Permanent Neurological Deficits Research Articles

PREDICTORS OF POSTOPERATIVE COMPLICATIONS AND FUNCTIONAL OUTCOMES IN PEDIATRIC PATIENTS WITH SURGICALLY TREATED FOURTH VENTRICLE TUMOR

Background Tumors of fourth ventricle are frequently treated pathologies in pediatric neurosurgery. Data regarding predictors for permanent neurological deficits, long-term functional outcomes, cerebellar mutism (CM), the extent of resection (EOR), and oncological outcomes are scarce. We attempt to contribute to this topic with analysis of our institutional cohort. Methods A retrospective single-center study of patients aged ? 19 years who underwent primary surgical resection of fourth ventricular tumor over a 15-year period (2006–2021). Predictors analyzed included: age, gender, surgical approach, anatomical pattern, tumor grade, EOR, tumor volume, and others as appropriate. Results 106 patients were included (64 males, mean age 7.3 years). Rate of permanent neurological deficit was 24.2%; lateral tumor extension (p = 0.036) and tumor volume greater than 38 cm3 (p = 0.020) were significant predictors. Presence of deficit was the only significant predictor of reduced (less than 90) Lansky score (p = 0.005). CM occurred in 20.8% of patients and was influenced by medulloblastoma histology (p = 0.011), lateral tumor extension (p = 0.017), and male gender (p = 0.021). No significant difference between transvermian and telovelar approach in development of CM was detected (p = 0.478). No significant predictor was found for EOR. EOR was not found to be significant predictor of overall survival for both low-grade and high-grade tumors, however, gross total resection (GTR) was protective against tumor recurrence compared to near-total or subtotal resection (p < 0.001). Survival was found to be better in older patients (? 7.0 years, p = 0.019). Conclusion The overall rate of postoperative complications remains high due to the eloquent localization. Older patients (>7 years) have been found to have better outcomes and prognosis. Achieving GTR whenever feasible and safe has been shown to be critical for tumor recurrence. CM was more common in patients with medulloblastoma, and in patients with tumors extending through the foramen of Luschka. The telovelar approach uses a safe and anatomically sparing corridor, however, it has not been associated with a lower incidence of CM and neurological sequelae in our series, showing that each case should be assessed on an individual basis.

Dorsolateral Transdural Surgical Management of Spontaneous Intracranial Hypotension From Ventral Dural Cerebrospinal Fluid Leaks: Case Series and Technical Report

BACKGROUND and OBJECTIVES: Spontaneous intracranial hypotension is an uncommon but debilitating condition that commonly involves positional headaches and vertigo. One cause is cerebrospinal fluid (CSF) leakage from ventral dural defects from calcified spinal discs. Patients can undergo epidural blood or fibrin glue patches as treatment; however, in cases where the leak does not resolve, surgical repair of the dural tear may be warranted. We aim to describe a case series and technical notes for these patients. METHODS: Patients with spontaneous intracranial hypotension because of myelography-confirmed ventral dural defect from calcified thoracic disc, who were treated surgically between June 2020 and March 2024, were included in the study cohort. Demographic information, clinical course, and postoperative outcomes were collected. The surgical technique was also described based on an illustrative case. RESULTS: Twelve consecutive patients underwent surgery between June 2020 and March 2024 with postoperative records. The median age at the time of surgery was 41.5 years (range: 28-58 years). Male patients comprised 50% of the cohort. Dural defects were spread throughout the thoracic spine in the cohort. While all patients reported positional headaches, other symptoms included vertigo, pulsatile tinnitus, and neck pain. Median length of follow-up time was 6.5 weeks. There were no surgical complications or permanent neurologic deficits. All patients had radiologic cure of their leaks with absence of extradural CSF on postoperative MR imaging. Ten patients (83.3%) had complete resolution of spontaneous intracranial hypotension-related symptoms. Two patients did suffer from rebound headaches postoperatively. CONCLUSION: The dorsolateral transdural surgical approach is a safe and effective method to repair type 1 CSF leaks caused by ventral dural defects. Our case series of 12 patients did not involve any surgical or immediate postoperative complications, and all patients had radiologic resolution of their leaks with relief of positional headaches. Two patients experienced continued headaches after treatment.

Awake surgery with mapping-based resection to treat focal epilepsy in eloquent brain areas.

