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Background and ObjectivesSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can cause a wide range of neurologic complications; however, its neuropenetrance during the acute phase of the illness is unknown.MethodsExtracellular vesicles were isolated from brain biopsy tissue from a patient undergoing epilepsy surgery using ultracentrifugation and analyzed by Western blot and qPCR for the presence of virus protein and RNA, respectively. Biopsy tissue was assessed by immunohistochemistry for the presence of microvascular damage and compared with 3 other non-COVID surgical epilepsy brain tissues.ResultsWe demonstrate the presence of viral nucleocapsid protein in extracellular vesicles and microvascular disease in the brain of a patient undergoing epilepsy surgery shortly after SARS-CoV-2 infection. Endothelial cell activation was indicated by increased levels of platelet endothelial cell adhesion molecule-1 and was associated with fibrinogen leakage and immune cell infiltration in the biopsy tissue as compared with control non-COVID surgical epilepsy brain tissues.DiscussionDespite the lack of evidence of viral replication within the brain, the presence of the nucleocapsid protein was associated with disease-specific endothelial cell activation, fibrinogen leakage, and immune cell infiltration.

Background Prior treatment with magnetic resonance-guided, laser-induced thermal therapy (LITT) is widely assumed not to be a contraindication for further treatment of brain lesions, including further iterations of LITT. However, the safety and efficacy of repeat LITT treatments have never been formally investigated. Objective To evaluate treatment with multiple iterations of LITT. Methods All patients treated with LITT at least twice at our institution were included in the study. Outcomes and neurological examinations from before and after surgery were retrospectively examined from clinic notes. Perilesonal edema was determined at various timepoints using volumetric data derived from manual tracings of fluid-attenuated inversion recovery (FLAIR) enhancement on magnetic resonance imaging (MRI). Finally, a literature review of prior cases of repeat LITT was performed. Results A total of 9 patients underwent 18 treatments with LITT; all but 1 of whom were treated for metastatic brain lesions. One patient had a transient cerebrospinal fluid leak, whereas a second patient had a superficial wound infection, both of which resolved with standard medical care. The remaining 7 patients tolerated all LITT procedures without complication. Analysis of perilesional edema volume demonstrated a correlation with the amount of energy delivered during LITT. Literature review found 5 published papers describing 9 patients who underwent LITT more than once, the majority of whom tolerated repeat LITT well. Conclusion LITT is a safe and promising treatment modality and may be used multiple times without issue. There appears to be an association between the amount of energy delivered during a LITT session and the degree of postoperative perilesional edema.

Laser interstitial thermal therapy (LITT) is an adjuvant treatment for intracranial lesions that are treatment refractory or in deep or eloquent brain. Initial studies of LITT in surgical neuro-oncology are limited in size and follow-up.To present our series of LITT in surgical neuro-oncology to better evaluate procedural safety and outcomes.An exploratory cohort study of all patients receiving LITT for brain tumors by a single senior neurosurgeon at a single center between 2013 and 2018. Primary outcomes included extent of ablation (EOA), time to recurrence (TTR), local control at 1-yr follow-up, and overall survival (OS). Secondary outcomes included complication rate. Outcomes were compared by tumor subtype. Predictors of outcomes were identified.A total of 91 patients underwent 100 LITT procedures; 61% remain alive with 72% local control at median 7.2 mo follow-up. Median TTR and OS were 31.9 and 16.9 mo, respectively. For lesion subtypes, median TTR (months, not applicable [N/A] if50% rate observed), local control rates at 1-yr follow-up, and median OS (months) were the following: dural-based lesions (n = 4, N/A, 75%, 20.7), metastases (n = 45, 55.9, 77.4%, 16.9), newly diagnosed glioblastoma (n = 11, 31.9, 83.3%, 32.3), recurrent glioblastoma (n = 14, 5.6, 24.3%, 7.3), radiation necrosis (n = 20, N/A, 67.2%, 16.4), and other lesions (n = 6, 12.3, 80%, 24.4). TTR differed by tumor subtype (P = .02, log-rank analysis). EOA predicted local control (P = .009, multivariate proportional hazards regression); EOA85% predicted longer TTR (P = .006, log-rank analysis). Complication rate was 4%.Our series of LITT in surgical neuro-oncology, 1 of the largest to date, further evidences its safety and outcomes profile.

