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Background Facial paresis is one of the complications after treatment for vestibular schwannoma (VS). Acupuncture has been used for Bell palsy but not in iatrogenic facial paresis. The objective of this study is to measure the efficacy of using acupuncture for iatrogenic facial nerve palsy and patients' satisfaction. Methods This is a single-center retrospective study with patients from 2007–2019 received treatment for newly diagnosed or recurrent VS. Some patients who suffered facial paresis after surgery had self-initiated acupuncture. All patients who had facial paresis were included. Their facial nerve status before and immediately after surgery, postoperative 6 months and 12 months, were recorded. Those who received acupuncture also answered 6- and 12-month patient satisfaction surveys over the phone. Adverse effects were also assessed. Results There were 123 patients in this period. Of these, 29 patients had iatrogenic facial paresis and 23 of them received acupuncture. There was significant improvement of facial paresis for the acupuncture group compared with the nonacupuncture group at 6 and 12 months. More than 80% of patients who received acupuncture were satisfied. They had motor improvement and experienced less pain and tightness. No adverse effects were reported. Conclusions Acupuncture for postresection VS facial paresis seemed to speed up its recovery. Both patients' recovery and satisfaction were good after acupuncture, and it seemed to be a safe procedure in trained hands.

Background Fall with head injury is a pervasive challenge, especially in the aging population. Contributing factors for mortality include the development of cerebral contusions and delayed traumatic intracerebral hematoma. Currently, there is no established specific treatment for these conditions. Object This study aimed to investigate the impact of independent factors on the mortality rate of traumatic brain injury with contusions or traumatic subarachnoid hemorrhage. Methods Data were collected from consecutive patients admitted for cerebral contusions or traumatic subarachnoid hemorrhage at an academic trauma center from 2010 to 2016. The primary outcome was the 30-day mortality rate. Independent factors for analysis included patient factors and treatment modalities. Univariate and multivariate analyses were conducted to identify independent factors related to mortality. Secondary outcomes included thromboembolic complication rates associated with the use of tranexamic acid. Results In total, 651 consecutive patients were identified. For the patient factors, low Glasgow Coma Scale on admission, history of renal impairment, and use of warfarin were identified as independent factors associated with higher mortality from univariate and multivariate analyses. For the treatment modalities, univariate analysis identified tranexamic acid as an independent factor associated with lower mortality (P = 0.021). Thromboembolic events were comparable in patients with or without tranexamic acid. Conclusion Tranexamic acid was identified by univariate analysis as an independent factor associated with lower mortality in cerebral contusions or traumatic subarachnoid hemorrhage. Further prospective studies are needed to validate this finding.

Introduction Normal skull base structures are destroyed either by the skull base pathology itself or during surgery that results in cerebrospinal fluid (CSF) leak. Skull base repair is usually performed transnasally by using a nasal septal flap. But when NSF is not available and failed repeated transnasal repair, a cranionasal repair with frontal pericranial flap (PF) can be attempted to achieve the highest successful chance. We performed a dual layer/split PF repair of a skull base defect using cranionasal approach and here we describe the technique. Case Description A 74-year-old man suffered from CSF leak and ventriculitis after multiple transnasal surgeries for pituitary macroadenoma despite multiple repairs with intranasal vascularized flaps. We performed repair by cranionasal approach and using frontal PF. The frontal PF was divided into left and right halves. The left half went intradural, through the chiasmatic window to reach the sella and cover the tubercular and sellar defect from above. The right half went through the nasion into the nose to cover the defect from below. So the defect was covered by two vascularized flap from a single frontal PF. The repair was successful with no CSF leak and infection successfully treated by antibiotics. Conclusion We introduced the cranionasal dual layer/split PF technique to repair anterior skull base and successfully stopped the CSF leak in a patient after multiple EEA surgeries. This technique should only be considered in specific difficult situation where usual repair by EEA is impossible.

