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Neurosurgery May 2018Multiple subpial transections (MST) are a treatment for seizure foci in nonresectable eloquent areas.
BACKGROUND
Multiple subpial transections (MST) are a treatment for seizure foci in nonresectable eloquent areas.
OBJECTIVE
To systematically review patient-level data regarding MST.
METHODS
Studies describing patient-level data for MST procedures were extracted from the Medline and PubMed databases, yielding a synthetic cohort of 212 patients from 34 studies. Data regarding seizure outcome, patient demographics, seizure type, surgery type, and complications were extracted and analyzed.
RESULTS
Seizure freedom was achieved in 55.2% of patients undergoing MST combined with resection, and 23.9% of patients undergoing MST alone. Significant predictors for seizure freedom were a temporal lobe focus (odds ratio 4.9; 95% confidence interval 1.71, 14.3) and resection of portions of the focus, when feasible (odds ratio 3.88; 95% confidence interval 2.02, 7.45). Complications were frequent, with transient mono- or hemiparesis affecting 19.8% of patients, transient dysphasia 12.3%, and permanent paresis or dysphasia in 6.6% and 1.9% of patients, respectively.
CONCLUSION
MST is an effective treatment for refractory epilepsy in eloquent cortex, with greater chances of seizure freedom when portions of the focus are resected in tandem with MST. The reported rates of seizure freedom with MST are higher than those of existing neuromodulatory therapies, such as vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, though these latter therapies are supported by randomized-controlled trials, while MST is not. The reported complication rate of MST is higher than that of resection and neuromodulatory therapies. MST remains a viable option for the treatment of eloquent foci, provided a careful risk-benefit analysis is conducted.
Topics: Adolescent; Adult; Child; Drug Resistant Epilepsy; Female; Humans; Male; Middle Aged; Neurosurgical Procedures; Treatment Outcome
PubMed: 28637175
DOI: 10.1093/neuros/nyx311 -
Neurology India 2017Hemifacial spasm (HS) is a rare disorder caused by the compression of facial nerve root exit zone (REZ) at the brainstem by a vascular loop. Microvascular decompression... (Review)
Review
INTRODUCTION
Hemifacial spasm (HS) is a rare disorder caused by the compression of facial nerve root exit zone (REZ) at the brainstem by a vascular loop. Microvascular decompression (MVD) is a popular treatment modality for HS.
OBJECTIVE
The purpose of this study was to determine the long-term efficacy and safety of MVD for HS by assessing the effect of the procedure from the literature published over the last 25 years.
MATERIALS AND METHODS
A systematic data review from 1992 to 2015 using specific eligibility criteria yielded 27 studies on MVD for HS, the data of which were pooled and subjected to a meta-analysis.
RESULTS
The pooled odds ratio (OR) revealed by the meta-analysis showed that anterior inferior cerebellar artery was the most common offending vessel in 37.8% (95% confidence interval [CI]: 27.8-47.7%) of the patients. Complete resolution of HS was seen in 88.5% (95% CI: 86.7-90.4%) of the patients after a long-term follow up. The complication rate was low following MVD, the most common being temporary facial paresis in 5.9% (95% CI: 4.3-7.5%) of patients.
CONCLUSIONS
MVD is a safe and effective treatment for HS with long-term benefits and a low complication rate.
Topics: Hemifacial Spasm; Humans; Longitudinal Studies; Microvascular Decompression Surgery; Treatment Outcome
PubMed: 28488609
DOI: 10.4103/neuroindia.NI_1166_16 -
Langenbeck's Archives of Surgery Jun 2017Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring... (Meta-Analysis)
Meta-Analysis Review
The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses.
PURPOSE
Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring (I-IONM) has been proposed to reduce prevalence of RLN injury following thyroidectomy and has gained increasing acceptance in recent years.
METHODS
A comprehensive database search was performed, and data from eligible meta-analyses meeting the inclusion criteria were extracted. Transient, permanent, and overall RLN injuries were the primary outcome measures. Quality assessment via AMSTAR, heterogeneity appraisal, and selection of best evidence was performed via a Jadad algorithm.
RESULTS
Eight meta-analyses met the inclusion criteria. Meta-analyses included between 6 and 23 original studies each. Via utilization of the Jadad algorithm, the selection of best evidence resulted in choosing of Pisanu et al. (Surg Res 188:152-161, 2014). Five out of eight meta-analyses demonstrated non-significant (p > 0.05) RLN injury reduction with the use of I-IONM versus nerve visualization alone.
CONCLUSIONS
To date, I-IONM has not achieved a significant level of RLN injury reduction as shown by the meta-analysis conducted by Pisanu et al. (Surg Res 188:152-161, 2014). However, most recent developments of IONM technology including continuous vagal IONM and concept of staged thyroidectomy in case of loss of signal on the first side in order to prevent bilateral RLN injury may provide additional benefits which were out of the scope of this study and need to be assessed in further prospective multicenter trials.
