The Use of Standardized Intraoperative Language Tests in Awake Craniotomies: A Scoping Review.

Assessment of speech and language functions is an essential part of awake craniotomies. Although standardized and validated tests have several advantages compared to homemade (or mixed) batteries, in the literature it is unclear how such tests are used or whether they are used at all. In this study, we performed a scoping review in order to locate standardized and validated intraoperative language tests. Our inquiry included two databases (PubMED and MEDLINE), gray literature, and snowball referencing. We discovered 87 studies reporting use of mixed batteries, which consist of homemade tasks and tests borrowed from other settings. The tests we found to meet the validation and standardization criteria we set were ultimately three (n = 3) and each one has its own advantages and disadvantages. We argue that tests with high sensitivity and specificity not only can lead to better outcomes postoperatively, but they can also help us to gain a better understanding of the neuroanatomy of language.

Machine Learning in Meningioma MRI: Past to Present. A Narrative Review.

Meningioma is one of the most frequent primary central nervous system tumors. While magnetic resonance imaging (MRI), is the standard radiologic technique for provisional diagnosis and surveillance of meningioma, it nevertheless lacks the prima facie capacity in determining meningioma biological aggressiveness, growth, and recurrence potential. An increasing body of evidence highlights the potential of machine learning and radiomics in improving the consistency and productivity and in providing novel diagnostic, treatment, and prognostic modalities in neuroncology imaging. The aim of the present article is to review the evolution and progress of approaches utilizing machine learning in meningioma MRI-based sementation, diagnosis, grading, and prognosis. We provide a historical perspective on original research on meningioma spanning over two decades and highlight recent studies indicating the feasibility of pertinent approaches, including deep learning in addressing several clinically challenging aspects. We indicate the limitations of previous research designs and resources and propose future directions by highlighting areas of research that remain largely unexplored. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 2.

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience.

BACKGROUND: It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS: In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS: Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS: Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.

The Greek linguistic assessment for awake brain surgery: development process and normative data.

Language mapping with direct electrical stimulation is considered the gold standard in surgical treatment of brain tumors. Assessing a variety of language functions intraoperatively can affect the extent of the tumor resection as well as the patient's postoperative quality of life. Although most tests include preoperative sessions where tasks are personalised to each patient, normative data are essential since they can ensure that the presented stimuli can be responded appropriately. In this study, we describe the development and standardisation procedures of the first linguistic test in Greek, designed specifically for brain mapping during awake craniotomies. The tasks are developed to comply with the special conditions and restrictions of language assessment inside the operating room. Each task is controlled for various psycholinguistic and lexical variables and it is associated with specific neuroanatomical areas and linguistic processes. Our population consists of 80 right-handed, healthy, Greek-speaking individuals aged 20-60 years. We found only a few main effects and interactions of demographic variables on our test scores. Most differences were found between age groups, since older participants tend to perform slightly worse than younger ones. Therefore, percentiles and cut-off scores were calculated separately for each demographic group. Regarding the clinical application of GLAABS, we describe the procedures we followed to administer it to brain tumor patients from our department and also discuss how sensitivity and specificity can affect patients' postoperative course.

Machine learning assisted DSC-MRI radiomics as a tool for glioma classification by grade and mutation status.

BACKGROUND: Combining MRI techniques with machine learning methodology is rapidly gaining attention as a promising method for staging of brain gliomas. This study assesses the diagnostic value of such a framework applied to dynamic susceptibility contrast (DSC)-MRI in classifying treatment-naïve gliomas from a multi-center patients into WHO grades II-IV and across their isocitrate dehydrogenase (IDH) mutation status. METHODS: Three hundred thirty-three patients from 6 tertiary centres, diagnosed histologically and molecularly with primary gliomas (IDH-mutant = 151 or IDH-wildtype = 182) were retrospectively identified. Raw DSC-MRI data was post-processed for normalised leakage-corrected relative cerebral blood volume (rCBV) maps. Shape, intensity distribution (histogram) and rotational invariant Haralick texture features over the tumour mask were extracted. Differences in extracted features across glioma grades and mutation status were tested using the Wilcoxon two-sample test. A random-forest algorithm was employed (2-fold cross-validation, 250 repeats) to predict grades or mutation status using the extracted features. RESULTS: Shape, distribution and texture features showed significant differences across mutation status. WHO grade II-III differentiation was mostly driven by shape features while texture and intensity feature were more relevant for the III-IV separation. Increased number of features became significant when differentiating grades further apart from one another. Gliomas were correctly stratified by mutation status in 71% and by grade in 53% of the cases (87% of the gliomas grades predicted with distance less than 1). CONCLUSIONS: Despite large heterogeneity in the multi-center dataset, machine learning assisted DSC-MRI radiomics hold potential to address the inherent variability and presents a promising approach for non-invasive glioma molecular subtyping and grading.

