2014), Koski et al. (2015) studied 15 adult patients with mild traumatic brain injury who present with persistent post concussion syndrome. They explored the safety, tolerability, and efficacy of high-frequency rTMS placed over the left dorsolateral prefrontal cortex. The important point that needs to be highlighted is the contribution of this study to the development of rTMS as a potential therapeutic tool in posttraumatic syndrome, the ultimate goal of this initial pilot study. Authors chose to conduct an open-label study. Although uncontrolled studies have significant limitations, they are useful at the initial stage of clinical development. They applied a protocol involving 20 sessions. Number of sessions is an important point to be discussed using rTMS as a therapeutic tool for posttraumatic disorders. Based on prior successful experience on the treatment of psychiatric and neurological disorders, a high-frequency rTMS (10 Hz) protocol can be a good option (Pallanti et al., 2010). Practical decision about the number of sessions is a hard decision. Twenty sessions of stimulation is a common option for neurological diseases (Koski et al., 2015), however, it may be unfeasible in most of traumatic brain injury subjects. So, ten sessions of stimulation is more feasible and would provide good results. A double-blind, randomized clinical trial should be performed to investigate whether rTMS is a good treatment method for patients with alcohol use disorder, mild traumatic brain injury, and posttraumatic stress disorder. It is important to find the optimal, or at least the most effective, stimulation parameters for the treatment of alcohol use disorder, traumatic brain injury, and posttraumatic stress disorder. Furthermore, the reported results may be because of a placebo effect or spontaneous recovery, since most of the patients with these disorders improve spontaneously (Alves et al., 1993; McClincy et al., 2006; Covassin et al., 2007). Nevertheless, it is fundamental to eliminate at least the chance that future randomized clinical trials addressing this question are negative because of poor choice of stimulation parameters. Nowadays, we have no treatment methods for persistent posttraumatic symptoms. What can we expect in the future? So, the idea of rTMS protocol seems an interest tool to treat these disorders.