New-onset Neurological Deficits Research Articles

Unsatisfactory Neurological Outcome in an Intramedullary Thoracic Intermediate-Grade Melanocytoma-Systematic Review and Illustrative Case.

Intramedullary melanocytomas are exceedingly rare, with only twenty-four cases reported up to now. They present as local invasive tumors despite their benign biological behavior. Attempting a complete safe resection often results in severe post-operative neurological deficits, as in our case presented here. A systematic review was conducted across the PubMed and Scopus databases including studies published till February 2024. A total of 19 studies were included, encompassing 24 cases. A similar distribution between sexes was noted (M:F 13:11), with ages ranging from 19 to 79 years. The thoracic segment was most affected, and intermediate-grade melanocytoma (19 cases) was the most common histotype. Radiographically, intramedullary melanocytomas usually appear as hyperintense hemorrhagic lesions peripheral to the central canal with focal nodular enhancement. Intraoperatively, they are black-reddish to tan and are tenaciously adherent lesions. In the sampled studies, IONM employment was uncommon, and post-operative new-onset neurological deficits were described in 16 cases. Adjuvant RT was used in four cases and its value is debatable. Recurrence is common (10 cases), and adjuvant therapies (RT or repeated surgery) seem to play a palliative role. A 68-year-old woman presented with a three-year history of worsening spastic paraparesis and loss of independence in daily activities (McCormick grade 4). An MRI revealed an intramedullary tumor from Th5 to Th7, characterized by T1-weighted hyperintensity and signs of recent intralesional hemorrhage. Multimodal neuromonitoring, comprising the D-Wave, guided the resection of a black-tan-colored tumor with hyper-vascularization and strong adherence to the white matter. During final dissection of the lesion to obtain gross total resection (GTR), a steep decline in MEPs and D-Wave signals was recorded. Post-operatively, the patient had severe hypoesthesia with Th9 level and segmental motor deficits, with some improvement during neurorehabilitation. Histopathology revealed an intermediate-grade melanocytoma (CNS WHO 2021 classification). A four-month follow-up documented the absence of relapse. This literature review highlights that intramedullary T1 hyperintense hemorrhagic thoracic lesions in an adult patient should raise the suspicion of intramedullary melanocytoma. They present as locally aggressive tumors, due to local invasiveness, which often lead to post-operative neurological deficits, and frequent relapses, which overwhelm therapeutic strategies leading to palliative care after several years.

Longitudinal impact of intracerebral low-grade glioma disease on health-related quality of life.

The aim of this study was to assess health-related quality of life (HRQOL) before and after treatment for intracerebral low-grade glioma. Patients with low-grade glioma who underwent surgical tumor removal between 2012 and 2018 were eligible for this study. All individuals and their closest relatives received thorough preoperative (<seven days before surgery) and posttreatment (12 months after surgery) neuropsychological testing investigating quality of life. The assessment consisted of the Aachen Life Quality Inventory (ALQI) and the Short Form 36 (SF36) questionnaire. Calculated SF36 values were compared with reference values from population-based studies. A set of clinical features were investigated for their association with longitudinal HRQOL deterioration. A total of 25 patients were referred for further analysis, after adjustment to the 2021 WHO classification for central nervous system tumors. Compared to the values of a healthy reference population, the patients expressed significant limitations in several SF36 items, both before and after treatment. Under treatment, there were no significant changes in the SF36 items, but the ALQI questionnaire indicated decreasing HRQOL over time. Data derived from relatives revealed a high degree of concordance with the rating results of the patients. Univariate analysis identified neurological deterioration and ongoing epileptic seizures as predictors for unfavorable HRQOL after one year. Low-grade glioma disease has a significant impact on HRQOL and treatment might contribute to further deterioration. New-onset neurological deficits and ongoing epileptic seizures are predictors of limitations in quality of life. Since the results are based on a small cohort with limited follow-up time, the generalizability of these statements is limited and further studies are required.

Feasibility and efficacy of endoscopic transorbital optic canal decompression for meningiomas causing compressive optic neuropathy.

