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BackgroundResection is a critical component in the initial treatment of glioblastoma (GBM). Often GBMs are resected using an intralesional method. Circumferential perilesional resection of GBMs has been described, but with limited data.ObjectiveTo conduct an observational retrospective analysis to test whether perilesional resection produced a greater extent of resection.MethodsWe identified all patients with newly diagnosed GBM who underwent resection at our institution from June 1, 1993 to December 31, 2015. Demographics, presenting symptoms, intraoperative data, method of resection (perilesional or intralesional), volumetric imaging data, and postoperative outcomes were obtained. Complete resection (CR) was defined as 100% resection of all contrast-enhancing disease. Univariate analyses employed analysis of variance (ANOVA) and Fisher's exact test. Multivariate analyses used propensity score-weighted multivariate logistic regression.ResultsNewly diagnosed GBMs were resected in 1204 patients, 436 tumors (36%) perilesionally and 766 (64%) intralesionally. Radiographic CR was achieved in 69% of cases. Multivariate analysis demonstrated that perilesional tumor resection was associated with a significantly higher rate of CR than intralesional resection (81% vs 62%, multivariate odds ratio = 2.5, 95% confidence interval: 1.8-3.4, P

Current clinical brain imaging techniques used for surgical planning of tumor resection lack intraoperative and real-time feedback; hence surgeons ultimately rely on subjective evaluation to identify tumor areas and margins. We report a fluorescence lifetime imaging (FLIm) instrument (excitation: 355 nm; emission spectral bands: 390/40 nm, 470/28 nm, 542/50 nm and 629/53 nm) that integrates with surgical microscopes to provide real-time intraoperative augmentation of the surgical field of view with fluorescent derived parameters encoding diagnostic information. We show the functionality and safety features of this instrument during neurosurgical procedures in patients undergoing craniotomy for the resection of brain tumors and/or tissue with radiation damage. We demonstrate in three case studies the ability of this instrument to resolve distinct tissue types and pathology including cortex, white matter, tumor and radiation-induced necrosis. In particular, two patients with effects of radiation-induced necrosis exhibited longer fluorescence lifetimes and increased optical redox ratio on the necrotic tissue with respect to non-affected cortex, and an oligodendroglioma resected from a third patient reported shorter fluorescence lifetime and a decrease in optical redox ratio than the surrounding white matter. These results encourage the use of FLIm as a label-free and non-invasive intraoperative tool for neurosurgical guidance.

Background Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT). Objective To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward. Methods Review of the medical files of three patients and description of clinical and surgical outcomes. Results Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up. Conclusion The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

Currently, the common neurosurgical robot systems rely on traditional optical navigation for positioning and movement, which is large and expensive, and its clinical application is limited. In recent years, the neurosurgical robot systems have gradually developed to the direction of collaborative robot systems. Collaborative robot systems can cooperate with the surgeon to improve the efficiency of surgery and ensure more accurate and safe surgery. Compared to supervisory control system and master⁃slave system, collaborative robot systems are simpler to construct and operate, less costly, more closely integrated with human perception, and can be directly integrated into surgical scenarios. This article reviews the structure and working principle of Evolution 1, ROVOT⁃m, RoboticScope, iArmS, Craniostar prototype and a new surgical cooperative robot based on 3D machine vision, which are 6 kinds of surgical robot systems for stabilizing surgical procedures and facilitating observation of surgical field, to promote its clinical application in neurosurgery.

Patients with drug-resistant epilepsy often require surgery to become seizure-free. While laser ablation and implantable stimulation devices have lowered the morbidity of these procedures, seizure-free rates have not dramatically improved, particularly for patients without focal lesions. This is in part because it is often unclear where to intervene in these cases. To address this clinical need, several research groups have published methods to map epileptic networks but applying them to improve patient care remains a challenge. In this study we advance clinical translation of these methods by: (i) presenting and sharing a robust pipeline to rigorously quantify the boundaries of the resection zone and determining which intracranial EEG electrodes lie within it; (ii) validating a brain network model on a retrospective cohort of 28 patients with drug-resistant epilepsy implanted with intracranial electrodes prior to surgical resection; and (iii) sharing all neuroimaging, annotated electrophysiology, and clinical metadata to facilitate future collaboration. Our network methods accurately forecast whether patients are likely to benefit from surgical intervention based on synchronizability of intracranial EEG (area under the receiver operating characteristic curve of 0.89) and provide novel information that traditional electrographic features do not. We further report that removing synchronizing brain regions is associated with improved clinical outcome, and postulate that sparing desynchronizing regions may further be beneficial. Our findings suggest that data-driven network-based methods can identify patients likely to benefit from resective or ablative therapy, and perhaps prevent invasive interventions in those unlikely to do so.

Petrosal vein (PV) is an important drainage vein of posterior cranial fossa, needs to be properly preserved during cerebellopontine angle (CPA) surgery. Whether it is safe to sacrifice PV is a topic of intense debate and worth discussing. On one hand, some systematic studies concluded that the complications after obliteration of PV were negligible, and on the other hand, fatal complications caused by the sacrifice of PV were reported intermittently. This paper intends to review the anatomy of PV, the complications after sacrifice of PV, the evidence and opinions on the safety of PV sacrifice, and preoperative or intraoperative methods for evaluating the safety of PV sacrifice, so as to refine the surgical management of PV by neurosurgeons.

Objective To explore the influencing factors of long⁃term prognosis of patients with spontaneous cerebellar hemorrhage (SCH) after surgery. Methods Total 121 patients with SCH admitted to the Second Affiliated Hospital of Air Force Military Medical University from January 2012 to September 2019 were included. The prognosis was assessed by the modified Rankin Scale (mRS) 12 months after surgery, and the risk factors related to dismal prognosis were screened by univariate and multivariate Logistic regression analysis. Results The age (P=0.001), proportion of Glasgow Coma Scale (GCS) score≤8 (P=0.000), activated partial thromboplastin time (P=0.003), random blood glucose level (P=0.044) and ventilator assisted ventilation ratio (P=0.015) of patients with poor prognosis (mRS score 4-6, n=79) were higher than those of patients with good prognosis (mRS score 0-3, n=42), while platelet count was lower than those of patients with good prognosis (P=0.017). There was significant difference in surgery modes between 2 groups (P=0.001). Logistic regression analysis showed that older age (OR=1.090, 95%CI: 1.032-1.151; P=0.002), high serum D⁃dimer level (OR=1.339, 95%CI: 1.034-1.735; P=0.027), craniotomy hematoma removal (OR=4.949, 95%CI: 1.310-18.691; P=0.018) and hematoma puncture drainage (OR=6.789, 95%CI: 1.249-36.912; P=0.027) were the main risk factors for long⁃term dismal prognosis after surgery for SCH. Conclusions Older age, high serum D⁃dimer level and surgery modes are the risk factors for long⁃term dismal prognosis after surgery for SCH.

Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60–0.70), 0.57 (95% CI 0.51–0.63), and 0.75 (95% CI 0.60–0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60–0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range. [ABSTRACT FROM AUTHOR]

Objective To explore the application value of endovascular embolization plus microneurosurgery for vascular rich tumors in children. Methods From July 2019 to July 2021, five children with giant intracranial vascular tumor undergoing combined surgery were recruited as research objects.And perioperative complications and outcomes were reviewed retrospectively. Results Among them, there were atypical teratoma/rhabdomyoma (AT/RT) in posterior fossa (WHO Grade Ⅳ, n=2), hairy cell astrocytoma in posterior fossa (WHO Grade Ⅰ, n=1), giant cell astrocytoma (WHO Grade Ⅰ) under ependymal membrane of temporal lobe (WHO Grade Ⅰ, n=1) and polymorphic yellow astrocytoma (WHO Grade Ⅱ, n=1). All patients underwent compound surgery.All of them remained conscious post-operation.Four of them could move their limbs and intracranial hemorrhage was absent on postoperative computed tomography (CT). During a follow-up period of 3 months, magnetic resonance imaging (MRI) reexamination showed no tumor recurrence or progression. Conclusion During microsurgery, preoperative occlusion of major tumor blood supply vessels may significantly minimize hemorrhage and maintain a distinct surgical field.And embolic material has the intraoperative function of positioning and navigation so that it ensures a complete resection of huge vascular rich tumors for retaining normal brain tissue as much as possible and protecting brain function.Compound surgery has an important application value for nervous system tumors. [ABSTRACT FROM AUTHOR]

In our recent study, the attempt to classify neurosurgical operative reports into routinely used expert-derived classes exhibited an F-score not exceeding 0.74. This study aimed to test how improving the classifier (target variable) affected the short text classification with deep learning on real-world data. We redesigned the target variable based on three strict principles when applicable: pathology, localization, and manipulation type. The deep learning significantly improved with the best result of operative report classification into 13 classes (accuracy = 0.995, F1 = 0.990). Reasonable text classification with machine learning should be a two-way process: the model performance must be ensured by the unambiguous textual representation reflected in corresponding target variables. At the same time, the validity of human-generated codification can be inspected via machine learning. [ABSTRACT FROM AUTHOR]

Background: Intracranial tumors are commonly approached through a craniotomy, and the bone flap is later reattached with plates and screws. The gap created around the bone flap may cause the skin to submerge, potentially influencing the facial and head aesthetic appearance. The aim of this study was to examine patient satisfaction with cosmetic outcome after craniotomy for intracranial tumor resection. Methods: In a prospective questionnaire-based study, patients were asked to report their degree of satisfaction with the scar and overall cosmetic appearance, and the extent of change to their facial appearance using 0–10 rating scales. The questionnaire was sent six months after surgery to patients undergoing first-time craniotomy for tumor resection at either of two neurosurgical departments. Results: Of the 70 patients included in the study, 49 (70%) completed the questionnaire. Median scores were 9.3 for satisfaction with the scar and 9.0 for overall cosmetic satisfaction (a score of 10 reflected highest satisfaction). The median score was 1.7 for degree of change in facial appearance (a score of 0 reflected no change). However, 24.5% of patients reported major alterations to facial appearance. Satisfaction levels were similar by age, sex, and tumor type, but patients with occipital craniotomies were less satisfied with the overall cosmetic result than those with temporal craniotomies. Conclusion: Most patients were satisfied with the cosmetic outcome of the craniotomy, but a considerable proportion reported major facial alterations. While the level of overall cosmetic satisfaction did not differ according to age, sex, or tumor type, the location of the craniotomy seemed to be a factor in satisfaction with the aesthetic outcome. Further studies are needed to investigate how the cosmetic result from craniotomy could be improved from the patient's perspective.

In patients with medically refractory epilepsy, resective surgery is the mainstay of therapy to achieve seizure freedom. However, ∼20-50% of cases have intractable seizures post-surgery due to the imprecise determination of epileptogenic zone. Recent intracranial studies suggest that high frequency oscillations between 80 and 200 Hz could serve as one of the consistent epileptogenicity biomarkers for localization of the epileptogenic zone. However, these high frequency oscillations are not adopted in the clinical setting because of difficult non-invasive detection. Here, we investigated non-invasive detection and localization of high frequency oscillations and its clinical utility in accurate pre-surgical assessment and post-surgical outcome prediction. We prospectively recruited 52 patients with medically refractory epilepsy who underwent standard pre-surgical workup including magnetoencephalography (MEG) followed by resective surgery after determination of the epileptogenic zone. The post-surgical outcome was assessed after 22.14 ± 10.05 months. Interictal epileptic spikes were expertly identified, and interictal epileptic oscillations across the neural activity frequency spectrum from 8 to 200 Hz were localized using adaptive spatial filtering methods. Localization results were compared with epileptogenic zone and resected cortex for congruence assessment and validated against the clinical outcome. The concordance rate of high frequency oscillations sources (80-200 Hz) with the presumed epileptogenic zone and the resected cortex were 75.0% and 78.8%, respectively, which is superior to that of other frequency bands and standard dipole fitting methods. High frequency oscillation sources corresponding with the resected cortex, had the best sensitivity of 78.0%, positive predictive value of 100% and an accuracy of 78.84% to predict the patient's surgical outcome, among all other frequency bands. If high frequency oscillation sources were spatially congruent with resected cortex, patients had an odds ratio of 5.67 and 82.4% probability of achieving a favourable surgical outcome. If high frequency oscillations sources were discordant with the epileptogenic zone or resection area, patient has an odds ratio of 0.18 and only 14.3% probability of achieving good outcome, and mostly tended to have an unfavourable outcome (χ2 = 5.22; P = 0.02; φ = -0.317). In receiver operating characteristic curve analyses, only sources of high-frequency oscillations demonstrated the best sensitivity and specificity profile in determining the patient's surgical outcome with area under the curve of 0.76, whereas other frequency bands indicate a poor predictive performance. Our study is the first non-invasive study to detect high frequency oscillations, address the efficacy of high frequency oscillations over the different neural oscillatory frequencies, localize them and clinically validate them with the post-surgical outcome in patients with medically refractory epilepsy. The evidence presented in the current study supports the fact that HFOs might significantly improve the presurgical assessment, and post-surgical outcome prediction, where it could widely be used in a clinical setting as a non-invasive biomarker.