Complications after Anterior Temporal Lobectomy for Medically Intractable Epilepsy: A Systematic Review and Meta-Analysis.

BACKGROUND: The efficacy of surgery in the management of patients with longstanding temporal lobe epilepsy has been established. Anterior temporal lobectomy (ATL) is the most frequently implemented procedure. However, there is an obvious need to assess its perioperative safety. OBJECTIVE: We conducted a meta-analysis to estimate the postoperative mortality (Q1) and morbidity (Q2) associated with ATL for medically intractable epilepsy. In addition, we tried to identify the most frequent complications after ATL and assess their relative frequency (Q3) in children and adults. METHODS: Fixed- and random-effects model meta-analysis was conducted to assess the proportion estimate for each outcome individually. RESULTS: The postoperative mortality and cumulative morbidity were estimated to be as high as 0.01 (95% CI: 0.01, 0.02) and 0.17 (95% CI: 0.12, 0.24), respectively. Psychiatric disorders were the most common postoperative complications after ATL, with an estimated frequency as high as 0.07 (95% CI: 0.04, 0.10), followed by visual field defects (0.06; 0.03, 0.11), and cognitive disorders (0.05; 0.02, 0.10). Less frequent complications included hemiparesis and language disorders (0.03; 0.01, 0.06), infections (0.03; 0.02, 0.04), hemorrhage (0.02; 0.01, 0.05), cranial nerve deficits (0.03; 0.02, 0.05), extra-axial fluid collections (0.02; 0.01, 0.03), and medical complications (0.02; 0.01, 0.03). CONCLUSIONS: Even though the mortality after ATL is minimal, the overall morbidity cannot be ignored. Psychiatric disturbances, visual field defects, and cognitive disorders are the most common postoperative complications, and should be considered during the preoperative planning and consultation.

Effect of integrin AV and B8 gene polymorphisms in patients with traumatic brain injury.

Background: Α few genetic variants are associated with the outcome after traumatic brain injury (TBI). Integrins are glycoprotein receptors that play an important role in the integrity of microvasculature of the brain. Objective: To examine the role of integrin-AV (ITGAV) and integrin-B8 (ITGB8) tag single nucleotide polymorphisms (SNPs) on the outcome of patients with TBI. Methods: 363 participants were included and genotyped for 11 SNPs for ITGAV and 11 for ITGB8 gene. SNPs were tested for associations with the 6-month outcome after TBI, the presence of a hemorrhagic event after TBI, and the initial TBI severity after adjustment for TBI's main predictors. Results: The ITGAV rs3911239 CC and rs7596996 GG genotypes were associated with an unfavorable outcome after TBI, compared to the TT and AA genotypes, respectively. The ITGB8 rs10239099 CC and rs3757727 CC genotypes were associated with increased risk of any cerebral hemorrhagic event after TBI compared to GG and TT respectively. The ITGAV rs7589470 and rs7565633 were associated with the TBI's initial severity. Conclusions: ITGAV gene SNPs may be implicated in the outcome after TBI, as well as in the initial TBI severity, and also of ITGB8 gene SNPs in the risk of hemorrhagic event after a TBI.

Intradural extramedullary Ewing's sarcoma: A case report and review of the literature.