The endoscopic transorbital approach (ETOA) and transorbital anterior clinoidectomy have been suggested as novel procedures through which to reach the superolateral compartments of the orbit, allowing optic canal decompression. However, there is limited literature describing the technical details and surgical outcomes of these procedures. In this study, the authors aimed to analyze the feasibility and efficacy of endoscopic transorbital decompression of the optic canal through anterior clinoidectomy for compressive optic neuropathic lesions. Between 2016 and 2022, the authors performed ETOA for compressive optic neuropathic lesions in 14 patients. All these patients underwent transorbital anterior clinoidectomy through the surgically defined "intraorbital clinoidal triangle," which is composed of the roof of the superior orbital fissure, the medial margin of the optic canal, the medial border of the superior orbital fissure, and the optic strut. Demographic data, tumor characteristics, pre- and postoperative imaging, pre- and postoperative visual examinations, and surgical outcomes were retrospectively reviewed. The mean age at the time of ETOA was 53.3 years (range 41-64 years), and the mean follow-up was 16.8 months (range 6.7-51.4 months). The inclusion criterion in this study was having a meningioma (14 patients). In the preoperative visual function examination, 7 patients with a meningioma showed progressive visual impairment. After endoscopic transorbital optic canal decompression, visual function improved in 5 patients, remained unchanged in 8 patients, and worsened in 1 patient. No new-onset neurological deficit was associated with ETOA and anterior clinoidectomy in any patients. Endoscopic transorbital decompression of the optic canal with extradural anterior clinoidectomy is a safe and feasible technique that avoids significant injury to the clinoidal internal carotid artery and surrounding neurovascular structures.

Linking Patterns of Intraoperative Neuromonitoring (IONM) Alerts to the Odds of a New Postoperative Neurological Deficit: Analysis of 27,808 Cervical Spine Procedures From a National Multi-institutional Database.

Retrospective review of a national multi-institutional database of 27,808 extradural cervical spine procedures performed between January 2017 and May 2021. Characterize intraoperative neuromonitoring alerts by the patterns of modalities and nerves/muscles involved and quantify risk of new-onset neurological deficit for patients with a primary diagnosis of myelopathy, stenosis, or radiculopathy. Phenotyping alert patterns and linking those patterns with risk is needed to facilitate clinical decision-making. Cases with alerts were categorized by patterns of modalities or nerves/muscles involved, and alert status at closure. Unadjusted odds ratios (ORs) for new-onset neurological deficit were calculated. A mixed-effects logistic regression model controlling for demographic and operative factors, with random intercepts to account for clustering in outcomes by surgeon and surgical neurophysiologist was also used to calculate ORs and probabilities of neurological deficit. There was significantly increased risk of a new neurological deficit for procedures involving posterior compared with anterior approaches (OR: 1.82, P=0.001) and procedures involving three levels compared with one (OR: 2.17, P=0.001). Odds of a deficit were lower for patients with radiculopathy compared with myelopathy (OR: 0.69, P=0.058). Compared with cases with no alerts, those with unresolved Spinal Cord alerts were associated with the greatest elevation in risk (OR: 289.05) followed by unresolved C5-6 Nerve Root (OR: 172.7), C5-T1 Nerve Root/Arm (OR: 162.89), C7 Nerve Root (OR:84.2), and C8-T1 Nerve Root alerts (OR:75.49, all P<0.001). Significant reductions in risk were seen for resolved Spinal Cord, C5-6 Nerve Root, and C8-T1 nerve alerts. Overall, unresolved motor evoked potential and somatosensory evoked potential alerts were associated with the greatest elevation in risk (OR:340.92) followed by unresolved motor evoked potential-only (OR:140.6) and unresolved somatosensory evoked potential-Only alerts (OR:78.3, all P<0.001). These relationships were similar across diagnostic cohorts. Risk elevation and risk mitigation after an intraoperative neuromonitoring alert during surgery is dependent on the type and pattern of alert.