BackgroundThis report documents the clinical characteristics, molecular grouping, and outcome of young children with ependymoma treated prospectively on a clinical trial.MethodsFifty-four children (aged ≤3 y) with newly diagnosed ependymoma were treated on the St Jude Young Children 07 (SJYC07) trial with maximal safe surgical resection, 4 cycles of systemic chemotherapy, consolidation therapy using focal conformal radiation therapy (RT) (5-mm clinical target volume), and 6 months of oral maintenance chemotherapy. Molecular groups were determined by tumor DNA methylation using Infinium Methylation EPIC BeadChip and profiled on the German Cancer Research Center/Molecular Neuropathology 2.0 classifier.ResultsOne of the 54 study patients had metastases (cerebrospinal fluid positive) at diagnosis. Gross or near-total resection was achieved in 48 (89%) patients prior to RT. At a median follow-up of 4.4 years (range, 0.2-10.3 y), 4-year progression-free survival (PFS) was 75.1% ± 7.2%, and overall survival was 92.6% ± 4.4%. The molecular groups showed no significant difference in PFS (4-year estimates: posterior fossa ependymoma group A [PF-EPN-A; 42/54], 71.2% ± 8.3%; supratentorial ependymoma positive for v-rel avian reticuloendotheliosis viral oncogene homolog A [ST-EPN-RELA; 8/54], 83.3% ± 17.0%; and supratentorial ependymoma positive for Yes-associated protein [4/54], 100%, P = 0.22). Subtotal resection prior to RT was associated with an inferior PFS compared with gross or near-total resection (4-year PFS: 41.7% ± 22.5% vs 79.0% ± 7.1%, P = 0.024), as was PF-EPN-A group with 1q gain (P = 0.05). Histopathologic grading was not associated with outcomes (classic vs anaplastic; P = 0.89).ConclusionsIn this prospectively treated cohort of young children with ependymoma, ST-EPN-RELA tumors had a more favorable outcome than reported from retrospective data. Histologic grade did not impact outcome. PF-EPN-A with 1q gain and subtotal resection were associated with inferior outcomes.

BackgroundChromosomal instability is associated with earlier progression in isocitrate dehydrogenase (IDH)-mutated astrocytomas. Here we evaluated the prognostic significance of polysomy in gliomas tested for 1p/19q status.MethodsWe analyzed 412 histologic oligodendroglial tumors with use of 1p/19q testing at 8 institutions from 1996 to 2013; fluorescence in situ hybridization (FISH) for 1p/19q was performed. Polysomy was defined as more than two 1q and 19p signals in cells. Tumors were divided into groups on the basis of their 1p/19q status and polysomy and were compared for progression-free survival (PFS) and overall survival (OS).ResultsIn our cohort, 333 tumors (81%) had 1p/19q loss; of these, 195 (59%) had concurrent polysomy and 138 (41%) lacked polysomy, 79 (19%) had 1p/19q maintenance; of these, 30 (38%) had concurrent polysomy and 49 (62%) lacked polysomy. In agreement with prior studies, the group with 1p/19q loss had significantly better PFS and OS than did the group with 1p/19q maintenance (P < 0.0001 each). Patients with 1p/19q loss and polysomy showed significantly shorter PFS survival than patients with 1p/19q codeletion only (P < 0.0001), but longer PFS and OS than patients with 1p/19q maintenance (P < 0.01 and P < 0.0001). There was no difference in survival between tumors with >30% polysomic cells and those with

BackgroundSturge-Weber syndrome (SWS) is caused by a somatic mutation in GNAQ leading to capillary venous malformations in the brain presenting with various neurological, ophthalmic, and cognitive symptoms of variable severity. This clinical variability makes accurate prognosis difficult. We hypothesized that the greater extent of physical factors (extent of skin, eye, and brain involvement), presence of possible genetic factors (gender and family history), and age of seizure onset may be associated with greater symptom severity and need for surgery in patients with SWS.MethodsThe questionnaire was collected from 277 participants (age: two months to 66 years) with SWS brain involvement at seven US sites.ResultsBilateral brain involvement was associated with both learning disorder and intellectual disability, whereas port-wine birthmark extent was associated with epilepsy and an increased likelihood of glaucoma surgery. Subjects with family history of vascular birthmarks were also more likely to report symptomatic strokes, and family history of seizures was associated with earlier seizure onset. Learning disorder, intellectual disability, strokelike episodes, symptomatic stroke, hemiparesis, visual field deficit, and brain surgery were all significantly associated with earlier onset of seizures.ConclusionThe extent of brain and skin involvement in SWS, as well as the age of seizure onset, affect prognosis. Other genetic factors, particularly variants involved in vascular development and epilepsy, may also contribute to neurological prognosis, and further study is needed.

New groups of high-grade neuroepithelial tumours (HGNET) have emerged from the reclassification of central nervous system (CNS) embryonal tumours that have recognised CNS HGNET with BCOR alteration (CNS HGNET-BCOR). We report a two-year, nine-month-old Omani boy who presented to the Royal Hospital, Muscat, Oman, in 2015 with subacute head tilting and neck pain. A well-defined cerebellar lesion was found and he was treated with standard chemoradiotherapy. After a relapse at the age of five years, molecular testing revealed a BCOR alteration. He was treated with further surgery and high-dose chemotherapy; unfortunately, he relapsed and died three years after he was diagnosed.

Epidural electrical stimulation (EES) of the spinal cord has been shown to restore function after spinal cord injury (SCI). Characterization of EES-evoked motor responses has provided a basic understanding of spinal sensorimotor network activity related to EES-enabled motor activity of the lower extremities. However, the use of EES-evoked motor responses to guide EES system implantation over the spinal cord and their relation to post-operative EES-enabled function in humans with chronic paralysis attributed to SCI has yet to be described. Herein, we describe the surgical and intraoperative electrophysiological approach used, followed by initial EES-enabled results observed in 2 human subjects with motor complete paralysis who were enrolled in a clinical trial investigating the use of EES to enable motor functions after SCI. The 16-contact electrode array was initially positioned under fluoroscopic guidance. Then, EES-evoked motor responses were recorded from select leg muscles and displayed in real time to determine electrode array proximity to spinal cord regions associated with motor activity of the lower extremities. Acceptable array positioning was determined based on achievement of selective proximal or distal leg muscle activity, as well as bilateral muscle activation. Motor response latencies were not significantly different between intraoperative recordings and post-operative recordings, indicating that array positioning remained stable. Additionally, EES enabled intentional control of step-like activity in both subjects within the first 5 days of testing. These results suggest that the use of EES-evoked motor responses may guide intraoperative positioning of epidural electrodes to target spinal cord circuitry to enable motor functions after SCI.

Glioblastoma is the most common primary malignant brain tumor in adults and is associated with poor survival. The Ivy Foundation Early Phase Clinical Trials Consortium conducted a randomized, multi-institution clinical trial to evaluate immune responses and survival following neoadjuvant and/or adjuvant therapy with pembrolizumab in 35 patients with recurrent, surgically resectable glioblastoma. Patients who were randomized to receive neoadjuvant pembrolizumab, with continued adjuvant therapy following surgery, had significantly extended overall survival compared to patients that were randomized to receive adjuvant, post-surgical programmed cell death protein 1 (PD-1) blockade alone. Neoadjuvant PD-1 blockade was associated with upregulation of T cell- and interferon-γ-related gene expression, but downregulation of cell-cycle-related gene expression within the tumor, which was not seen in patients that received adjuvant therapy alone. Focal induction of programmed death-ligand 1 in the tumor microenvironment, enhanced clonal expansion of T cells, decreased PD-1 expression on peripheral blood T cells and a decreasing monocytic population was observed more frequently in the neoadjuvant group than in patients treated only in the adjuvant setting. These findings suggest that the neoadjuvant administration of PD-1 blockade enhances both the local and systemic antitumor immune response and may represent a more efficacious approach to the treatment of this uniformly lethal brain tumor.

Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin lymphoma that affects the brain parenchyma, spinal cord, eyes, and cerebrospinal fluid without evidence of systemic, non-CNS involvement. PCNSL is uncommon and only a few randomized trials have been completed in the first-line setting. Over the past decades, the prognosis of PCNSL has improved, mainly due to the introduction and widespread use of high-dose methotrexate, which is now the backbone of all first-line treatment polychemotherapy regimens. Despite this progress, durable remission is recorded in only 50% of patients, and therapy can be associated with significant late neurotoxicity. Here, we overview the epidemiology, clinical presentation, staging evaluation, prognosis, and current up-to-date treatment of immunocompetent PCNSL patients.

Synchronized oscillations within and between brain areas facilitate normal processing, but are often amplified in disease. A prominent example is the abnormally sustained beta-frequency (∼20 Hz) oscillations recorded from the cortex and subthalamic nucleus of Parkinson's disease patients. Computational modeling suggests that the amplitude of such oscillations could be modulated by applying stimulation at a specific phase. Such a strategy would allow selective targeting of the oscillation, with relatively little effect on other activity parameters. Here, activity was recorded from 10 awake, parkinsonian patients (6 male, 4 female human subjects) undergoing functional neurosurgery. We demonstrate that stimulation arriving on a particular patient-specific phase of the beta oscillation over consecutive cycles could suppress the amplitude of this pathophysiological activity by up to 40%, while amplification effects were relatively weak. Suppressive effects were accompanied by a reduction in the rhythmic output of subthalamic nucleus (STN) neurons and synchronization with the mesial cortex. While stimulation could alter the spiking pattern of STN neurons, there was no net effect on firing rate, suggesting that reduced beta synchrony was a result of alterations to the relative timing of spiking activity, rather than an overall change in excitability. Together, these results identify a novel intrinsic property of cortico-basal ganglia synchrony that suggests the phase of ongoing neural oscillations could be a viable and effective control signal for the treatment of Parkinson's disease. This work has potential implications for other brain diseases with exaggerated neuronal synchronization and for probing the function of rhythmic activity in the healthy brain.SIGNIFICANCE STATEMENT In Parkinson's disease (PD), movement impairment is correlated with exaggerated beta frequency oscillations in the cerebral cortex and subthalamic nucleus (STN). Using a novel method of stimulation in PD patients undergoing neurosurgery, we demonstrate that STN beta oscillations can be suppressed when consecutive electrical pulses arrive at a specific phase of the oscillation. This effect is likely because of interrupting the timing of neuronal activity rather than excitability, as stimulation altered the firing pattern of STN spiking without changing overall rate. These findings show the potential of oscillation phase as an input for "closed-loop" stimulation, which could provide a valuable neuromodulation strategy for the treatment of brain disorders and for elucidating the role of neuronal oscillations in the healthy brain.

Xenon possesses some, but not all, of the clinical features of an ideal anesthetic agent. Besides well-known advantages of rapid awakening, stable hemodynamics and lack of biotransformation, preclinical data lead to the expectation of xenon's advantageous use for settings of acute ongoing brain injury; a single randomized clinical trial using an imaging biomarker for assessing brain injury corroborated xenon's preclinical efficacy in protecting the brain from further injury. In this review, we discuss the mechanisms and hence the putative applications of xenon for brain protection in neurosurgery. Although the expense of this rare monoatomic gas will likely prevent its widespread penetration into routine clinical neurosurgical practice, we draw attention to the theoretical benefits of xenon anesthesia over other anesthetic regimens for awake craniotomy and for neurosurgery in older, high-risk, and sicker patients.

Objective To evaluate the clinical effect of oblique lumbar interbody fusion (OLIF) surgery using anchored spacers in patients with lumbar degenerative diseases. Methods Total 10 patients with lumbar degenerative diseases treated at Xuanwu Hospital, Capital Medical University from April 2020 to January 2022 were enrolled in this retrospective study. All cases underwent OLIF surgery with anchored spacer. Visual Analog Scales (VAS), Japan Orthopedic Association Scores (JOA) and Oswestry Disability Index (ODI) were used to evaluate the pain symptoms and degree of neurology dysfunction improvement, while X⁃ray scan, 3D⁃CT scan and MRI were used to evaluate radiology outcomes and surgical complications during one week and 6 months after the surgery. Results All 10 patients completed the surgery successfully, the mean surgical time was (128.90±35.16) min, and the mean blood loss was (30.00±14.14) ml. VAS (F=332.566, P=0.000), JOA (F=244.125, P=0.000) and ODI (F=36.918, P=0.000) scores during one week and 6 months after the surgery showed significant improvement, compared with preoperative scores. VAS and ODI scores decreased at 6 months after the surgery than that before surgery (P=0.000, for all) and one week after surgery (P=0.000, for all). JOA score increased at 6 months after the surgery than that before surgery (P=0.000) and one week after surgery (P=0.000). The postoperative height of intervertebral space (t=9.406, P=0.000) and area of dural sac (t=8.853, P=0.000) were also significantly improved. At 6 months after the surgery, all patients had bony fusion at the surgical segment, and no complications such as fusion cage displacement, articular surface collapse or disc degeneration at the adjacent segment occurred. Conclusions OLIF surgery leads to satisfactory clinical outcomes in the treatment of lumbar degenerative diseases. The use of anchored spacers can reduce the need for posterior internal fixation, it has no effect on the stability of the surgical segment and has high safety.

Objective To explore the effects of goal-directed fluid therapy (GDFT) guided by pulse pressure variability (PPV) on the management of craniopharyngioma resection, and the impact of outcome in children. Methods A total of 40 children aged 1 -5 years with American Society of Anesthesiologists physical status II — III underwent elective craniopharyngioma resection. They were randomized into two groups of GDFT (group G) and conventional fluid treatment (group C). Intraoperative PPV-guided fluid infusion was offered in group G and traditional “4-2-1” fluid infusion in group C. Values of mean arterial pressure (MAP) and heart rate (HR) at the beginning of operation (T1), before dural incision (T2),at the end of operation (T3), intraoperative fluid status, utilization rate of antidiuretics and vasoactive agents, electrolyte status and postoperative hospital stay were recorded. Results At T3,HR was significantly higher in group C than that in group G [ (96. 1 +22.4) bpm vs. (82.4 +8.4) bpm] (P<0.05) and at T1[ (96. 1 +22. 4) bpm vs. (82.4 8.4) bpm]. No significant inter-group difference existed in HR or MAP at other timepoints (P >0.05). In terms of fluid input/output, crystal fluid volume [ (826. 0 + 341.8) mL vs. (610. 0 + 266. 7) mL] and urine volume { (495.0 +216.2) mb vs. (284.0 + 202. 1) mL] were significantly higher in group G than those in group G (P <0.05) and the rest had no statistical significance. The incidence of electrolyte disturbance [0% (0/20) vs. 25% (5/20) ] (K² ) and postoperative hospitalization time [ (8.6 +1.8)d vs. (10.6 +3.2)d] were significantly lower in group G than those in group C (P <0.05). No significant inter-group difference existed in intra-operative utilization rate of antidiuretics [5% (1/20) vs. 5% (1/20) ] and vasoactive agents [0% (0/20) vs. 5% (1/20) ] or operative duration [ (324. 8 + 47. 7) min vs. (328. 0 + 68. 0) min] (P > 0. 05).  Conclusion In children undergoing elective craniopharyngioma resection, PPV-guided GDFT may maintain the stability of intraoperative hemodynamics, reduce the incidence of postoperative electrolyte disorders and shorten postoperative hospitalization stay. [ABSTRACT FROM AUTHOR]

