Questionnaire-Based Assessment of the Masticatory Function and Facial Nerve Recovery Post Pterional Approach in Brain Tumors Surgery

Background: The pterional approach for craniotomy, one of the most used surgical intervention in neurosurgery, results in a series of postoperative changes that, if they persist, affect the patient’s life, social reintegration, and his/her physical and mental recovery. The aim of the present study was to develop and validate a questionnaire for indicating directly affected masticatory muscles groups and facial nerve branches, in patients undergoing the pterional approach in neurosurgery, so that the recovery therapy can be monitored and personalized. Methods: A self-reporting questionnaire consisting of 18 items (12 for postoperative masticatory status and 6 for facial nerve branches involvement), validated on fifteen patients, following three steps: items development, scale development, and scale evaluation, was prospectively applied twice, at a one-year interval (T0 and T1), with thirty-two patients suffering from vascular or tumoral pathology and surgically treated through a pterional approach. Results: No statistically significant correlation could be found between postoperative outcomes and age or gender. Facial nerve branch involvement could not be correlated with any of the assessed variables. Pathology and time elapsed from surgery were statistically significantly correlated to preauricular pain on the non-operated side (p = 0.008 and p = 0.034, respectively). Time elapsed from surgery was statistically significantly correlated to the ability to chew hard food, pain while yawning, and preauricular pain during back and forward jaw movements and gradual mouth opening. Conclusions: We created and validated a valuable patient-centered questionnaire that can be employed as a tool for postoperative assessment of directly affected masticatory muscles and groups of facial nerve branches.

Limb Muscle Reinnervation with the Nerve-Muscle-Endplate Grafting Technique: An Anatomical Feasibility Study

Background. Peroneal nerve injuries results in tibialis anterior (TA) muscle paralysis. TA paralysis could cause “foot drop,” a disabling condition that can make walking difficult. As current treatment methods result in poor functional recovery, novel treatment approaches need to be studied. The aim of this study was to explore anatomical feasibility of limb reinnervation with our recently developed nerve-muscle-endplate grafting (NMEG) in the native motor zone (NMZ). Methods. As the NMEG-NMZ technique involves in nerves and motor endplates (MEPs), the nerve supply patterns and locations of the MEP bands within the gastrocnemius (GM) and TA muscles of rats were investigated using Sihler’s stain and whole-mount acetylcholinesterase (AChE) staining, respectively. Five adult rats underwent TA nerve transaction. The denervated TA was reinnervated by transferring an NMEG pedicle from the ipsilateral lateral GM. At the end of a 3-month recovery period, maximal muscle force was measured to document functional recovery. Results. The results showed that the TA was innervated by the deep peroneal nerve. A single MEP band was located obliquely in the middle of the TA. The GM was composed of two neuromuscular compartments, lateral (GM-l) and medial (GM-m), each of which was innervated by a separate nerve branch derived from the tibial nerve and had a vertically positioned MEP band. The locations of MEP bands in the GM and TA muscles and nerve supply patterns demonstrated that an NMEG pedicle can be harvested from the GM-l and implanted into the NMZ within the TA muscle. The NMEG-NMZ pilot study showed that this technique resulted in optimal muscle force recovery. Conclusion. NMEG-NMZ surgery is feasible for limb reinnervation. Specifically, the denervated TA caused by peroneal nerve injuries can be reinnervated with a NMEG from the GM-l.

