Unilateral deep brain stimulation (DBS) of nucleus ventralis intermedius thalami (Vim) for the treatment of post-traumatic tremor in children: a multicentre experience.

PURPOSE: Deep brain stimulation (DBS) of nucleus ventralis intermedius thalami (Vim) is a validated technique for the treatment of essential tremor (ET) in adults. Conversely, its use for post traumatic tremor (PTT) and in paediatric patients is still debated. We evaluated the efficacy of Vim-DBS for lesional tremor in three paediatric patients with drug-resistant post-traumatic unilateral tremor. METHODS: We retrospectively collected data regarding three patients with unilateral tremor due to severe head injury, with no MRI evidence of basal ganglia lesions. The three patients underwent stereotactic frame-based robot-assisted DBS of Vim contralateral to the tremor side. RESULTS: Mean follow-up was 48 months (range: 36-60 months). Tremor was reduced in all patients with a better control of voluntary movements and improvement of functional status (mean FIM scale improvement + 7 points). No surgical complications occurred. CONCLUSION: Unilateral contralateral DBS of Vim could be efficacious in post-traumatic tremor, even in paediatric patients and should be offered in PTT drug-resistant patients.

Rare Onset of Erdheim-Chester Disease in Children and Young Adults: A Case Series and Review of the Literature.

INTRODUCTION: Erdheim-Chester disease (ECD) is a rare histiocytic neoplasm that affects patients, predominantly males aged 40-70 years, with very heterogeneous clinical presentation and prognosis. In 2020, Goyal et al. proposed consensus recommendations for the management of patients with ECD, remarking on the exceptional presentation of the disease in the pediatric population. CASE PRESENTATION: The first patient, a 20-year-old male, underwent cervical laminectomy and partial removal of a cervical spine lesion, initially apparently consistent with cervical schwannomas. The second patient, a 9-year-old female, received surgery for an extra-axial lesion of the greater sphenoid wing, radiologically consistent with a meningioma. CONCLUSION: At present, 15 pediatric cases have been reported in the literature with involvement of the central nervous system, with no consensus on the diagnostic and therapeutic management, as Pegoraro et al. evidenced in their pediatric multicenter case series. The present article adds two new cases of ECD with onset in childhood and young adulthood, who received the diagnosis after neurosurgical procedures.

Robot-assisted transcerebellar stereotactic approach to the posterior fossa in pediatric patients: a technical note.

PURPOSE: During the last decade, there has been renewed interest in stereotactic approaches to diffuse intrinsic pontine gliomas (DIPGs) in children, due to the development of new concepts in molecular biology and management, and subsequent need for tissue sampling. Stereotactic frame-based and robot-assisted techniques are associated with reduced target error and have been incorporated into standard practice at our institution. METHODS: Four children (age 2-7 years) underwent a robot-assisted frame-based transcerebellar approach using the Leksell G frame coupled with Renishaw's neuromate® stereotactic robot. The procedures included 3 biopsies (two brainstem tumors and one cerebellar hemispheric lesion) and 1 depth electrode implantation into a low-grade tumor remnant (ganglioglioma) of the middle cerebellar peduncle causing drug-resistant epilepsy in a young girl. Targeting was based on MRI, and in one case, 18F-FET-PET was coregistered to MRI to improve sampling accuracy. The frame was applied 180° rotated compared to standard orientation, and patients were positioned prone during surgery and stereotactic preoperative CT scan. Postoperative CT scan ruled out complications and was coregistered to preoperative MRI to check the target accuracy. RESULTS: No complications occurred, and targeting was accurate in all cases. All tissue samplings provided proper histology; depth electrode EEG exploration was diagnostic and led subsequent resective surgery. CONCLUSIONS: According to our experience, the transcerebellar frame-based robotic stereotactic approach to the cerebellum and the brainstem is feasible, safe, and effective even in young children.

Airgun Wound with Superior Sagittal Sinus Involvement in a Child: Case Report and Review of the Literature.

INTRODUCTION: Although still considered quite harmless, nonpowder guns (NPG) may cause severe head injuries in children. We present the case of a depressed skull fracture with superior sagittal sinus involvement following NPG injury. Decision-making and surgical management are discussed, and the current literature concerning NPG-related pediatric head injuries is reviewed. CASE PRESENTATION: A 4-year-old boy hit by a compressed-air rifle came to our center. CT scan showed a depressed skull fracture of the occipital bone on the midline and intracranial penetration of some fragments of the pellet. CT angiography documented a compression of the superior sagittal sinus without thrombosis. Soon after hospital admission, the patient showed deterioration of the neurological status suggesting intracranial hypertension. Surgery was performed with fracture elevation, removal of metal fragments, and wound debridement. The patient had a full recovery without subsequent neurological deficits. DISCUSSION/CONCLUSION: Modern airguns may produce severe penetrating head injuries in children. Parents and physicians should be aware of the danger of NPG. Depressed skull fracture and dural venous sinus involvement can occur, and even a stable neurological condition may worsen. In such instances, a thorough preoperative assessment including vascular imaging is mandatory. The surgical risk is not negligible due to the possible injury of the sinus wall and subsequent intraoperative bleeding. This has to be weighted against potential complications of the penetrating injury, such as infection, sinus thrombosis, and intracranial hypertension. Our case suggests that prompt surgical treatment can be a safe and effective option.

