AJNR Blog

1. Sharrief A. Diagnosis and Management of Cerebral Small Vessel Disease. Continuum (Minneap Minn). 2023;29(2):501-518. doi:10.1212/CON.0000000000001232 Cerebral small vessel disease (CSVD) is one of the most common clinical conditions that a neuroimager will encounter. CSVD is associated with an increased

1. Dittrich TD, Sporns PB, Kriemler LF, et al. Mechanical Thrombectomy Versus Best Medical Treatment in the Late Time Window in Non-DEFUSE-Non-DAWN Patients: A Multicenter Cohort Study. Stroke. 2023;54(3):722-730. doi:10.1161/STROKEAHA.122.039793 The authors assessed the efficacy and safety of mechanical thrombectomy

1. Kato S, Maesawa S, Bagarinao E, et al. Magnetic resonance–guided focused ultrasound thalamotomy restored distinctive resting-state networks in patients with essential tremor. J Neurosurg. 2023;138(2):306-317. doi:10.3171/2022.5.JNS22411 Magnetic resonance–guided focused ultrasound (MRgFUS) thalamotomy ameliorates symptoms in patients with essential tremor

1. Wu KY, Spinner RJ, Shin AY. Traumatic brachial plexus injury: diagnosis and treatment. Curr Opin Neurol. 2022;35(6):708-717. doi:10.1097/WCO.0000000000001124 A comprehensive physical examination aids in localizing (preganglionic or postganglionic) and characterizing the severity of injury (partial or complete). This is

1. Kamagata K, Andica C, Takabayashi K, et al. Association of MRI Indices of Glymphatic System With Amyloid Deposition and Cognition in Mild Cognitive Impairment and Alzheimer Disease. Neurology. 2022;99(24):e2648-60. doi:10.1212/WNL.0000000000201300 According to the glymphatic hypothesis, subarachnoid CSF enters the

1. Boulenoir N, Turc G, ter Schiphorst A, et al. Should Patients With Acute Minor Ischemic Stroke With Isolated Internal Carotid Artery Occlusion Be Thrombolysed? Stroke. 2022;(November):3304-3312. doi:10.1161/strokeaha.122.039228 Isolated cervical or intracranial internal carotid artery occlusion (iICAo), without associated occlusion

1. Benjamini D, Priemer DS, Perl DP, Brody DL, Basser PJ. Mapping astrogliosis in the individual human brain using multidimensional MRI. Brain. Published online August 12, 2022:5-6. doi:10.1093/brain/awac298 There are currently no noninvasive imaging methods available for astrogliosis assessment or

1. Makarenko S, Alzahrani I, Karsy M, Deopujari C, Couldwell WT. Outcomes and surgical nuances in management of giant pituitary adenomas: a review of 108 cases in the endoscopic era. J Neurosurg. 2022;137(September):1-12. doi:10.3171/2021.10.jns21659 Pituitary adenomas are histologically benign lesions

1. Frisoli FA, Srinivasan VM, Catapano JS, et al. Vertebrobasilar dissecting aneurysms: microsurgical management in 42 patients. J Neurosurg 2022;137(August):393–401 Dissecting intracranial aneurysms are formed by a longitudinally oriented tear in the arterial wall that creates a false lumen with intramural thrombus and luminal stenosis. Multiple consequences of these aneurysms include vessel thrombosis, thromboembolism, and subarachnoid hemorrhage (SAH). Unlike saccular aneurysms, dissecting aneurysms are not amenable to conventional clipping or coil obliteration. Experiences with endovascular management using VA sacrifice, stent coiling, and flow diversion have shown good results, but fewer modern microsurgical series have been published. Three surgical options exist to treat VBD aneurysms: clip wrapping, bypass trapping, and parent artery occlusion. The medical records of patients with dissecting aneurysms affecting the intracranial VA (V4), basilar artery, and PICA that were treated microsurgically over a 19-year period were reviewed. Patient demographics, aneurysm characteristics, surgical procedures, and clinical outcomes were analyzed. Forty-two patients with 42 VBD aneurysms were identified. Twenty-six aneurysms (62%) involved the PICA, 14 (33%) were distinct from the PICA origin on the V4 segment of the VA, and 2 (5%) were located at the vertebrobasilar junction. Thirty-four patients (81%) presented with SAH with a mean Hunt and Hess grade of 3.2 at presentation. Six (14%) of the 42 patients had been previously treated using endovascular techniques. Nineteen aneurysms (45%) underwent clip wrapping, 17 (40%) were treated with bypass trapping, and 6 (14%) underwent parent artery sacrifice. The complete aneurysm obliteration rate was 95% (n = 40), and the surgical complication rate was 7% (n = 3). Good outcomes (mRS score ≤ 2) were observed in 20 patients (48%). Eight patients (19%) died. These data demonstrate that patients with VBD aneurysms often present after a rupture in poor neurological condition, but favorable results can be achieved with open microsurgical … The post Journal Scan – This Month in Other Journals, October 2022 appeared first on AJNR Blog.