INTRODUCTION: Extra-skeletal Ewing's sarcomas are very rare lesions to the spine surgeon, with the intradural, extramedullary lesions being even rarer. Herein we present a patient with an intradural, extramedullary form of Ewing's sarcoma and review the relevant literature. The medical records, operative reports, radiographical studies and histological examinations of a single patient are retrospectively reviewed. CASE REPORT: A 31-year old male presented with back-pain, right-leg progressive paraparesis, and inability to walk. Both motor and sensory disturbances were revealed on the right leg at the clinical examination. Lumbar MRI showed two lesions. The first one was an intradural, extramedullary lesion at the L2-L3 level, while the second was smaller, located at the bottom of the dural sac. The patient underwent gross total resection of the L2-L3 lesion after a bilateral laminectomy. Histological examination was compatible with Ewing's sarcoma, and was verified by molecular analysis. No other extra-skeletal or skeletal lesion was found. A chemotherapy scheme was tailored to the patients' histological diagnosis. The patient presented with local recurrence and bone metastasis 2 years after his initial diagnosis. A second operation was performed and the follow up of the patient showed no disease progression 18 months after revision surgery. CONCLUSION: The spine surgeon should be aware of the existence of such rare entities, in order to timely fulfill the staging process and institute the proper therapy. The management of patients with extra-skeletal Ewing's sarcomas involves professionals as members of a multidisciplinary team, all of which should co-operate for the patient's optimal outcome.

The role of diffusion tensor imaging and fractional anisotropy in the evaluation of patients with idiopathic normal pressure hydrocephalus: a literature review.

OBJECTIVE Diffusion tensor imaging (DTI) for the assessment of fractional anisotropy (FA) and involving measurements of mean diffusivity (MD) and apparent diffusion coefficient (ADC) represents a novel, MRI-based, noninvasive technique that may delineate microstructural changes in cerebral white matter (WM). For example, DTI may be used for the diagnosis and differentiation of idiopathic normal pressure hydrocephalus (iNPH) from other neurodegenerative diseases with similar imaging findings and clinical symptoms and signs. The goal of the current study was to identify and analyze recently published series on the use of DTI as a diagnostic tool. Moreover, the authors also explored the utility of DTI in identifying patients with iNPH who could be managed by surgical intervention. METHODS The authors performed a literature search of the PubMed database by using any possible combinations of the following terms: "Alzheimer's disease," "brain," "cerebrospinal fluid," "CSF," "diffusion tensor imaging," "DTI," "hydrocephalus," "idiopathic," "magnetic resonance imaging," "normal pressure," "Parkinson's disease," and "shunting." Moreover, all reference lists from the retrieved articles were reviewed to identify any additional pertinent articles. RESULTS The literature search retrieved 19 studies in which DTI was used for the identification and differentiation of iNPH from other neurodegenerative diseases. The DTI protocols involved different approaches, such as region of interest (ROI) methods, tract-based spatial statistics, voxel-based analysis, and delta-ADC analysis. The most studied anatomical regions were the periventricular WM areas, such as the internal capsule (IC), the corticospinal tract (CST), and the corpus callosum (CC). Patients with iNPH had significantly higher MD in the periventricular WM areas of the CST and the CC than had healthy controls. In addition, FA and ADCs were significantly higher in the CST of iNPH patients than in any other patients with other neurodegenerative diseases. Gait abnormalities of iNPH patients were statistically significantly and negatively correlated with FA in the CST and the minor forceps. Fractional anisotropy had a sensitivity of 94% and a specificity of 80% for diagnosing iNPH. Furthermore, FA and MD values in the CST, the IC, the anterior thalamic region, the fornix, and the hippocampus regions could help differentiate iNPH from Alzheimer or Parkinson disease. Interestingly, CSF drainage or ventriculoperitoneal shunting significantly modified FA and ADCs in iNPH patients whose condition clinically responded to these maneuvers. CONCLUSIONS Measurements of FA and MD significantly contribute to the detection of axonal loss and gliosis in the periventricular WM areas in patients with iNPH. Diffusion tensor imaging may also represent a valuable noninvasive method for differentiating iNPH from other neurodegenerative diseases. Moreover, DTI can detect dynamic changes in the WM tracts after lumbar drainage or shunting procedures and could help identify iNPH patients who may benefit from surgical intervention.

Effect of angiotensin-converting enzyme tag single nucleotide polymorphisms on the outcome of patients with traumatic brain injury.