The interlaminar contralateral approach to far-lateral lumbar disc herniations: a single-center comparison with traditional techniques.

BACKGROUND: The interlaminar contralateral approach (ICA) is a promising surgical alternative for the treatment of far-lateral lumbar disc herniations (FLLDH). To date no study has compared ICA and FLLDH conventional surgical treatments, namely the intertransverse, the transmuscular and the intermuscular approaches, in terms of safety and outcome. METHODS: Patients who underwent FLLDH surgery at our Institution between January 2015 and September 2018 were reviewed. ICA complications and clinical outcomes were compared with those of conventional approaches at 1-month postoperatively and at the last follow-up available. Improvement was defined as reduction of at least two point in the Visual Analogue Scale (VAS) or increase of at least 1 point in the Medical Research Council (MRC) scale of muscle strength. Patient-reported outcome was assessed with the Oswestry Disability Index (ODI). RESULTS: Among 38 patients, 18 underwent ICA and 20 a conventional approach (intertransverse in 16, transmuscular in two, intermuscular in two). Median follow-up was 21 months (range, 2-47). At 1 month, no differences between the two groups were noticed in terms of clinical outcome and symptoms relief (P> 0.05). The median postoperative ODI score was significantly lower in the Conventional approach group at 1 month (P<0.05), but this difference was no longer significant at the last follow-up evaluation (P>0.05). No differences were found between the two groups in surgical complication and recurrence rates. CONCLUSIONS: Our data suggest that the ICA is a safe and effective alternative to conventional approaches in FLLDH surgery. Larger prospective studies are needed to confirm our results.

SMARCE1-related meningiomas: A clear example of cancer predisposing syndrome.

We report the case of a 16-year-old girl presenting with spinal clear-cell multiple meningiomas (CCMs). In view of this presentation, we sequenced a bioinformatic panel of genes associated with susceptibility to meningioma, identifying a germline heterozygous variant in SMARCE1. Somatic DNA investigations in the CCM demonstrated the deletion of the wild-type allele (loss of heterozygosity, LOH), supporting the causative role of this variant. Family segregation study detected the SMARCE1 variant in the asymptomatic father and in the asymptomatic sister who, nevertheless, presents 2 spinal lesions. Germline heterozygous loss-of-function (LoF) variants in SMARCE1, encoding a protein of the chromatin-remodeling complex SWI/SNF, have been described in few familial cases of susceptibility to meningioma, in particular the CCM subtype. Our case confirms the role of NGS in investigating predisposing genes for meningiomas (multiple or recurrent), with specific regard to SMARCE1 in case of pediatric CCM. In addition to the age of onset, the presence of familial clustering or the coexistence of multiple synchronous meningiomas also supports the role of a genetic predisposition that deserves a molecular assessment. Additionally, given the incomplete penetrance, it is of great importance to follow a specific screening or follow-up program for symptomatic and asymptomatic carriers of pathogenic variants in SMARCE1.

Pediatric neurosurgery AC-after COVID-19: What has really changed? A review of the literature.

The COVID-19 outbreak has dramatically changed the organization of Pediatric Neurosurgery all over the world. The departments involved developed similar plans to maintain emergency surgeries without reducing clinical activities. The Association of Pediatric Neurosurgeons wrote different memoranda to detail the surgical procedures not to be postponed with special attention given to high-risk pathology for COVID-19 contamination, like trans-naso-sphenoidal surgery. On this basis, we have conducted a complete literature review focusing on many topics: hospital organization, patients and parents screening, surgical indication criteria, outpatient clinic and teleconsultation, telematic conference and meeting, fellowship and training, and virtual multidisciplinary meeting.

Complete section of the left vagus nerve does not preclude the efficacy of vagus nerve stimulation: illustrative case.

BACKGROUND: Vagus nerve stimulation (VNS) represents a valid therapeutic option for patients with medically intractable seizures who are not candidates for epilepsy surgery. Even when complete section of the nerve occurs, stimulation applied cranially to the involved nerve segment does not preclude the efficacy of VNS. Complete vagus nerve section with neuroma causing definitive left vocal cord palsy has never been previously reported in the literature. OBSERVATIONS: Eight years after VNS implant, the patient experienced worsening of seizures; the interrogation of the generator revealed high impedance requiring surgical revision. On surgical exploration, complete left vagus nerve section and a neuroma were found. Vocal cord atrophy was found at immediate postoperative laryngeal inspection as a confirmation of a longstanding lesion. Both of these events might have been caused by direct nerve injury during VNS surgery, and they presented in a delayed fashion. LESSONS: VNS surgery may be complicated by direct damage to the left vagus nerve, resulting in permanent neurological deficits. A complete section of the nerve also enables an efficacious stimulation if applied cranially to the involved segment. Laryngeal examination should be routinely performed before each VNS surgery to rule out preexisting vocal cord dysfunction.