1. Catapano JS, Labib MA, Srinivasan VM, et al. Saccular aneurysms in the post–Barrow Ruptured Aneurysm Trial era. J Neurosurg 2021;137(July):1–8 The Barrow Ruptured Aneurysm Trial (BRAT) was a single-center trial that compared endovascular coiling to microsurgical clipping in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). However, because patients in the BRAT were treated more than 15 years ago, and because there have been advances since then—particularly in endovascular techniques—the relevance of the BRAT today remains controversial. Some hypothesize that these technical advances may reduce retreatment rates for endovascular intervention. In this study, the authors analyzed data for the post-BRAT (PBRAT) era to compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the two time periods and to examine how the results of the original BRAT have influenced the practice of neurosurgeons at the study institution. Of the 1014 patients with aSAH during the study period, 798 (79%) were confirmed to have saccular aneurysms. Neurological outcomes at ≥ 1-year follow-up did not differ between patients treated with microsurgery (n = 451) and those who received endovascular (n = 347) treatment (p = 0.51). The number of retreatments was significantly higher among patients treated endovascularly (32/347, 9%) than among patients treated microsurgically (6/451, 1%). The retreatment rate after endovascular treatment was lower in the post BRAT era (9%) than in the BRAT (18%). Similarly to the BRAT results, the post BRAT-era results showed no significant difference in neurological outcomes between endovascular and microsurgical intervention for saccular aneurysms. Hence, in quaternary centers with expert neurosurgeons, neurological outcomes in aSAH patients are likely associated with the inherent risk of the hemorrhage and, to a lesser extent, with the specific treatment modality. For example, in the present analysis, the average aneurysm size was 5.5 mm, and 35% of aneurysms were < 5 … The post Journal Scan – This Month in Other Journals, September 2022 appeared first on AJNR Blog.

1. Chalif EJ, Murray RD, Mozaffari K, et al. Malignant pineal parenchymal tumors in adults: a National Cancer Database analysis. Neurosurgery 2022;90:807–15 Pineal parenchymal tumors (PPTs) are rare tumors of the pineal gland that account for <1% of primary central nervous system tumors in adults. Although these tumors are heterogeneous and display a wide degree of morphological variation, the World Health Organization (WHO) Classification of Tumors separates these into 5 distinct histological entities: pineocytoma (WHO grade I), PPT of intermediate differentiation (PPTID, WHO grade II/III), pineoblastoma (PB, grade IV), papillary tumor of the pineal region (PTPR, WHO grade II/III), and the recently characterized desmoplastic myxoid SMARCB1-mutant. The National Cancer Database was queried for histologically confirmed PPT diagnosed from 2007 to 2016. Univariate and multivariate Cox regressions were used to evaluate the prognostic impact of covariates. Kaplan–Meier survival curves were generated for comparative subanalyses. Of the 251 patients who met inclusion criteria, 172 had PPTs of intermediate differentiation (PPTID) and 79 had pineoblastoma. A plurality of patients with pineoblastomas were treated with trimodal therapy (39.1%), whereas patients with PPTID were commonly treated with either surgery alone or surgery and radiation (33.7% each). Factors independently associated with improved overall survival include younger patient age, female sex, lower comorbidity score, lower tumor grade, and treatment with surgery or radiation. Subanalyses confirm the effect of radiation on survival in patients with grade III PPTID with subtotal resection; however, no survival benefit of adjuvant radiation is demonstrated in patients with grade II PPTID with subtotal resection. The authors conclude that although radiotherapy and surgery were found to increase survival in all patients with PPT, there was no demonstrable survival benefit of adjuvant radiation in surgically treated patients with grade II PPTID. 6 figures, 2 tables with no imaging 2. Hannan CJ, Hammerbeck-Ward C, Pathmanaban ON, … The post Journal Scan – This Month in Other Journals, August 2022 appeared first on AJNR Blog.