BACKGROUND: Genetic variants appear to influence, at least to some degree, the extent of brain injury and the clinical outcome of patients who have sustained a traumatic brain injury (TBI). Angiotensin-converting enzyme (ACE) is a zinc metallopeptidase that is implicated in the regulation of blood pressure and cerebral circulation. ACE gene polymorphisms were found to regulate serum ACE enzyme activity. OBJECTIVE: The present study aimed to investigate possible influence of ACE gene region variants on patients' outcome after TBI. PATIENTS AND METHODS: In total, 363 TBI patients prospectively enrolled in the study were genotyped for five tag single nucleotide polymorphisms (SNPs) across the ACE gene. Using logistic regression analyses, tag SNPs and their constructed haplotypes were tested for associations with 6-month Glasgow Outcome Scale scores, after adjustment for age, sex, Glasgow Coma Scale scores at admission, and the presence of a hemorrhagic event in the initial computed tomography scan. RESULTS: Significant effects on TBI outcome were found for three neighboring tag SNPs in the codominant (genotypic) model of inheritance [rs4461142: odds ratio (OR) 0.26, 95% confidence interval (CI) 0.12-0.57, P = 0.0001; rs7221780: OR 2.67, 95% CI 1.25-5.72, P = 0.0003; and rs8066276: OR 3.82, 95% CI 1.80-8.13, P = 0.0002; for the heterozygous variants compared with the common alleles]. None of the constructed common tag SNPs haplotypes was associated with TBI outcome. CONCLUSION: The present study provides evidence of the possible influence of genetic variations in a specific region of the ACE gene on the outcome of TBI patients. This association may have pharmacogenetic implications in identifying those TBI patients who may benefit from ACE inhibition.

Localization of Vestibular Cortex Using Electrical Cortical Stimulation: A Systematic Literature Review.

The vestibular system plays a fundamental role in body orientation, posture control, and spatial and body motion perception, as well as in gaze and eye movements. We aimed to review the current knowledge regarding the location of the cortical and subcortical areas, implicated in the processing of vestibular stimuli. The search was performed in PubMed and Scopus. We focused on studies reporting on vestibular manifestations after electrical cortical stimulation. A total of 16 studies were finally included. Two main types of vestibular responses were elicited, including vertigo and perception of body movement. The latter could be either rotatory or translational. Electrical stimulation of the temporal structures elicited mainly vertigo, while stimulation of the parietal lobe was associated with perceptions of body movement. Stimulation of the occipital lobe produced vertigo with visual manifestations. There was evidence that the vestibular responses became more robust with increasing current intensity. Low-frequency stimulation proved to be more effective than high-frequency in eliciting vestibular responses. Numerous non-vestibular responses were recorded after stimulation of the vestibular cortex, including somatosensory, viscero-sensory, and emotional manifestations. Newer imaging modalities such as functional MRI (fMRI), Positron Emission Tomography (PET), SPECT, and near infra-red spectroscopy (NIRS) can provide useful information regarding localization of the vestibular cortex.

The role of intraoperative micro-Doppler ultrasound in verifying proper clip placement in intracranial aneurysm surgery.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage constitutes a clinical entity associated with high mortality and morbidity. It is widely accepted that improper clip placement may have as a result of incomplete aneurysm occlusion and/or partial or complete obstruction of an adjacent vessel. Various modalities, including intraoperative or postoperative digital subtracting angiography, near-infrared indocyanine green angiography, micro-Doppler ultrasonography (MDU), and neurophysiological studies, have been utilized for verifying proper clip placement. The aim of our study was to review the role of MDU during aneurysmal surgery. METHODS: A literature search was performed using any possible combination of the following terms: "aneurysm," "brain," "cerebral," "clip," "clipping," "clip malpositioning," "clip repositioning," "clip suboptimal positioning," "Doppler," "intracranial," "microsurgery," "micro-Doppler," "residual neck," "ultrasonography," "ultrasound," and "vessel occlusion". Additionally, reference lists from the retrieved articles were reviewed for identifying any additional articles. Case reports and miniseries were excluded. RESULTS: A total of 19 series employing intraoperative MDU during aneurysmal microsurgery were retrieved. All studies demonstrated that MDU accuracy is extremely high. The highest reported false-positive rate of MDU was 2 %, while the false-negative rate was reported as high as 1.6 %. It has been demonstrated that the presence of subarachnoid hemorrhage, specific anatomic locations, and large size may predispose to improper clip placement. Intraoperative MDU's technical limitations and weaknesses are adequately identified, in order to minimize the possibility of any misinterpretations. CONCLUSION: Intraoperative MDU constitutes a safe, accurate, and low cost imaging modality for evaluating blood flow and for verifying proper clip placement during microsurgical clipping.