External Validation of an Extreme Gradient Boosting Model for Prediction of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Delayed cerebral ischemia (DCI) may significantly worsen the functional status of patients with aneurysmal subarachnoid hemorrhage (aSAH). Several authors have designed predictive models for early identification of patients at risk of post-aSAH DCI. In this study, we externally validate an extreme gradient boosting (EGB) forecasting model for post-aSAH DCI prediction. A 9-year institutional retrospective review of patients with aSAH was performed. Patients were included if they underwent surgical or endovascular treatment and had available follow-up data. DCI was diagnosed as new-onset neurologic deficits at 4-12 days after aneurysm rupture, defined as worsening Glasgow Coma Scale score for ≥2 points, and new ischemic infarcts at imaging. We collected 267 patients with aSAH. At admission, median Hunt-Hess score was 2 (range, 1-5), median Fisher score 3 (range, 1-4), and median modified Fisher score 3 (range, 1-4). One-hundred and forty-five patients underwent external ventricular drainage placement for hydrocephalus (54.3%). The ruptured aneurysms were treated with clipping (64%), coiling (34.8%), and stent-assisted coiling (1.1%). Fifty-eight patients (21.7%) were diagnosed with clinical DCI and 82 (30.7%) with asymptomatic imaging vasospasm. The EGB classifier correctly predicted 19 cases of DCI (7.1%) and 154 cases of no-DCI (57.7%), achieving sensitivity of 32.76% and specificity of 73.68%. The calculated F1 score and accuracy were 0.288% and 64.8%, respectively. We validated that the EGB model is a potential assistant tool to predict post-aSAH DCI in clinical practice, finding moderate-high specificity but low sensitivity. Future research should investigate the underlying pathophysiology of DCI to allow the development of high-performing forecasting models.

Octogenarian Brain Tumor Registry: Single-Institution Surgical Outcomes and Mortality Study.

Surgical intervention for brain tumor patients aged 80 to 89 years is controversial, as the comorbidities and physiology associated with aging are often thought to increase surgical risks. Surgical outcomes, however, are not well characterized for octogenarians. This review therefore assessed the outcomes and mortality risk associated with tumor removal in octogenarians at our academic institution. Retrospective review of patients aged 80 to 89 who underwent craniotomy for tumor resection (CTR) at our institution between 2004-2021 and who were diagnosed with meningioma, glioblastoma, or metastatic disease. Primary outcome was 30-day mortality. Sixty-one CTRs were included in analysis. Median age was 83 (interquartile range 81-85) years, and the most common preoperative comorbidity was hypertension (n=44). Most patients (n=35) had a preoperative modified Rankin Scale (mRS) score between 0-2. Seventeen (27.9%) patients experienced postoperative complications (i.e., urinary tract infection, deep venous thrombosis, etc.), and 26.2% (n=16) experienced new-onset neurologic deficits postoperatively (i.e., aphasia, motor deficits, etc.). Upon discharge, most patients (n=43) had an mRS score of 3-4. Within 30 days of surgery, 14.8% (n=9) of patients were readmitted to the hospital and 8.2% (n=5) of patients died: 2 with meningioma, 1 with glioblastoma, and 2 with metastatic disease. The most common cause of death was intracranial hemorrhage (n=3). Three-month mortality was 23.0% (n=14). Mean survival after surgery was 33 months for meningioma patients, 6.9 months for glioblastoma patients, and 15 months for patients with metastatic lesions. Our review found a 30-day mortality rate of 8.2% across all tumor types, and mean survival was similar to that previously reported for patients across all age groups. Surgical intervention for octogenarian tumor patients is therefore feasible, safe, and likely worthwhile for extending and improving lives.

“Asymptomatic” Moyamoya Angiopathy: Is it Truly Asymptomatic?

IntroductionAn ambiguous definition of “asymptomatic” Moyamoya Angiopathy(aMMA) of absence of ischemic/hemorrhagic episodes in MMA patients, has led to its variable adaptation in the limited past-studies. ObjectiveTo observe the clinic-radiological characteristics and prospective follow-up of apparently “asymptomatic” MMA, and to determine if it is truly asymptomatic or not. Materials and MethodsAn observation, cohort study of 122 angiographically proven MMA over 6 years was undertaken from a single, tertiary-care-center to observe the clinico-radiological characteristics, prospective follow-up of apparently aMMA. Amongst them, 6 had an initial diagnosis of aMMA following evaluation by atleast one post-graduate doctor, which were further scrutinized by 3 different neurologists for epidemiological, clinical, radiological characteristics and subsequent follow-up. Data were analyzed using descriptive statistics. ResultsMean age was 23.7 ± 13.14 years. 3 of 6 underwent brain-imaging for evaluation of non-migraine-like headache, 1 for dizziness, 2 as part of familial screening for MMA. 4 of 6 patients had specific-triggers for aggravation of symptoms. Brain-imaging revealed old vascular insults and ivy sign in 5 of 6 each (83.3%), mean suzuki staging was 3.6±0.82. 4 of 6 underwent cerebral perfusion study, all had hypoperfusion. Revascularization surgery was done in 2 of 6, rest were managed conservatively. None had any new-onset neurological deficit or radiological progression over a mean follow-up period of 22.3 ± 20.22 months. ConclusionsApparently aMMA may not be truly asymptomatic and often have subtle “paroxysmal events” precipitated by specific-triggers, indicative of transient ischemic symptoms. Thus, warrants for a more precise definition to avoid misclassification of aMMA.