Resective surgery is a potential therapeutic option for select patients with intractable focal epilepsy. However, the presence of ictal onset zones within or surrounding highly functional brain areas presents a surgical challenge, leading to poor seizure and functional outcomes. This report describes our experiences with awake mapping-tailored resection of epileptogenic areas involving eloquent cortices and evaluates their feasibility, tolerance, limitations, and significance. The study included patients who underwent surgery for drug-resistant focal epilepsy at our center under awake conditions. The surgical approach aimed to achieve maximum resection of preoperatively defined epileptogenic zones, considering the boundaries defined by surrounding functional areas. We collected data on preoperative evaluations, intraoperative tests and seizures, postoperative status epilepticus, and neurological functional outcomes. We included 22 patients, 10 of whom had non-lesional epilepsy. Language, motor function, and sensory function were at risk in 19, 9, and 4 patients, respectively. Resection was performed as planned in 14 (63.6%) patients, while modifications were necessary in 8 (36.4%) patients due to functional constraints. The mean follow-up duration was 29.8months. Sixteen (72.7%) patients achieved Engel class Ia outcomes, indicating seizure freedom, while none of the patients experienced clinically significant permanent postoperative neurological deficits. Resective surgery with intraoperative brain mapping under awake conditions was a valid treatment option for achieving a cure in cases of drug-resistant focal epilepsy, even in situations in which the condition is considered inoperable due to the risk of significant postoperative neurological deficits.

Microsurgical Clipping of Unruptured Middle Cerebral Artery Bifurcation Aneurysms: A Single-Center Experience

Background/Objectives: Microsurgical clipping has traditionally been considered a standard treatment for middle cerebral artery (MCA) aneurysms. Recently, a caseload reduction related to improved endovascular treatment options has occurred in cerebrovascular neurosurgery. Therefore, studies that report the clinical and radiological outcomes after clipping are highly warranted. Methods: Patients with an unruptured MCA bifurcation aneurysm, who were surgically treated at the Department of Neurosurgery in Linz between 2002 and 2019, were included in this study. Clinical and radiological outcome parameters were evaluated for each patient. Results: Overall, 272 patients were eligible for inclusion. Complete aneurysm occlusion was demonstrated in 266 (99.3%) of the 268 (98.5%) patients who underwent postoperative digital subtraction angiography. In six (2.2%) patients, a permanent new neurological deficit (pNND) persisted after treatment. Intraoperative aneurysm rupture was a significant factor (p = 0.0049) in the logistic regression. At the last follow-up, only two patients (0.7%) had an unfavorable outcome (mRS > 2). More recent surgeries were associated with fewer cases of pNND (p = 0.009). A transient new neurological deficit occurred in 13 patients (4.8%), with aneurysm size being a significant risk factor (p = 0.009). Surgical site infections were reported in four patients (1.5%), with patient age (p = 0.039) and time (p = 0.001) being significant factors. Two patients died (0.7%) perioperatively and two patients (0.7%) needed a retreatment in the long-term follow-up. Conclusions: The findings indicate that microsurgical clipping is a safe procedure with minimal need for retreatment. It achieves a high occlusion rate while maintaining a very low rate of adverse outcomes. Continuous intraoperative enhancements over time have contributed to a progressive improvement in clinical outcomes in recent years. This trend is exemplified by the absence of detectable pNND in the era of ICG angiography. Consequently, these data support the conclusion that microsurgical clipping should still be considered an appropriate treatment option for unruptured MCA bifurcation aneurysms.

Interhemispheric axonal sprouting occurs after pial removal in mice.

White matter lacks the kind of plasticity that is present in the cortex, and subcortical injuries often result in permanent neurological deficits. Because cortical regions share common subcortical nuclei, creating new intergyral connections may allow for the bypass of subcortical damage. In this manuscript, a surgical interhemispheric bridge is created in mice, providing a model for an intercortical transpial bypass. To model this bypass, a midline craniotomy followed by interhemispheric (IH) pial removal was performed in C57BL/6 mice, allowing for the juxtaposition of the right and left prefrontal cortices. Adeno-associated virus (AAV) expressing tdTomato under a neuronal-specific promoter were injected into the right hemisphere. Animals were sacrificed two and four weeks after surgery, and axonal sprouting and glial changes were assessed in the "bypass" (BP) operation and sham surgery. Surgery did not result in any clear functional impairments. Removing the pia resulted in the formation of a physical connection between the hemispheres and the loss of the normal pial IH barrier. Cortical layer I became thinner with neuronal bodies in closer proximity than in the sham group. New interhemispheric axonal crossings were visible at two and four weeks in the BP group but not in the sham mice. These findings constitute the first step in the development of a cortico-cortico transpial bypass, allowing us to test a new way to surgically restore neurological function.

Carotid artery stenting for symptomatic carotid near occlusions: Feasibility, safety and outcome analysis.