Quantification of normal CSF flow through the aqueduct using PC-cine MRI at 3T.

INTRODUCTION: Quantification of cerebrospinal fluid (CSF) flow through the cerebral aqueduct is of paramount importance in patients with hydrocephalus. The purpose of this study was to evaluate the normal CSF flow measurements at three different anatomical levels of the aqueduct utilizing 3-Tesla (3 T) magnetic resonance imaging. MATERIALS AND METHODS: The CSF hydrodynamics in 22 healthy volunteers were evaluated. Phase-contrast cine MRI was performed on a 3 T General Electric MR system (GE Medical Systems, Milwaukee, WI, USA). A cardiac-gated, flow-compensated GRE sequence with flow encoding was used, and the aqueduct was visualized using a sagittal T1 FLAIR sequence. Velocity maps were acquired at three different anatomical levels. Region-of-interest (ROI) analysis was performed. RESULTS: CSF flow velocities were slightly increased at the upper in comparison with the lower part of the aqueduct. The mean values for the peak positive and negative velocity and the mean average flow were calculated for both ROIs. DISCUSSION/CONCLUSIONS: CSF peak positive velocity, peak negative velocity, and mean flow through the aqueduct were calculated in 22 young healthy volunteers performed at 3 T. Our measurements did not show significant difference compared with the reported measurements obtained at 1.5 T. Slight differences were observed in the CSF hydrodynamic measurements, depending on the anatomical level of the aqueduct; however, they did not vary significantly.

Role of endoscopic third ventriculostomy in treatment of selected patients with normal pressure hydrocephalus.

OBJECTIVE: The purpose of our study was to evaluate the results of endoscopic third ventriculostomy (ETV) in the management of patients with idiopathic normal pressure hydrocephalus (INPH). METHODS: Our prospective study included seven patients (five men and two women; ages ranging between 68 and 78 years) with two or more typical NPH symptoms of short duration (<6 months), with no other morbidity factors, with a Mini-Mental State Examination (MMSE) score ≥18, aqueductal cerebrospinal fluid (CSF) stroke volume ≥42 µL, and positive lumbar drain test. The etiology of NPH was idiopathic in all of these cases. Their preoperative work-up included brain magnetic resonance imaging (MRI) and cine-MR, MMSE test, and CSF lumbar drain test, in all cases. The clinical status of all participants was graded using the Japanese intractable hydrocephalus system. An ETV was performed in all participants. Follow-up included periodic clinical evaluations, MMSE, and MRI with cine-MR studies. The follow-up time range was 12-72 months. RESULTS: The mean postoperative clinical grade was 3.1, while the preoperative was 6.1. Gait disturbance and urinary incontinence were the most responsive symptoms. The mean postoperative MMSE score was 23.6, while the preoperative score was 20.3. The mean postoperative aqueductal CSF stroke volume, 6 months after the procedure, was 31.6 µL, while the preoperative volume was 48.8 µL. CONCLUSIONS: ETV may be a safe alternative surgical option for a limited number of carefully selected INPH patients.

Temporal pole proton preoperative magnetic resonance spectroscopy in patients undergoing surgery for mesial temporal sclerosis.

