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This article investigates the clinical and radiological characteristics of captive bolt gun head injuries, a rare form of low-velocity penetrating brain injury. Eleven consecutive patients were included in the study. Vascular injuries and the rate of infection were systematically analyzed. Radiological findings reveal common bolt trajectories in the anterior cranial fossa, with identified risk factors for a poor outcome including trajectory crossing midline, hematocephalus, and paranasal sinus involvement. Only one patient had a good outcome. Despite meticulous microsurgical techniques, this study highlights often unfavorable clinical outcomes in captive bolt gun injuries, with vascular injury identified as a potential contributing risk factor for a poor outcome. Knowledge of variant vascular tree anatomy and corresponding vascular territory is important. To avoid potential vascular injuries, a complete removal of bone fragments was not always performed and it did not increase the rate of infection, challenging the conventional wisdom advocating for the complete removal of bone fragments. These findings contribute novel insights into captive bolt gun-related injuries, paving the way for further research.

Occult spinal dysraphisms (OSDs) are caused by various defects in the embryogenesis of the spinal cord and represent an obstacle to the ascent of the conus, which allows the conus to pass from the lower levels of the spinal canal to the final position between L1 and L2 during normal foetal life. When an OSD tethers the spinal cord at the lower levels, it can lead to neurological symptoms, better known as tethered cord syndrome. Surgical treatment of OSD is primarily aimed at untethering the spinal cord. In asymptomatic patients, this can protect against the long-term development of neurological deficits. In symptomatic patients, this can halt or limit the progression of existing symptoms. The aim of this study is to examine all paediatric and adult patients diagnosed with OSD and treated in the Department of Neurosurgery at the University Medical Centre Ljubljana during the 5-year period of 2016-2021. All patients diagnosed with OSD during this period were included in the study. Patient characteristics, treatment modalities and outcomes were studied with the aim of describing the differences between the paediatric and adult population and defining the rationality of treating these pathological conditions. We included in the study 52 patients with 64 occult dysraphic lesions. Adults (>18 years old) represented 15/52 (28.8%) of all patients, while 37/52 (71.8%) were children. The most common OSDs were conus lipomas, followed by dermal sinus tracts, filum terminale lipomas and split cord malformations. Surgical treatment was performed in 35/52 (67.3%) cases, while conservative management was chosen in 17/52 (32.6%) cases. The preoperative presence of symptoms was statistically higher in adults than in children ( p = 0.0098). Surgery on complex spinal cord lipomas was statistically related to a higher rate of postoperative neurological complications ( p = 0.0002). The treatment of OSD is complex and must be based on knowledge of the developmental anomalies of the spine and spinal cord. Successful surgical treatment relies on microsurgical techniques and the use of neuromonitoring. Successful treatment can prevent or limit the occurrence of neurological problems.

Worldwide, the novel coronavirus disease 2019 (COVID-19) has become a significant threat to global health. Worldwide, COVID-19 has affected the health service also in Slovenia. During this time, neurosurgery is facing difficulties in its service, both in emergency and elective surgeries. In the article, we describe the anti-COVID-19 measures taken at our neurosurgical department in a medical centre in Ljubljana, Slovenia, and analysed and compared the number of emergency and elective neurosurgical procedures during the time of the pandemic.

Chiari malformations encompass various radiological and clinical entities, sharing the herniation of the rhombencephalic structures through the foramen magnum as a common characteristic. They can be symptomatic or asymptomatic. The therapeutic strategies for these malformations differ on the basis of the diverse pathophysiologic processes that cause them. As Chiari malformations are caused by various pathophysiologic processes, they must be recognized promptly to select the best treatment for each single case., Competing Interests: Conflict-of-interest statement: The authors of this manuscript having no conflicts of interest to disclose., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Spinal schwannomas coexisting with meningiomas in patient without neurofibromatosis are extremely rare lesions. Here we present a case of 59-year-old patient with concurrent spinal meningioma and schwannoma at L1-L2 spinal level. This is the first case of the concurrent intradural tumours at the same lumbar level.