Extracranial internal carotid stenosis (EICS) is a well-established cause of stroke. Carotid near-occlusion (CNO), either distally collapsed or not, is a rare sub-type of EICS with conflicting data regarding the necessity for treatment. The aim of this study is to evaluate the results of carotid artery stenting (CAS) for patients with symptomatic CNOs. Institutional review board (I06-420-23) approval was obtained for this retrospective study. Consecutive data from January 2019 to January 2023 was obtained. Sixty-five patients underwent 66 procedures for symptomatic CNOs. Diagnosis of CNOs were made with DSA images. Treatment decisions were made by a multidisciplinary team. Patient data including age, gender, clinical presentation, affected side, complications (initial/ follow-up), and pre and post mRS scores were recorded and analyzed. There were 22 female and 43 male patients with symptomatic CNOs (mean age: 71.52 ± 9.32 years). The mean time from symptom-to-treatment was 3.91 weeks ± 3.74 weeks (ranging from 0 to 20 weeks). There were eight events recorded in the 30 days period after CAS; five (7.7%) were cerebral hyperperfusion syndrome (one causing haemorrhage) and three (4.5%) ischemic complications. Permanent neurologic deficit rate was 6% and 61 patients (94%) mRS scores were unchanged during last follow-up. Mean follow-up period was 22.94 ± 16.67 months (ranging from 0.5 to 60 months). Our study demonstrated that in the complex population of patients with symptomatic CNOs, CAS is a feasible option with acceptable rate of permanent neurologic deficits. Further studies are needed to assess its safety and long-term efficacy.

Extracorporeal Off-Pump Antegrade Cerebral Perfusion in Reconstructive Surgery for Type A Aortic Dissection With Cerebral Malperfusion.

Introduction Type A aortic dissection (TAAD) is a life-threatening condition that often leads to cerebral malperfusion (CM), a severe complication that can result in permanent neurological damage. Traditionally, a cardiopulmonary bypass (CPB) with selective antegrade cerebral perfusion (ACP) is employed during aortic arch reconstruction to protect cerebral circulation. However, the use of CPB carries inherent higher risks, including embolic events, hypothermia, and interrupted cerebral perfusion, especially in patients with CM. This study evaluates an innovative off-pump extra-corporeal ACP technique using an axillo-axillary shunt to provide uninterrupted bihemispheric cerebral perfusion during branch-first stage total aortic arch replacement (BF-TAR)for TAAD with CM; the shunt depends on cardiac contradiction to transfuse blood from the donor axillary artery to the recipient axillary artery, which then flows to through the carotid and vertebral arteries to the brain. Methods Between 2021 and 2023, 18 patients with TAAD complicated by CM underwent BF-TAR; the novel axillo-axillary shunt technique was employed for ACP because of the risks of ischemic neurologic injury. Outcomes measured included operative mortality, neurological complications, cardiopulmonary bypass times (measured after completion of the branch-first stage), and overall morbidity. Results The axillo-axillary shunt provided stable, continuous ACP in all patients. No new permanent neurological deficits were observed. Five (27.8%) patients experienced transient neurological symptoms such as blurred vision, dizziness, and confusion, which resolved within 48 hours. Operative mortality was 5.6% (1 patient), and minor complications included transitory lower limbs ischemia in 3 patients (16.7%) and deep sternal wound infection in 1 patient (5.6%). All transitory complications were managed by "watchful waiting". The mean CPB time was 145.3 ± 48.6 minutes, while the mean cross-clamp time was 100.6 ± 17.4 minutes, which was better than the average of 227 ± 32 minutes and 147 ± 23 minutes reported in other studies. Postoperative imaging confirmed well-reconstructed aortic arches with no residual malperfusion or graft-related complications. Conclusion The off-pump axillo-axillary shunt technique provides a safe and effective method for maintaining continuous bihemispheric cerebral perfusion during total aortic arch replacement in patients with TAAD complicated by CM. This approach minimizes the risks associated with CPB, including embolic events and interrupted cerebral perfusionwhile achieving favorable neurological and surgical outcomes. Further studies with larger cohorts and longer follow-ups are warranted to validate the long-term benefits of this innovative technique.

Postoperative reorganization of the supplementary motor area complex: A possible latent bihemispheric network

PurposeBrain plasticity after multistep surgery in low-grade glioma is highly variable; the neurosurgical approach must be individualised and functional imaging can be used for this purpose.In supplementary motor area complex (SMAC) tumors, the early and adequate functional recovery of patients raises the possibility of a latent bihemispheric or “mirror” cortico-subcortical network, which would develop depending on the needs of each patient. MethodsFunctional and DTI-MR data from 4 right-handed patients with left frontal low grade gliomas near the SMAC, who were operated at least in two occasions were collected. The time of the reintervention was variable (18 months- 8 years), related to the tumor growth. All patients were evaluated by a neuropsychologist and imaged before each surgery, in a 3 T MR, with a 24 multichanel head coilMotor and expressive language task-fMRI and DTI sequences were obtained to evidence the main cortico-subcortical components of the SMAC. Data were processed with Brainwave (GE Medical Systems) and with an Iplan Fiber Tracking tool (MEDTRONIC), respectively ResultsNone of our patients presented permanent neurological deficits after the first or second functional surgery. Three patients with partial or complete resection of the left middle and / or inferior frontal gyrus, and the left frontal aslant tract evidenced new right hemispherical cortical activity. This right shift were not observed in the patient without left middle gyrus resection, indeed with partial absent of the left frontal aslant tract. ConclusionSMAC is a latent cortico-subcortical bihemispheric network that allows it to reorganize itself in response to specific neurological deficits. We highlight the importance in the cortical reorganization of the left middle frontal gyrus in the SMAC, closely connected with the essential language areas of this region, but also we focused in the potential cortioco-subcortical changes to compensate the functionality of the FAT.