In emergency neurosurgical patients, evaluation with Glasgow Coma Scale (GCS) alone immediately after stopping sedation post-operatively might not differentiate those with good recovery from those with poor outcomes at 3 months. This study aimed to evaluate the prognostic value of measuring the Bispectral Index (BIS) and the correlation to propofol dosage during the use of sedation in the early post-operative period.This is a prospective study on consecutive post-operative neurosurgical patients admitted to the neurosurgical ICU on propofol sedation. The primary outcome was the correlation between early post-operative BIS and the Propofol dosage with the modified Rankin scale (mRS) at 3 months. Secondary outcomes included the post-operative propofol requirement in patients with good functional outcomes (mRS 0-3) versus poor functional outcomes (mRS 4-6) at 3 months.In total, 728 BIS readings were collected from twenty-four patients for analysis. The BIS readings were significantly correlated to the propofol dosage in patients with good function outcomes at 3 months (p 0.0001). BIS readings in patients with no associations to changes in propofol dosage during their ICU stay had poor outcomes (mRS 4-6) at 3 months (r = -0.0407). For patients with good functional outcomes at 3 months, a significantly higher propofol dosage was used for deep sedation (BIS 40 - 60) during the post-operative period (p 0.001).For emergency neurosurgical patients whose BIS readings had lost correlation to the propofol dosage upon recovery, their functional outcomes at 3 months were poor. For those with good functional outcomes at 3 months, a significantly higher propofol dosage was required for deep sedation during their ICU stay. Patients with preserved correlation of BIS readings to changes in propofol dosages during the early post-operative period were associated with good functional outcomes at 3 months.

Purpose/Objective(s) Indications for postoperative radiotherapy after meningioma resection are controversial. DNA methylation profiling identifies meningiomas at risk for recurrence, but logistic and technical barriers have encumbered clinical translation of this approach. The aim of this study was to optimize and validate a clinically-tractable targeted gene expression biomarker to predict meningioma outcomes and responses to postoperative radiotherapy. Materials/Methods Targeted gene expression and Illumina 850k DNA methylation profiling were performed on a discovery cohort of 173 meningiomas (median follow-up 7.8 years) and an external validation cohort of 331 meningiomas (median follow-up 5.8 years) from patients treated with surgery (n = 504) and postoperative radiotherapy (n = 73) at independent, international institutions (70% WHO grade 1, 24% WHO grade 2, 6% WHO grade 3). RNA sequencing was performed on the discovery cohort, and 125 genes were selected for targeted gene expression profiling based on associations with meningioma recurrence. Regularized Cox regression was used to develop continuous gene expression risk score for local freedom from recurrence (LFFR). The model (34 meningioma genes and 7 housekeeping genes) and risk quartiles (low, low-intermediate, high-intermediate, and high) were locked and validated on the external cohort. Multivariate regressions (MVR) incorporating WHO grade, DNA methylation grouping, extent of resection, primary versus recurrent presentation, and postoperative radiotherapy were used to assess the risk score across clinical contexts. Results The gene expression risk score (concordance-index 0.78 ± 0.03) outperformed DNA methylation grouping (0.71 ± 0.03) and WHO grade (0.65 ± 0.03) in stratifying meningioma LFFR in the validation cohort (n = 331). The risk score classified 43% of WHO grade 1 meningiomas as high-intermediate (n = 82) or high risk (n = 34), with 5-year LFFR and overall survival (OS) of 83% and 89% for high-intermediate risk WHO grade 1 meningiomas, and 41% and 73% for high risk WHO grade 1 meningiomas, respectively. Low risk WHO grade 1 meningiomas (n = 50) had 5-year LFFR and OS of 92% and 88%, respectively. High and high-intermediate risk scores were independently prognostic for LFFR (HR 2.9, 95% CI 1.2-4.4) and OS (HR 2.7, 95% CI 1.3-5.6) on MVR. An interaction term between postoperative radiotherapy and risk score was predictive for LFFR (P = 0.046) and OS (P = 0.001) on MVR in the validation cohort, suggesting meningiomas with higher risk scores derived greater benefit from postoperative radiotherapy. Conclusion Here we use targeted gene expression profiling to develop a risk score predicting meningioma outcomes and responses to postoperative radiotherapy. This cost-effective assay outperforms DNA methylation grouping and WHO grade in discriminating meningioma outcomes, and may be useful for guiding clinical trial design.

Background Neurogenic bladder refers to dysfunction of the urinary bladder secondary to diseases of the nervous system that result in problems with urine storage, micturition, or both. The most common causes are multiple sclerosis and spinal cord injury. Patients commonly present with recurrent UTIs, obstructive uropathies, and urinary retention. Without proper treatment, neurogenic bladder may result in nephropathy and renal failure, both of which have a significant negative impact on the health and life expectancy of patients. Restoration of lost neural function using artificial stimulators is a feasible therapeutic strategy. This article reviews the pathophysiology of neurogenic bladder and the 2 most commonly employed sacral nerve stimulation methods—the Brindley procedure and sacral neuromodulation.