1. Huynh J, Donovan J, Phu NH, et al. Tuberculous meningitis: progress and remaining questions. Lancet Neurol 2022;21:450–64. Available from: http://dx.doi.org/10.1016/S1474-4422(21)00435-X Tuberculosis affects 10 million people globally each year, of which an estimated 2–5% have tuberculous meningitis. The true incidence of tuberculous meningitis is unknown; however, tuberculous meningitis is the leading cause of bacterial brain infections in settings with a high tuberculosis burden, disproportionately affecting young children and individuals with HIV. Here, the authors review advances made in the past 7 years concerning the pathogenesis, diagnosis, and treatment of tuberculous meningitis, emphasizing areas of uncertainty and updating Reviews published in The Lancet Neurology in 2005 and 2013. This Review focuses mainly on adult tuberculous meningitis and briefly emphasizes novel research advances in pediatric tuberculous meningitis, including important clinical trials on its management. Confirming a diagnosis of tuberculous meningitis is challenging because it requires detection of M tuberculosis in CSF. CSF Ziehl-Neelsen staining and microscopy is rapid, inexpensive, and can be performed in many laboratories with few resources. However, a study of 618 individuals with tuberculous meningitis in Vietnam, South Africa, and Indonesia reported that its sensitivity was generally poor (ie, approximately 30%) and was not improved by adaptations to enhance staining of intracellular bacteria. PCR-based tests, such as GeneXpert MTB/RIF and GeneXpert MTB/RIF Ultra (Cepheid, Sunnyvale, CA, USA), are rapid and offer identification of rifampicin resistance. Although these tests are useful when positive, the negative predictive values of GeneXpert MTB/RIF is insufficient to rule out tuberculous meningitis. Large-volume CSF sampling and meticulous processing steps are essential to optimize the performance of smear, culture, and nucleic acid amplification tests. Brain MRI features that predict future outcome and treatment response are poorly defined. Tools based on artificial intelligence and machine learning are being developed to enable an unbiased and automated assessment of … The post Journal Scan – This Month in Other Journals, July 2022 appeared first on AJNR Blog.

1.         Stevens MN, Gallant JN, Feldman MJ, et al. Management of postradiation late hemorrhage following treatment for HPV-positive oropharyngeal squamous cell carcinoma. Head Neck 2022;44:1079–85. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/35150023/ Acute hemorrhage is an uncommon but potentially deadly complication for patients with head and neck cancer, especially in patients receiving RT. Previous reports have focused on hemorrhage following RT in all head and neck subsites without isolating HPV-positive malignancies. In this article, the authors focus specifically on patients with previously treated HPV-positive OPSCC given (1) the increasing prevalence and survival of this population and (2) the critical role RT plays in its treatment. They detail patient characteristics and cancer treatments leading to hemorrhagic events and include the acute interventions used in these life-threatening situations to better characterize this patient population. A total of 12 patients with HPV-positive OPSCC were included. Six patients had base of tongue (BoT) tumors and 6 patients had tonsil tumors. The majority of patients were male (83%) with a mean age at diagnosis of 58 years. Fifty percent had advanced primary tumors (T3/T4). Median time from completion of chemoradiation to first hemorrhagic event was 186 days (range 66–1466 days). Seven patients (58%) required intervention to secure their airway. All patients were evaluated for endovascular intervention, 6 (50%) were embolized. Eight patients (67%) had a second hemorrhagic event; median time to second bleed was 22 days (range 3–90 days). CTA was performed for 11 patients and demonstrated active extravasation in 1 patient, pseudoaneurysm (2), a combination of both extravasation and pseudoaneurysm (1), luminal irregularity (5), and no radiographic indication of vessel abnormality (2). Seven of the 12 patients in the cohort ultimately required tracheostomy to secure their airway. In this study population, once the airway was established, attention was turned to control of hemorrhage with oropharyngeal packing with … The post Journal Scan – This Month in Other Journals, June 2022 appeared first on AJNR Blog.

1. Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022;21:273–83. Available from: http://dx.doi.org/10.1016/S1474-4422(21)00359-8 The benefit of carotid endarterectomy in patients with symptomatic carotid stenosis was established in the final two decades of the past century. In the NASCET trial, the 2-year risk of any ipsilateral stroke (including perioperative events) in patients with severe symptomatic carotid stenosis (≥70% narrowing of the lumen) was reduced from 26% to 9%. Modest benefit was also observed in patients with moderate stenosis (50–69%) by a reduction of stroke risk from 22.2% to 15.7% after 5 years. In the European Carotid Surgery Trial (ECST), endarterectomy prevented stroke only in patients with symptomatic carotid stenosis of 80% or greater, but measurement of the degree of stenosis on angiography differed between the trials. In a pooled analysis of NASCET, ECST, and the smaller Veterans Affairs trial, in which ECST angiograms were reanalyzed using the NASCET method, the absolute 5-year risk reduction from endarterectomy was 15.9% in patients with severe (≥70%) stenosis and 4.6% in patients with moderate (50–69%) stenosis. Thus, the number needed to treat would be six patients with severe symptomatic stenosis, or 22 patients with moderate symptomatic stenosis, had to be operated on to prevent one ipsilateral stroke after 5 years. Furthermore, extracranial-intracranial bypass surgery is not effective to prevent stroke in patients with carotid artery occlusion. Among patients with symptomatic carotid stenosis, randomized controlled trials have consistently shown that the risk of periprocedural stroke or death is greater with stenting than with endarterectomy. However, this outcome was mainly caused by a higher risk of minor stroke occurring with stenting, and the extra events largely occurred in patients older than 70 years. Conversely, stenting reduces the risk of procedure-related myocardial infarction, cranial nerve palsy, and hematoma … The post Journal Scan – This Month in Other Journals, May 2022 appeared first on AJNR Blog.

1. Pingree GM, Fleming C, Reavey-Cantwell J, et al. Neurosurgical causes of pulsatile tinnitus: contemporary update. Neurosurgery 2022;90:161–69 This review details the most common treatable neurosurgical entities that can present with pulse-synchronous tinnitus: Cervical carotid stenosis, ICA dissection, FMD, Petrous carotid dissection/aneurysm, Cavernous carotid dissection/aneurysm, AVM/AVFs, glomus tumors, and various venous stenoses, and thrombosis, among others. Patients with internal carotid artery dissection can present unilateral headaches, posterior cervical pain, cranial nerve palsies, oculosympathetic palsy, and cerebral or retinal ischemia. Objective bruits may be detected on arterial auscultation. Pulsatile tinnitus has been reported in 5% to 15% of patients with ICAD but is infrequently the sole presenting symptom. ICADs are typically identified on MRI/ magnetic resonance angiography (MRA) or computed tomography (CT) angiography, or conventional angiography.  Many cases of ICAD are self-limiting, with stenosis resolving in approximately 46% to 90% of patients over a 3- to 6-mo interval. Invasive options such as angioplasty and stenting are reserved for cases of hemodynamically significant stenosis or expanding lesions with progressive stenosis. In the majority of cases of PT secondary to ICAD, PT spontaneously improves together with the arterial injury over the course of 2 to 6 months. Patients with petrous carotid dissection may present with deafness, vertigo, and facial nerve weakness and even nausea, vomiting, and cranial nerve involvement with more severe diseases. PT can be the sole presenting symptom. As in the cervical carotid, treatment of spontaneous and asymptomatic dissections is typically medical management with antiplatelet medications. Endovascular treatment can be given for patients with increasing pseudoaneurysm size or recurrent ischemia, despite medical management.  Improvement in PT symptoms has been reported after both medical treatment and endovascular treatment of petrous segment dissections. 2 tables, 6 figures with MR, CT and catheter angio 2. Delev D, Hakvoort K, Krüger MT, et al. Choroidal … The post Journal Scan — This Month in Other Journals, April 2022 appeared first on AJNR Blog.