SPIN-03 PROFILE OF MALIGNANT SPINAL CORD COMPRESSION AMONG CHILDREN AT A SINGLE CENTRE IN JOHANNESBURG, SOUTH AFRICA

Abstract OBJECTIVE Malignant spinal cord compression (MSCC) in children can lead to permanent neurological deficits and therefore warrants urgent referral, prompt diagnosis and treatment. There is limited data on paediatric MSCC in Sub-Saharan Africa. The objective was to assess the characteristics, aetiology, clinical presentation, treatment and long-term outcomes of MSCC. METHODS Records of 23 patients with MSCC were retrospectively assessed over a 15-year period (2008-2023) at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa. RESULTS The median age of MSCC diagnosis was four years (range: 5 months to 15 years). The median interval between symptom onset and confirmed diagnosis was three months (1 week to 20 months). MSCC’s leading causes were central nervous system tumours (30%), lymphomas (22%), sarcomas (17%), germ cell tumours (9%), teratoid tumours (9%), neuroblastomas (9%) and leukaemias (4%). Commonest presenting symptoms were motor deficits (96%), pain (35%) and sphincter dysfunction (22%). Magnetic resonance imaging (MRI) of the spine was diagnostic in all cases. The primary tumour was managed using a multimodality approach: 70% underwent neurosurgical intervention and 39% received radiotherapy. The median follow-up duration was two years (1 month to 15 years). There were six deaths (two cases of ependymoma and a case each of glioblastoma multiforme, alveolar rhabdomyosarcoma, acute lymphoblastic leukaemia and Burkitt lymphoma) at a median interval of 4.5 months from diagnosis (1 month to 2 years). The commonest long-term sequelae were motor deficits (52%) and sphincter dysfunction (26%) and 22% of patients were asymptomatic. CONCLUSION We documented longer diagnostic delays than published in the literature and recommend increased awareness and rapid referral to decrease permanent sequelae. Patients presenting with new-onset neurological deficits suggestive of MSCC should have urgent radiological imaging; preferably MRI, followed by prompt referral to a specialised centre with an experienced multidisciplinary team.

Electrocorticography and navigated transcranial magnetic stimulation-tailored supratotal resection for epileptogenic low-grade gliomas.

Epilepsy is commonly associated with low-grade gliomas (LGGs), impacting patients' well-being. While resection is the primary treatment, seizures can persist postoperatively in 27%-55% of cases. The authors aimed to evaluate an electrocorticography (ECoG) and navigated transcranial magnetic stimulation (nTMS)-tailored supratotal resection (ETT-SpTR) for LGG in controlling seizures, preserving neurological function, and enhancing treatment effectiveness. The authors retrospectively analyzed a prospectively enrolled cohort of patients with LGG presenting with epileptic seizures with ictal/interictal activity on electroencephalography (EEG) who underwent resective surgery. The authors performed preoperative nTMS to identify functional cortical areas. ECoG was used to guide the removal of the high-risk epilepsy cortical areas (HREAs). Patients were divided into two groups: group I, the control group, underwent gross-total resection alone, whereas group II patients underwent removal of HREAs identified by ECoG (ETT-SpTR). Resection avoided functionally eloquent areas as identified on nTMS, checked with cortical mapping. Postoperative seizure outcome was assessed using the Engel classification. Fifteen patients who underwent LGG resection between January and July 2023 were included. Among 24 identified nTMS-positive points, none were included in the resection. Overall, 73.3% of patients (11/15) showed positive intraoperative ECoG, with better outcomes in group II (85.7% Engel class IA) than in group I (25% Engel class IA) at the follow-up (p = 0.02, OR 0.5 [95% CI 0.035-7.10], RR 0.19 [95% CI 0.03-1.2]). Seizure control was significantly better in group II, with no notable differences in postoperative transient neurological deficits between the two groups (p = 0.45). No permanent neurological deficits were observed during follow-up. Statistical analysis revealed significant differences between the two groups (p < 0.05). This preliminary study affirms the predictive value of TMS for postoperative neurological status and safety in epileptic patients. Intraoperative ECoG effectively identified peritumoral HREAs. ETT-SpTR significantly improved epileptic outcomes, preserving functions without permanent neurological worsening. Additional resection targets the HREAs in the temporal, frontal, and parietal lobes.