Loss to long-term follow-up in children with spinal tuberculosis: a retrospective cohort study at a tertiary hospital in the Western Cape, South Africa

Introductionchildren with spinal tuberculosis (TB) are at risk of kyphotic deformity both during and after the active phase of the disease. Management guidelines include follow-up until skeletal maturity. Little is known about adherence to this recommendation. This study aimed to investigate loss to long-term spine clinic follow-up (LTFU) among children with spinal TB at a tertiary hospital in the Western Cape Province, South Africa.Methodsthis retrospective cohort study included all children diagnosed with spinal TB at Tygerberg Hospital between January 2012 and December 2015. Spine clinic follow-up was investigated for five years following diagnosis. Relevant surgical interventions and re-presentation were evaluated until 31st December 2020.Resultsthirty-two children, median age 6 years (range 1-14 years), were diagnosed with spinal TB and intended for spine clinic follow-up. Twenty-seven (84%) children were LTFU within five years of diagnosis with 16 (50%) LTFU within 10.5 months. Among children in follow-up, one child had further surgery for progression of deformity two years from diagnosis and one child had further surgery for new-onset neurological deficit eight years from diagnosis.Conclusionmost children with spinal TB did not receive the recommended follow-up until skeletal maturity. Without further data on these children, the clinical significance of this LTFU could not be evaluated. Further studies are needed to investigate sequelae during skeletal maturation in the context of current management for paediatric spinal TB.

Classification of Adverse Events Following Surgery in Patients With Diffuse Lower-Grade Gliomas.

BackgroundRecently, the Therapy-Disability-Neurology (TDN) was introduced as a multidimensional reporting system to detect adverse events in neurosurgery. The aim of this study was to compare the novel TDN score with the Landriel–Ibanez classification (LIC) grade in a large cohort of patients with diffuse lower-grade glioma (dLGG). Since the TDN score lacks validation against patient-reported outcomes, we described health-related quality of life (HRQoL) change in relation to TDN scores in a subset of patients.MethodsWe screened adult patients with a surgically treated dLGG World Health Organization (WHO) grade 2 and 3 between 2010 and 2020. Up until 2017, it consists of a retrospective cohort (n = 158). From 2017 and onwards, HRQoL was registered using EuroQoL-5-dimension, three levels of response (EQ-5D 3L) questionnaire at baseline and 3 months follow-up, in a prospectively recruited cohort (n = 102). Both the LIC grade and TDN score were used to classify adverse events.ResultsIn total, 231 patients were included. In 110/231 (47.6%) of the surgical procedures, a postoperative complication was registered. When comparing the TDN score to LIC grades, only a minor shift towards complications of higher order could be observed. EQ-5D 3L was reported for 45 patients. Patients with complications related to surgery had pre- to postoperative changes in EQ-5D 3L index values (n = 27; mean 0.03, 95% CI −0.06 to 0.11) that were comparable to patients without complications (n = 18; mean −0.06, 95% CI −0.21 to 0.08). In contrast, patients with new-onset neurological deficit had a deterioration in HRQoL at follow-up, with a mean change in the EQ-5D 3L index value of 0.11 (n = 13, 95% CI 0.0 to 0.22) compared to −0.06 (n = 32, 95% CI −0.15 to 0.03) for all other patients.ConclusionsIn patients with dLGG, TDN scores compared to the standard LIC tend to capture more adverse events of higher order. There was no clear relation between TDN severity and HRQoL. However, new-onset neurological deficit caused impairment in HRQoL. For the TDN score to better align with patient-reported outcomes, more emphasis on neurological deficit and function should be considered.