Topics: Humans; Intraoperative Complications; Intraoperative Neurophysiological Monitoring; Postoperative Complications; Recurrent Laryngeal Nerve Injuries; Thyroidectomy; Vocal Cord Paralysis
PubMed: 28378238
DOI: 10.1007/s00423-017-1580-y -
Pituitary Jun 2017Parasellar plasmacytomas are rare tumors localized to the sellar region arising from plasma cells. Knowledge of clinical, imaging, surgical, and pathological... (Review)
Review
PURPOSE
Parasellar plasmacytomas are rare tumors localized to the sellar region arising from plasma cells. Knowledge of clinical, imaging, surgical, and pathological characteristics is limited to single case reports.
METHODS
A retrospective analysis of five primary cases was conducted, followed by systematic review of English language articles using PubMed in accordance with PRISMA guidelines.
RESULTS
Five primary case patients include four men and one woman, ages 60-77, followed up to 3 years. A systematic review identified 65 additional patients, of whom 65% presented with cranial nerve palsies and 15% with hypopituitarism. Sixteen percent had history of known multiple myeloma (MM) while 37% were diagnosed concurrently with MM on presentation of parasellar plasmacytoma. Imaging showed median tumor size of 38 mm (range, 4-70 mm), with MRI intensity similar to that of other sellar masses. Surgical biopsy with immunohistochemical studies confirmed plasmacytoma diagnosis. Eighty-one percent underwent parasellar radiotherapy, and chemotherapy initiated in 59% of the 69 patients with MM. Overall survival rate was 74% at follow-up (median 12 months), with 18% having parasellar recurrences and 38% progressing to systemic MM after presentation of a solitary plasmacytoma (median 3 months).
CONCLUSIONS
Parasellar plasmacytomas are rare tumors that should be considered in the differential diagnosis for lesions involving the sella and arising from the clivus, especially when cranial nerve paresis is apparent, even in the absence of known MM. Although recurrence rates for parasellar plasmacytoma is low, patients should be monitored for progression to MM. Treatment depends on the presence of systemic disease at diagnosis.
Topics: Aged; Female; Humans; Male; Multiple Myeloma; Plasmacytoma; Retrospective Studies
PubMed: 28251542
DOI: 10.1007/s11102-017-0799-5 -
Swiss Medical Weekly 2017Chronic subdural haematoma (cSDH), one of the most common neurosurgical entities, occurs typically in elderly patients. The incidence is expected to double by the year... (Review)
Review
Chronic subdural haematoma (cSDH), one of the most common neurosurgical entities, occurs typically in elderly patients. The incidence is expected to double by the year 2030, owing to the continuous aging of the population. Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations. We provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. "Wait and watch" or "wait and scan" management is indicated in patients with no or minor symptoms (Markwalder score 0-1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, our knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treat-ment of cSDH.
Topics: Anticoagulants; Antifibrinolytic Agents; Hematoma, Subdural, Chronic; Humans; Incidence; Risk Factors
PubMed: 28102879
DOI: 10.57187/smw.2017.14398 -
Scientific Reports Dec 2016To conduct a meta-analysis of clinical trials that examined the effect of music-supported therapy on stroke-induced motor dysfunction, comprehensive literature searches... (Meta-Analysis)
Meta-Analysis Review
To conduct a meta-analysis of clinical trials that examined the effect of music-supported therapy on stroke-induced motor dysfunction, comprehensive literature searches of PubMed, Embase and the Cochrane Library from their inception to April 2016 were performed. A total of 10 studies (13 analyses, 358 subjects) were included; all had acceptable quality according to PEDro scale score. The baseline differences between the two groups were confirmed to be comparable. Compared with the control group, the standardized mean difference of 9-Hole Peg Test was 0.28 (-0.01, 0.57), 0.64 (0.31, 0.97) in Box and Block Test, 0.47 (0.08, 0.87) in Arm Paresis Score and 0.35 (-0.04, 0.75) in Action Research Arm Test for upper-limb motor function, 0.11 (-0.24, 0.46) in Berg Balance Scale score, 0.09 (-0.36, 0.54) in Fugl-Meyer Assessment score, 0.30 (-0.15, 0.74) in Wolf Motor Function Test, 0.30 (-0.15, 0.74) in Wolf Motor Function time, 0.65 (0.14, 1.16) in Stride length and 0.62 (0.01, 1.24) in Gait Velocity for total motor function, and 1.75 (0.94, 2.56) in Frontal Assessment Battery score for executive function. There was evidence of a positive effect of music-supported therapy, supporting its use for the treatment of stroke-induced motor dysfunction. This study was registered at PRESPERO (CRD42016037106).
Topics: Executive Function; Female; Humans; Male; Motor Activity; Music Therapy; Stroke; Upper Extremity
PubMed: 27917945
DOI: 10.1038/srep38521 -
Frontiers in Human Neuroscience 2016Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life... (Review)
Review
Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.