The Use of Diffusion Tensor Imaging in the Differentiation and Surgical Planning of Suprasellar Hypothalamic-Opticochiasmatic Glioma and Craniopharyngioma in Children

Background and ObjectivesSuprasellar hypothalamic-opticochiasmatic glioma (HOCG) and craniopharyngioma (CP) have similar appearances on conventional MRI and are difficult to distinguish. Moreover, these tumors are situated near vital structures like the optic chiasm and hypothalamus, rendering conventional surgery susceptible to significant complications. We mainly discussed the surgical application value and diagnostic value of diffusion tensor imaging (DTI) in HOCG and CP. MethodsThe retrospective analysis of 13 cases of HOCG and 16 cases of CP was conducted. All patients underwent conventional MRI and DTI prior to surgery, and were pathologically diagnosed postoperatively. ResultsBoth CP and HOCG appeared as heterogeneous mixed signal masses on conventional MRI. For HOCGs, fiber tractography revealed two different growth patterns of the tumor: infiltrative type and inflated type. The surgical approach and risk levels differ between these growth patterns. Additionally, fiber tractography demonstrates significant differences compared to CPs. The surgical approach and extent of resection for all cases of these two tumors were guided by DTI. ConclusionDTI enhances the accuracy of HOCG and CP differentiation. Furthermore, patterns of tractography described in this study assist neurosurgeons in delineating the surgical pathway and tumor resection range without damaging important fiber bundles, thereby avoiding permanent neurological deficits and improving survival quality for patients.

Endoscopic Endonasal Skull Base Surgery: Analysis of the Results in the Author’s Initial 200 Cases

Background Endoscopic endonasal approaches represent currently an important tool for approaching the skull base. The evolution of new techniques is based in the continuous acquisition of skills and abilities and it is paramount to determine the safety and effectiveness of new approaches. Based on that, the aim of this study is to analyze our results after the first 200 cases. Material and methods We performed a retrospective review of all cases operated on through an endoscopic endonasal approach in our Skull Base Unit, between January 2007 and May 2018. We analyze the results and all the per-operative complications associated. Results In this study we included 200 cases, comprising 105 female (52,2 %) and 95 male (47,5 %), with a mean age of 45,6 (range 21-85 years-old). The most commonly reported pathology was the pituitary adenoma, comprising 121 cases (60,5 %), followed by 13 meningocele (6,5 %), 9 chordoma (4,5 %), 6 skull base meningioma (3 %) and 7 cranyopharingioma (3,5 %). 161 cases (81 %) represented first surgery. The most frequently reported complication was diabetes insipidous in 17 % of all cases, followed by CSF leak, represented by 15 cases (7,5 %). 12 CSF leak cases were successfully treated by external lumbar draining and 3 patients required second surgery to skull base repair. In the last 50 cases, only one CSF leak has been reported, representing an incidence of 2 %, successfully treated by endoscopic repair. This decrease in CSF leak represents the impact of the learning curve in skull base reconstruction. 5 % of patients suffered meningitis and 5 % presented permanent anosmia. In our serie we reported 1,6 % of transient neurologic deficit represented by oculomotor palsy and 1,6 % of permanent neurologic deficit due to infarction. 3 patients in this serie has died, two due to malignant ICA occlusion and 1 due to infection (overall mortality 1,5 %). The most commonly used approach was the transsphenoidal transsellar approach (58 %), followed by transplanum-transtubercullum approach (8 %). Gross total resection was achieved in 76 % of tumoral pathology, 71 % in cases of pituitary adenomas. Conclusion From this review we can conclude that, in our serie, endoscopic endonasal surgeries represent safe approaches to the skull base to a huge variety of pathologies. Progressive acquisition of skills and experience is paramount to improve the results, avoiding and reducing complications. Appropriate patient and pathology selection is also mandatory.

Aortic arch registry of type a aortic dissection (AoArch) - rationale, design and definition criteria