Objective: The aim of this article is to present our experience with continuous dynamic mapping (CDM) of the corticospinal tract (CST) when removing tumors in motor eloquent regions., Methods: We studied 44 patients with a brain tumor adjacent to the CST where CDM was used. The mapping probe was integrated at the tip of the suction device. Thresholds for eliciting MEPs were recorded. In all patients, along with CDM, MEPs to direct cortical stimulation were also monitored throughout the operation. Motor function was assessed preoperatively, after the procedure and on discharge., Results: In the series, there were 37 patients with gliomas, six with brain metastasis, and one with cavernoma. The threshold to elicit MEPs in CDM was >20 mA in 17 cases, 16-20 mA in six cases, 11-15 mA in six cases, 6-10 mA in nine cases and 2-5 mA in six cases. MEPs to direct cortical stimulation were preserved in all patients. In three cases a new temporary motor deficit was noted. No new permanent motor deficit occurred. Gross total resection was reached in 57% of cases., Conclusions: From our experience, the combined use of CDM and MEPs to direct cortical stimulation improves the safety of surgery in the proximity of the CST, and at the same time offers the possibility of higher rates of gross total resection., (Copyright © 2020 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

Aims: Despite the important prognostic value of brain invasion in meningiomas, little attention has been paid to its massessment, and the parameters associated with brain invasion assessability (identification of brain tissue in the surgical specimen) are not well characterized. The aim of our study was to determine the parameters that are associated with brain invasion assessability and brain invasion in meningiomas., Material and Methods: By binary logistic regression analysis, we studied the association of various clinical and pathologic parameters with brain invasion assessabilitym and brain invasion in 294 meningiomas: 149 unselected consecutive meningiomas with extensive sampling, diagnosed in 2009 and 2010, collected prospectively, and 145 meningiomas diagnosed in 1999 and 2000 when little attention was paid to brain invasion assessment., Results: Meningioma grade, size and number of tissue blocks were independent predictors of brain invasion assessability. Brain tissue was identified in 78 of 233 (33%) benign, 33 of 51 (65%) atypical, and 10 of 10 (100%) malignant meningiomas. In univariate analysis, group (prospective vs.retrospective), type (recurrent vs. primary), cleavability, meningioma grade and mitotic count were predictors of brain invasion, while only meningioma grade, and group retained predictive value in multivariate analysis. Brain invasion, when assessable, was identified in 22 of 78 (28%) benign, 21 of 33 (64%) atypical, and 10 of 10 (100%) malignant meningiomas., Conclusions: Brain invasion assessability is related to meningioma grade and size and can be improved by extensive sampling of meningioma surgical.

Background: Since precise diagnostic criteria for atypical and malignant meningiomas (AMMs) were provided for the first time in the 2000 World Health Organization (WHO) criteria, there is only sparse information about possible prognostic factors in the group of AMMs., Objective: To evaluate the prognostic significance of various histological and clinical parameters in AMMs, with an emphasis on location, mitotic count, brain invasion, and Ki67 labeling index., Methods: We analyzed 86 primary AMMs, 76 of which were atypical and 10 of which were malignant, diagnosed according to the 2000 WHO classification. Multivariate Cox survival analyses were performed., Results: High mitotic count, brain invasion, and the parasagittal-falcine location of the tumor were significantly associated with decreased recurrence-free survival in multivariate analysis. Brain invasion was present in 25 of 37 cases in which brain tissue was identified in the tumor specimens. When brain invasion was not included in the analysis because of the limited number of cases in which it could be assessed, high mitotic count, Ki67 index >4%, the presence of macronucleoli, and parasagittal-falcine location were significant predictors of shorter recurrence-free survival., Conclusion: AMMs, as defined by 2000 WHO, are biologically heterogeneous. Recurrence-free survival can be further stratified by location and histological parameters, especially mitotic count, brain invasion, and Ki67 labeling index. Not only brain invasion, but also the presence or absence of brain tissue in surgical specimens should be reported, because the absence of brain invasion, when brain tissue is identified, provides very important positive prognostic information.