Evaluating patient and neurosurgeon perspectives on virtualisation of neurosurgery clinics in the COVID-19 era: a prospective mirror survey study

Background The COVID-19 pandemic has compelled a global shift in healthcare service delivery towards virtualisation, including in Neurosurgery. Our study aims to elucidate the patient and neurosurgeon perceptions of virtual neurosurgery consultations (VNCs) and formulate a guidance algorithm based on our experience. Methods Between June 2020 and December 2020, we prospectively surveyed patients and neurosurgeons following their VNCs using a 10-item survey (four qualitative and six five-point Likert scale questions). Non-parametric hypothesis testing and grounded coding with inter-coder agreement was used to analyse quantitative and qualitative data, respectively. Results 106 patients and 10 neurosurgeons completed the survey. Wilcoxon rank-sum test revealed a statistically significant difference between the neurosurgeon and patient responses (p < 0.001). Patients perceived VNCs benefits to be enhanced efficiency (n = 142) and communication (28); and VNCs drawbacks as safety (46), technological (32), and administration (15) issues. Neurosurgeons perceived VNCs benefits to be enhanced efficiency (13), reduced COVID-19 exposure (2); and VNCs drawbacks as examination practicality (14), technological (6), and concerns for patients (6). Neurosurgeons perceived the relative indications for VNCs as postoperative follow-up clinics, and scan result discussions; and relative contraindications as neuro-oncology, new patients, and patients with worsening neurological symptoms. Conclusions Our mirror-survey study provides preliminary evidence that VNCs render increased efficiency, communication, and safety in the current COVID-19 era. Going forward, we believe that further improvements in technology and administration are necessary, greater neurosurgeon appreciation of the patient-perceived benefits of VNCs is required, and neurosurgeons are to exercise clinical discernment on when to use VNCs. Key Points What are the perceptions of patient and consultant neurosurgeons towards virtual neurosurgery consultations (VNCs)? Patient-perceived benefits of VNCs: enhanced efficiency/communication; VNC drawbacks: safety, technological, and administration issues. Neurosurgeon-perceived VNCs benefits of VNCs: enhanced efficiency, reduced COVID-19 exposure; VNC drawbacks: examination practicality, technological, and concerns for patients. Post-operative reviews and scan result discussions are perceived relative indications for VNCs; whereas new patient consultations, neuro-oncology and patients with new-onset neurological deficits are perceived relative contraindications for VNCs. Improvement in technology and administration is necessary; greater neurosurgeon appreciation of patient-perceived VNCs benefits is required, and neurosurgeons are to exercise clinical discernment on when to use VNCs.

Multimodality treatment of supratentorial arteriovenous malformations with microsurgery after embolization: A retrospective two-center study in Vietnam

BackgroundPreoperative embolization with microsurgical resection has been used as a multimodality treatment of cerebral arteriovenous malformations (AVMs) in recent years. However, the role of this combined approach has not been well established. ObjectivesThis retrospective study aims to evaluate the outcomes of multimodality treatment with microsurgery after embolization for supratentorial AVMs in Vietnam. MethodsA two-center, retrospective case series of 26 patients with supratentorial AVMs who underwent treatment with surgical resection after embolization between January 2017 and August 2020 was performed. Sixty-three feeding arteries were embolized preoperatively in 29 sessions. We analyzed the AVM size, degree of preoperative obliteration, complications related to embolization, intraoperative blood loss, surgical complications, complete resection rate, and postoperative outcomes at 3 months after discharge. ResultsThe average size and Spetzler-Martin (SM) grade of AVMs were 4.98 cm (largest, 8 cm) and 3.19, respectively. The average preoperative volumetric obliteration was 55.38%. The intraoperative average blood loss was 573 ml. Complications related to embolization were post-embolization cerebral hemorrhage in 2 cases (7.69%), new-onset neurological deficits in 1 (3.38%). Surgical complications included death in 2 cases (7.69%) and new-onset neurological deficits in 5 (19.23%). At 3-month follow-up, four patients with new-onset neurological deficits had recovered completely or nearly completely. Complete resection of AVMs was confirmed by postoperative imaging modalities in 24/24 cases. Favorable outcome was achieved in 23 cases (88.46%). ConclusionMultimodality treatment with microsurgery after embolization is a relatively safe and effective method which can be considered for managing large and complex brain AVMs.