Background High-flow extracranial–intracranial (EC-IC) bypass followed by sacrifice of the native internal carotid artery (ICA) is a recognized treatment option for giant ICA aneurysm and skull base tumor involving the ICA. Distal clipping at the supraclinoid portion of the ICA is technically straightforward, but it can potentially compromise ophthalmic artery (OA) perfusion. Because of the extensive EC-IC anastomoses with the OA, visual symptoms are fortunately uncommon. We report a patient who developed complete blindness after distal trapping of the supraclinoid ICA; it was reversed after emergency clip removal. Case Description Our patient is a 47-year-old man with recurrent nasopharyngeal carcinoma in close proximity to the left petrosal ICA. The first stage of the procedure involved an EC-IC bypass using radial artery graft, followed by a second stage with combined craniofacial excision. Trapping of the native ICA was achieved using a permanent aneurysm clip placed at the supraclinoid ICA distal to the origin of the OA. He complained of a new onset of complete left eye visual loss approximately 6 hours after the distal aneurysm clip was applied. He was immediately sent to the operating theatre for the removal of the supraclinoid aneurysm clip. On the next day, his vision improved and left pupil became reactive again. Discussion OA flow following ICA trapping is complicated and precarious. Delayed onset of visual loss is possible. Prompt action by direct exploration and clip removal is needed and can be effective in reversing blindness.

Background Natural killer cell lymphoma is an uncommon hematologic malignancy, and central nervous system metastasis is rare. The classic magnetic resonance imaging appearance of lymphoma in the brain is T1 hypointense with strong homogeneous gadolinium enhancement, variable T2 signal, and restricted diffusion on diffusion-weighted images. Gadolinium enhancement is an important feature to differentiate lymphoma from infarction. Case Description We present the case of a middle-aged man who presented with recurrent natural killer cell lymphoma that metastasized to the cerebellum. Computed tomography and magnetic resonance imaging did not show a contrast-enhancing lesion; imaging features were more suggestive of cerebral infarction. The patient subsequently died, and postmortem examination confirmed natural killer cell lymphoma metastasis to the cerebellum. Conclusions Lymphoma can mimic cerebral infarction on computed tomography and magnetic resonance imaging. An imaging appearance of cerebral infarction in a patient with a history of lymphoma should raise suspicions of lymphoma metastasis.

Background Primary central nervous system (CNS) natural killer (NK)-cell lymphoma is rare with only 7 cases reported previously. Magnetic resonance spectroscopy (MRS) and [ 18 F]fluorodeoxyglucose (FDG) positron emission tomography (PET) are frequently used for disease diagnosis and monitoring. Choline (CHO) PET is gaining popularity for identifying CNS lesions because of its high disease to background radioactivity ratio compared with FDG. Normally, CNS lymphoma shows high choline uptake on CHO-PET and a high choline peak on MRS. We present an unusual case of primary CNS NK-cell lymphoma with high choline uptake but absence of a high choline peak on MRS. Case Description A 39-year-old woman presented with subacute onset of cognitive deterioration. Magnetic resonance imaging of the brain showed a gadolinium-enhancing lesion in the left temporal lobe. MRS showed suppressed N -acetyl-aspartate and the absence of a high choline peak. CHO-PET confirmed that it was the only hypermetabolic lesion in the body with moderate uptake of choline. The differential diagnoses included encephalitis and neoplasm. She was initially treated for the former but did not respond to steroids, intravenous immunoglobulin, and plasmapheresis. A surgical biopsy later confirmed NK-cell lymphoma. She was then treated as primary CNS NK-cell lymphoma with intravenous and intrathecal chemotherapy. Conclusions We presented a unique case of primary CNS NK-cell lymphoma with atypical imaging findings characterized by moderately increased uptake of choline without a corresponding high choline peak on MRS. Although CHO-PET was suggestive of malignancy, surgical biopsy was required to confirm the diagnosis.

Background Hypertrophic pachymeningitis has been described as a manifestation of a number of conditions, like infection and neoplasms such as dural carcinomatosis or lymphomas. IgG4-related hypertrophic pachymeningitis is a new entity identified during the past decade and most reports described pachymeningeal involvement only. Case Description We present a 58-year-old woman with isolated IgG4 hypertrophic pachymeningitis at the falx cerebrii that exhibited cerebral parenchymal invasion. She initially presented with left lower limb weakness. Magnetic resonance imaging of brain showed a contrast enhancing lesion located at the falx and that eroded into the right frontal lobe. Subsequent excisional biopsy confirmed the lesion with brain parenchyma invasion. The pathologic diagnosis was IgG4-related disease. She had no evidence of extracranial involvement. Conclusions Overall, this is an uncommon condition that may exhibit parenchymal invasion. Surgical biopsy would serve to establish a definitive diagnosis, and prompt comprehensive management of what is essentially a systemic and treatable condition.