Deep learning-accelerated image reconstruction in back pain-MRI imaging: reduction of acquisition time and improvement of image quality.

INTRODUCTION: Low back pain is a global health issue causing disability and missed work days. Commonly used MRI scans including T1-weighted and T2-weighted images provide detailed information of the spine and surrounding tissues. Artificial intelligence showed promise in improving image quality and simultaneously reducing scan time. This study evaluates the performance of deep learning (DL)-based T2 turbo spin-echo (TSE, T2DLR) and T1 TSE (T1DLR) in lumbar spine imaging regarding acquisition time, image quality, artifact resistance, and diagnostic confidence. MATERIAL AND METHODS: This retrospective monocentric study included 60 patients with lower back pain who underwent lumbar spinal MRI between February and April 2023. MRI parameters and DL reconstruction (DLR) techniques were utilized to acquire images. Two neuroradiologists independently evaluated image datasets based on various parameters using a 4-point Likert scale. RESULTS: Accelerated imaging showed significantly less image noise and artifacts, as well as better image sharpness, compared to standard imaging. Overall image quality and diagnostic confidence were higher in accelerated imaging. Relevant disk herniations and spinal fractures were detected in both DLR and conventional images. Both readers favored accelerated imaging in the majority of examinations. The lumbar spine examination time was cut by 61% in accelerated imaging compared to standard imaging. CONCLUSION: In conclusion, the utilization of deep learning-based image reconstruction techniques in lumbar spinal imaging resulted in significant time savings of up to 61% compared to standard imaging, while also improving image quality and diagnostic confidence. These findings highlight the potential of these techniques to enhance efficiency and accuracy in clinical practice for patients with lower back pain.

Anatomy and microsurgical relevance of the outer arachnoid envelope around the olfactory bulb based on endoscopic cadaveric observations.

BACKGROUND: Surgical approaches to the anterior cranial fossa have great risk of damaging the olfactory tract and bulb. The goal of this study was to describe the outer arachnoid envelope around the olfactory bulb which plays significant role in the approach-related injury of the nerve. MATERIAL AND METHODS: A total of 20 fresh human cadaveric heads were examined as a following: 5 cadaveric heads were used to describe a gross overview of the topographic anatomy of the outer arachnoid cover of the olfactory bulb. In 15 cadaveric heads endoscopic surgical approaches were performed to examine the in situ undisrupted anatomy of the outer arachnoid around the olfactory bulb. Four cadaveric heads were used for lateral subfrontal approach, 5 heads for medial subfrontal, 3 heads for median subfrontal approach and 3 heads for anterior interhemispheric approach. RESULTS: The outer arachnoid membrane of the frontal lobe attaches the olfactory bulb strongly to the above lying olfactory sulcus. Only the most rostral portion of the olfactory bulb became slightly detached from the frontal lobe. The outer arachnoid forms a decent protrusion around the tip of the olfactory bulbs. The fila olfactoria have their own outer arachnoid cover as a continuation of the same layer of the olfactory bulb. The effect of brain retraction and manipulation forces on the olfactory bulb and the role of the here located arachnoid membranes were visually analysed and described in detail through the performed four different neurosurgical approaches. CONCLUSION: The results of our observations provide important anatomical details for the preservation of smelling during neurosurgical procedures.

Surgical management of syringomyelia associated with spinal arachnoid web: strategies and outcomes.