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Introduction: Craniopharyngiomas are benign tumors, of which up to 50% occur in children. However, there are no studies in Peruvian children. Objective: to describe the clinical and histopathological characteristics of children with craniopharyngioma hospitalized at the Edgardo Rebagliati Martins National Hospital between August 2019 and May 2021. The study: The design is cross-sectional and the data source were medical records. Information on sex, age, surgeries and characteristics related to the first tumor resection surgery were collected. Findings: We included 12 patients. 83.3% were male, at the time of diagnosis the median age was 6 years and visual symptoms predominated, all had hormonal deficiencies after the first resection surgery. Conclusions: three received radiotherapy, one developed malignant transformation and one died. Future prospective studies are necessary. [ABSTRACT FROM AUTHOR]

Introduction: Acinetobacter is a non fermenting, Gram negative bacillus, a causative pathogen of hospital-acquired infections due to its inherent Multidrug-Resistant (MDR) property. It is held responsible for the majority of nosocomial meningitis in patients undergoing neurosurgical procedures. Aim: To identify the clinical characteristics, drug-resistance and mortality rate among the patients suffering from meningitis caused by Acinetobacter baumannii. Materials and Methods: This retrospective, single-centre study was carried out in the Bacteriology section of the Department of Microbiology at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, from February 2019 to February 2022. A total of 150 Cerebrospinal Fluid (CSF) samples from routine bacterial culture-confirmed patients were included in the study. All clinical data were extracted from the Hospital Information System (HIS). All the isolates were identified by Matrix Assisted Laser Desorption/Ionisation-Time of Flight-Mass Spectrometry (MALDI-TOF-MS) assay and antibiotic sensitivity testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: The study included 150 (7.55%) cases of culture-proven bacterial meningitis among 1986 CSF samples collected from February 2019 to February 2022. There were 45 (30.0%) cases of Acinetobacter meningitis. Thirty-five (77.8%) patients had undergone neurosurgical procedures for the removal of spaceoccupying lesions from the brain parenchyma. Forty-two (93.3%) isolates were resistant to amikacin and a cumulative resistance of almost 93.3-95.6% was observed among cephalosporins. Fluoroquinolone resistance was observed in 43 (95.6%) patients and carbapenem resistance was observed in 42 (93.33%) isolates. Overall, 12 (26.7%) succumbed to their infections. Conclusion: Acinetobacter meningitis causes delay in the recovery of the patient undergoing intracranial surgery, amounting to a delay in brain parenchyma healing in the case of neurosurgical patients. [ABSTRACT FROM AUTHOR]

Copyright of Universidad Médica Pinareña is the property of Editorial Ciencias Medicas and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Parkinson's disease (PD) is a complex, chronic and progressive neurodegenerative disease. When medication doesn't work well, surgical treatments should be considered to improve symptoms. Currently, surgical treatments to PD include not only neurosurgical ablation with different principles, such as radiofrequency ablation (RFA), magnetic resonance guided laser interstitial thermal therapy (MRgLITT), magnetic resonance guided focused ultrasound (MRgFUS) and stereotactic radiotherapy (SRT), but also neuromodulation techniques including deep brain stimulation (DBS). In addition, spinal cord stimulation (SCS), gene and transplantation therapy to PD are also being explored. This review focuses on advances of above treatments of PD, and analyzes their efficacy and safety in order to provide more theory and basis for clinical researchs.

Objective To investigate clinical efficacy and optimal therapeutic strategy for ventricular intracranial pressure (ICP) monitoring and process management in patients with traumatic bifrontal contusions (TBC). Methods Total 387 TBC patients between January 2010 and January 2016 were enrolled in 904th Hospital of Chinese PLA, in which 105 patients with TBC who underwent ventricular ICP monitoring (ICP group) and 282 patients with TBC who did not (non⁃ICP group). Conservative treatment and surgical treatment were performed respectively (unilateral craniotomy for contusion and hematoma removal, bilateral craniotomy for contusion and hematoma removal, and decompressive craniotomy). Rates of successful conservative treatment, ratio of bilateral craniotomy and decompressive craniectomy, length of stay, medical expenses and incidence of related complications were compared between 2 groups. Glasgow Outcome Scale (GOS) was used to assess all patients after 6 months follow⁃up. Results Compared with non⁃ICP group, ICP group had a significantly better successful conservative treatment rate [64.76% (68/105) vs. 47.16% (133/282); χ2=9.493, P=0.002], lower decompressive craniectomy rate [8.11% (3/37) vs. 23.49% (35/149); χ2=4.314, P=0.038]; shorter length of stay [(13.22 ± 1.83) d vs. (18.51 ± 5.08) d; t=10.410, P=0.000] and lower medical expenses [(8.34 ± 3.26) ten thousand yuan vs. (9.67 ± 4.42) ten thousand yuan; t=2.811, P=0.004]. No significantly difference in operative methods (χ2=2.673, P=0.102), pulmonary infection [33.33% (35/105) vs. 39.72% (112/282); χ2=1.321, P=0.250], intracranial infection [10.47% (11/105) vs. 8.16% (23/282); χ2=0.513, P=0.473], hydrocephalus [3.81% (4/105) vs. 6.74% (19/282); χ2=1.173, P=0.279], epilepsy [6.67% (7/105) vs. 10.99% (31/282); χ2=1.617, P=0.203] and bradycardia [28.57% (30/105) vs. 34.75% (98/282); χ2=1.320, P=0.251]. There were no significant differences in prognosis between 2 groups (χ2=1.492, P=0.474). Conclusions Condition of patients with TBC progresses rapidly. Patients should undergo ventricular ICP probe implantation in a timely manner. Although ventricular ICP monitoring do not significantly improve the prognosis of patients, it can increase the success rate of conservative treatment, reduce the rate of decompressive craniectomy, shorten the length of stay, and reduce the medial expenses. Ventricular ICP monitoring warrants further clinical research.