Involvement of Different Nerve Branches in Trigeminal Neuralgia on Right and Left Sides- A Retrospective Study

One of the most common symptoms in the orofacial region is pain. Trigeminal neuralgia is characterized by pain affecting the trigeminal nerve and its related areas of distribution and is known to have significant impact on the quality of life. Misdiagnosis of trigeminal neuralgia has been reported by dentists in several previous studies in the literature. With this rationale, the aim of the present study is to determine the most commonly involved nerve branch and the side affected in trigeminal neuralgia patients. The present retrospective study involved 72 patients diagnosed with trigeminal neuralgia who reported from October 2013 to October 2014. Data regarding the age of onset, gender, side of involvement was analyzed from their clinical records. Out of the 72 patients, males were 42(58.3%) and females were 30(41.7%). In our study, a total of 56 % (i.e., 40) patients showed involvement on the right and 44% (i.e., 32) (i.e, 32) patients on the left side of the face. In this retrospective study, ophthalmic branch (V1) was affected only in 3 patients. Mandibular nerve (V3) alone was involved in 24 patients. Involvement of all the three divisions V1, V2 and V3 was seen in 16(22.3%) of patients. Clinical similarities of trigeminal neuralgia that have an impact on different populations were demonstrated in this study. Detailed history and proper identification of involved nerve branch play an important role in the diagnostic accuracy and treatment satisfaction. Most involved branch in our study was the mandibular (V3) branch and the most affected side was the right side. Correlation of systemic factors with trigeminal neuralgia can be attempted in future research.

Complete Facial Paralysis Caused by Stabbing With a Car Key at the Stylomastoid Foramen

Non-iatrogenic traumatic facial paralysis is most common in intratemporal facial nerve injury caused by temporal bone fracture, followed by intraparotid facial nerve branch injury. Facial paralysis caused by injury to the extratemporal trunk of the facial nerve is extremely rare. We present a case of a 60-year-old man suffering from immediate complete left peripheral facial paralysis due to blunt transection of extratemporal trunk of facial nerve by stabbing with a car key. There was a facial nerve defect about 1 cm in length. The great auricular nerve was grafted to repair the facial nerve. Over 12 months, his facial nerve function improved to a House–Brackmann III/VI.

Corneal Nerve Loss in Patients With TIA and Acute Ischemic Stroke in Relation To Circulating Markers of Inflammation and Vascular Integrity

Background Vascular and inflammatory mechanisms are implicated in the development of cerebrovascular disease and corneal nerve loss occurs in patients with transient ischemic attack (TIA) and acute ischemic stroke (AIS). We have assessed whether serum markers of inflammation and vascular integrity are associated with the severity of corneal nerve loss in patients with TIA and AIS. Methods Corneal confocal microscopy (CCM) was performed to quantify corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL) in 105 patients with TIA or AIS and age matched control subjects (n=56). Circulating levels of IL-6, MMP-2, MMP-9, E-Selectin, P-Selectin and VEGF were quantified in patients within 48 hours of presentation with a TIA or AIS. Results CNFL (P=0.000, P=0.000), CNFD (P=0.122, P=0.000) and CNBD (P=0.002, P=0.000) were reduced in patients with TIA and AIS compared to controls, respectively with no difference between patients with AIS and TIA. The NIHSS Score (P=0.000), IL-6 (P=0.011) and E-Selectin (P=0.032) were higher in patients with AIS compared to TIA with no difference in MMP-2 (P=0.636), MMP-9 (P=0.098), P-Selectin (P=0.395) and VEGF (P=0.831). CNFL (r=0.218, P=0.026) and CNFD (r=0.230, P=0.019) correlated with IL-6 and multiple regression analysis showed a positive association of CNFL and CNFD with IL-6 (P=0.041, P=0.043). Conclusions Patients with TIA and stroke have evidence of corneal nerve loss and elevated IL6 and E-selectin levels. Larger longitudinal studies are required to determine the association between inflammatory and vascular markers and corneal nerve fiber loss in patients with cerebrovascular disease.

