Health-related quality of life 2 years after pedicle subtraction osteotomy for sagittal imbalance: a single-center experience of 65 patients.

PURPOSE: Pedicle subtraction osteotomy (PSO) as an invasive procedure with high reoperation and complication rates in an often elderly population has often been questioned. The purpose of our study was to evaluate the impact of PSO for sagittal imbalance (SI) on patient-reported outcomes including self-reported satisfaction and health-related quality of life 2 years postoperatively. METHODS: Consecutive patients who underwent correction of their spinal deformity by thoracolumbar PSO were assessed using self-reporting questionnaires 2 years postoperatively. Outcome was measured by visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and EQ-5D scores. Additionally, a Patient Satisfaction Index (PSI) rated in four grades (A: very satisfied to D: not satisfied), walking range, and the Timed Up and Go (TUG) Test were evaluated. RESULTS: Sixty-five patients were included, and each parameter was assessed preoperatively and 24 months postoperatively. The intervention led to significant improvements in back pain (8.1 ± 1.2 vs. 2.9 ± 1.9; p < 0.001), as well as ODI scores (57.7 ± 13.9 vs. 32.6 ± 18.9; p < 0.001), walking range (589 ± 1676 m vs. 3265 ± 3405 m; p < 0.001), and TUG (19.2 s vs. 9.7 s; p < 0.05). 90.7% of patients (n = 59/65) reported a PSI grade "A" or "B" 24 months postoperatively. CONCLUSION: Patient satisfaction 24 months after PSO for SI is high. Quality of life improved significantly by restoring sagittal balance.

Anidulafungin and Micafungin Concentrations in Cerebrospinal Fluid and in Cerebral Cortex.

Anidulafungin and micafungin were quantified in cerebrospinal fluid (CSF) of critically ill adults and in cerebral cortex of deceased patients. In CSF, anidulafungin levels (<0.01 to 0.66 µg/ml) and micafungin levels (<0.01 to 0.16 µg/ml) were lower than those in plasma concentrations (0.77 to 5.07 and 1.21 to 8.70 µg/ml, respectively) drawn simultaneously. In cerebral cortex, anidulafungin and micafungin levels were 0.21 to 2.34 and 0.18 to 2.88 µg/g, respectively. Thus, MIC values of several pathogenic Candida strains exceed concentrations in CSF and in brain.

Symptomatic hemiparkinsonism due to extensive middle and posterior fossa arachnoid cyst: case report.

INTRODUCTION: Intracranial neoplasms are an uncommon cause of symptomatic parkinsonism. We here report a patient with an extensive middle and posterior fossa arachnoid cyst presenting with parkinsonism that was treated by neurosurgical intervention. METHODS: Retrospective chart review and clinical examination of the patient. CASE REPORT: This 55-year-old male patient with hemiparkinsonism and recurrent bouts of headaches was first diagnosed in 1988. CT scans revealed multiple cystic lesions compressing brainstem and basal ganglia, which were partially resected. Subsequently, the patient was free of complaints for 20 years. In 2009 the patient presented once more with severe unilateral tremor and thalamic pain affecting the right arm. Despite symptomatic treatment with L-Dopa and pramipexole symptoms worsened over time. In 2014 there was further progression with increasing hemiparkinsonism, hemidystonia, unilateral thalamic pain and pyramidal signs. Repeat CT scanning revealed a progression of the cysts as well as secondary hydrocephalus. Following repeat decompression of the brainstem and fenestration of all cystic membranes parkinsonism improved with a MDS- UPDRS III score reduction from 39 to 21. Histology revealed arachnoid cystic material. CONCLUSION: We report on a rare case of recurrent symptomatic hemiparkinsonism resulting from arachnoid cysts.

Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement.

There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.

Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons.

Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients' wishes, their surrogates' wishes, and patient demographics on treatment decisions chosen by neurosurgeons. An online questionnaire was sent to all German neurosurgical units via the German Society of Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, nine addressed indication and treatment plan and four evaluated the neurosurgeon's interest in gathering additional information on the patient's social environment and supposed patient's wishes or advance directive. Eighty-five percent of the interviewed neurosurgeons would perform an emergency operation in the presented case. Midline shift (84%), hematoma thickness (81%), and time between traumatic injury and treatment (81%) were considered to be the most important factors for surgical treatment. Gathering information on the social environment of the patient (66%) and discussion with family members (57%) were felt to be either unimportant. Neurosurgeons in Central Europe tend to treat acute subdural hematoma in very old patients based on imaging findings and according to mechanistic views. Social circumstances and patient wishes are considered to be less important. Education of the medical profession and the general public should aim to bring these factors into focus in the decision-making process.

"I am not afraid of death"-a survey on preferences concerning neurosurgical interventions among patients over 75 years.

INTRODUCTION: Treatment decisions in elderly patients with traumatic brain injury (TBI) are mainly determined by trauma severity and patient age. The aim of this study was to explore personal preferences of potential patients regarding life-prolonging neurosurgical interventions by interviewing ambulatory, autonomous elderly people. METHODS: One hundred consecutive patients older than 75 years frequenting the outpatient clinic of the Department of Neurosurgery were interviewed about their attitudes regarding the hypothetical case of an 81-year-old patient with TBI and a space-occupying acute subdural hematoma (aSDH) using a 21-point questionnaire. RESULTS: Fifty-one percent of the consulted persons declined life-prolonging surgical measures. If surgery was associated with physical disability, 68% of the people wished no surgery. In case of cognitive impairment after surgery, 91% were against any surgical intervention. The majority feared being a burden to relatives (76%) and becoming unable to master an independent life (75%). Four-fifths of the interviewed patients (82%) were not afraid of death. CONCLUSIONS: The majority of elderly patients only consent to surgical measures if no relevant disabilities are involved and if they can return to their previous life. These findings need consideration in case of life-threatening neurosurgical emergencies as well as in the surgical treatment of elderly patients in general.

Reconstruction of large cranial defects with poly-methyl-methacrylate (PMMA) using a rapid prototyping model and a new technique for intraoperative implant modeling.

BACKGROUND: Reconstruction of large cranial defects after craniectomy can be accomplished by free-hand poly-methyl-methacrylate (PMMA) or industrially manufactured implants. The free-hand technique often does not achieve satisfactory cosmetic results but is inexpensive. In an attempt to combine the accuracy of specifically manufactured implants with low cost of PMMA. METHODS: Forty-six consecutive patients with large skull defects after trauma or infection were retrospectively analyzed. The defects were reconstructed using computer-aided design/computer-aided manufacturing (CAD/CAM) techniques. The computer file was imported into a rapid prototyping (RP) machine to produce an acrylonitrile-butadiene-styrene model (ABS) of the patient's bony head. The gas-sterilized model was used as a template for the intraoperative modeling of the PMMA cranioplasty. Thus, not the PMMA implant was generated by CAD/CAM technique but the model of the patients head to easily form a well-fitting implant. Cosmetic outcome was rated on a six-tiered scale by the patients after a minimum follow-up of three months. RESULTS: The mean size of the defect was 74.36cm2. The implants fitted well in all patients. Seven patients had a postoperative complication and underwent reoperation. Mean follow-up period was 41 months (range 2-91 months). Results were excellent in 42, good in three and not satisfactory in one patient. Costs per implant were approximately 550 Euros. CONCLUSION: PMMA implants fabricated in-house by direct molding using a bio-model of the patients bony head are easily produced, fit properly and are inexpensive compared to cranial implants fabricated with other RP or milling techniques.

Calcium-binding proteins in focal cortical dysplasia.