Spinal arachnoid web (SAW) is a rare disease entity characterized as band-like arachnoid tissue that can cause spinal cord compression and syringomyelia. This study aimed to analyze the surgical management of the spinal arachnoid web in patients with syringomyelia, focusing on surgical strategies and outcomes. A total of 135 patients with syringomyelia underwent surgery at our department between November 2003 and December 2022. All patients underwent magnetic resonance imaging (MRI), with a special syringomyelia protocol (including TrueFISP and CINE), and electrophysiology. Among these patients, we searched for patients with SAW with syringomyelia following careful analysis of neuroradiological data and surgical reports. The criteria for SAW were as follows: displacement of the spinal cord, disturbed but preserved CSF flow, and intraoperative arachnoid web. Patients were evaluated for initial symptoms, surgical strategies, and complications by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. Of the 135 patients, 3 (2.22%) fulfilled the SAW criteria. The mean patient age was 51.67 ± 8.33 years. Two patients were male, and one was female. The affected levels were T2/3, T6, and T8. Excision of the arachnoid web was performed in all cases. No significant change in intraoperative monitoring was noted. Postoperatively, none of the patients presented new neurological symptoms. The MRI 3 months after surgery revealed that the syringomyelia improved in all cases, and caliber variation of the spinal cord could not be detected anymore. All clinical symptoms improved. In summary, SAW can be safely treated by surgery. Even though syringomyelia usually improves on MRI and symptoms also improve, residual symptoms might be observed. We advocate for clear criteria for the diagnosis of SAW and a standardized diagnostic (MRI including TrueFISP and CINE).

Surgical Treatment of Craniopharyngiomas in Adults: Comparison between Primary Surgery and Surgery for Recurrence.

OBJECTIVE: Few studies have investigated the differences in outcomes between primary and repeat surgery for a craniopharyngioma in adults. As a result, a treatment concept for adult patients with a craniopharyngioma has not yet been established. The present study aimed to retrospectively analyze adult patients with craniopharyngioma to compare surgical outcomes between primary surgery and surgery for recurrence. METHODS: The demographic and clinical data of 68 adult patients with craniopharyngioma who had primary surgery (n=50) or surgery for recurrence (n=18) were retrospectively analyzed. In addition, the patients were followed up for an average of 38.6 months (range: 1-133 months). RESULTS: The cohorts of patients undergoing primary surgery or repeat surgery did not differ preoperatively in terms of demographic data, or radiological tumor features. However, patients with recurrent craniopharyngioma had significantly more pituitary hormone deficits and hypothalamo-pituitary disorders before surgery compared with patients with newly diagnosed craniopharyngioma. The success rate of complete resection in primary surgery was 53.2%. Even after repeat surgery, a satisfactory rate of complete resection of 35.7% was achieved. Operative morbidity was increased neither in patients with repeat surgery compared with those with primary surgery (postoperative bleeding P=0.560; meningitis P=1.000; CSF leak P=0.666; visual disturbance P=0.717) nor in patients with complete resection compared with those with partial resection. We found no difference in recurrence-free survival between initial surgery and repeat surgery (P=0.733). The recurrence rate was significantly lower after complete resection (6.9%) than after partial resection (47.8%; P<0.001). CONCLUSION: Attempting complete resection is justified for not only those with newly diagnosed craniopharyngioma but also for those with recurrent craniopharyngioma. However, the surgeon must settle for less than total resection if postoperative morbidity is anticipated.

Case Report: Posterolateral Epidural Supra-C2-Root Approach (PESCA) for Biopsy of a Retro-Odontoid Lesions in Same Sitting After Occipitocervical Fixation and Decompression in a Case of Crowned Dens Syndrome With Brainstem Compression and Displacement.

Background: 'Crowned dens syndrome' (CDS) is a special form of calcium pyrophosphate dihydrate deposition disease which is characterized radiologically by a halo-like or crown-like distribution in the periodontoid region and clinically by cervical pain. Herein, we will describe our experience of posterolateral epidural supra-C2-root approach (PESCA) for biopsy of retro-odontoid lesions in one surgical session after occipitocervical fixation and decompression in a patient with CDS and massive brainstem compression. Case Presentation: A 70-year-old woman presented to our department with a 4-week history of progressive walking impairment, neck pain, neck rigidity, fever, dizziness, slight palsy of the left hand, and multiple fall episodes. Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) and cervical spine revealed a lesion of the odontoid process and the retro-odontoid region with mainly solid components, as well as small cystic components, and brainstem compression and displacement. In first step, fusion surgery of the CVJ C0-C4 was performed with occiptocervical decompression. After fusion and decompression the lower lateral part of the C1 arc and the lateral superior part of the left side of the C2 arc were removed. The entry point was located directly above the superior part of the C2 root. A biopsy of the lateral portions of the lesions was obtained by bioptic forceps under microscope guidance. Pathologic examination of the mass revealed deposition of birefringent crystals compatible with calcium pyrophosphate. In addition to the clinical symptoms (especially neck pain), the diagnosis of CDS was made. Non-steroidal inflammatory drugs (NSAIDs) and colchicine (and later magnesium) were started. At follow-up examination 6 months after surgery, an MRI scan of the cervical spine revealed regression of the pannus and the cyst with replacement of the brainstem, clinical improvement of walking, and increased strength of the left hand. Conclusions: This study demonstrates that PESCA can be used to obtain tissue for pathological analysis in one surgical sitting after fusion and decompression and that fusion, decompression, and PESCA (in the same session) together with subsequent conservative management could be a good alternative for the treatment of CDS.