BackgroundType A acute aortic dissection (TAAAD) is a deadly condition that demands immediate surgery, because it involves a critically. The mortality and morbidity associated with it are significant, and it is vital that the patient’s conditions and treatment strategies are fully understood to ensure the appropriate management of TAAAD. This study aims to ascertain whether hemiarch repair (HAR) versus extended arch repair (EAR) with or without descending aortic intervention results in better perioperative and late outcomes for patients with TAAAD.MethodsFour leading centers of cardiac surgery from two European countries have joined forces to create a groundbreaking multicenter observational registry (AoArch). This study was approved by the institutional review board (IRB 202201173). We conducted a retrospective review (NCT 0591263) of our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from January 1, 2005 to March 2024 (NCT 05927090). We will analyze how patient co-morbidities, referral conditions, and surgical strategies involving hemi-arch repair (HAR) and extended arch repair (EAR) impact early and late adverse events. We have developed a procedure urgency algorithm based on the severity of preoperative hemodynamic conditions and malperfusion due to TAAAD, and we will use it to assess the primary clinical outcomes: in-hospital mortality, late mortality, and reoperations on the aorta. We will define secondary outcomes as permanent neurologic deficit, the need for new dialysis, respiratory failure, a composite of major adverse events (myocardial infarction, cerebrovascular accidents, the need for dialysis, or the need for tracheostomy), and a composite of major adverse pulmonary events (intubation over 48 h, pneumonia, reintubation, tracheostomy), and reoperation due to bleeding.DiscussionThis multicenter registry will definitively determine the prognostic significance of critical preoperative conditions and the efficacy of extended arch interventions and hemiarch repair in reducing the risk of early adverse events after surgery for TAAAD. This registry will provide insights into the long-term durability of different strategies of surgical repair for TAAAD.

The risk of intraoperative venous air embolism from neurosurgical procedures performed in the lounging position: an in-depth analysis of detection, management, and outcomes of 1000 consecutive cases

OBJECTIVE The overall benefit of employing a sitting/semisitting position for neurosurgical procedures remains under criticism due to concerns for additional risk, especially the risk of intraoperative venous air embolism (VAE). The aim of this single-center cohort study was to evaluate the frequency and severity of VAEs and associated complications in patients undergoing neurosurgery in the lounging position. METHODS From 2010 to 2020, 1000 patients, including 172 patients with a patent foramen ovale, underwent surgery in the lounging position for different neurosurgical pathologies. All patients were monitored intraoperatively using continuous transesophageal echocardiography (TEE). The anesthesia team documented any observed incidences of VAEs and scored their severity according to the Tuebingen classification system (TCS) for VAE (TCS-VAE). The patients’ clinical condition, radiological findings, and hospital course were subsequently analyzed to assess complications in a retrospective analysis of prospectively collected data. RESULTS In the cohort of 1000 patients, 5 underwent cervical spine surgery and 995 underwent suboccipital craniotomy. VAE was detected by TEE in 51.4% (95% CI 48.4%–54.5%) of patients, with synchronous changes in end-tidal CO2 (grade 2–5 TCS-VAE) noted in 10.2% (95% CI 8.3%–12.3%). None of the patients presented with hemodynamic instability (grade 5 TCS-VAE). Patients with high-grade VAEs were significantly older (p = 0.02) and had lower BMIs (p = 0.001) than the respective mean value of the cohort. VAE grade was not associated with any of the outcome measures such as Karnofsky Performance Scale score, duration of ventilation, length of intensive care unit stay, and length of hospital stay. Postoperative acute respiratory distress syndrome (ARDS) was diagnosed in 0.3% (95% CI 0.0%–0.7%, n = 3) of all cases, and ARDS was associated with perioperative VAE grade (p = 0.001). No patient suffered a new permanent neurological deficit due to a paradoxical VAE. CONCLUSIONS In this large cohort, the risk of an intraoperative VAE during neurosurgery in the lounging position was assessed, and contrary to the general perception in the field, no permanent sequelae or fatal adverse events attributable to VAEs were observed. Furthermore, the overall incidence of ARDS was very low. This study clearly establishes that experienced interdisciplinary teams can safely use the lounging position for neurosurgical procedures.

Aseptic meningitis with recurrent headache episodes, vomiting, and central fever as first manifestation of isolated neurosarcoidosis: a case report

BackgroundNeurosarcoidosis is a rare entity, usually within the context of systematic sarcoidosis. Isolated neurosarcoidosis and especially a manifestation with pachymeningitis is a notable rarity.Case ReportA 26-year-old patient presented to the emergency department with acute onset, recurrent episodes of occipital headaches spreading over the whole cranium and vomiting without food consumption, for three days. The clinical examination did not reveal any neurological deficits. The laboratory exams showed no pathological findings. A CT examination with angiography did not detect any acute intracranial or vessel pathology. A lumbar puncture was performed to rule out subarachnoid hemorrhage. The results showed a lymphocytic pleocytosis of 400/µL, elevated protein levels of 1077 mg/dL and reduced glucose levels (CSF: 55 mg/dL, Serum: 118 mg/dL). Extensive infectiological examinations did not reveal any signs of infection, including Borrelia spp. and M. tuberculosis. No positive auto-antibodies or vasculitis-related auto-antibodies were detected. The CSF analysis showed negative oligoclonal bands but an isolated increase in β2-microglobulin, neopterin, and IL-2R levels. The MRI examination revealed a dural gadolinium-enhancement, pronounced in the basal cerebral structures and the upper segment of the cervical spine, consistent with neurosarcoidosis. Corticosteroid treatment rapidly led to a significant improvement of the symptoms. No systemic manifestations of sarcoidosis were found.ConclusionsThis case report aims to highlight aseptic meningitis with atypical, acute onset headache attacks as a possible manifestation of isolated neurosarcoidosis. Neurosarcoidosis is a clinical entity that requires prompt treatment to avoid permanent neurological deficits.