Objective To explore the application value of multi ⁃ modal image fusion three ⁃ dimensional (3D) reconstruction technology in operation of meningioma in the central area. Methods and Results Using multi⁃modal image fusion 3D reconstruction technology to study 46 patients admitted to The First Affiliated Hospital of University of Science and Technology of China from April 2019 to May 2021. 3D Slicer software was used to process the original imaging data to reconstruct 3D models of tumor, peritumoral vein, cerebral cortex, skull, scalp, etc., and intraoperatively Sina software was used for projection assisted incision design to verify the actual tumor position and its adjacency structures preoperatively. To reconstruct the effect before surgery, the tumor was removed under microscopy. All patients completed the preoperative reconstruction. The intraoperative verification showed that the tumor and its adjacency structures were in good agreement with the preoperative 3D model. All patients did not cause unnecessary injury due to insufficient preoperative exposure caused by improper preoperative planning. Forty⁃six cases of meningioma in the central area were completely removed under the microscopy, 32 cases had no limb dysfunction, 8 cases had significant improvement in limb function, and 6 cases had decreased muscle strength. None of the patients had epileptic seizures. One patient had postoperative infection, after active anti⁃infection, he was cured and discharged. There was no death. Conclusions The 3D Slicer reconstruction technology applied to meningioma in the central area can display the tumor adjacent structures in a intuitive, multi-dimensional and dynamic 3D manner, guide the maximum resection of the tumor and protect the peritumoral vein and cortex during the operation. Sina software has clinical and practical value in preoperative positioning of meningioma in the central area, such as accuracy, safety, non-invasiveness, and convenience, and it is worthy of further research and promotion.

Background and Aims: Blood loss in neurosurgical procedures can be rapid and tremendous leading to consequential hemodynamic instability. HemoCue is a portable photometer used for the measurement of blood hemoglobin concentration. Using this point of care device, we contemplated this study to assess the reliability of HemoCue for suction hemoglobin determination and calculation of surgical blood loss by comparing with the gold standard laboratory Coulter Counter method in patients undergoing neurosurgical procedures. Material and Methods: This prospective observational study was conducted in 233 patients undergoing elective neurosurgical procedures in the age group of 18 to 60 years and having preoperative hemoglobin (Hb) values above 9 g/dL. Values of preoperative hemoglobin, suction hemoglobin, and volume in the suction container were used to obtain the estimated blood loss. The normality of the data was tested using the Kolmogorov Smirnov test. Bland Altman analysis was used to test the reliability of HemoCue in estimating hemoglobin and blood loss with reference to the gold standard laboratory Coulter Counter automated hematology analyzer. Results: Median blood loss calculated in our study using HemoCue was 554.65 mL with an interquartile range of 336.81 mL to 982.39 mL. Laboratory counter method estimated median blood loss was 533.37 mL with an interquartile range of 335.21 mL to 994.73 mL. The majority of the data obtained and analyzed using the Bland and Altman analysis method were within a 95% confidence interval. Conclusion: The HemoCue method is a reliable method and henceforth can be used to estimate blood loss in suction fluid in patients undergoing neurosurgical procedures.

Introduction. A transorbital intracranial injury with a foreign body can be a very complex and controversial therapeutic problem. The orbit's content is susceptible to penetrating trauma, and neurovascular skull base structures are at high risk from injury. There are some traditional cranial surgical approaches and more recently reported different endoscopic approaches for treating this kind of injury. Case report. We presented a case of a 30-year-old male who had an accident at work when a piece of wood hit him in his head and entered through the medial aspect of his left orbit with skull base and cavernous sinus injury. Rapid and complete radiological and clinical assessments were performed, and the patient was treated in a minimally invasive manner. The foreign body was manually extracted with an endoscopic and endovascular team ready to treat adverse events. No postoperative complications were reported, and visual acuity increased at the one-month follow-up. Conclusion. Penetrating wounds of the orbit represent a challenge that re-quires a multidisciplinary assessment and well-organized management. Combined endoscopic minimally invasive approaches should be considered during the treatment of this kind of injury.

Background/Aim. Among the various factors that can influence continued postoperative back pain and/or leg pain, and functional disability after lumbar microdiscectomy are gender, depression, and pessimism. The aim of this study was to determine the correlations between these factors. Methods. The research was conducted after microdiscectomy on 198 patients (95 men and 103 women), with a mean age of 50.20 ± 10.26 years. The following questionnaires were used for examinations: for assessment of pain and its intensity and character – PainDETECT Test; for functional disability – Oswestry Low Back Pain Disability Questionnaire; for the presence and degree of depression – Beck Depression Inventory-II; and questionnaire for the assessment of personal expectations (pessimistic/optimistic) about the treatment results. These assessments were carried out after microdiscectomy – just before rehabilitation treatment, one month later, and then 3 and 6 months after a microdiscectomy. Results. Depression (p < 0.01) and pessimism (p < 0.01) had significant negative influences on the pain and functional disability. The subjective sensation of pain was significantly higher in women than in men (p < 0.01), while men had a greater degree of functional disability (p < 0.01) than women. Conclusion. Pain and functional disability of the patients after lumbar microdiscectomy are significantly interconnected with gender, depression, and pessimism. The sensation of pain was higher in women, while men had a greater degree of functional disability. Globally, the intensity of pain and functional disability were significantly greater in patients with a higher degree of depression and pessimism, and, by registering mentioned factors, it is possible to predict the postoperative results.

Introduction: Acinetobacter is a non fermenting, Gram negative bacillus, a causative pathogen of hospital-acquired infections due to its inherent Multidrug-Resistant (MDR) property. It is held responsible for the majority of nosocomial meningitis in patients undergoing neurosurgical procedures. Aim: To identify the clinical characteristics, drug-resistance and mortality rate among the patients suffering from meningitis caused by Acinetobacter baumannii. Materials and Methods: This retrospective, single-centre study was carried out in the Bacteriology section of the Department of Microbiology at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, from February 2019 to February 2022. A total of 150 Cerebrospinal Fluid (CSF) samples from routine bacterial culture-confirmed patients were included in the study. All clinical data were extracted from the Hospital Information System (HIS). All the isolates were identified by Matrix Assisted Laser Desorption/Ionisation-Time of Flight-Mass Spectrometry (MALDI-TOF-MS) assay and antibiotic sensitivity testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: The study included 150 (7.55%) cases of culture-proven bacterial meningitis among 1986 CSF samples collected from February 2019 to February 2022. There were 45 (30.0%) cases of Acinetobacter meningitis. Thirty-five (77.8%) patients had undergone neurosurgical procedures for the removal of space-occupying lesions from the brain parenchyma. Forty-two (93.3%) isolates were resistant to amikacin and a cumulative resistance of almost 93.3-95.6% was observed among cephalosporins. Fluoroquinolone resistance was observed in 43 (95.6%) patients and carbapenem resistance was observed in 42 (93.33%) isolates. Overall, 12 (26.7%) succumbed to their infections. Conclusion: Acinetobacter meningitis causes delay in the recovery of the patient undergoing intracranial surgery, amounting to a delay in brain parenchyma healing in the case of neurosurgical patients.