Glioma-Specific Diffusion Signature in Diffusion Kurtosis Imaging.

PURPOSE: This study aimed to assess the relationship between mean kurtosis (MK) and mean diffusivity (MD) values from whole-brain diffusion kurtosis imaging (DKI) parametric maps in preoperative magnetic resonance (MR) images from 2016 World Health Organization Classification of Tumors of the Central Nervous System integrated glioma groups. METHODS: Seventy-seven patients with histopathologically confirmed treatment-naïve glioma were retrospectively assessed between 1 August 2013 and 30 October 2017. The area on scatter plots with a specific combination of MK and MD values, not occurring in the healthy brain, was labeled, and the corresponding voxels were visualized on the fluid-attenuated inversion recovery (FLAIR) images. Reversely, the labeled voxels were compared to those of the manually segmented tumor volume, and the Dice similarity coefficient was used to investigate their spatial overlap. RESULTS: A specific combination of MK and MD values in whole-brain DKI maps, visualized on a two-dimensional scatter plot, exclusively occurs in glioma tissue including the perifocal infiltrative zone and is absent in tissue of the normal brain or from other intracranial compartments. CONCLUSIONS: A unique diffusion signature with a specific combination of MK and MD values from whole-brain DKI can identify diffuse glioma without any previous segmentation. This feature might influence artificial intelligence algorithms for automatic tumor segmentation and provide new aspects of tumor heterogeneity.

Posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process in same sitting after occipitocervical fixation and decompression-perioperative management and how to avoid vertebral artery injury.

This study aims to describe the posterolateral epidural supra-C2-root approach (PESCA), which might be a good alternative to the transoral, anterolateral, and other posterolateral approaches for biopsy of lesions of the odontoid process (OP). The preoperative planning of PESCA included computerized tomography (CT), CT-angiography, and three-dimensional reconstruction (if possible, even with three-dimensional print) to analyze the angle of the trajectory and the anatomy of the vertebral artery (VA). For PESCA, the patient is positioned under general anesthesia in prone position. In case of an osteolytic lesion with fracture of the OP, an X-ray is performed after positioning to verify anatomic alignment. In the first step, in case of instability and compression of the spinal cord, a craniocervical fusion and decompression is performed (laminectomy of the middle part of the C1 arc and removal of the lower part of the lateral C1 arc). The trajectory is immediately above the C2 root (and under the upper rest of the lateral part of C1 arc). Even if the trajectory is narrowed, it is possible to perform PESCA without relevant traction of the spinal cord. The vertical segment of V3 of the VA at the level of C2 is protected by the vertebral foramen, and the horizontal part of V3 is protected by the remnant upper lateral part of the C1 arc (in case of normal variants). PESCA might be a good choice for biopsy of selected lesions of the OP in same sitting procedure after craniocervical stabilization and decompression.

Surgical management of primary and secondary pilocytic astrocytoma of the cerebellopontine angle (in adults and children) and review of the literature.

