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Percutaneous cannulation of foramen ovale (FO) for treatment of trigeminal neuralgia, classically performed according to empirical landmarks and under fluoroscopic guide, may be difficult, time-consuming, and burdened with vascular or neurological complications related to close anatomic relationships.To investigate cannulation of FO for treatment of trigeminal neuralgia assisted by O-Arm O2-based navigation, to assess safety and accuracy.Nineteen patients underwent percutaneous balloon compression of Gasserian ganglion assisted by navigation provided by O-Arm O2 and StealthStation. Clinical outcomes according to Barrow Neurological Institute Pain Score, time of recurrence, side effects, and complications, as well as technical aspects as time of the procedure and number of tracks were investigated and evaluated. Obtained data were compared with current literature in a systematic review.The median time for procedure was 46 minutes; cannulation of the FO was performed in a median of 3 minutes and 47 seconds, in a single track in 16 patients, while 3 cases required a further O-Arm acquisition to check the needle position. No complications were observed. Onset of facial hypoesthesia was recorded in 10 patients and dysesthesia in 5. Although at a median follow-up of 12.7 months 7 patients had recurrence after an average pain-free period of 7.3 months, all but 2 patients had improvement in pain score.Advantages powered by navigation should be addressed in accuracy, lower complication rate, and success of cannulation even in case of previous treatments or anatomic variations, rather than in effective reduction of surgical time.

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

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

Hereditary spastic paraplegia (HSP) include various sporadic and hereditary neurodegenerative disorders, characterized by progressive spasticity and weakness of lower limbs, possibly associated to additional features.We report a male HPS patient in his 40 s, showing mental retardation associated with language impairment, dysarthria, and increased urinary frequency. Three months after treatment with electric chronic high-frequency cervical spinal cord stimulation (HF-SCS), he showed an amelioration of motor symptoms (lower limbs spasticity and gait), dysarthria, cognitive functioning (language and constructive praxic abilities), and urinary symptoms (decreased urinary frequency). Single-photon emission computed tomography (SPECT) showed a postoperative increase of cerebral perfusion in right frontal cortex and temporal cortex bilaterally.In our patient, HF-SCS might have induced an activation of ascending neural pathways, resulting in changes in activity in various cortical areas (including sensory-motor cortical areas), which may give rise to a modulation of activity in spared descending motor pathways and in neural networks involved in cognitive functions, including language. Although further studies in patients with HPS are needed to clarify whether HF-SCS can be a suitable treatment option in HSP, our observation suggests that HF-SCS, a minimally invasive neurosurgical procedure, might induce beneficial effects of on various symptoms of such orphan disease.

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

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

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

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

Background: Subthalamic deep brain stimulation (STN-DBS) effects may decrease with Parkinson’s disease (PD) progression. There is no indication if, when, and how to consider the interruption of DBS treatment in late-stage PD. The objective of the current study was to investigate the percentage of “poor stimulation responders” among late-stage PD patients for elaborating an algorithm to decide whether and when DBS discontinuation may be considered. Methods: Late-stage PD patients (Hoehn Yahr stage ≥4 and Schwab and England Scale

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

Background Elbow trauma, cubitus valgus deformity, and prolonged flexion of the elbow are recognized risk factors for ulnar nerve entrapment. Case Description The 3 conditions coincided in the present case. In fact, a 36-year-old woman had a bilateral severe congenital cubitus valgus. A trauma of the right elbow caused luxation and supracondylar humeral fracture for which the joint was fixed in flexion at 90° for 1 month. The patient developed a severe ulnar nerve entrapment syndrome that did not respond to several months of physiotherapy and active mobilization of the elbow. The symptoms recovered after surgical decompression and anterior subcutaneous transposition of the nerve. Conclusions The present case illustrates how the development of a cubital tunnel syndrome should be considered as the expected outcome of a long immobilization in flexion of an elbow with a severe cubitus valgus. A simple subcutaneous anterior transposition of the ulnar nerve might be recommended before a long immobilization of a cubitus valgus elbow is performed.

Motor cortex stimulation (MCS) was introduced by Tsubokawa in 1991 1 for the treatment of thalamic pain, after coming to the conclusion that the hyperactivity of thalamic neurons after spino-thalamic tractotomy was inhibited by stimulation of the motor cortex. MCS has been reported not only to be effective on pain, but also to improve movement disorders such as Parkinson's disease, tremor, dystonia, poststroke movement disorders and hemiparesis. Most of these publications are case reports or small series, and the real impact of MCS on movement disorders remains to be determined.In order to clarify this point, we conducted a PubMed search from 1991 to 2016 using established MeSH words. A total of 40 papers were selected and examined. Furthermore, personal experience with MCS for Parkinson's disease and akinesia, is reported.Only four studies were randomized controlled clinical trials: three out of four failed to demonstrate the efficacy of MCS at short term.At long term, MCS seems to show a clinical positive effect in the studies prolonged in an open observational trial.