OBJECT: The purpose of this prospective study was to compare the results of proton MR spectroscopy (MRS) in temporal poles in patients with unilateral mesial temporal sclerosis (MTS) with the histopathological findings of the resected temporal poles. METHODS: A total of 23 patients (14 male and 9 female) with a mean age of 25.2 years (range 17-45 years) were included in this study, which was conducted over a 4-year period. All patients suffered medically refractory epilepsy due to unilateral, MRI-proven MTS, with no other imaging abnormalities. All participants underwent preoperative single-voxel proton MRS using a 3-T MRI unit. The hippocampi and temporal poles were examined bilaterally. The concentrations of N-acetyl-aspartate (NAA), choline (Cho), and creatine (Cr) were measured, and the NAA/Cho, NAA/Cr, and NAA/Cho+Cr ratios were calculated. All patients underwent anterior temporal lobectomy and ipsilateral amygdalohippocampectomy, and surgical specimens from the temporal poles were sent for histopathological examination. Comparisons of the spectroscopic and histopathological results of the resected temporal poles were performed. The modified Engel classification system was used for evaluating seizure outcome in the cohort. RESULTS: The preoperative spectroscopic profiles of the sclerotic hippocampi were abnormal in all patients, and the contralateral hippocampus showed altered spectroscopic findings in 12 patients (52.2%). Spectroscopy of the temporal poles demonstrated severely decreased concentrations of NAA, markedly increased concentrations of Cho, and increased concentrations of Cr in the temporal pole ipsilateral to the MTS in 15 patients (65.2%). Similarly, the NAA/Cho, NAA/Cr, and NAA/Cho+Cr ratios were severely decreased in the temporal pole ipsilateral to the MTS in 16 patients (69.6%). Histopathological examination of the resected temporal poles demonstrated ischemic changes in 5 patients (21.7%), gliotic changes in 4 (17.4%), demyelinating changes in 3 (13.0%), and microdysplastic changes in 1 patient (4.3%). Comparisons of the spectroscopic and histopathological findings showed that the sensitivity of proton MRS was 100%, its specificity was 80%, its positive predictive value was 87%, and its negative predictive value was 100%. The mean follow-up time in this study was 3.4 years. At the end of the 2nd postoperative year, 17 patients (73.9%) were in Engel Class I, 5 (21.7%) were in Class II, and 1 (4.3%) was in Class III. CONCLUSIONS: Proton MRS detected altered ipsilateral temporal pole metabolism in patients with unilateral MTS. These metabolic changes were associated with permanent histological abnormalities of the temporal pole. This finding demonstrates that MTS may be a more diffuse histological process, and exact preoperative knowledge of its temporal extent becomes of paramount importance in the selection of the best surgical approach in these patients. Further validation of the observations is necessary for defining the role of temporal pole proton MRS in cases of temporal lobe epilepsy.

The Role of Extra-Operative Cortical Stimulation and Mapping in the Surgical Management of Intracranial Gliomas.

BACKGROUND: Aggressive resection without compromising the patient's neurological status remains a significant challenge in treating intracranial gliomas. Our current study aims to evaluate the efficacy and safety of extra-operative stimulation and mapping via implanted subdural electrodes with or without depth (EOCSM), offering an alternative approach when awake mapping is contraindicated. METHODS: Fifty-one patients undergoing EOCSM for glioma resection in our institution formed the sample study of our current retrospective study. We assessed the effectiveness and safety of our approach by measuring the extent of resection and recording the periprocedural complications, respectively. RESULTS: The mean age of our participants was 58 years (±9.4 years). The lesion was usually located on the left side (80.4%) and affected the frontal lobe (51.0%). EOCSM was successful in 94.1% of patients. The stimulation and electrode implantation procedures lasted for a median of 2.0 h and 75 h, respectively. Stimulation-induced seizures and CSF leakage occurred in 13.7% and 5.9% of our cases. The mean extent of resection was 91.6%, whereas transient dysphasia occurred in 21.6% and transient hemiparesis in 5.9% of our patients, respectively. CONCLUSIONS: Extraoperative stimulation and mapping constitute a valid alternative mapping option in glioma patients who cannot undergo an awake craniotomy.

Bing-Neel syndrome presenting with bilateral lumbar radiculopathy: A case report of a rare clinical entity.

