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Electric Extradural Motor Cortex Stimulation (EMCS) is a neurosurgical procedure suggested for treatment of patients with advanced Parkinson’s disease (PD). We report two PD patients treated by EMCS, who experienced worsening of motor symptoms and cognition 5 years after surgery, when EMCS batteries became discharged. One month after EMCS restoration, they experienced a subjective improvement of motor symptoms and cognition. Neuropsychological assessments were carried out before replacement of batteries (off-EMCS condition) and 6 months afterward (on-EMCS condition). As compared to off-EMCS condition, in on-EMCS condition both patients showed an improvement on tasks of verbal episodic memory and backward spatial short-term/working memory task, and a decline on tasks of selective visual attention and forward spatial short-term memory. These findings suggest that in PD patients EMCS may induce slight beneficial effects on motor symptoms and cognitive processes involved in verbal episodic memory and in active manipulation of information stored in working memory.

Background In most centers, the surgery of deep brain stimulation (DBS) is performed using a stereotactic frame. Compared with frame-based technique, frameless stereotaxy reduces the duration of surgical procedure and patient’s discomfort, with lead placing accuracy equivalent after the learning curve. Although several studies have investigated the targeting accuracy of this technique, only a few studies reported clinical outcomes, with data of short-term follow-up. Objective To assess clinical efficacy and safety of frameless bilateral subthalamic nucleus (STN) DBS in Parkinson’s disease (PD) patients at 1- and 3-year follow-up. Methods Consecutive PD patients who underwent bilateral STN-DBS with a manual adjustable frameless system were included in the study. The data were collected retrospectively. Results Eighteen PD patients underwent bilateral STN-DBS implant and were included in the study. All patients completed 1-year observation and ten of them completed 3-year observation. At 1-year follow-up, motor efficacy of STN stimulation in off-med condition was of 30.1% (P = 0.003) and at 3-year follow-up was of 36.3%, compared with off-stim condition at 3-year follow-up (P = 0.005). Dopaminergic drugs were significantly reduced by 31.2% 1 year after the intervention (P = 0.003) and 31.7% 3 years after the intervention (P = 0.04). No serious adverse events occurred during surgery. Conclusions Frameless stereotaxy is an effective and safe technique for DBS surgery at 1- and 3-year follow-up, with great advantages for patients’ discomfort during surgery.

Previous investigations have reported on the motor benefits and safety of chronic extradural motor cortex stimulation (EMCS) for patients with Parkinson’s disease (PD), but studies addressing the long-term clinical outcome are still lacking. In this study, nine consecutive PD patients who underwent EMCS were prospectively recruited, with a mean follow-up time of 5.1 ± 2.5 years. As compared to the preoperatory baseline, the Unified Parkinson’s Disease Rating Scale (UPDRS)-III in the off-medication condition significantly decreased by 13.8% at 12 months, 16.1% at 18 months, 18.4% at 24 months, 21% at 36 months, 15.6% at 60 months, and 8.6% at 72 months. The UPDRS-IV decreased by 30.8% at 12 months, 22.1% at 24 months, 25% at 60 months, and 36.5% at 72 months. Dopaminergic therapy showed a progressive reduction, significant at 60 months (11.8%). Quality of life improved by 18.0% at 12 months, and 22.4% at 60 months. No surgical complication, cognitive or behavioral change occurred. The only adverse event reported was an infection of the implantable pulse generator pocket. Even in the long-term follow-up, EMCS was shown to be a safe and effective treatment option in PD patients, resulting in improvements in motor symptoms and quality of life, and reductions in motor complications and dopaminergic therapy.

Objectives: Video-assisted telescope operating monitor (VITOM) or exoscope is currently applied in different surgical specialties with clear visualization advantages in terms of magnification, illumination, and wide field of view. The small and deep surgical field of anterior lumbar interbody fusion (ALIF) seemed to be an ideal setting to assess efficacy of exoscope, also considering limits related to microscopic and endoscopic visualization currently employed. Methods: We reported our preliminary experience with exoscope in 9 cases of ALIF at L5-S1 level. These data were retrospectively compared with those obtained from an equal sample of ALIF procedures performed with endoscope as visualization instrument. The technical aspects taken into account were time for procedure and blood loss. Reports from the surgeon about ergonomics and confidence with both techniques were also evaluated. Results: Exoscope proved, in our experience, good visualization and ergonomics and unobstructed access to a small and deep surgical field, allowing abundant space to insert and manipulate the instruments. Conclusions: The instrument contained dimension and its long working distance, superior to endoscope and comparable with operating microscope, showed clear advantages of maneuverability. Moreover, the stereoscopic vision provided by 3-dimensional images proved to be crucial in hand-eye coordination.