Cavernomas located in subcortical or eloquent locations are difficult lesions to access safely. Tubular retractors, which distribute retraction pressure radially, have been increasingly employed successfully. These retractors may be beneficial in subcortical cavernoma resection.To review a single institution's case series to determine the safety profile and efficacy of transcortical-transtubular cavernoma resections and to describe our transtubular operative technique.We reviewed a single institution's transcortical-transtubular cavernoma resections using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) tubular retractors performed from 2013 to 2018 (n = 20).Gross total resection was achieved in all patients. When a developmental venous anomaly (DVA) was present, avoidance of DVA resection was achieved in all cases (n = 4). All patients had a supratentorial cavernoma with mean depth below cortical surface of 44.1 mm. Average postoperative clinical follow-up was 20.4 wk. Early neurologic deficit rate was 10% (n = 2); permanent neurologic deficit rate was 0%. One patient (5%) experienced early postoperative seizures ( 1 wk postop). No patients experienced late seizures ( 1 wk follow-up). Engel class 1 seizure control at final clinical follow-up was achieved in 87.5% of patients presenting with preoperative epilepsy.Tubular retractors provide a low-profile, minimally invasive operative corridor for resection of subcortical cavernomas. There were no permanent neurologic complications in our series of 20 cases, and long-term seizure control was achieved in all patients. Thus, tubular retractors appear to be a safe and efficacious tool for resection of subcortical cavernomas.

BACKGROUND Treatment strategies for deep intracranial gliomas remain limited to stereotactic biopsy in many cases due to the morbidity of aggressive surgical resection. Since no cytoreductive therapy is offered, outcomes have been demonstrably poor compared to patients who are able to undergo primary surgical resection. OBJECTIVE To present our practice, in an effort to reduce morbidity and still offer cytoreductive treatment, of offering the possibility of laser interstitial thermal therapy (LITT) for the primary treatment of intracranial deep gliomas that would be otherwise unamenable for resection. METHODS From 2010 to 2017, 74 patients were identified from a single surgeon at a single tertiary care referral center who had been treated with LITT. We conducted an exploratory cohort study on patients (n = 6) who have undergone contemporaneous biopsy and laser ablation for the treatment of deep gliomas with a mean tumor volume of 10.9 cc (range 4.2-52 cc). RESULTS In our cohort, mean extent of ablation (EOA) was 98.5% on postoperative MRI; mean progression-free survival was 14.3 mo, and 5 patients (83%) remained alive at mean follow-up time of 19.7 mo without any complications. Additionally, there was a negative linear relationship between preoperative lesion size and EOA (P

BACKGROUND Magnetic resonance-guided laser-interstitial thermotherapy (MR-LITT) is a minimally invasive technique that shows promise in neuro-oncology because of its superiority in delivering precise minimally invasive thermal energy with minimal collateral damage. OBJECTIVE In this analysis, we investigate initial data on the use of MR-LITT in the treatment of newly diagnosed high-grade gliomas. METHODS With the use of the PubMed, OVID, and Google-scholar database systems, a comprehensive search of the English literature was performed. Eighty-five articles were identified plus 1 that is pending publication. Four articles were accounted for in this review, including 25 patients with newly diagnosed high-grade gliomas who underwent MR-LITT treatment. We evaluated safety, progression-free survival, and overall survival. RESULTS Twenty-five patients with a mean age of 53.8 years underwent LITT treatments. On average, 82.9% of the pretreatment lesion volume was ablated. The average tumor volume treated was 16.5 cm. The mean follow-up time was 7.6 months. Median overall survival was found to be 14.2 months (range 0.1-23 months). The median progression-free survival was 5.1 months (range 2.4-23 months); however, these data are limited by the relatively short follow-up of the patients reviewed and small sample size of only 25 patients. There was 1 (3.4%) major perioperative complication, which was a central nervous system infection. CONCLUSION MR-LITT is a promising technology for the treatment of small, yet difficult-to-treat newly diagnosed high-grade gliomas. This study demonstrates that MR-LITT is safe, and future randomized studies are needed to evaluate its role as a treatment adjunct for newly diagnosed high-grade gliomas. ABBREVIATIONS BBB, blood-brain barrierHGG, high-grade gliomaLITT, laser-interstitial thermal therapyWHO, World Health Organization.

