Historically, many neurosurgical diagnoses only became known under extreme conditions. However, with technological advances and our ability to easily, safely and noninvasively look inside the brain and spine, the incidence of many of these same entities has increased dramatically. Moreover, the connection between
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Defining the Appropriate: When to Screen Patients with Positive Family History of Aneurysmal SAH
Amir R. Dehdashti, MD—What is the appropriate screening in patients with positive family history of aneurysmal subarachnoid hemorrhage? Despite documented evidence of higher risk of subarachnoid hemorrhage (SAH) in individuals with positive family history of aneurysm, the overall screening, management and counseling is not uniform. Assessing Risk Factors The first determinant factor is to identify who is the individual at risk. Only individuals with two or more first-degree relatives who have had aneurysmal SAH (or unruptured intracranial aneurysms), have an increased risk of aneurysms and aneurysmal SAH. Any description beyond this would not fit the criteria for screening in the context of positive family history. The decision as to whether to screen for intracranial aneurysms should take into account several factors, including the frequency and natural history of intracranial aneurysms, the cost of screening, the treatment options, the patient’s age, co-morbidities and inevitable psychosocial impact of diagnosing an aneurysm. When There’s a Family History The risk of rupture of an incidental intracranial aneurysm is estimated at about 0.5-1 percent per year if the aneurysm is about, or more…
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Screening and Management of Pediatric Concussion
Sudhakar Vadivelu, DO—A growing number of children are visiting the ER for mild traumatic brain injuries resulting from sports-related events. With this, more attention has been placed on the recognition of the severity of second impact syndrome, the management of pediatric concussions, and the overall evolving definition of “concussion.” Identifying “Concussions” Today, “mild traumatic brain injury” is used almost synonymously with the term “concussion” in the medical literature. The 4th International Conference on Concussion in Sport, held in Zurich in 2012, stressed the notion of an evolving definition of “concutere” (Latin for concussion), often referred to as commotio cerebri, to represent the most common subset of mild traumatic brain injury and defined as “a complex pathophysiological process affecting the brain, induced by biomechanical forces and including common features, such as 1. direct blow with impulsive force to the head, rapid onset of neurological impairment that may resolve or in some cases have delayed onset; 2. symptoms as a result of functional change rather than structural abnormality on imaging studies, and 3. graded symptoms that may not involve…
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Point: Patients with Incidentally Found Gliomas Should Always Be Offered Treatment
Mitchel S. Berger, MD, FAANS—Editor’s Note: To read another perspective on treatment of low-grade glioma, read “Counterpoint: Conservative Treatment for an Incidentally Found Supratentorial Low-grade Glioma.” The management of patients with low-grade gliomas (LGG) continues to evolve and must be based on multiple factors. At the forefront of this decision-making process is the role of surgery as a component of the initial management strategy. The advantages of taking an aggressive approach, such as maximal resection, includes providing much-needed tissue to provide a molecular profile of the tumor, which, in turn, will allow for a more accurate prognosis. Emerging data from The Cancer Genome Atlas (TCGA) study on LGGs and from a combined University of California, San Francisco (UCSF)/Mayo SPORE analysis reveals strong prognostic relevance to the genotype of the LGG involving such markers as 1p, 19q co-deletion, IDH-1 mutation and a TERT promoter mutation. However, an accurate profile of the tumor is often not possible with just a small biopsy due to sampling errors, thus making the argument to provide more tissue to go beyond a histological diagnosis (1,…
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Counterpoint: Conservative Treatment for an Incidentally Found Supratentorial Low-grade Glioma
Andrew H. Jea, MD, FAANS—Editor’s Note: To read another perspective on treatment of low-grade glioma, read “Point: Patients with Incidentally Found Gliomas Should Always Be Offered Treatment.” For the purposes of this counter-perspective article, some strong assumptions will be made: 1. Magnetic resonance imaging (MRI) demonstrates a supratentorial tumor; 2. the radiographic appearance is typical of low-grade glioma; 3. the patient is asymptomatic; and 4. the diagnosis is secure. With these assumptions, the case for conservative treatment of incidentally found supratentorial low-grade gliomas will be made. Why Take a Conservative Approach? There is no argument that early surgery and radiation therapy are appropriate for a subset of patients with low-grade glioma of the cerebral hemispheres. For other patients, the risk of malignant degeneration is often cited as a justification for early surgery in cases of low-grade glioma. However, it is a stretch to support early aggressive treatment for all patients. Porous evidence weakly and tenuously upholds the proposition that the natural history of low-grade gliomas is poor, and that low-grade gliomas uniformly degenerate into anaplastic gliomas or glioblastoma multiforme (2,…
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Registry Science Has Identified Opportunities for Improvement in Spine Care
Scott L. Parker, MD; and Anthony L. Asher, MD, FAANS—Health care, as a proportion of the U.S. gross domestic product, has increased faster than any other industry. (1) As a result, “value-based” reforms are being adopted by most stakeholders to help achieve sustainability of the U.S. health-care system. Value-based health care seeks to bend the cost curve and optimize population health by providing effective care, while eliminating unnecessary services and avoidable expenses. (2) Reliable data related to the safety and effectiveness of care is fundamental to understanding and promoting health-care value. Current benchmarks of acceptable morbidity and treatment effectiveness are generally based on retrospective reviews or a limited number of tightly controlled studies. These traditional analyses often fail to account for important variations across patient populations, disease states or health-care settings, and have been inappropriately applied in clinical settings not represented by the research environments. Additional drawbacks related to randomized prospective trials include significant costs, complexity and practical/ethical considerations related to randomization. Given the limitations of traditional forms of evidence to inform value-based decision-making, clinical registries have been increasingly employed to generate evidence and…
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Screening for Chiari I Malformation
Karin M. Muraszko, MD, FAANS; Hugh J. L. Garton, MD, MHSc, FAANS; and Cormac O. Maher, MD, FAANS—Who should be screened for Chiari Malformation Type I (CM)? It is impossible to have a “cookbook” standard that will apply to everyone. Consideration of symptomatology in relation to known associated conditions should lead the clinician to consideration for obtaining an MRI scan to diagnose a CM. Diagnosing Chiari I Malformation The symptoms associated with CM are, in many cases, non-specific and protean. Based on reviews of the extensive literature on CM, it is apparent that most neurological symptoms have at some point been associated with CM. The most common symptom is clearly headaches, but any number of brainstem and spinal cord associated symptoms has been attributed to CM in some patients. Many symptoms are, by themselves, commonly found in those with other neurological disorders or conditions. Therefore, the diagnosis of a symptomatic CM requires the clinician to actively include CM in the differential diagnosis, while also being careful to include other conditions that may mimic Chiari symptoms. The decision to perform an MRI scan, particularly to rule out a CM, should start with a…
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