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Intracranial arachnoid cysts (IACs) are benign, slow-growing developmental anomalies. In 4–14% of cases, IACs are accompanied by seizures. Since most cysts do not cause any symptoms, many lesions remain clinically silent and are found incidentally. As these lesions are slow-growing, they can become symptomatic over time and may give rise to epileptic seizures. Since IAC localization and seizure focus do not always coincide, a unifying theory between IACs and epileptogenesis is still lacking. We present a case of a 49-year old man who presented himself as a result of a first tonic-clonic insult. No major risk factors nor antecedents in his medical history were present. MRI confirmed a voluminous cystic lesion at the transition of motor cortex and supplementary motor area. Due to the large volume (with risk of cyst rupture) and compatible clinical, radiographic, and electroencephalographic features, cyst fenestration through craniotomy was performed. Epileptic seizures were resolved completely after this procedure. IACs are not uncommon and are frequently encountered incidentally in patients who present with epilepsy. Some authors have been classifying this association as rather exceptional. However, we illustrated a case in which excellent surgical results were obtained in a patient with focal epilepsy in which both clinical and electroencephalographic features were compatible with arachnoid cyst localization. Therefore, in patients with no other identifiable causes for epilepsy, thorough evaluation should be performed and surgical intervention should be considered. We developed a flowchart in order to guide clinicians in the appropriate approach of these patients. Therefore, this summary could serve as a scaffold for future high-quality studies concerning this topic.

Objectives Intraneural ganglia are benign fluid-filled cysts contained within the subepineurial space of peripheral nerves. The common peroneal nerve at the fibular neck is by far the most frequently involved, although other nerves can be affected as well. Although the differential diagnosis of foot drop in adults and children show some differences, clinical presentation, diagnostic workup, treatment and follow-up of intraneural ganglia are quite similar in both groups. The primary objective was to create an overview of intraneural ganglia in children, with an emphasis on diagnostic workup and potential pitfalls during neurosurgical intervention, based on all available literature concerning this topic and own center experiences. As a secondary objective, we tried to raise the awareness concerning this unique cause of foot drop in childhood. Patients and Methods We performed a review of the literature, in which children who developed foot drop secondary to an intraneural ganglion cyst of the common peroneal nerve were examined. A total of eleven articles obtained from MEDLINE were included. Search terms included: “pediatric”, “children”, “child”, “intraneural ganglia”, “intraneural ganglion cysts”, “foot drop”, “peroneal nerve” and “fibular nerve”. Additional studies were identified by checking reference lists. Furthermore, we present the case of a 12-year old girl with foot drop caused by an intraneural ganglion cyst. She underwent cyst decompression with evacuation of intraneural cyst fluid and articular branch disconnection. PRISMA and CARE statement guidelines were followed. Results We hypothesize that minor injury caused a breach in the joint capsule, resulting in synovial fluid egression along the articular nerve branch, corroborating the unifying articular theory and emphasizing the need for ligation of said branch. Foot drop is a predominant characteristic, explained by the proximity of the anterior tibial muscle motor branch near the articular branch nerve. In children, satisfactory motor recovery after surgical decompression is to be expected. Conclusion Sudden or progressive foot drop in children warrants an exhaustive neurophysiological and radiological workup. The management of intraneural ganglia is specific, consisting of nerve decompression, articular branch ligation and joint disarticulation, if deemed necessary. Our surgical results support the unifying articular theory and emphasize the importance of ligation and transection of the articular branch nerve, distally from the anterior tibial muscle branch, in order to prevent intraneural ganglia recurrence. This well-documented case adds depth to the current literature on this sparsely reported entity.