Glial tumors in the cerebellopontine angle (CPA) are uncommon and comprise less than 1% of CPA tumors. We present four cases of pilocytic astrocytoma of the CPA (PA-CPA) that were treated in our department. Patients who received surgical treatment for PA-CPA from January 2004 to December 2019 were identified by a computer search of their files from the Department of Neurosurgery, Tübingen. Patients were evaluated for initial symptoms, pre- and postoperative facial nerve function and cochlear function, complications, and recurrence rate by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. We identified four patients with PA-CPA out of about 1500 CPA lesions (~ 0.2%), which were surgically treated in our department in the last 16 years. Of the four patients, three were male, and one was a female patient. Two were adults, and two were children (mean age 35 years). A gross total resection was achieved in three cases, and a subtotal resection was attained in one case. Two patients experienced a moderate facial palsy immediately after surgery (House-Brackmann grade III). In all cases, the facial function was intact or good (House-Brackmann grades I-II) at the long-term follow-up (mean follow-up 4.5 years). No mortality occurred during follow-up. Three of the patients had no recurrence at the latest follow-up (mean latest follow-up 4.5 years), while one patient had a slight recurrence. PA-CPA can be safely removed, and most complications immediately after surgery resolve in the long-term follow-up.

Intracardial Catheter Migration of a Ventriculoperitoneal Shunt: Pathophysiology and Interdisciplinary Management.

BACKGROUND: Intracardial migration of a ventriculoperitoneal (VP) shunt (ICMVP) is a rare complication that has been described in only single case reports. Here we report the successful interdisciplinary management of an ICMVP and provide a review of the relevant literature. CASE DESCRIPTION: A 38-year-old-patient with shunt-dependent hydrocephalus caused due to a Blake's pouch cyst presented in our hydrocephalus outpatient clinic with thoracic pain and nocturnal cough at 7 months after VP shunt implantation (with initially a proper location on computed tomography scan of the head and X-ray of the abdomen). A new X-ray of the abdomen and the thorax revealed a dislocated shunt with migration of the distal catheter into the superior cava vein, right atrium, and right heart ventricle, with some loops in both pulmonary arteries. The catheter was successfully removed by an interdisciplinary team in general anesthesia under ultrasound, X-ray guidance, and cardiovascular parameter control by withdrawing the shunt into the superior cava vein and removing the remnant portion of the distal catheter (with a knot) by interventional snaring. Cardiac and vascular surgeons were on standby. CONCLUSIONS: The management of an ICMVP is complex and carries a high risk for severe potential complications. Two different pathophysiological mechanisms have been discussed in the literature, including gradual erosion into an adjacent vein and transvenous catheter placement of the initial shunt secondary to subcostal placement of shunt tunneling instruments. The suction effect of the venous system results in gradual pulling of the catheter into the venous system.

Interoptic, Trans-lamina Terminalis, Opticocarotid Triangle, and Caroticosylvian Windows From Mini-Supraorbital, Frontomedial, and Pterional Perspectives: A Comparative Cadaver Study With Artificial Lesions.

Introduction: The mini-supraorbital (MSO) and pterional (PT) approaches have been compared in a number of studies focusing on the treatment of aneurysms, craniopharyngiomas, and meningiomas. The goal of this study was to analyze the surgical exposure to different artificial lesions through interoptic (IO), trans-lamina terminalis (TLT), opticocarotid triangle (OCT), and caroticosylvian (CS) windows from the MSO, frontomedial (FM), and PT perspectives. Methods: The MSO, PT, and FM approaches were performed sequentially in two fixed cadaver heads. Three colored spheres were placed around the optic chiasm: (1) between the optic nerves; (2) between the optic nerve and the internal carotid artery; and (3) between the internal carotid artery and the oculomotor nerve. The surgical exposures to these structures by using the IO, TLT, OCT, and CS windows were compared. Results: (1) IO window: from the MSO and PT approaches, the total surgical exposure mainly allows visualization of contralateral lesions. The FM approach was superior for exploration of both sides of the area between the optic nerves. (2) TLT pathway: the MSO and PT approaches mainly expose the contralateral third ventricle wall. (3) OCT window: the PT approach allows exposure of a larger part of the sphere between the optic nerve and the internal carotid artery than the MSO approach. (4) CS window: the PT approach allows a better exposure of lateral structures such as the oculomotor nerve and of the medial prepontine area in comparison to the MSO approach. Conclusion: Simulation of the surgical situation with artificial lesions is a good model for comparing surgical perspectives and for analyzing feasibility of lesion exposure and resection.