Objectives: Restrictive measures adopted during the COVID-19 pandemic, in order to limit contagion, have had a severe impact on mental health. The burden of lockdown has been particularly heavy on patients with chronic neurologic diseases such as People with Epilepsy (PwE). Our survey aims to describe the struggles and needs of Drug-Resistant (DR) PwE with implanted Vagal Nerve Stimulator (VNS) during the first wave of the COVID-19 lockdown in order to find strategies that help patients cope with present or future periods of restriction.Methods: We collected answers from 30 respondents who underwent an online survey including socio-demographic and clinical information and COVID-19-related information. Depression, anxiety symptoms, and sleep quality were investigated in patients through BDI II, GAD-7, and the PSQI scale.Results: In all, 46% of our sample reported an increase in the number of seizures; the entire sample complained of epilepsy-related issues (medication availability, VSN adjustments, anxiety, sleep disturbance); one out of three participants reported major epilepsy issues felt urgent; 30% had to postpone scheduled examination. Significantly higher scores for depression and anxiety scales were found in patients who perceived seizure frequency worsening and reported major epilepsy-related issues.Conclusion: Preliminary findings showed that the first lockdown influenced the clinical and psychological status of PwE and was related to seizures worsening. The lack of medical assistance and control on VNS therapy left patients to cope with the situation without a chance to contact a specialist. We discuss how a wider implementation of telemedicine programs could facilitate remote assistance of PwE with a VNS implant.

Objectives: To describe how the recent lock-down, related to SARS-COV-II outbreak in Italy, affected People With Epilepsy (PwE), we designed a survey focused on subjective reactions. Using Natural Language Processing (NLP), we analyzed words PwE and People without Epilepsy (PwoE) chose to express their reactions. Methods: As a subset of a larger survey, we collected from both PwE (427) and PwoE (452) single words (one per subject) associated to the period of lock down. The survey was spread thanks to the efforts of Italian league against epilepsy Foundation during the days of maximum raise of the pandemic. Data were analyzed via bag of word and sentiment analysis techniques in R. Results: PwoE and PwE showed significantly different distribution in word choice (X2, p = 4.904e-13). A subset of subject used positive words to describe this period, subjects with positive feelings about the lock down were more represented in the PwE group (X2, p = 0.045). Conclusion: PwoE developed reactive stress response to the restrictions enacted during lock-down. PwE, instead, chose words expressing sadness and concern with their disease. PwE appear to internalize more the trauma of lock down. Interestingly PwE also expressed positive feelings about this period of isolation more frequently than PwoE. Our study gives interesting insights on how People with Epilepsy react to traumatic events, using methods that evidence features that do not emerge with psychometric scales.

The effects of spinal cord stimulation (SCS) on cerebral blood flow (CBF) are well known based on experimental investigations, and its vasodilator effect on peripheral arteries is widely used in clinical settings in the treatment of peripheral vascular disease. Since Hosobuchi’s [Appl Neurophysiol 1985;48:372–376] first observations on the effects of SCS on CBF were published 22 years ago, many advances have been made in understanding SCS-mediated effects on CBF. This paper reviews the main laboratory observations and analyzes the most significant neurophysiological theories on the SCS-mediated effect on CBF. Most significant experimental data have been discussed, with specific reference to possible mechanisms such as ‘functional reversible sympathectomy’, cerebral infarction and related ischemic edema, hemodynamic deterioration in experimental combined ischemic-traumatic brain injury and cerebral vasospasm. The authors revised the published experiences in humans with hypoperfusion syndromes and ‘adjuvant’ locoregional CBF increase in chemotherapy of brain tumors. SCS represents a new perspective in challenging neurosurgical clinical fields such as cerebral ischemia and vasospasm, and seems promising as a new trend of functional neurosurgery in cerebrovascular diseases.

