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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;79:17 6–84. 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 132 participants randomly assigned to the drug-eluting stent group and 131 to the BMS group. The 1-year in-stent restenosis rate was lower in the DES group than in the BMS group (10 [9.5%] vs 32 [30.2%]). The DES group also had a significantly lower ischemic stroke recurrence rate from day 31 to 1 year (1 [0.8%] vs 9 [6.9%]). No significant difference in the rate of any stroke or death within 30 days was observed between the DES and BMS groups.

The findings of this trial indicated that DESs were superior to BMSs in reducing the incidence of ISR and risk of ischemic stroke recurrence in the target vessel territory in patients with high-grade symptomatic ICAS.

3 tables, 2 figures, no images

2. Swanson LC, Ahmed R. Epilepsy syndromes: current classifications and future directions. Neurosurg Clin N Am 2022;33:11 3–34. Available from: https://doi.org/10.1016/j.nec.2021.09.009

Epilepsy is one of the most common neurologic diseases with an estimated lifetime prevalence of 7.6 per 1000 people. It is a heterogeneous disorder with significant variability in etiology, clinical presentation, treatment, and prognosis across the human lifespan. Individual epilepsies were, therefore, initially categorized in syndromes, with shared clinicopathological features, to facilitate a uniform approach for diagnosis and treatment. However, ongoing diagnostic advancements and delineation of epilepsy subtypes challenge the concept and utility of syndromic classifications in clinical practice. Classification of epilepsy syndromes is, therefore, expected to evolve from shared clinical features toward the molecular underpinnings of the disease process that may facilitate tailored therapeutic approaches. Although the most recent report from the International League Against Epilepsy (ILAE) in 2017 classifies seizure types based on initial clinical manifestation (focal, generalized, mixed, and unknown), this review discusses major pediatric epilepsy syndromes categorized by the age of onset.

The review will provide summarized clinical descriptions of current syndromic epilepsies (Table 1) and characterizes epilepsies of structural etiology that may be amenable to surgical intervention (Table 2). Lastly, emerging technologies are highlighted that will facilitate future syndromic classifications through an improved understanding of the underlying pathophysiological basis of epilepsy.

2 giant tables, no images

3. Voglis S, Romagna A, Germans MR, et al. Spinal arachnoid web—a distinct entity of focal arachnopathy with favorable long-term outcome after surgical resection: analysis of a multicenter patient population. Spine J 2022;22:12 6–35. Available from: https://doi.org/10.1016/j.spinee.2021.06.018

Spinal arachnoid web (SAW) is a rare pathology causing spinal cord compression due to the formation of thickened arachnoid tissue. It can lead to spinal cord compression or focal syrinx formation causing symptoms of myelopathy such as progressive (neuropathic) pain, weakness, sensory deficits, or other less common neurological findings. Syringomyelia is frequent and caused by mass effect of the SAW or obstruction of cerebrospinal fluid (CSF) flow. In the present study, the authors retrospectively analyzed 12 surgically treated Spinal arachnoid webs from three different neurosurgical centers and compared the multicentric experience regarding diagnosis, surgical treatment, and clinical outcome with the available literature.

In all cases, the spinal arachnoid web was localized in the upper and mid thoracic spine (83%, 10/12 involving Th 3-6), with the mass effect located in the dorsal aspect of the dural sac, compressing the spinal cord from posterior. MR revealed the presence of the previously described “scalpel sign” in all 12 cases. In some cases, constructive interference in steady-state (CISS) or cardiac-gated phase-contrast cine mode MR sequences were used to visualize the adhesive arachnoid membranes or the CSF flow obstruction.

Histologically, the resected membrane (specimens of three patients available) consisted of fibrovascular connective tissue as well as small nests of meningothelial cells. Immunohistochemical preparations showed reactivity for epithelial membrane antigen (EMA) in the meningothelial cells, confirming arachnoid origin.

In the current study, the authors evaluate the largest series of surgically confirmed SAW and illustrate the distinctive radiographic, histopathological, and intraoperative features of this unique form of focal spinal arachnopathy. In addition, they document the favorable clinical course after microsurgical excision of the arachnoid web.

5 figures, 3 tables, including MR, histopathology and ultrasound

4. Baig AM. Counting the neurological cost of COVID-19. Nat Rev Neurol 2021;18(January):5–6

This is a commentary on a Neurology paper (Refers to Misra, S. et al. Frequency of neurologic manifestations in COVID-19: a systematic review and meta-analysis. Neurology https://doi.org/10.1212/WNL.0000000000012930 (2021)).

Although COVID-19 was initially thought to be a disease of the respiratory passages, SARS-CoV-2 was recognized as a potential neurotropic virus in the early months of 2020, and the possibility that the virus could access the brain via the olfactory mucosa and the cribriform plate was raised. Subsequent studies have reported involvement of the olfactory pathways in the spread of SARS-CoV-2 to the brain. The neurotropism of SARS-CoV-2 could be mediated by angiotensin-converting enzyme 2 receptors on olfactory mucosal cells and/or neuropilin-1 on the olfactory epithelium. Other potential routes of SARS-CoV-2 entry into the CNS could include the bloodstream, a breached blood–brain barrier and retrograde axonal transport.

With the ongoing COVID-19 pandemic, clusters of patients have emerged with symptoms that continue beyond the acute phase of the disease — a condition commonly known as ‘long COVID’. A substantial proportion of these so-called ‘long-haulers’ have neurological manifestations, and there is an urgent need to address their health issues. A global consensus is needed on diagnostic approaches, management modalities and follow-up to ensure the well-being of long-haulers in general, and to address the neurological features of COVID-19 in particular.

1 graphic showing COVID-19 related neurologic deficits

5. Abola MV, Lin CC, Colasanti CA, et al. Treatment outcomes in American football players after intervertebral disk herniation: systematic review and meta-analysis. Neurosur