Surgical management of collision-tumors between vestibular schwannoma and meningioma in the cerebellopontine angle in patients with neurofibromatosis type 2.

INTRODUCTION: When vestibular schwannoma (VS) collides with meningioma at the cerebellopontine angle (CPA), a particular threat occurs. Sudden acceleration of tumor growth and unpredictable involvement of cranial nerves results in a special environment that aggravates management. The goal of this study was to analyze the extent of resection, postoperative facial and cochlear function, surgical strategy, and survival rates in patients with neurofibromatosis type 2 (NF2) with meningioma-vestibular schwannoma (M-VS) collision tumors. METHODS: A total of 1284 VS, including 165 NF2 VS were operated at our department between January 2004 and May 2018. Out of these cases, a group of six NF2 patients with seven M-VS collision tumors was found following careful analysis of neuroradiological data and pathological and surgical reports. Patients were evaluated for extent of tumor resection and, furthermore, postoperative facial and hearing function. RESULTS: Six patients with NF2 with seven M-VS collision tumors were included in this study. Mean age was 32 ± 8.2 years. A gross total resection (GTR) of both colliding tumors was achieved in only one case, a GTR of the meningioma and a subtotal resection (STR) of the VS in four cases and in two cases only, the meningioma was removed. In five of the cases, facial function was intact or good (House and Brackmann grades I-II) at long-term follow-up (mean follow-up 22 months). No mortality occurred during follow-up. CONCLUSIONS: Collision between M and VS at the CPA is a particular phenomenon in NF2 patients that may aggravate the situation with less favorable surgical outcome than NF-2 VS without meningioma.

Surgical Management of Primary Cerebellopontine Angle Melanocytoma: Outcome, Recurrence and Additional Therapeutic Options.

OBJECTIVE: Meningeal melanocytomas of the central nervous system are extremely rare, with an incidence of 1 per 10 million individuals. Cases of primary cerebellopontine angle melanocytoma (PCPAM) have only been described in single case reports. The goal of the present study was to analyze the surgical management of PCPAM, with a particular focus on early and late treatment outcomes and recurrence rates. METHODS: The patients who had undergone surgery for PCPAM from January 2004 to May 2018 were identified by a local database query. The patients were evaluated for initial symptoms, pre- and postoperative facial and cochlear nerve function, complications, and recurrence rate by reviewing the patients' medical records. RESULTS: We identified 4 patients with PCPAM of >1500 cerebellopontine angle lesions (∼0.2%) that had been surgically treated at our department in the past 14 years. Of the 4 patients, 2 were men and 2 were women, with a mean age of 47 years. Anatomical facial and cochlear nerve preservation was achieved in all 4 patients. One patient experienced a new moderate facial palsy immediately after surgery (House-Brackmann grade III). Of the 4 patients, 3 had undergone radiotherapy and 1 had undergone ion beam therapy for tumor recurrence (6 years after surgery). Of the 4 patients, 3 had presented with tumor recurrence at 2, 3, and 6 years of follow-up respectively. The long-term follow-up examination had not yet been conducted for 1 patient. CONCLUSIONS: At long-term follow-up, 3 patients had developed recurrence. Because of the high recurrence rate of PCPAM, we believe that radiotherapy in addition to surgery should be considered in the future to avoid early recurrence.

Transsphenoidal Removal of Recurrent Osteoid Osteoma of Clivus.