Depression and ability to work after vestibular schwannoma surgery: a nationwide registry-based matched cohort study on antidepressants, sedatives, and sick leave

BackgroundIn patients with vestibular schwannomas (VS), tumor control is often achieved, and life expectancy is relatively good. The main risks of surgical treatment are hearing loss and facial nerve function. The occurrence of mood and sleeping disorders in relation to surgery is an important aspect of health that has rarely been studied. Similarly, only limited data exist on the rate of sick leave for patients with VS. In this nationwide registry-based study, we define the use of antidepressants and sedatives and the sick leave pattern before and after VS surgery.MethodsAdult patients with histopathologically verified VS were identified in the Swedish Brain Tumor Registry (SBTR) and clinical data were linked to relevant national registries after assigning five matched controls to each patient. We studied patterns of dispensed antidepressants and sedative drugs as well as patterns of sick leave compared to respective controls at 2 years before and 2 years following surgery.ResultsWe identified 333 patients and 1662 matched controls. The rate of antidepressant use was similar between patients and controls 2 years before surgery (6.0% vs 6.3%) and 2 years after surgery (10.1% vs 7.5%). The rate of sedative use was also similar 2 years before surgery (3.9% vs 4.3%) and 2 years after surgery (4.8% vs 5.3%). The rate of sick leave was similar at baseline between patients and controls, but at 2 years after surgery, 75% of patients vs 88% of controls (p < 0.01) had no registered sick leave. Long-term sick leave after surgery was predicted by use of sedatives (OR 0.60, 95% CI 0.38–0.94, p = 0.03), more preoperative sick leave (OR 0.91, 95% CI 0.89–0.93, p < 0.001), and new-onset neurological deficits after surgery (OR 0.42, 95% CI 0.24–0.76, p = 0.004).ConclusionThis nationwide study shows no significant differences in the use of antidepressants and sedatives between patients and controls, while the rate of postoperative sick leave was higher in patients than in controls after VS surgery. Our findings underpin the importance of avoiding surgical sequelae and facilitating return to normal professional life.

Single-Position Prone Transpsoas Lateral Interbody Fusion Including L4L5: Early Postoperative Outcomes

The lateral lumbar interbody fusion (LLIF) was a revolutionary approach devised by Luiz Pimenta that allowed the surgeon to access the lumbar spine through the major psoas muscle. Although the traditional LLIF had enabled enormous advances, the technique has its drawbacks. A new concept to perform the traditional LLIF has been proposed, with the patient being prone to decubitus with slightly extended legs. Our study aims to analyze the early outcomes of patients who had undergone the prone transpsoas (PTP) for degenerative spine pathologies including the L4/5 level. This study was multicentric, retrospective, nonrandomized, noncomparative, and observational. Only participants who received PTP in L4/5, with no more than 3 levels of intersomatics and fixation no further than S1, were included. The primary outcomes were the onset of new neurologic deficits and postoperative complications. Also, surgery details, such as blood loss and surgery duration, were measured. Neurologic deficits were accessed at the postoperative visit, which ranged from 7 to 14 days after surgery. Twenty-seven patients fulfilled the inclusion and exclusion criteria, with the majority receiving PTP only in L4/5 (66.6%). The mean surgery time was 182, with 29 minutes of mean transpsoas time. Of the patients, only 1 presented the onset of a motor deficit, while 3 patients presented a new sensory deficit. Five complications occurred, none intraoperative and 5 postoperative, with only 1 directly correlated with the access. The prone transpsoas is safe and feasible for approaching the L4/5 disk, presenting with a low rate of complication and new-onset neurologic deficits.

Application of clip remodeling technique in microsurgical treatment of intracranial aneurysms via keyhole approaches

Objective: To discuss the value and technique of clip remodeling in microsurgical treatment of intracranial aneurysms via keyhole approaches. Methods: The clinical data of patients with intracranial aneurysms, who were treated by microsurgical clipping via keyhole approaches from January 2017 to December 2019, were retrospectively analyzed. The clips were remodeled based on the aneurysmal characteristics during the procedure in 27 cases. Angiography was obtained within one week after surgery in order to evaluate the position of clips and the security of lesions. All patients were followed up at the outpatient clinic to assess the clinical outcomes. Results: A total of 27 patients harbored 30 intracranial aneurysms, including 23 ruptured lesions and 7 unruptured ones. There were 9 middle cerebral artery aneurysms, 11 anterior communicating artery aneurysms, 9 posterior communicating artery aneurysms and 1 anterior cerebral artery aneurysm, respectively. Nine patients were operated via supraorbital keyhole approach, as well as 17 via pterional keyhole approach and one via hemispheric keyhole approach. Postoperative angiography revealed complete obliteration of lesions without residual filling in all cases. Twenty-five patients recovered well at discharge and two presented with mild disability. After 3-36 months of follow-up, no rebleeding and new-onset neurological deficits were noted. Conclusion: Clip remodeling technique is a simple and effective option, which can alleviate the limitation of manipulative freedom under keyhole approaches and improve the microsurgical effect of intracranial aneurysms.