Brain abscesses are a rare but potentially lethal neurological lesions, generally occurring after septic episodes in immunodeficient patients or complicating neurosurgical procedures. Even though they are known complications of surgically treated intracerebral haemorrhages (ICH), the presence of a brain abscess at the site of an untreated ICH is a rare event. Such cases may result from haematogenous spread from distant foci or contiguous sites and are often preceded by episodes of sepsis and local infection. Immunodeficiency, AIDS, age, diabetes mellitus and vitamin-K deficiency are predisposing factors. Abscess formation should be considered in case of clinical deterioration, headache, and any neurological deficit after febrile episodes. Early diagnosis with neuroradiological imaging, infection blood markers and microbiological identification of the causative pathogen is crucial for treatment with surgical drainage or excision and specific antibiotic therapy, which guarantee good outcome and long-term survival. In fact, while prompt diagnosis and treatment guarantee good outcome and long-term survival, morbidity and mortality are very high in case of misdiagnosis. We report a case of a 49-year old man presenting with a brain abscess 13 weeks after a spontaneous ICH, without previous episodes of sepsis and with a suspected septic arthritis 2 weeks after abscess drainage.

Background The primary motor cortex, which is part of the corticobasal ganglia loops, may be an alternative option for the surgical treatment of Parkinson disease. Objective To report on the 1-year safety and efficacy of unilateral extradural motor cortex stimulation in Parkinson disease. Methods A quadripolar electrode strip was extradurally implanted over the motor cortex. Stimulation was continuously delivered through the electrode paddle contralateral to the most affected clinical side. Subjects were prospectively evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS) and the Parkinson's Disease Quality of Life Questionnaire. In addition, an extensive cognitive and behavioral assessment and electroencephalogram recording were performed. Results Nine patients were included in this study. No surgical complications or adverse events occurred. Moreover, no cognitive or behavioral changes were observed. Under the off-medication condition, the UPDRS III at baseline was decreased by 14.1%, 23.3%, 19.9%, and 13.2%, at 1, 3, 6, and 12 months, respectively. The motor effects were bilateral, appeared after 3 to 4 weeks of stimulation, and outlasted the stimulation itself for 3 to 4 weeks in 1 case of stimulator accidental switching off. The UPDRS IV was decreased by 40.8%, 42.1%, and 35.5% at 1, 3, and 12 months, respectively. The scores on the Parkinson's Disease Quality of Life Questionnaire were increased at months 3, 6, and 12. Conclusion Extradural motor cortex stimulation is a safe procedure. After 12 months, the patients demonstrated a moderate improvement of motor symptoms (particularly axial symptoms) and quality of life.

A 42-year-old man with a 9-month history of right leg paresthesias was admitted because of the acute onset of numbness and weakness of the left leg with gait impairment. Neurologic examination demonstrated bilateral lower …

According to Menezes’ algorithm, pre-operative dynamic neuroradiological investigation in C1–C2 dislocations (C1C2D) instability is strongly advocated in order to exclude those patients not eligible for posterior fixation and fusion without previous anterior trans-oral decompression. Anterior irreducible compression due to C1C2D instability, it is said, needs trans-oral anterior decompression. We reviewed our experience in order to refute such a paradigm. The study involves 23 patients who were operated on for cranio-vertebral junction (CVJ) instability; all of them had C1C2D of varying degree on x-ray, computerised tomography (CT) and magnetic resonance (MR) imaging of the CVJ. Pre-operatively, irreducible C1C2D was demonstrated only in 3 patients, (2 with Down’s Syndrome, one of them was harbouring os odontoideum, 1 Rheumatoid Arthritis), i.e. 13.04%; the remaining 19 (86.9%) had reducible C1–C2 dislocation. After an unsuccessful traction test conducted in the pre-operative phase under sedation, it was possible to completely reduce the C1C2D (with a combination of axial traction with light extension of the neck on the chest and a light flexion of the head on the neck by using a Mayfield head holder) and proceed to posterior fixation in all the patients under general anaesthesia using a precise “timing sequences fixation technique”. Wiring (C0 and C3 were fixed first being stretched up to approximately 10 lbs, then C2 in order to pull up this vertebra last by forcing approximately 8 lbs) or screw fixation methods were used to achieve fusion along with post-operative external orthosis and neuroradiological assessment of the C1C2D. The instrumentation produced a lever and pulley effect which assisted reduction of the dislocation. At follow up (range 34–55 months-mean 45.33 months) the clinical picture was improved or stable in all patients. Pre-operative irreducibility of the C1C2D should not be an absolute indication for trans-oral decompression. An attempt to reduce the dislocation under general anaesthesia and during posterior fixation should be attempted in Down’s syndrome, os odontoideum and rheumatoid arthritis.