Relation of the lumbosacral trunk to the sacro-iliac joint

This study aims to evaluate the relation between the lumbosacral trunk (LT) and the sacro-iliac joint (SIJ). In forty anatomic specimens (hemipelves) a classical antero-lateral approach to the SIJ was performed. The SIJ was marked at the linea terminalis (reference point A). Reference point B was situated at the upper edge of the interosseous sacro-iliac ligament. The length of the SIJ (distance A to B) and the distance between point A and the ventral branch of the fourth (L4) and fifth (L5) lumbar spinal nerves at the linea terminalis were measured. The SIJ had a mean length of 58.0 mm. The ventral branch of L5 was located closer to the SIJ in very long SIJs (mean length: ≥ 6.5 cm; mean distance: 9.8 mm) compared to very short joints (≤ 5 mm; mean distance: 11.3 mm). For the ventral branch of L4, very long SIJs had a mean distance of 7 mm and very short joints an average distance of 9.7 mm between point A and the nerve branch. A safe zone of approximately 1 cm to 2 cm (anterior to posterior) is present on the sacral surface (lateral to medial) for safe fixation of plates during anterior plate stabilization of the SIJ. Pelves with a shorter dorsoventral diameter of the most superior part of the SIJ apparently give more space for inserting plates.

Corneal nerve loss as a surrogate marker for poor pial collaterals in patients with acute ischemic stroke

In patients with acute ischemic stroke, pial collaterals play a key role in limiting neurological disability by maintaining blood flow to ischemic penumbra. We hypothesized that patient with poor pial collaterals will have greater corneal nerve and endothelial cell abnormalities. In a cross-sectional study, 35 patients with acute ischemic stroke secondary to middle cerebral artery (MCA) occlusion with poor (n = 12) and moderate-good (n = 23) pial collaterals and 35 healthy controls underwent corneal confocal microscopy and quantification of corneal nerve and endothelial cell morphology. In patients with MCA stroke, corneal nerve fibre length (CNFL) (P < 0.001), corneal nerve fibre density (CNFD) (P = 0.025) and corneal nerve branch density (CNBD) (P = 0.002) were lower compared to controls. Age, BMI, cholesterol, triglycerides, HDL, LDL, systolic blood pressure, NIHSS and endothelial cell parameters did not differ but mRS was higher (p = 0.023) and CNFL (p = 0.026) and CNBD (p = 0.044) were lower in patients with poor compared to moderate-good collaterals. CNFL and CNBD distinguished subjects with poor from moderate-good pial collaterals with an AUC of 72% (95% CI 53–92%) and 71% (95% CI 53–90%), respectively. Corneal nerve loss is greater in patients with poor compared to moderate-good pial collaterals and may act as a surrogate marker for pial collateral status in patients with ischemic stroke.

Comparing the results of manual and automated quantitative corneal neuroanalysing modules for beginners

This study aimed to evaluate the reliability of in vivo confocal microscopic neuroanalysis by beginners using manual and automated modules. Images of sub-basal corneal nerve plexus (SCNP) from 108 images of 18 healthy participants were analyzed by 7 beginner observers using manual (CCMetrics, [CCM]) and automated (ACCMetrics, [ACCM]) module. SCNP parameters analyzed included corneal nerve fiber density (NFD), corneal nerve branch density (NBD), corneal nerve fiber length (NFL), and tortuosity coefficient (TC). The intra-observer repeatability, inter-observer reliability, inter-module agreement, and left–right eye symmetry level of SCNP parameters were examined. All observers showed good intra-observer repeatability using CCM (intraclass correlation coefficient [ICC] > 0.60 for all), except when measuring TC. Two observers demonstrated especially excellent repeatability in analyzing NFD, NBD, and NFL using manual mode, indicating the quality of interpretation may still be observer-dependent. Among all SCNP parameters, NFL had the best inter-observer reliability (Spearman’s rank-sum correlation coefficient [SpCC] and ICC > 0.85 for the 3 original observers) and left–right symmetry level (SpCC and ICC > 0.60). In the additional analysis of inter-observer reliability using results by all 7 observers, only NFL showed good inter-observer reliability (ICC = 0.79). Compared with CCM measurements, values of ACCM measurements were significantly lower, implying a poor inter-module agreement. Our result suggested that performance of quantitative corneal neuroanalysis by beginners maybe acceptable, with NFL being the most reliable parameter, and automated method cannot fully replace manual work.