Health care- and device-associated central nervous system (CNS) infections have a distinct epidemiology, pathophysiology, and microbiology that require a unique diagnostic approach. Most clinical signs, symptoms, and tests used to diagnose community-acquired CNS infections are insensitive and nonspecific in neurosurgical patients due to postsurgical changes, invasive devices, prior antimicrobial exposure, and underlying CNS disease. The lack of a standardized definition of infection or diagnostic pathway has added to this challenge. In this review, we summarize the epidemiology, microbiology, and clinical presentation of these infections, discuss the issues with existing microbiologic tests, and give an overview of the current diagnostic approach.

As the population ages, the question of how to manage brain arteriovenous malformations in the elderly becomes increasingly relevant. Is resection a reasonable option for these patients? In this study, the authors examined the outcomes of surgical patients 60 years or older and found that favorable outcomes were achieved with careful patient selection. Preoperative grading scales were more predictive of outcomes in patients older than 65 years than in those 60-65 years of age.

ObjectiveTo evaluate the use of interictal high-frequency oscillations (HFOs) in epilepsy surgery for prediction of postsurgical seizure outcome in a prospective multicenter trial.MethodsWe hypothesized that a seizure-free outcome could be expected in patients in whom the surgical planning included the majority of HFO-generating brain tissue while a poor seizure outcome could be expected in patients in whom only a few such areas were planned to be resected. Fifty-two patients were included from 3 tertiary epilepsy centers during a 1-year period. Ripples (80-250 Hz) and fast ripples (250-500 Hz) were automatically detected during slow-wave sleep with chronic intracranial EEG in 2 centers and acute intraoperative electrocorticography in 1 patient.ResultsThere was a correlation between the removal of HFO-generating regions and seizure-free outcome at the group level for all patients. No correlation was found, however, for the center-specific analysis, and an individual prognostication of seizure outcome was true in only 36 patients (67%). Moreover, some patients became seizure-free without removal of the majority of HFO-generating tissue. The investigation of influencing factors, including comparisons of visual and automatic analysis, using a threshold analysis for areas with high HFO activity, and excluding contacts bordering the resection, did not result in improved prognostication.ConclusionsOn an individual patient level, a prediction of outcome was not possible in all patients. This may be due to the analysis techniques used. Alternatively, HFOs may be less specific for epileptic tissue than earlier studies have indicated.

ObjectiveRefractory psychiatric disease is a major cause of morbidity and mortality worldwide, and there is a great need for new treatments. In the last decade, investigators piloted novel deep brain stimulation (DBS)-based therapies for depression and obsessive-compulsive disorder (OCD). Results from recent pivotal trials of these therapies, however, did not demonstrate the degree of efficacy expected from previous smaller trials. To discuss next steps, neurosurgeons, neurologists, psychiatrists and representatives from industry convened a workshop sponsored by the American Society for Stereotactic and Functional Neurosurgery in Chicago, Illinois, in June of 2016.DesignHere we summarise the proceedings of the workshop. Participants discussed a number of issues of importance to the community. First, we discussed how to interpret results from the recent pivotal trials of DBS for OCD and depression. We then reviewed what can be learnt from lesions and closed-loop neurostimulation. Subsequently, representatives from the National Institutes of Health, the Food and Drug Administration and industry discussed their views on neuromodulation for psychiatric disorders. In particular, these third parties discussed their criteria for moving forward with new trials. Finally, we discussed the best way of confirming safety and efficacy of these therapies, including registries and clinical trial design. We close by discussing next steps in the journey to new neuromodulatory therapies for these devastating illnesses.ConclusionInterest and motivation remain strong for deep brain stimulation for psychiatric disease. Progress will require coordinated efforts by all stakeholders.

Intracranial electrical recordings and stimulation of neurosurgical patients have been central to the advancement of human neuroscience. The use of these methods has rapidly expanded over the last decade due to theoretical and technical advances, as well as the growing number of neurosurgical patients undergoing functional procedures for indications such as epilepsy, tumor resection, and movement disorders. These methods pose the potential for ethical conflict, as they involve basic neuroscientific research utilizing invasive procedures in human patients undergoing treatment for neurological illnesses. This review addresses technical aspects, clinical contexts, and issues of ethical concern, utilizing a framework that is informed by, but also departs from, existing bioethical literature on matters in clinical research. We conclude with proposals for improving informed consent processes to address potential problems specific to intracranial electrophysiology research, a general schema for scrutinizing research-related risk associated with different methods, and a call for the development of consensus to ensure continuing scientific progress alongside crucial patient protections in this promising area of human neuroscience.

BackgroundMultiple subpial transections (MST) are a treatment for seizure foci in nonresectable eloquent areas.ObjectiveTo systematically review patient-level data regarding MST.MethodsStudies describing patient-level data for MST procedures were extracted from the Medline and PubMed databases, yielding a synthetic cohort of 212 patients from 34 studies. Data regarding seizure outcome, patient demographics, seizure type, surgery type, and complications were extracted and analyzed.ResultsSeizure freedom was achieved in 55.2% of patients undergoing MST combined with resection, and 23.9% of patients undergoing MST alone. Significant predictors for seizure freedom were a temporal lobe focus (odds ratio 4.9; 95% confidence interval 1.71, 14.3) and resection of portions of the focus, when feasible (odds ratio 3.88; 95% confidence interval 2.02, 7.45). Complications were frequent, with transient mono- or hemiparesis affecting 19.8% of patients, transient dysphasia 12.3%, and permanent paresis or dysphasia in 6.6% and 1.9% of patients, respectively.ConclusionMST is an effective treatment for refractory epilepsy in eloquent cortex, with greater chances of seizure freedom when portions of the focus are resected in tandem with MST. The reported rates of seizure freedom with MST are higher than those of existing neuromodulatory therapies, such as vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, though these latter therapies are supported by randomized-controlled trials, while MST is not. The reported complication rate of MST is higher than that of resection and neuromodulatory therapies. MST remains a viable option for the treatment of eloquent foci, provided a careful risk-benefit analysis is conducted.

BackgroundCerebrospinal fluid (CSF) leak is a well-recognized complication after surgical resection of vestibular schwannomas and is associated with a number of secondary complications, including readmission and meningitis.ObjectiveTo identify risk factors for and timing of 30-d readmission with CSF leak.MethodsPatients who had undergone surgical resection of a vestibular schwannoma from 1995 to 2010 were identified in the California Office of Statewide Health Planning and Development database. The most common admission diagnoses were identified by International Classification of Disease, ninth Revision, diagnosis codes, and predictors of readmission with CSF leak were determined using logistic regression.ResultsA total of 6820 patients were identified. CSF leak, though a relatively uncommon cause of admission after discharge (3.52% of all patients), was implicated in nearly half of 490 readmissions (48.98%). Significant independent predictors of readmission with CSF leak were male sex (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.32-2.25), first admission at a teaching hospital (OR 3.32, 95% CI 1.06-10.39), CSF leak during first admission (OR 1.84, 95% CI 1.33-2.55), obesity during first admission (OR 2.10, 95% CI 1.20-3.66), and case volume of first admission hospital (OR of log case volume 0.82, 95% CI 0.70-0.95). Median time to readmission was 6 d from hospital discharge.ConclusionThis study has quantified CSF leak as an important contributor to nearly half of all readmissions following vestibular schwannoma surgery. We propose that surgeons should focus on technical factors that may reduce CSF leakage and take advantage of potential screening strategies for the detection of CSF leakage prior to first admission discharge.