Far lateral lumbar disc herniation part 1: Imaging, neurophysiology and clinical features.

Far lateral lumbar disc herniations (FLLDH) represent a separate category of disc pathology which includes both intraforaminal and extraforaminal lumbar disc herniations, that are characterized by a peculiar clinical presentation, diagnostic and treatment modalities as compared to the more frequent median and paramedian disc hernias. Surgical treatment often represents the only effective weapon for the cure of this disease and over the years different approaches have been developed that can reach the region of the foramen or external to it, with different degrees of invasiveness. The diagnosis is more demanding and still underestimated as it requires a more detailed knowledge in the spine anatomy and dedicated radiological studies. Computerized tomography and in particular magnetic resonance imaging are the appropriate tools for the diagnosis of FLLDH. Despite the widespread use of these diagnostic tests, many cases of FLLDH are overlooked due to insufficiently detailed radiological examinations or due to the execution of exams not focused to the foraminal or the extraforaminal region. Neurophysiological studies represent a valid aid in the diagnostic classification of this pathology and in some cases they can facilitate the differential diagnosis with other types of radiculopathies. In the present study, a comprehensive review of the clinical presentation, epidemiology, radiological study and the neurophysiological aspects is presented.

Herpes Simplex Reactivation After Surgical Treatment of Trigeminal Neuralgia: A Retrospective Cohort Study.

BACKGROUND: Herpes simplex virus (HSV) reactivation after surgery for trigeminal neuralgia has long been recognized. Only a few studies to date have focused on this complication, and its actual incidence remains unknown. The aim of this study was to investigate the incidence of postoperative herpes labialis (HL) in a cohort of patients treated with either percutaneous balloon compression or microvascular decompression to identify potentially significant differences between different treatments. METHODS: A total of 92 patients who were operated on for TN with microvascular decompression (group A) or percutaneous balloon compression (group B) in the period 2010-2017 were retrospectively evaluated. The 2 subgroups of patients were compared according to history of previous HL and incidence of postoperative HL. RESULTS: The final cohort comprised 56 male and 36 female patients. Average age was 58.50 years; 30 male patients belonged to group A and 26 male patients belonged to group B. Lifetime incidence of episodes of HL before surgery in 18/58 patients in group A (31.0%) and 12/34 patients in group B (35.3%), with no statistically significant difference among subgroups. Postoperatively, 1/56 patients in group A (1.7%) experienced HL compared 5/34 patients in group B (14.7%), with a strongly statistically significant difference between the 2 subgroups. CONCLUSIONS: In our clinical experience, herpes simplex virus reactivation after surgery for trigeminal neuralgia is not so rare and is still not completely understood. Postoperative herpes simplex virus reactivation could be due to a direct mechanical injury on gasserian ganglion neurons, which is more common after percutaneous balloon compression.

Human fetal striatal transplantation in huntington's disease: a refinement of the stereotactic procedure.

BACKGROUND: Human fetal striatal transplantation (HFST) is an experimental stereotactic intervention in the treatment of Huntington's disease (HD). This procedure has proved feasible, safe, well tolerated and it offers a potential strategy for brain repair in HD patients. Target areas are the nucleus caudatus caput (NCc) and the precommissural and postcommissural putamen (Pu). A suboptimal spatial distribution of grafts was frequently reported, especially for the postcommissural Pu, because of striatal atrophy and the concurrent ventricular frontal horn enlargement. An improvement of the stereotactic procedure aimed to optimize the intrastriatal placement of grafts is therefore considered a timely issue. METHODS: Eight consecutive HD patients underwent bilateral HFST. For the first 6 procedures (first group) we performed both caudate and putaminal tracks through a single frontal entry point. For the following 10 procedures (second group), we adopted two completely distinct routes, with two separate entry points, for NCc and Pu tracks. The average number of stereotactic tracks and the average infused volume of tissue suspension were compared between the two groups. RESULTS: The average number of putaminal tracks and the average infused volume of suspension were significantly higher in the second group. CONCLUSION: Adopting two separate routes for caudate and putaminal trajectories allowed us to achieve a larger amount of fetal tissue deposits and a better spatial distribution of grafts.

Development of human striatal anlagen after transplantation in a patient with Huntington's disease.

Replacement of damaged neuronal population by fetal tissue transplantation represents a potential treatment for neurodegenerative diseases. Consistent success has been achieved with fetal striatal transplantation in Huntington's disease animal models and patients. We report the neo-generation of metabolically active tissue with striatum-like imaging features after transplantation of striatal primordia in a patient with Huntington's disease. This study represents the first "in vivo" demonstration that a human striatal anlagen, transplanted into the adult human brain, is able to progress in its development and to generate a new anatomical structure in the host, without evidence of neoplasia or teratoma.