AAV-Mediated Expression of miR-17 Enhances Neurite and Axon Regeneration In Vitro.

Neurodegenerative disorders, including traumatic injuries to the central nervous system (CNS) and neurodegenerative diseases, are characterized by early axonal damage, which does not regenerate in the adult mammalian CNS, leading to permanent neurological deficits. One of the primary causes of the loss of regenerative ability is thought to be a developmental decline in neurons' intrinsic capability for axon growth. Different molecules are involved in the developmental loss of the ability for axon regeneration, including many transcription factors. However, the function of microRNAs (miRNAs), which are also modulators of gene expression, in axon re-growth is still unclear. Among the various miRNAs recently identified with roles in the CNS, miR-17, which is highly expressed during early development, emerges as a promising target to promote axon regeneration. Here, we used adeno-associated viral (AAV) vectors to overexpress miR-17 (AAV.miR-17) in primary cortical neurons and evaluate its effects on neurite and axon regeneration in vitro. Although AAV.miR-17 had no significant effect on neurite outgrowth and arborization, it significantly enhances neurite regeneration after scratch lesion and axon regeneration after axotomy of neurons cultured in microfluidic chambers. Target prediction and functional annotation analyses suggest that miR-17 regulates gene expression associated with autophagy and cell metabolism. Our findings suggest that miR-17 promotes regenerative response and thus could mitigate neurodegenerative effects.

Timing of diffusion tensor imaging in the management of a ruptured pediatric arteriovenous malformation: illustrative case.

Diffusion tensor imaging (DTI) can characterize eloquent white matter tracts affected by brain arteriovenous malformations (AVMs). However, DTI interpretation can be difficult in ruptured cases due to the presence of blood products. The authors present the case of a ruptured pediatric AVM in the corticospinal tract (CST) and discuss how DTI at different time points informed the treatment. A 9-year-old female presented with a sudden headache and left hemiparesis. She was found to have a Spetzler-Martin grade III, Supplementary grade I AVM in the right caudate and centrum semiovale, with obliteration and corresponding reduced fractional anisotropy (FA), fiber density (FD), and tract count (TC) of the adjacent CST on DTI. The patient remained stable and was scheduled for elective resection following a 6-week period to facilitate hematoma resorption. After 6 weeks, repeat DTI showed part of the nidus within intact CST fibers with concordant improvement in FA, FD, and TC. Considering the nidus location, CST integrity, and motor function recovery, surgery was deferred in favor of stereotactic radiosurgery. In ruptured AVMs, DTI may initially create an incomplete picture and false assumptions about white matter tract integrity. DTI should be repeated if delayed treatment is appropriate to ensure informed decision-making and prevent avoidable permanent neurological deficits. https://thejns.org/doi/10.3171/CASE24225.

Surgical Treatment Strategies for Severe and Neglected Spinal Deformities in Children and Adolescents without the Use of Radical Three-Column Osteotomies.

Background: Severe spinal deformity manifests as a pronounced deviation from the normal curvature of the spine in the frontal, sagittal, and horizontal planes, where the coronal plane curvature exceeds 90 degrees and may coincide with hyperkyphotic deformity. The most severe deformities exhibit rigidity, with flexibility below 30%. If left untreated or improperly treated, these deformities can result in serious complications associated with progression of the curvature. A combination of surgical techniques is frequently employed to attain optimal outcomes and minimize the risk of complications. The overall medical condition of the patient, their capacity to endure extensive procedures, the expertise of the surgeon, and the resources available all play significant roles in determining the course of management. A systematic and thorough review of the relevant literature was conducted utilizing a variety of electronic databases. The primary objective of this study was to scrutinize the surgical techniques commonly employed in complex spine surgeries for the management of severe scoliosis without resection vertebral body techniques, with higher potential risk of major complications, including permanent neurological deficit. Conclusions: Halo-gravity traction, halo femoral traction, and all techniques for releases of the spine (anterior, posterior, or combine), as well as thoracoplasty, have demonstrated significant effectiveness in managing severe and rigid idiopathic scoliosis. The combination of several of these methods can lead to optimal alignment correction without the need to perform high-risk techniques involving three-column osteotomies. Surgeons must customize the indications based on factors such as available resources, characteristics of the deformity, and the patient's individual profile. Surgical correction of severe scoliosis without vertebral body resection surgeries decreases the potential risks related to neurological and pulmonary complications while providing significant clinical improvement outcomes. The powerful Ponte osteotomy is indicated for severe scoliosis, curves with poor flexibility, for better restoration of hypokyphosis, and decrease of hyperkyphosis. These corrective techniques combined with HGT or temporary internal distraction rods are recommended as viable options for managing individuals with severe rigid spine deformity characteristics. Therefore, they also should be considered and performed by a proficient surgical team. The presence of neuromonitoring is crucial throughout these procedures.