Background: In the present article, we assessed the role, adequacy and application accuracy of intraoperative visual guidance based on the computer 3D visualisation of preoperative medical images in the surgery of superficial brain tumours., Materials and Methods: For 30 consecutive patients with convexity meningioma or cortical/subcortical brain tumour, we used 3D visualisation of post-contrast fast spoiled gradient recalled (FSPGR) MR images to plan optimal positions for the trepanation opening and/or corticotomy site. At the beginning of the surgery, planned positions were transferred to the scalp and the cortical surface of the patient by visually matching the 3D surfaces with the operative field. The feasibility of visual matching was assessed by counting the number of cases in which this was possible. On the exposed cortical surface, we measured the mismatch between the centre of the actual trepanation opening and the planned corticotomy site, where possible., Results: During computer-assisted 3D planning, the centre of the trepanation opening, initially defined on the basis of 2D diagnostic images, was redefined in all our cases by an average repositioning distance of 19.7 mm  +/- 7.6 mm. During surgery, the transfer of the planned centre of the trepanation opening and the corticotomy site was possible in all (30/30) and in 70% (19/27) of the cases, respectively. Where assessable, the mismatch between the centre of the actual trepanation opening and the planned corticotomy site was less than 1 cm in 70% of cases (12/17) and more than 2 cm in 6% (1/17) of cases., Conclusions: Intraoperative visual guidance based on 3D visualisation proved to be adequate and accurate for locating superficial brain tumours in cases where transfer of planned surgical targets to the surgical field was possible. Decision about its use should be based on preoperative computer-assisted 3D planning, in which the feasibility of visual matching during surgery can and must be assessed.

Background: The objectives of this study were to correlate preoperative changes in SEPs with clinical sensory dysfunction and to establish their importance in planning the microsurgical approach, either by DM myelotomy or by DREZ myelotomy, for patients with syringomyelia., Methods: In addition to conducting clinical sensory examination, we evaluated the N13 potential after median nerve stimulation and CPs after tibial nerve stimulation intraoperatively before performing myelotomy on patients with syringomyelia (N = 14)., Results: Eleven patients with intact DS presented with unilateral PTD, and 9 had distressing unilateral dermatomal pain. Deep sensibility was affected in 3 patients (bilaterally in 1 patient) without PTD. Patients with PTD were likely to have spontaneous pain (P = .005). A significant correlation between preoperative PTD and the absence of the N13 potential was demonstrated on the right (P = .015) and left (P = .004) sides. In patients with PTD, DREZ myelotomy on the symptomatic side is suggested as the treatment of choice, whereas DM myelotomy might be superior in patients without PTD., Conclusions: Absence of pain or temperature sensation in patients with syringomyelia is usually accompanied by same-sided loss of the N13 potential, suggesting damage to the DH gray matter. Deep sensibility is typically normal, and DREZ myelotomy with preservation of DCs is proposed as the treatment of choice. Conducted potentials are usually distorted in patients with normal pain or temperature sensation and affected vibration and posture sensation, suggesting damage to DCs and making DM myelotomy the treatment of choice. Electrophysiologic and clinical data support the use of DREZ myelotomy in syringosubarachnoid shunting for syringomyelia in patients whose DCs have an intact function.

Dysplastic gangliocytoma of the cerebellum is a rare disorder requiring surgical resection. During surgical exploration, the margin with normal cerebellar tissue is often not distinct. We present here a case in which we surgically treated a patient with Lhermitte-Duclos disease, and discuss radical resection of the tumour. The patient was first admitted at the age of 34 years. A MRI scan revealed a large left cerebellar mass typical of dysplastic gangliocytoma. Postoperatively the patient developed severe cerebellar syndrome with only partial recovery after 4 years. MRI revealed no impairment of cerebrospinal fluid circulation; the mass in the left cerebellum had been removed, and no recurrent disease was visible. Clinical problems after gross total or complete removal of Lhermitte-Duclos lesions have not been reported in the literature, but herein we stress the importance of extreme caution in removing these lesions in cerebellar areas that have no distinct border between the tumour and normal tissue.