The differential diagnosis of bilateral lower extremity weakness is broad. We present a very rare case of a 48-year old male patient, with walking difficulties due to Bing-Neel syndrome. On clinical examination, there was a significant loss of muscle power in all his lower extremities key-muscle groups. The lumbar spine magnetic resonance imaging (MRI) showed only mild degenerative changes, whereas the MRI of the head indicated a diffuse meningeal thickening at the right temporal region, characterized by significant enhancement after contrast administration. Serum protein electrophoresis detected an IgM-kappa monoclonal protein. The patient received intrathecal chemotherapy with methotrexate and cytarabine, and was started on oral ibrutinib 420mg daily. In conclusion, a past medical history of Waldenstrom macroglobulinemia in conjunction with neurological manifestations should alert the treating physician for Bing-Neel syndrome. A complete diagnostic imaging and serologic protocol helps in setting the final diagnosis. Steroids are part of the treatment, but should be given after the diagnosis is set. Neurosurgical intervention is indicated for histologic confirmation in the case of diagnostic uncertainty.

Posterior Fossa Intra-Axial Lesion: There Are Pathologies Beyond Metastases.

Cerebellar metastases represent the most common lesion requiring surgical treatment in the daily neurosurgical praxis. We report a rare case with Lhermitte-Duclos disease presenting to the neurosurgical outpatient department and describe our diagnostic and treatment challenges. A 57-year-old man presented with transient cerebellar manifestations, including walking difficulties, dizziness, and a persistent occipital headache. The magnetic resonance imaging demonstrated a high-intensity lesion in the right cerebellar hemisphere on T2-weighted images. We initially considered surgery to establish a histopathological diagnosis. However, the magnetic resonance spectroscopy was compatible with a dysplastic gangliocytoma of the cerebellum. Therefore, we preferred a more conservative approach. Posterior fossa contrast-enhancing lesions are much more than metastases. The role of advanced magnetic resonance in avoiding unnecessary surgical interventions is priceless.

Association between white matter lesions and Parkinson's disease: an impact on Postural/Gait difficulty phenotype and cognitive performance.

BACKGROUND: White matter hyperintensities (WMHs) may be observed on Magnetic Resonance Imaging (MRI) in patients with Parkinson disease with or without vascular risk factors. Whether WMHs may influence motor and non-motor aspects of Parkinson disease is a subject of debate. The aim of this study is to evaluate the impact of WMH severity on various aspects of Parkinson disease in combination to the estimation of the impact of cerebrovascular risk factors. MATERIALS AND METHODS: We included a cohort of patients with Parkinson's disease who underwent MRI examination. The Fazekas visual rating scale was used to assess the severity and location of WMHs, and patient clinical characteristics were correlated with MRI data. RESULTS: All vascular risk factors were associated with higher Fazekas score in both periventricular and deep white matter. Periventricular white matter hyperintensities (PWMHs) and deep white matter hyperintensities (DWMHs) were associated with lower scores in the ACE-R cognitive assessment scale (p < 0.001). Furthermore, PWMHs and DWMHs severity was associated with higher UPDRS motor score (p < 0.001), while the Postural Instability Gait Difficulty (PIGD) phenotype was correlated with higher burden of WMHs. CONCLUSIONS: Comorbid WMHs may contribute to multi-dimension dysfunction in patients with Parkinson disease and consequently the management of vascular risk factors may be crucial to maintain motor and non-motor functions in PD.

Bing-Neel syndrome presenting with bilateral lumbar radiculopathy: A case report of a rare clinical entity.

The differential diagnosis of bilateral lower extremity weakness is broad. We present a very rare case of a 48-year old male patient, with walking difficulties due to Bing-Neel syndrome. On clinical examination, there was a significant loss of muscle power in all his lower extremities key-muscle groups. The lumbar spine magnetic resonance imaging (MRI) showed only mild degenerative changes, whereas the MRI of the head indicated a diffuse meningeal thickening at the right temporal region, characterized by significant enhancement after contrast administration. Serum protein electrophoresis detected an IgM-kappa monoclonal protein. The patient received intrathecal chemotherapy with methotrexate and cytarabine, and was started on oral ibrutinib 420mg daily. In conclusion, a past medical history of Waldenstrom macroglobulinemia in conjunction with neurological manifestations should alert the treating physician for Bing-Neel syndrome. A complete diagnostic imaging and serologic protocol helps in setting the final diagnosis. Steroids are part of the treatment, but should be given after the diagnosis is set. Neurosurgical intervention is indicated for histologic confirmation in the case of diagnostic uncertainty.