Reversible cerebral vasoconstriction syndrome post-cardiac transplantation: a therapeutic dilemma: case report

BackgroundReversible cerebral vasoconstriction syndrome (RCVS) is characterized by diffuse, multifocal segmental narrowing of cerebral arteries and can result in ischaemic stroke. Causal factors, identified in 60% of cases, include immunosuppressant pharmacotherapy. The few reports following heart transplantation are almost all in Asian recipients. We report on a Caucasian Australian patient with immunotherapy induced RCVS post heart transplantation to highlight the state of knowledge of the condition and the treatment dilemma it poses.Case presentationA 51-year-old female underwent orthotopic heart transplantation at our institution. Induction immunotherapy comprised basiliximab, mycophenolate mofetil and methylprednisolone. On day 6 post-transplantation the patient was transitioned to oral prednisolone and tacrolimus. On day 7 the patient began to experience bilateral, severe, transient occipital and temporal headaches. On day 9 tacrolimus dose was up-titrated. A non-contrast computed tomography brain (CTB) was normal. Endomyocardial biopsy on day 12 demonstrated moderate Acute Cellular Rejection (ACR), which was treated with intravenous methylprednisolone. That evening the patient experienced a 15-minute episode of expressive dysphasia. The following morning she became confused, aphasic, and demonstrated right sided neglect and right hemianopia. A CT cerebral perfusion scan demonstrated hypoperfusion in the left middle cerebral artery (MCA) territory and cerebral angiography revealed widespread, focal multi-segmental narrowing of the anterior and posterior circulations. A diagnosis of RCVS was made, and nimodipine was commenced. As both steroids and tacrolimus are potential triggers of RCVS, cyclosporin replaced tacrolimus and methylprednisolone dose was reduced. A further CTB demonstrated a large left MCA territory infarct with left M2 MCA occlusion. The patient made steady neurological improvement. She was discharged 34 days post-transplantation with mild residual right lower limb weakness and persistent visual field defect on verapamil, cyclosporine, everolimus, mycophenolate mofetil and prednisolone.ConclusionReversible cerebral vasoconstriction syndrome is rare after orthotopic heart transplantation. Until now, RCVS has been almost exclusively described in Asian recipients, and is typically caused by immunotherapy. The condition may lead to permanent neurological deficits, and in the absence of definitive treatments, early recognition and imaging based diagnosis is essential to provide the opportunity to remove the causal agent(s). Co-existent ACR, can pose unique treatment difficulties.

Initial Experience with the Derivo 2Heal Flow Diverter under Standard or Reduced-Dose Single Antiplatelet Therapy.

Flow diverters with surface modifications or coatings have been recently introduced to clinical practice with the expectation that they can reduce the rate of thromboembolic complications and residual aneurysms. The purpose of this study is to evaluate the utility of the Derivo 2Heal (D2H) device, a new fibrin and heparin-coated flow diverter. Patients treated by a single operator by using the D2H were retrospectively evaluated for demographic data, aneurysm characteristics, procedural variables, and follow-up data. All patients were treated by using a single D2H, monitored by platelet function testing and kept under single antiplatelet therapy with regular or half-dose clopidogrel or prasugrel after the procedure. Twenty patients with 26 aneurysms were treated. Three presented acutely with subarachnoid hemorrhage. Adjunctive devices were used in 6 patients. There were no technical failures and 2 periprocedural self-limited nonthrombotic minor adverse events. During follow-up, 1 of the acutely ruptured aneurysms reruptured, and 1 patient had a visual TIA. All patients were doing well clinically (19 with mRS of 0 and 1 with 1) at the last follow-up after discharge. The rates of total occlusion on very early angiographic (MRA/CTA or DSA, mean: 2.4 months), DSA (mean: 5.8 months), and midterm angiographic (mean: 14.5 months) follow-up for all versus uncoiled aneurysms were 68% versus 70%, 77.8% versus 90.0%, and 91.7% versus 90.1%, respectively. The absence of permanent neurologic deficits in the periprocedural period and favorable occlusion rates in this preliminary study suggest that the novel coating comprising fibrin and heparin may have the potential to increase the safety and efficacy of flow diversion and needs to be further studied by comparing the D2H device with its bare counterpart and other coated or surface-modified flow diverters.