November 2012

This months selection was provided by Dr Kamal Subhas, Clinical Fellow, NHNN, London & Dr Ian Appleby, Consultant, NHNN, London

Unique biology of gliomas: challenges and opportunities. Watkins SSontheimer H.

Trends Neurosci. 2012 Sep;35(9):546-56. Epub 2012 Jun 8.

Gliomas are terrifying primary brain tumors for which patient outlook remains bleak. Recent research provides novel insights into the unique biology of gliomas. For example, these tumors exhibit an unexpected pluripotency that enables them to grow their own vasculature. They have an unusual ability to navigate tortuous extracellular pathways as they invade, and they use neurotransmitters to inflict damage and create room for growth. Here, the authors review studies that illustrate the importance of considering interactions of gliomas with their native brain environment. Such studies suggest that gliomas constitute a neurodegenerative disease caused by the malignant growth of brain support cells. The chosen examples illustrate how targeted research into the biology of gliomas is yielding new and much needed therapeutic approaches to this challenging nervous system disease.

Neurocritical care and periprocedural blood pressure management in acute stroke. Sheth KNSims JR.

Neurology. 2012 Sep 25;79(13 Suppl 1):S199-204.

The purpose of this article is to review the literature on periprocedural blood pressure (BP) management in acute ischemic stroke and to establish guidelines regarding management of BP. These guidelines are drawn from available evidence and expert opinion. This article reviews the pathophysiologic considerations of BP in ischemic stroke. It also examines the natural history of BP changes during stroke, as well as data on induced BP reduction and hypertension, particularly in light of reperfusion therapy. Finally, the article reviews major ongoing clinical trials for BP management in this setting. Recommendations made in this article may serve as a benchmark for future research in BP management in this patient population.

Timing of antiepileptic drug withdrawal and long-term seizure outcome after paediatric epilepsy surgery (TimeToStop): a retrospective observational study. Boshuisen KArzimanoglou ACross JHUiterwaal CSPolster Tvan Nieuwenhuizen OBraun KPTimeToStop study group.

Lancet Neurol. 2012 Sep;11(9):784-91. Epub 2012 Jul 27.

Postoperative antiepileptic drug (AED) withdrawal practices remain debatable and little is known about the optimum timing. This study was aimed to assess the relation between timing of AED withdrawal and subsequent seizure recurrence and long-term seizure outcome. The study included 766 children aged less than 18 years from 15 centres in Europe who underwent surgery between Jan 1, 2000, and Oct 1, 2008, had at least 1 year of postoperative follow-up, and who started AED reduction after having reached postoperative seizure freedom. Time intervals from surgery to start of AED reduction and complete discontinuation  were studied in relation to seizure recurrence during or after AED withdrawal, seizure freedom for at least 1 year, and cure (defined as being seizure free and off AEDs for at least 1 year) at latest follow-up. The study found that early AED withdrawal does not affect long-term seizure outcome or cure. It might unmask incomplete surgical success sooner, identifying children who need continuous drug treatment and preventing unnecessary continuation of AEDs in others.

A multicentre, randomised, open-label, controlled trial evaluating equivalence of inhalational and intravenous anaesthesia during elective craniotomy. Citerio GPesenti ALatini RMasson SBarlera SGaspari F,Franzosi MGNeuroMorfeo Study Group.

Eur J Anaesthesiol. 2012 Aug;29(8):371-9.

The NeuroMorfeo trial was designed to test equivalence of inhalational and intravenous anaesthesia maintenance techniques in the postoperative recovery of patients undergoing elective supratentorial surgery. Fourteen Italian neuroanaesthesia centres participated in the study from December 2007 to March 2009. Four hundred and eleven adult patients scheduled for elective supratentorial intracranial surgery under general anaesthesia were enrolled in this study. Patients were randomised to one of three anaesthesia maintenance protocols to determine if sevoflurane-remifentanil or sevoflurane-fentanyl were equivalent to propofol-remifentanil. The primary outcome was the time to achieve an Aldrete postanaesthesia score of at least 9 after tracheal extubation. Secondary endpoints included haemodynamic parameters, quality of the surgical field, perioperative neuroendocrine stress responses and routine postoperative assessments. The study showed equivalence for inhalational and intravenous maintenance anaesthesia in times to reach an Aldrete score of at least 9 after tracheal extubation. Haemodynamic variables, the quality of surgical field and postoperative assessments were also similar. Perioperative endocrine stress responses were significantly blunted with propofol-remifentanil and higher analgesic requirements were recorded in the remifentanil groups.

Which patient requires neuroendocrine assessment following traumatic brain injury, when and how? Glynn NAgha A.

Clin Endocrinol (Oxf). 2012 Aug 14. doi: 10.1111/cen.12010. [Epub ahead of print]

Hypopituitarism is a common occurrence among survivors of traumatic brain injury (TBI) and may contribute to the associated morbidity seen in the acute and chronic phases following injury. The available data suggest that survivors of moderate to severe TBI should undergo screening for hypopituitarism particularly in the first year after injury. This requires a close liaison between endocrinologists, neurosurgeons, neuropsychologists, intensive care, and rehabilitation physicians. Patients who suffer milder forms of TBI should also be considered for endocrine evaluation if they exhibit any clinical features of pituitary hormone deficiencies.

Modulation of neural plasticity as a basis for stroke rehabilitation. Pekna MPekny MNilsson M.

Stroke. 2012 Oct;43(10):2819-28. Epub 2012 Aug 23.

Current understanding of the mechanisms underlying neural plasticity changes after stroke stems from experimental models as well as clinical studies and provides the foundation for evidence-based neurorehabilitation. In this review, the authors first describe the main structural and functional constituents of neural plasticity that are believed to contribute to recovery of function after stroke. Next, they discuss selected behavioral manipulations and adjuvant therapies that can stimulate neural plasticity and improve recovery of function, particularly when applied in combination with task-specific physiotherapy and in a stimulating environment.