BACKGROUND: An osteoid osteoma (OO) is a benign bone neoplasm that typically occurs in the long bone diaphysis. We found only 8 cases of OOs of the skull base in the literature, and none of them were located in the clivus. CASE DESCRIPTION: A 44-year-old female patient with a history of 2 previous transsphenoidal surgeries with partial removal of an OO of the clivus at another hospital, 11 and 4 years ago, presented to our department with recurrent progressive left-sided headache and facial pain over the past 6 months, which were aggravated at night. A new computed tomography (CT) scan of the head revealed a low-density, well-demarcated area surrounded by a high-density sclerotic bone in the clivus. A total transsphenoidal microscopic removal of the lesion was performed with the use of intraoperative neuronavigation. The patient recovered from surgery without any new deficits, and the headache was relieved during her inpatient hospital stay. A CT scan of the head that was performed 1 day after surgery revealed the complete removal of the lesion. The patient was discharged on day 5 after surgery. A follow-up examination conducted 3 months after surgery showed that the patient still had no headache or any other symptoms. A follow-up CT scan revealed no remnant or recurrent tumor. CONCLUSION: The transsphenoidal approach with the use of neuronavigation appears to be a good choice to achieve total removal of an OO of the upper part of the clivus in case of persistent pain and lack of sufficient effect by nonsteroidal antiinflammatory drugs.

Overshunting-Associated Myelopathy (OSAM) in a Patient with Bilateral Jugular Vein Occlusion.

BACKGROUND: Overshunting-associated myelopathy (OSAM) is a very rare complication of ventricular shunt therapy, and only 11 previous cases have been reported in the literature. We report the successful surgical management of a case of OSAM in a patient with bilateral jugular vein occlusion and congenital hydrocephalus. CASE DESCRIPTION: A 45-year-old patient with shunt-dependent, congenital hydrocephalus presented to our department with an 8-year history of progressive tetraparesis and gait disturbance. The patient was wheelchair-dependent. A new magnetic resonance imaging scan of the head revealed slit ventricle syndrome and dural enhancement due to shunt overdrainage. Magnetic resonance imaging and a computed tomography-phlebography of the cervical spine revealed engorgement of the epidural venous plexus with secondary compression of the spinal cord and myelomalacia. Surgery was performed, during which we implanted a shunt valve. The patient recovered from surgery without any new deficits. The tetraparesis improved during the inpatient hospital stay. Computed tomography-phlebography was performed 5 days after surgery and showed that the epidural venous plexus anterior to the cervical spinal cord had returned to nearly normal size. On follow-up examination 3 months after surgery, the patient's strength had improved, and he was able to walk short distances with assistance and with ankle foot orthosis on the right side. CONCLUSIONS: OSAM has to be considered according to the Monro-Kellie doctrine and is affected by an engorgement of the epidural cervical venous plexus, which can produce cervical myelopathy. Because it can be treated simply by increasing the shunt resistance, surgeons should be aware of the rarely detected overdrainage complication.

Neuroendoscopic Trans-Third Ventricular Approach for Surgical Management of Ecchordosis Physaliphora.

BACKGROUND: We sought to report the successful surgical management of a case of ecchordosis physaliphora (EP) using a neuro-endoscopic trans-third ventricular approach (ETTVA) and to provide a current review of literature on EP. CASE DESCRIPTION: A 57-year-old man presenting with a 2-year history of diplopia due to right abducens nerve palsy and paresthesia of the left body underwent magnetic resonance imaging, which revealed a retroclival intracisternal lesion. The cystic lesion was considered to be most likely EP according to neuroradiologic features. The patient underwent an endoscopic trans-third ventricular resection. A pediatric endoscope was passed from a precoronal burr hole through the left lateral into the third ventricle. The floor of the third ventricle was opened by a 2-micron laser. This approach permitted us to expose the lesion in the retroclival cistern and follow up with a subtotal removal. Remnants of the capsule, which were firmly adherent to small pontine arteries and the left abducens nerve, were left. Histology confirmed EP. The patient recovered well from surgery, and symptoms regressed at clinical follow-up. CONCLUSION: The endoscopic approach for third ventriculostomy can also be used for the surgical management of retroclival lesions. However, a small pediatric endoscope with an angled view, which can be passed through the floor of the third ventricle without causing harm, is mandatory to explore all important structures in the narrow surgical space. Limitations in this delicate environment are firm adhesions to vessels and nerves because only 1-instrument manipulation is possible and bleeding must be avoided.