Letter to the Editor Regarding “Failure of Surgery in Idiopathic Spinal Cord Herniation: Case Report and Review of the Literature”

Colloid cysts of the third ventricle are rare benign lesions, which amount to approximately 1% of all intracranial tumors. Because these lesions grow predominantly in the anterior aspect of the third ventricle, they may cause the occlusion of the foramina of Monro, generating obstructive hydrocephalus. Surgery is mandatory in cases of large cysts and/or in symptomatic patients. Among the different surgical strategies described in colloid cysts surgery, the microsurgical transcallosal approach still constitutes the procedure of choice in many centers. In this study, we describe a modified microsurgical transcallosal approach, the interhemispheric transgenual approach, in a series of 13 consecutive patients operated on for colloid cysts of the third ventricle.All the procedures were performed by the senior author (V.E.) at Neuromed Institute of Pozzilli (Is, Italy). The operative procedure is described in its various steps, illustrating the differences and potential advantages compared with the traditional microsurgical transcallosal approach.No surgical complications or new-onset neurologic deficits were observed in the postoperative period. The postoperative magnetic resonance imaging confirmed in all cases complete lesion removal without any sign of parenchymal damage. No lesion recurrence or need for permanent cerebrospinal fluid diversion was detected in the patients of this series during the follow-up period.In our experience, the interhemispheric transgenual approach has been effective in providing complete colloid cyst removal with minimal risk of vascular and parenchymal damage. Further studies are required to confirm its efficacy in improving the overall outcome of the microsurgical transcallosal approach.

The Interhemispheric Transgenual Approach for Microsurgical Removal of Third Ventricle Colloid Cysts. Technical Note

Colloid cysts of the third ventricle are rare benign lesions, which amount to approximately 1% of all intracranial tumors. Because these lesions grow predominantly in the anterior aspect of the third ventricle, they may cause the occlusion of the foramina of Monro, generating obstructive hydrocephalus. Surgery is mandatory in cases of large cysts and/or in symptomatic patients. Among the different surgical strategies described in colloid cysts surgery, the microsurgical transcallosal approach still constitutes the procedure of choice in many centers. In this study, we describe a modified microsurgical transcallosal approach, the interhemispheric transgenual approach, in a series of 13 consecutive patients operated on for colloid cysts of the third ventricle. All the procedures were performed by the senior author (V.E.) at Neuromed Institute of Pozzilli (Is, Italy). The operative procedure is described in its various steps, illustrating the differences and potential advantages compared with the traditional microsurgical transcallosal approach. No surgical complications or new-onset neurologic deficits were observed in the postoperative period. The postoperative magnetic resonance imaging confirmed in all cases complete lesion removal without any sign of parenchymal damage. No lesion recurrence or need for permanent cerebrospinal fluid diversion was detected in the patients of this series during the follow-up period. In our experience, the interhemispheric transgenual approach has been effective in providing complete colloid cyst removal with minimal risk of vascular and parenchymal damage. Further studies are required to confirm its efficacy in improving the overall outcome of the microsurgical transcallosal approach.

Using cortical function mapping by awake craniotomy dealing with the patient with recurrent glioma in the eloquent cortex

BackgroundAwake craniotomy is an effective method by which to reduce postoperative neurologic deficit in newly-diagnosed glioma patients. However, the level of functional preservation in patients undergoing resection of recurrent glioma remains unknown. Therefore, this study aimed to evaluate functional outcomes in patients with recurrent glioma undergoing awake craniotomy as compared with conservative general anesthesia craniotomy for tumor resection. MethodsWe retrospectively reviewed 225 patients who had recurrent gliomas from May 2013 to January 2016 in our institution. New-onset neurological deficits were evaluated on postoperative day 7 (early) and at 3 months (late). General performance was assessed both preoperatively and at 3 months postoperatively. ResultsThe early neurological deficit rate was 3.8% in the awake craniotomy group and 21.6% in the general anesthesia group (p. 0.032), while the late neurological deficit rates were 3.8% and 11.5%, respectively (p. 0.231). Moreover, 46.1% of patients in the awake craniotomy group and 12.6% in the general anesthesia group demonstrated an improvement in the Karnofsky performance status (KPS) score (p < 0.001). ConclusionAwake craniotomy is an effective and safe method by which to perform recurrent glioma surgery. The neurological outcomes and general performance after awake craniotomy in recurrent glioma patients were better than those in patients undergoing general anesthesia craniotomy.