PubMed: 27679565
DOI: 10.3389/fnhum.2016.00442 -
Journal of Rehabilitation Medicine Apr 2016To evaluate the evidence for, and clinical relevance of, immediate and long-term effects of trunk restraint during reach-to-grasp training poststroke on movement... (Review)
Review
OBJECTIVE
To evaluate the evidence for, and clinical relevance of, immediate and long-term effects of trunk restraint during reach-to-grasp training poststroke on movement patterns and functional abilities within the framework of the International Classification of Functioning, Disability and Health.
DATA SOURCES
PubMed, Web of Science, CINAHL, Embase, PEDro, Cochrane Library (publication dates January 1985 to March 2015).
STUDY SELECTION
Randomized controlled trials comparing training using trunk restraint with any other exercise training.
DATA EXTRACTION
Data were extracted by one researcher and checked by two other researchers. The Cochrane Collaboration's tool for assessing risk of bias and the Physiotherapy Evidence Database scale were used by two researchers to assess study quality and risk of bias.
DATA SYNTHESIS
Eight studies met the inclusion criteria. Five studies found better recovery of movement patterns (trunk displacement, elbow extension, and/or shoulder flexion - body function/structure) at post-test in the experimental compared with the control groups. Functional abilities (activity/participation) improved more in the experimental groups in 3 studies at post-test. Long-term effects were found in one study after 4 weeks.
CONCLUSION
Trunk restraint has immediate and some long-term effects in adults with chronic stroke. However, these effects are not consistently clinically relevant when referring to minimal detectable change or minimal clinically important difference values.
Topics: Elbow Joint; Exercise Therapy; Hand Strength; Humans; Paresis; Range of Motion, Articular; Recovery of Function; Restraint, Physical; Shoulder Joint; Stroke; Stroke Rehabilitation; Torso
PubMed: 27008369
DOI: 10.2340/16501977-2077 -
The Cochrane Database of Systematic... Oct 2015In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.
OBJECTIVES
To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.
SEARCH METHODS
We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).
SELECTION CRITERIA
Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.
DATA COLLECTION AND ANALYSIS
One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.
MAIN RESULTS
We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.
AUTHORS' CONCLUSIONS
CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.
Topics: Exercise Movement Techniques; Humans; Immobilization; Paresis; Randomized Controlled Trials as Topic; Stroke; Stroke Rehabilitation; Time Factors; Upper Extremity
PubMed: 26446577
DOI: 10.1002/14651858.CD004433.pub3 -
Thyroid Research 2015Several meta-analyses have been performed comparing the use of a variety of ultrasonic devices in thyroidectomy to conventional procedures. These studies have shown the... (Review)
Review
INTRODUCTION
Several meta-analyses have been performed comparing the use of a variety of ultrasonic devices in thyroidectomy to conventional procedures. These studies have shown the superiority of ultrasonic devices for most outcomes studied including faster operative time and less blood loss, and equivalent or better safety for recurrent laryngeal nerve paresis and hypocalcemia. The current work is the first to examine a single ultrasonic device specifically designed for thyroid surgery, the Harmonic Focus, in order to confirm its efficacy and safety in thyroidectomy.
METHODS
A comprehensive literature search without language restrictions was performed for randomized clinical trials comparing Harmonic Focus and conventional clamp, cut and tie in thyroidectomy. Outcome measures included operating time, blood loss, post-operative pain, length of hospital stay, hypocalcemia and recurrent laryngeal nerve paresis. Risk of bias was analyzed for all studies. Meta-analysis was performed using random effects models with the inverse-variance method for mean differences of continuous variables and the Mantel-Haenszel method for risk ratios of dichotomous variables.
RESULTS
A total of 14 studies met the inclusion criteria. Harmonic Focus reduced operative time by 29 min, a 31 % decrease (p < 0.001), intra-operative blood loss by 45 ml (p < 0.001), post-operative pain (p < 0.001), length of hospital stay by 0.68 days (p = 0.005), drainage volume by 29 ml (p = 0.01), and occurrence of transient hypocalcemia by 40 % (p = 0.001). There were no significant differences between Harmonic Focus and conventional procedures in rate of persistent hypocalcemia, or rates of transient and persistent recurrent laryngeal nerve paresis.
CONCLUSION
This is the first meta-analysis of Harmonic Focus in thyroid surgery. In agreement with meta-analyses previously performed on ultrasonic devices, use of the Harmonic Focus has been shown to be a more effective surgical procedure compared to conventional methods in thyroidectomy. The low occurrence of hypocalcemia and recurrent laryngeal nerve paresis confirms that Harmonic Focus can improve thyroidectomy efficiency without increasing the risk of complications.
PubMed: 26430471
DOI: 10.1186/s13044-015-0027-1