Awake craniotomy (AC) has seen an expanded role in brain tumor surgery over the past few decades. AC allows intraoperative cortical mapping and the continuous assessment of neurophysiological parameters, which are otherwise unattainable under general anesthesia (GA). The ability of AC to analyze eloquent brain areas makes it a powerful method for reducing the risks associated with tumor resection, especially in motor and language cortex. We present a review of the literature to examine the benefits and limits of using AC over GA.A literature search was performed using the Medline and PubMed databases from 1970 and 2012 that compared craniotomy for tumor resection under GA and AC. Data of interest included length of hospital stay, operating time, extent of resection, and neurological sequelae.A total of 8 studies with 951 patients (411 utilizing AC and 540 utilizing GA) were included in this review. Our interpretation of the literature suggests that AC (4 d, n=110) results in a shorter hospital stay than GA (9 d, n=116). Mean extent of resection was slightly less under awake conditions (41%, n=321) versus GA (44%, n=444), and postoperative deficits were less frequent under awake conditions (7%, n=411) versus GA (23%, n=520). Surgery time was slightly less in the AC group (165 min, n=324) versus GA (168 min, n=477).Given the effectiveness of AC for resection of eloquent tumors, the data suggests an expanded role for AC in brain tumor surgery regardless of tumor location.

With a shortage of supply of nurses and the increasing demand for nursing care, hospitals require or allow nurses to work extended shifts (in excess of 12 hours) and many shifts per week (up to and in excess of 60 hours per week). The result of these excessive hours of work is that many nurses care for patients while suffering from sleep deprivation. Sleep deprivation has been shown to negatively impact judgment and performance resulting in errors and accidents. Sleep deprivation also negatively affects the health of individuals. Sleep deprivation in nurses is a significant issue that requires more attention.

We have read the article by Garratt et al1 with interest. It appears that the patients in this study were of lower risk with low rates of major adverse cardiac and cerebrovascular events after the initial 12 months. Thirty months of dual-antiplatelet therapy (DAPT) demonstrated a reduction in major adverse cardiac and cerebrovascular events, mainly by reducing nonfatal myocardial infarction and stent thrombosis but with no mortality benefit. This was at the expense of excess bleeding. However, outcomes after percutaneous coronary intervention (PCI) are dependent on operator skills and experience, stent technology, …

Behcet syndrome (BS) is an uncommon systemic vasculitis, with limited understanding of the pathophysiology and treatment options are nonspecific. Associated morbidity is higher in men, specifically those affected by vascular, neuronal, or ocular involvement. Systemic veins and pulmonary arteries are predominantly involved, both of which carrying deoxygenated blood at low pressure, presenting as occlusive (thrombotic/stenotic) or aneurysmal lesions. Arteries are also affected by similar lesions, because of inflammation of the vasa-vasorum resulting in medial defragmentation of the vessel wall. Stenotic lesions are considered benign, whereas aneurysmal change can be progressive and rupture can be fatal. Stenotic lesions are thought to be better treated with stenting, as surgical repair can result in aneurysmal change at the site of vascular injury.1 A 32-year-old male, known to have BS with the presence of antiphospholipid antibody, multiple episodes of deep vein thrombosis and pulmonary emboli but no …