1. Jia B, Zhang X, Ma N, et al. Comparison of drug-eluting stent with bare-metal stent in patients with symptomatic high-grade intracranial atherosclerotic stenosis. JAMA Neurol 2022;79:176–84. Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2787238 Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide, accounting for 8%to 10% of strokes in North America and 30% to 50% of strokes in Asia. The current recommended strategy for stroke prevention in patients with ICAS is standard medical therapy. In recent years, standard medical therapy has substantially reduced stroke recurrence in patients with ICAS. However, a subset of patients are at a high risk for stroke recurrence despite medical treatment. For instance, patients with border zone infarcts and impaired collaterals in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial had a 37% 1-year stroke recurrence rate. As a potential treatment for ICAS with impaired flow, intracranial stenting was found to be inferior to medical management in the SAMMPRIS trial and the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) trial mainly because of the high complication rate associated with stenting. More recently, the Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China and the Wingspan Stent System Post Market Surveillance (WEAVE) trial showed rates of 2.6% to 4.3% for periprocedural complications, suggesting that intracranial stenting may be safe in strictly selected patients with ICAS. This study asked the question whether a drug-eluting stent (DES) superior to a standard bare-metal stent in reducing in-stent restenosis and stroke recurrence in patients with symptomatic high-grade intracranial atherosclerotic stenosis? Patients were randomly assigned to receive drug-eluting stent (NOVA intracranial sirolimus-eluting stent system) or BMS (Apollo intracranial stent system) treatment in a 1:1 ratio. A total of 263 participants (194 men [73.8%]) were included in the analysis, with … The post Journal Scan – This Month in Other Journals, March 2022 appeared first on AJNR Blog.

1. Lakomkin N, Stannard B, Fogelson JL, et al. Comparison of surgical invasiveness and morbidity of adult spinal deformity surgery to other major operations. Spine J 2021;21:1784–92. Available from: https://doi.org/10.1016/j.spinee.2021.07.013 Adult spinal deformity (ASD) surgery treats a variety of debilitating spinal conditions including degenerative scoliosis, idiopathic scoliosis, kyphoscoliosis, and flat-back syndrome, among others. Although ASD surgery leads to excellent postoperative outcomes, numerous studies have identified rates of perioperative complications at approximately 50% to 70%, along with large incidence of intraoperative transfusions, prolonged hospital length of stay (LOS), and mortality. A prospective surgical registry was used to identify all patients undergoing ASD surgery involving ≥ 7 segments. Seventeen additional procedures were included: coronary artery bypass grafting (CABG), pancreatectomy, and esophagectomy, among others. Perioperative factors (operative time, transfusions, ventilation) and complications were collected and combined with a previously validated Postoperative Morbidity Survey to create a Surgical Invasiveness and Morbidity Score (SIMS). A total of 1,245,282 surgical patients were included, 4,656 of which underwent ASD surgery. After multiple regression modeling controlling for patient demographics and comorbidities, ASD surgery ranked fourth in Surgical Invasiveness and Morbidity Score. ASD surgery had a significantly greater SIMS than 13 other major procedures including 6th esophagectomy, 8th pancreatectomy, 11th craniotomy for tumor, and 12th sacral chordoma resection. Among the 18 surgical procedures, ASD surgery ranked third in operative duration (351 min), surpassed only by microsurgical free flap (486 min) and esophagectomy (354 min). ASD ranked fourth in the proportion of patients requiring transfusion (50.9%), with only CABG (64.1%), open AAA repair (61.6%), and MVR (57.1%) with a greater incidence. These data suggest that the surgical invasiveness and morbidity of ASD correction may exceed some of the largest and traditionally highest-risk surgical operations. These relationships held true despite the fact that ASD patients presented with a significantly decreased comorbidity … The post Journal Scan – This Month in Other Journals, February 2022 appeared first on AJNR Blog.

1. Happi Ngankou E, Gory B, Marnat G, et al. Thrombectomy complications in large vessel occlusions: incidence, predictors, and clinical impact in the ETIS Registry. Stroke 2021;52:e764–68 This study is a retrospective analysis of 4029 stroke patients with anterior large vessel occlusions treated with thrombectomy between January 2015 and May 2020 in 18 centers. The authors systematically collected procedural data, incidence of embolic complications, perforations and dissections, clinical outcome at 90 days, and hemorrhagic complications. Procedural complications occurred in 7.99%, and embolus to a new territory (ENT) was the most frequent (5.2%). Predictors of embolus to a new territory were terminal carotid/tandem occlusion and an increased total number of passes. ENTs were associated to worse clinical outcomes, increased mortality, and symptomatic intracerebral hemorrhage. Perforations occurred in 1.69%.  Predictors of perforations were terminal carotid/tandem occlusions (39.7% versus 27.6%). 40.7% of patients died at 90 days, and the overall rate of poor outcome was 74.6% in case of perforation. Dissections occurred in 1.46% and were more common in younger patients. Dissections did not affect the clinical outcome at 90 days. Besides dissection, complications were independent of the thrombectomy technique. Whereas dissection did not affect clinical outcome, embolus to a new territory and perforations have a substantial negative clinical effect. ENTs and perforations were related to terminal carotid/tandem occlusions and an increased number of passes for ENTs, but the thrombectomy technique had no impact on procedural complications. 2 tables, 1 figure, no imaging 2. Visser MJ, Yang JY-M, Calamante F, et al. Automated perfusion-diffusion magnetic resonance imaging in childhood arterial ischemic stroke. Stroke 2021;52:3296–3304 Recent studies using automated perfusion imaging software have identified adults most likely to benefit from reperfusion therapies in extended time windows. The time course of penumbral tissue is poorly characterized in childhood arterial ischemic stroke (AIS). The authors explored … The post Journal Scan – This Month in Other Journals, January 2022 appeared first on AJNR Blog.