Cervical Spine Movement During Awake Orotracheal Intubation With Fiberoptic Scope and McGrath Videolaryngoscope in Patients Undergoing Surgery for Cervical Spine Instability: A Randomized Control Trial.

Cervical spine movement during intubation with direct laryngoscopy can predispose to new-onset neurological deficits in patients with cervical spine instability. While fiberoptic-guided intubation (FGI) is mostly preferred in such patients, this is not always possible. Videolaryngoscopy results in less cervical spine movement than direct laryngoscopy and may be an alternative to FGI in patients with cervical spine instability. The objective of this study was to compare cervical spine movement during awake FGI with those during awake McGrath videolaryngoscope-guided intubation (VGI) in patients undergoing surgery for cervical spine instability. Forty-six adult patients with upper cervical spine instability scheduled for stabilization surgery were randomized to awake FGI or awake VGI. Cervical spine movement during intubation was assessed by changes in lateral fluoroscopic-measured angles (α and β at C1/C2 and C3 levels, respectively) at 3 time points: T1, preintubation; T2, during intubation; T3, postintubation. Motor power was assessed before and after intubation. Patient demographics and airway characteristics were similar between the 2 groups. Cervical spine motion (in degrees) during intubation was significantly greater with VGI than FGI at C1/C2 (T3-T1, -8.02±8.11 vs. -1.47±3.31; P<0.001) but not at C3 (T3-T1, -2.17±5.16 vs. -1.85±3.29; P=0.960). No patient developed new-onset motor deficits following intubation in either group. Compared with FGI, VGI results in a greater degree of cervical spine movement at C1/C2 but not at C3.

A very rare case of isolated aphasia due to tension pneumocephalus after subdural hematoma (SDH) evacuation: a case presentation

BackgroundPneumocephalus is a common complication presented as air in the cranial cavity after cranial surgery. We present a very rare case of isolated new onset aphasia due to pneumocephalus after evacuation of subdural hematoma (SDH). Tension pneumocephalus presenting as isolated aphasia has not been reported earlier although associated paresis has been reported.Case presentationWe present the case of a 13-year-old male child with a history of fall before the onset of symptoms like headache and vomiting. The immediate MRI of the brain showed left-sided frontotemporoparietal subacute SDH with significant midline shift and subfalcine herniation. The child was subsequently managed with craniotomy and evacuation of hematoma with duraplasty. The patient developed aphasia on second-day post-surgery which progressed from moderate to severe aphasia by day 4. Computed tomography (CT) scan revealed pneumocephalus and an increase in the pneumocephalus in imaging on post-op day 4 with no other abnormalities. The condition was then managed by removing the subgaleal drain and administering high flow oxygen of 10 l/min.ConclusionThis case signifies the importance of proper diagnosis of new-onset neurological deficits after evacuation of subdural hematoma for the better outcome.

Hydroxyurea can be used in children with sickle cell disease and cerebral vasculopathy for the prevention of chronic complications? A meta-analysis.

We conducted a systematic review for evaluating the impact of hydroxyurea and chronic blood transfusion in children with sickle cell disease (SCD). A search was done in four databases from inception to 2017. Trials enrolling pediatric patients with SCD and cerebral vasculopathy with or without previous episode of stroke and that reported outcomes of occurrence of stroke and other events were included. Trained reviewers determined eligibility, risk of bias, and abstracted data. Random-effects meta-analysis was conducted. We found that the primary outcome was the occurrence of stroke. We found two trials that recruited 254 patients. No difference was found for confirmed stroke occurrence (risk difference 0.04 [95% CI: -0.03 to 0.03]) and for new-onset neurological deficit (risk difference 0.11 [95% CI: -0.00 to 0.21]). Transfusions provided a significant lower risk of vaso-occlussive crisis (risk difference 0.10 [95% CI: 0.001 to 0.20]). Finally, transfusions provided a lower risk of having high concentrations of abnormal hemoglobin S (mean difference 37.94 [95% CI: 27.55 to 48.32]). As a conclusion, transfusions plus chelation therapy might be used instead of hydroxyurea in children with SCD. There is a lack of high-quality research in the care of children with SCD, and therefore a call for action is needed.