Optic pathway-hypothalamic gliomas (OPHGs) are rare, often unresectable tumors that mostly occur in childhood. Their biological behavior is unpredictable, although they tend to follow an aggressive clinical course in infants and a benign course in children with neurofibromatosis type 1. Optimal management is still controversial. Nonprogressing OPHGs are usually followed by surveillance alone. Surgery is advocated for progressing tumors to decompress the optic pathways, obtain a quick relief from intracranial hypertension and allow histologic examination (when needed). The current trend is in favor of conservative surgical behavior, except for resectable tumors. Chemotherapy is increasingly used in the management of OPHGs, especially in infants, to delay radiotherapy. Carboplatin and vincristine are the most frequently used drugs, although several chemotherapeutic agents in different combinations are currently employed with good results. Radiotherapy is utilized in children over 5 years of age as an adjuvant or as an alternative to surgery. The prognosis of OPHGs is quite good, with regard to the overall survival rate (70-100% at 5 years), but less favorable in terms of late morbidity.

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

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

End-to-side neurorrhaphy (ESN) or terminolateral neurorraphy consists of connecting the distal stump of a transected nerve, named the recipient nerve, to the side of an intact adjacent nerve, named the donor nerve, "in which only an epineurial window is performed". This procedure was reintroduced in 1994 by Viterbo, who presented a report on an experimental study in rats. Several experimental and clinical studies followed this report with various and sometimes conflicting results. In this paper we present a review of the pertinent literature. Our personal experience using a sort of end-to-side nerve anastomosis, in which the donor nerve is partially transected, is also presented and compared with ESN as defined above. When the proximal nerve stump of a transected nerve is not available, ESN, which is claimed to permit anatomic and functional preservation of the donor nerve, seems an attractive technique, though yet not proven to be effective. Deliberate axotomy of the donor nerve yields results that are proportional to the entity of axotomy, but such technique, though resembling ESN, is an end-to-end neurorrhaphy. Neither experimental or clinical evidence support liberalizing the clinical use of ESN, a procedure with only an epineurial window in the donor nerve and without deliberate axotomy. Much more experimental investigation needs to be done to explain the ability of normal, intact nerves to sprout laterally. Such procedure appears justified only in an investigational setting.

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

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

Spinal cord injury often results in irreversible and permanent neurologic deficits below the lesion level. Nowadays, treatment is limited to drugs and/or physiotherapy aimed at compensating disability. New experimental studies focus on the transplantation of cells capable of surviving, regenerating tissue, recovering functions and/or improving symptoms. A review of such type of studies on spinal cord reconstruction published between 1991 and 2004 is presented. In the latter years, cell transplantation appeared as the most promising approach in spinal cord regeneration research. To date, this promise has not been maintained, despite the appearance of new attractive cell populations for grafting, such as neural stem cells. The demonstration that stem cells exist in the adult brain and that they can be isolated and expanded in vitro offers the possibility to test such interesting cells in the paraplegic rat. Some neurotrophic factors can facilitate axonal regeneration and neuronal survival. Therefore, the development of strategies, such as implanting neural stem cells engineered to secrete neurotrophic factors directly in the lesion site, could be important to promote regeneration in the injured spinal cord. Despite all the strategies used till now, the problem of the paraplegic rat remains. Only the solution of such problem will authorize studies in higher mammals and, finally, the clinical application in human patients. The paraplegic adult rat with a T8 spinal cord transection should be considered the standard experimental model to be used in spinal cord reconstruction studies. Function and anatomic results are undisputed only after spinal cord transection.

Hypoglossal-facial nerve anastomosis (HFA) is the most popular surgical procedure to reinnervate facial muscles after injury of the facial nerve. Section of the hypoglossus causes paralysis and atrophy of the hemi-tongue. In the attempt to overcome this consequence, the hemihypoglossal-facial nerve anastomosis (HHFA) has been proposed and only a half of the main trunk of the hypoglossus is connected to the distal stump of the facial nerve. In the rat, we have studied experimentally the anatomical nuclear changes after HFA and HHFA with the aim of establishing the quantitative motoneuron innervation of facial muscles obtained with each one of the two operative options. Horseradish peroxidase (HRP) injected in both types of anastomosis labeled not only hypoglossal motoneurons, but also facial motoneurons. HFA appeared to offer a significant quantitative motoneuron innervation higher than HHFA and then a higher probable better functional recovery. Both HFA and HHFA performed immediately after section of the facial nerve in rats did not result in a phenomenon of motor hyperinnervation. In our experimental model, the proximal facial nerve stump was coagulated at the stylomastoid foramen to avoid regeneration. Then, the labeled motoneurons into the facial nucleus could really be the expression of axonal projections from facial motoneurons to the hypoglossus nerve and facial muscles. No labeled motoneurons were seen contralaterally as we observed previously after section and repair of several nerves.