Neurosurgery is an underutilized treatment that can potentially cure drug-refractory epilepsy. Careful, multidisciplinary presurgical evaluation is vital for selecting patients and to ensure optimal outcomes. Advances in neuroimaging have improved diagnosis and guided surgical intervention. Invasive electroencephalography allows the evaluation of complex patients who would otherwise not be candidates for neurosurgery. We review the current state of the assessment and selection of patients and consider established and novel surgical procedures and associated outcome data. We aim to dispel myths that may inhibit physicians from referring and patients from considering neurosurgical intervention for drug-refractory focal epilepsies. Ann Neurol 2018;83:676-690.

PURPOSE OF REVIEW:Three randomized controlled trials demonstrate that surgical treatment is safe and effective for drug-resistant epilepsy (DRE), yet fewer than 1% of patients are referred for surgery. This is a review of recent trends in surgical referral for DRE, and advances in the field. Reasons for continued underutilization are discussed. RECENT FINDINGS:Recent series indicate no increase in surgical referral for DRE over the past two decades. One study suggests that decreased referrals to major epilepsy centers can be accounted for by increased referrals to low-volume nonacademic hospitals where results are poorer, and complication rates higher. The increasing ability of high-resolution MRI to identify small neocortical lesions and an increase in pediatric surgeries, in part, explain a relative greater decrease in temporal lobe surgeries. Misconceptions continue to restrict referral. Consequently, advocacy for referral of all patients with DRE to epilepsy centers that offer specialized diagnosis and other alternative treatments, as well as psychosocial support, is recommended. Recent advances will continue to improve the safety and efficacy of surgical treatment and expand the types of patients who benefit from surgical intervention. SUMMARY:Surgical treatment for epilepsy remains underutilized, in part because of persistent misconceptions. Rather than promote referral for surgery, it would be more appropriate to advocate that all patients with DRE deserve a consultation at a full-service epilepsy center that offers many options for eliminating or reducing disability.

CONTEXT: Achievement of hypocortisolemia following transsphenoidal surgery (TSS) for Cushings disease (CD) is associated with successful adenoma resection. However, up to one-third of these patients recur. OBJECTIVE: We assessed whether delay in reaching post-operative cortisol nadir may delineate patients at risk of recurrence for CD following TSS. METHODS: A retrospective review of 257 patients who received 291 TSS procedures for CD at NIH, between 2003 and 2016. Early biochemical remission (serum cortisol nadir

Paraneurial adhesions have been implicated in the pathological progression of entrapment neuropathies. Surgical decompression of adhesions is often performed, with the intent of restoring nerve kinematics. The normal counterpart of adhesions, native paraneurium, is also thought to influence nerve deformation and mobility. However, influences of native or abnormal paraneurial structures on nerve kinematics have not been investigated. We measured regional strains in rat sciatic nerves before and immediately after decompression of native paraneurial tissue, and before and after decompression of abnormal paraneurial adhesions, which formed within 6 weeks of the initial decompression. Strain was significantly higher in the distal-femoral than in the mid-femoral region of the nerve before either decompression. Decompression of native and abnormal paraneurial tissue removed this regional strain difference. Paraneurial tissues appear to play a major role in distributing peripheral nerve strain. Normal nerve strain distributions may be reconstituted following decompression, even in the presence of paraneurial adhesions.

OBJECTIVE Dysfunction of distributed neural networks underlies many brain disorders. The development of neuromodulation therapies depends on a better understanding of these networks. Invasive human brain recordings have a favorable temporal and spatial resolution for the analysis of network phenomena but have generally been limited to acute intraoperative recording or short-term recording through temporarily externalized leads. Here, the authors describe their initial experience with an investigational, first-generation, totally implantable, bidirectional neural interface that allows both continuous therapeutic stimulation and recording of field potentials at multiple sites in a neural network. METHODS Under a physician-sponsored US Food and Drug Administration investigational device exemption, 5 patients with Parkinson's disease were implanted with the Activa PC+S system (Medtronic Inc.). The device was attached to a quadripolar lead placed in the subdural space over motor cortex, for electrocorticography potential recordings, and to a quadripolar lead in the subthalamic nucleus (STN), for both therapeutic stimulation and recording of local field potentials. Recordings from the brain of each patient were performed at multiple time points over a 1-year period. RESULTS There were no serious surgical complications or interruptions in deep brain stimulation therapy. Signals in both the cortex and the STN were relatively stable over time, despite a gradual increase in electrode impedance. Canonical movement-related changes in specific frequency bands in the motor cortex were identified in most but not all recordings. CONCLUSIONS The acquisition of chronic multisite field potentials in humans is feasible. The device performance characteristics described here may inform the design of the next generation of totally implantable neural interfaces. This research tool provides a platform for translating discoveries in brain network dynamics to improved neurostimulation paradigms. Clinical trial registration no.: NCT01934296 (clinicaltrials.gov).

ObjectiveTo evaluate lumbar drain (LD) efficacy in transnasal resection of pituitary macroadenomas in preventing postoperative cerebrospinal fluid (CSF) leak, technique safety, and effect on length of hospital stay.MethodsWe conducted a retrospective data review of pituitary tumor patients in our institution who underwent surgery between December 2006 and January 2013. All patients were operated on for complete surgical resection of pituitary macroadenoma tumors. Patients were divided into 2 groups: group 1 received a preoperative drain, while LD was not preoperatively inserted in group 2. In cases of tumors with suprasellar extension with anticipation of high-flow leak, LD was inserted after the patient was intubated and in a lateral position. Lumbar drain was used for 48 hours, and the drain was removed if no leak was observed postoperatively. In documented postoperative CSF leak patients with no preoperative drain, the leak was treated by LD trial prior to surgical reconstruction. Cases in which leak occurred 6 months postoperatively were excluded.ResultsOur study population consisted of 186 patients, 99 women (53%) and 87 men (47%), with a mean age of 50.3+/-16.1 years. Complications occurred in 7 patients (13.7%) in group 1 versus 21 (15.5%) in group 2 (p=0.72). Postoperative CSF leak was observed in 1 patient (1.9%) in group 1 and 7 (5%) in group 2 (Fisher exact test=0.3). Length of hospital stay was a mean of 4.7+/-1.9 days in group 1 and a mean of 2.7+/-2.4 days in group 2 (p