Objectives Tuberculous spondylitis (TS), also known as Pott’s disease (PD), is a form of tuberculosis in which the vertebral column is affected. Since the first description by Katz et al. in 1992, it became clear that Bacillus Calmette-Guerin (BCG) instillations in the treatment of superficial transitional cell carcinoma (TCC) form a plausible way in which PD is introduced. Nowadays, BCG forms the most effective treatment modality for superficial TCC. The incidence of other than minor complications have been estimated under five per cent. Here we report a case of TS after BCG-instillation in the treatment of TCC. Furthermore, all available literature concerning this topic was gathered into a systematic review. The primary objective was to create an overview of all available literature concerning TS after intravesical BCG-instillations, with an emphasis on the neurosurgical approach of these patients, forming a scaffold at which future case reports can be compared. As a secondary objective, we tried to raise the awareness concerning this very rare complication of intravesical BCG-instillation as a possible cause of low back pain (LBP). Patients and Methods We performed a systematic review, in which patients who developed TS after intravesical BCG-therapy in the treatment of TCC, were examined. A total of twenty-three articles (twenty-four cases) obtained from MEDLINE were included. Search terms included: “tuberculous spondylitis”, “Pott’s disease”, “vertebral osteomyelitis”, “intravesical”, “Bacillus Calmette-Guerin” and “transitional cell carcinoma”. Additional studies were identified by checking reference lists. Furthermore, we present a case concerning one of our own patients who consulted our Neurosurgical department with a similar clinical presentation. This systematic review is in conformity with the PRISMA-guidelines. The case report is in accordance with the CARE statement guidelines. Results Results are based on twenty-five cases (twenty-four cases extracted from previous literature and our case report). All included articles are case reports written in English. Publication year and recruitment time varies from 1992 to 2018. Mean age at clinical presentation varies from 35 to 94 years old (mean 74). All patients were male. Surgery was performed in 17 out of 25 cases (68%). A posterior approach was performed in seven cases (41%), zero anterior approaches (0%), a combined approach in five cases (29%) and not specified in five cases (29%). All patients received intravesical BCG-instillation in the treatment of TCC, ranging from one month to twelve years before clinical presentation (mean 26). Radiographic abnormalities were seen in thoracic vertebral segments in thirteen cases (52%), eleven cases in lumbar segments (44%), one at the thoracolumbar transition level (4%) and not in cervical vertebral segments. Conclusion Although very rare, TS should be part of the differential diagnosis in patients with LBP, even years after BCG-instillation for TCC. It mostly affects elderly men and involves the thoracolumbar spine through hematogenous spread via Batson’s plexus. Antitubercular therapy remains the mainstay in the treatment of TS. A posterior surgical approach, with debridement and stabilization, should be preferred when surgical intervention seems necessary. To our knowledge, this systematic review forms one of the first comprehensive reviews evaluating neurosurgical intervention for PD following intravesical BCG-therapy in the treatment of TCC.

Objectives Nowadays, several techniques have been developed in order to guide neurosurgeons during intended maximal safe resection of high-grade gliomas (HGG). Fluorescence-guided microsurgery using 5-aminolevulinic acid (5-ALA) is one of these. A large amount of studies have been performed evaluating benefits in newly diagnosed HGG. However, little is known about the safety, accuracy and efficacy in recurrent HGG. The primary objective of this thesis is to examine the value of 5-ALA in patients with recurrent HGG concerning diagnostic accuracy, extent of resection (EOR), safety and survival compared to white-light resection. As a secondary objective, we compared these results with current literature concerning 5-ALA in newly diagnosed HGG. Patients and methods We performed a systematic review and included eighteen articles obtained from MEDLINE, EMBASE, Web of Science and TRIP database. Search terms include “glioma” and “aminolevulinic acid”. Additional studies were identified through checking the reference lists. This study is in conformity with the PRISMA and BMJ guidelines. Results 5-ALA shows similar results regarding diagnostic accuracy in recurrent HGG compared to newly diagnosed HGG, although specificity and negative predictive value seem lower. It shows complementary value in identifying tumor boundaries compared to MRI-neuronavigation. Diagnostic accuracy is not influenced by previous chemo- or radiotherapy. New neurological deficits proved to be similar and were in general mainly temporary. However, adverse events overall were more common. Therefore, indications for repeat surgery should be followed strictly. 5-ALA might increase overall survival in recurrent gliomas, but has no clear impact on progression-free survival. Conclusion 5-ALA should be regarded as a useful and safe intraoperative tool in recurrent glioma surgery.

Background Peroneal nerve entrapment is the most common peripheral mononeuropathy of the lower limbs. Foot drop, a common presentation, leads to an impaired eversion and dorsiflexion of the foot. An intriguing observation is the occurrence of foot drop secondary to weight loss. Methods A retrospective study of patients surgically treated for peroneal nerve entrapment was performed between January 1, 1995 and December 31, 2016, at the Department of Neurosurgery, Genk, Belgium. Out of a total of 421 patients, 200 patients with foot drop secondary to weight loss were included. For each subject, motor and sensory outcomes after external neurolysis were investigated. As a primary objective, we examined the postoperative outcomes of external neurolysis as a treatment for foot drop in patients with peroneal nerve entrapment at the fibular head secondary to weight loss. As a secondary objective, we analyzed the correlation between patient characteristics and the success rate of external neurolysis. Results When defining success as a postoperative MRC score of 4 or 5, external neurolysis has a success rate of 85% in patients with foot drop secondary to weight loss. A significant difference (P = < 0.0001) between postoperative and preoperative MRC scores indicates that external neurolysis leads to significant improvement of motor function in patients with foot drop secondary to weight loss. A multiple logistic regression model showed that "preoperative MRC scores" and "duration of symptoms" were the only variables with an impact on postoperative MRC scores. Other variables such as "age," "gender," and "side of entrapment" had no significant impact on postoperative results. Conclusions Statistical analysis emphasizes the important role of external neurolysis in the treatment of peripheral peroneal nerve entrapment. Therefore, external neurolysis at the fibular head should be regarded as a very effective and safe procedure in patients with foot drop secondary to weight loss.