1. Requena M, Olivé-Gadea M, Muchada M, et al. Direct to angiography suite without stopping for computed tomography imaging for patients with acute stroke: a randomized clinical trial. JAMA Neurol 2021;78:1099–107 Direct transfer to angiography suite (DTAS) Door-to-puncture [DTP]) time Despite the efforts dedicated to reduce DTP times, published registries and clinical trials have shown the difficulties in decreasing DTP time below 60 minutes, a target that has been set by expert consensus. The HERMES meta-analysis reported DTP times ranging from 81 minutes for transferred patients to 116 minutes for patients directly admitted to an endovascular center. Research assessing optimized workflows has led to a newly proposed paradigm in the acute treatment of patients with severe stroke: direct transfer to angiography suite (DTAS). Protocols for DTAS were simultaneously designed in several centers mirroring the ST-segment elevation myocardial infarction strategy of bypassing the emergency department and conventional imaging. On arrival at the angiography suite, the use of flat-panel computed tomography (FPCT) enables the ruling out of either an intracranial hemorrhage (ICH) or a large established infarct. In addition, LVO can be diagnosed with a flat-panel angiography system immediately before arterial puncture or directly with initial diagnostic angiography. Regardless of the protocol details, DTAS has been consistently shown to be effective in decreasing DTP time to as low as 16 minutes without safety concerns. The effect of DTAS on long-term functional outcomes varies between published nonrandomized studies and is still unclear. The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Of 466 consecutive patients with acute stroke screened, 174 with suspected LVO acute stroke within 6 hours of symptom onset were included. Patients were randomly assigned (1:1) to follow either DTAS (89 patients) or conventional workflow (85 patients received direct transfer to computed tomographic imaging, with usual imaging performed and EVT … The post Journal Scan – This Month in Other Journals, December 2021 appeared first on AJNR Blog.

1. Avila MJ, Hurlbert RJ. Central cord syndrome redefined. Neurosurg Clin N Am 2021;32:353–63. Available from: https://doi.org/10.1016/j.nec.2021.03.007 The pathophysiology of CCS typically occurs in the setting of preexisting stenosis and involves a low-impact/low-velocity hyperextension injury to the neck. This causes buckling of the ligamentum flavum at the lordotic apex of the cervical spine (C4-C6) resulting in spinal cord compression against osteophytes and disks protruding into the anterior canal, displacing the spinal cord parenchyma into the less stenotic lateral recesses. The epicenter of compression is in the sagittal midline but spreads laterally proportional to the force involved and degree of preexisting stenosis. Spinal cord gray matter is affected first because of stretch and shear to the transversely oriented sensory afferents crossing the midline and the arteriole blood supply; their side-to-side horizontal trajectory makes them more susceptible to damage from lateral displacement than the longitudinally oriented white matter tracts. Gray matter injury results in sensory disturbance to the hands. With higher injury forces shear and contusion extend laterally to involve white matter tracts in a medial to- lateral preference. Motor weakness of the hands is precipitated from indiscriminate lateral corticospinal pathway involvement. With greater injury force there is additional lateral, anterior, and posterior white matter involvement affecting arm, leg, bowel, and bladder function. Of all the controversies surrounding CCS, the management of incomplete SCI in this setting is one of the most widely debated. In his original narrative, Schneider and coworkers described the surgical management of CCS to be “contraindicated because spontaneous improvement or complete recovery may occur. Furthermore, operation has actually been known to harm these patients rather than improve them.” In the 65 years ensuing since this warning, the philosophy of a more conservative approach toward surgical intervention for CCS continues to be championed and despaired. Even more widely debated … The post Journal Scan – This Month in Other Journals, November 2021 appeared first on AJNR Blog.