Aim: To analyze long-term clinical results of coagulation lesions of the dorsal root entry zone (DREZ) in patients with deafferentation pain due to brachial plexus avulsion and to correlate the pain relief after DREZ coagulation with pain duration before the DREZ coagulation., Methods: Twenty-six patients with intractable deafferentation pain after brachial plexus avulsion lesion were treated for pain at the Department of Neurosurgery. Junctional coagulation lesion was made with bipolar forceps along the DREZ. The patients assessed post-operative analgesic effect using a visual analog scale at 1 week, 1 year, 3 years, and 5 years after the surgery., Results: The greatest pain relief was reported immediately after the DREZ procedure. Over the 5-year follow-up period, the pain relief effect gradually and significantly decreased. There were no significant differences between the pain relief evaluated at 1 week and after 1 year and between the pain relief evaluated at 1 week and after 3 years. There was a correlation between the pain duration before the surgery and pain relief after the surgery, with best correlation found between pain duration before surgery and pain relief 5 years after DREZ procedure (r = 0.623, P = 0.007)., Conclusion: The long-term follow up showed that the pain relief gradually decreased over 5 years after surgery. However, the pain relief still did not significantly decrease after 3 years.

Low amplitude high frequency waves (LHW) were investigated in normal and patient cervical somatosensory evoked potentials after median nerve stimulation (CSEP) in parallel to normal and patient conducted somatosensory evoked potentials (SEP) after tibial nerve stimulation. Normal recordings were obtained in five subjects undergoing dorsal root entry zone (DREZ) coagulation for pain relief. Patient recordings were obtained in 11 subjects suffering from either syringomyelia, spinal cord tumour, or both. All recordings were made intraoperatively from the dorsal spinal cord surface using the subpial recording technique. Normal CSEP showed typical triphasic potential starting with an initial P9, followed by N13 and a final positivity, P1. Numerous LHW were superimposed on slow triphasic potential. To improve the visibility of LHW, slow triphasic potential was removed from the original CSEP. Potentials thus obtained contained only high frequency components of CSEP, i.e. LHW. They were compared with conducted SEP after tibial nerve stimulation. Comparison revealed similarities in high frequency, low amplitude and general wave form, LHW thus showing characteristics of conducted potential. Duration was found to be significantly shorter than normal duration in both patient LHW (Student's t-test, P < 0.0005) and patient conducted SEP (Student's t-test, P = 0.064). A shorter duration was associated with worsening of configuration in patient LHW and patient conducted SEP. These changes of LHW could not be connected with distortion of N13 seen in patient CSEP. A shorter duration and worsening of configuration in patient LHW were most prominent in cases with a loss of vibration and posture senses, but were also observed in cases where only pain and temperature senses were affected. We therefore concluded that cuneate fascicle is the most likely generator of LHW, although the participation of other cervical long sensory tracts, e.g. spinothalamic tract, cannot be ruled out.

Cortico-spinal potentials (CSPs) to transcutaneous motor cortex stimulation were recorded epidurally and subpially in 8 patients undergoing spinal cord surgery. In 6 patients without cortico-spinal tract involvement, a CSP consisted of a direct (D) wave, which was followed by indirect (I) waves at a higher stimulus intensity. The D wave appeared at 25-50% of the maximum stimulus intensity. With increasing stimulus its amplitude levelled off between 10 and 30 microV when recorded epidurally. At high stimulus a prominent indirect potential (I' wave) appeared which followed the D wave after 2.2-3.6 msec. The D and I' wave conduction velocities calculated in 3 cases were identical -65, 70 and 80 m/sec. Subpial records had larger amplitudes than epidural ones but were of the same configuration. In 2 patients with spastic paraparesis the CSP changes were detected below the site of the cord lesion.