OBJECTIVE: Alterations in γ-aminobutyric acid (GABA)-ergic cortical neurons have been reported in focal cortical dysplasia (FCD)Ia/IIIa, a malformation of cortical development associated with drug-resistant epilepsy. We compared numbers of neurons containing calcium-binding proteins parvalbumin (PV), calbindin (CB), and calretinin (CR) and densities of respective fibers in lateral temporal lobe surgical specimens of 17 patients with FCD with 19 patients who underwent anterior temporal lobe resection due to nonlesional temporal lobe epilepsy (non-FCD) as well as with 7 postmortem controls. METHODS: PV-, CB-, and CR-immunoreactive (IR) neurons were quantitatively investigated with use of two-dimensional cell counting and densitometry (reflecting mainly IR fibers) in cortical layers II, IV, and V. RESULTS: Numbers of PV-IR neurons, ratios of PV-containing to Nissl-stained neurons (correcting for eventual cell loss), and densities of PV-IR were higher in layer II of the cortex of FCD compared to non-FCD patients. Similarly, densities of CB-IR and CR-IR were also higher in layers II and V, respectively, of FCD than of non-FCD patients. Comparison with postmortem controls revealed significant higher cell numbers and fiber labeling for all three calcium-binding proteins in FCD cortex, whereas numbers of Nissl-stained neurons did not vary between FCD, non-FCD, and postmortem controls. In non-FCD versus postmortem controls, ratios of calcium-binding protein-IR cells to Nissl-stained neurons were unchanged in most instances except for increased CB/Nissl ratios and CB-IR densities in all cortical layers. SIGNIFICANCE: Increased numbers of PV neurons and fiber labeling in FCD compared to nondysplastic epileptic temporal neocortex and postmortem controls may be related to cortical malformation, whereas an increased number of CB-IR neurons and fiber labeling both in FCD and non-FCD specimens compared with postmortem controls may be associated with ongoing seizure activity. The observed changes may represent increased expression of calcium-binding proteins and thus compensatory mechanisms for seizures and neuronal loss in drug-resistant epilepsy.

Glutamate decarboxylase 67 is expressed in hippocampal mossy fibers of temporal lobe epilepsy patients.

Recently, expression of glutamate decarboxylase-67 (GAD67), a key enzyme of GABA synthesis, was detected in the otherwise glutamatergic mossy fibers of the rat hippocampus. Synthesis of the enzyme was markedly enhanced after experimentally induced status epilepticus. Here, we investigated the expression of GAD67 protein and mRNA in 44 hippocampal specimens from patients with mesial temporal lobe epilepsy (TLE) using double immunofluorescence histochemistry, immunoblotting, and in situ hybridization. Both in specimens with (n = 37) and without (n = 7) hippocampal sclerosis, GAD67 was highly coexpressed with dynorphin in terminal areas of mossy fibers, including the dentate hilus and the stratum lucidum of sector CA3. In the cases with Ammon's horn sclerosis, also the inner molecular layer of the dentate gyrus contained strong staining for GAD67 immunoreactivity, indicating labeling of mossy fiber terminals that specifically sprout into this area. Double immunofluorescence revealed the colocalization of GAD67 immunoreactivity with the mossy fiber marker dynorphin. The extent of colabeling correlated with the number of seizures experienced by the patients. Furthermore, GAD67 mRNA was found in granule cells of the dentate gyrus. Levels, both of GAD67 mRNA and of GAD67 immunoreactivity were similar in sclerotic and nonsclerotic specimens and appeared to be increased compared to post mortem controls. Provided that the strong expression of GAD67 results in synthesis of GABA in hippocampal mossy fibers this may represent a self-protecting mechanism in TLE. In addition GAD67 expression also may result in conversion of excessive intracellular glutamate to nontoxic GABA within mossy fiber terminals.

Current trends and outcomes of non-elective neurosurgical care in Central Europe during the second year of the COVID-19 pandemic.

Reflecting the first wave COVID-19 pandemic in Central Europe (i.e. March 16th-April 15th, 2020) the neurosurgical community witnessed a general diminution in the incidence of emergency neurosurgical cases, which was impelled by a reduced number of traumatic brain injuries (TBI), spine conditions, and chronic subdural hematomas (CSDH). This appeared to be associated with restrictions imposed on mobility within countries but also to possible delayed patient introduction and interdisciplinary medical counseling. In response to one year of COVID-19 experience, also mapping the third wave of COVID-19 in 2021 (i.e. March 16 to April 15, 2021), we aimed to reevaluate the current prevalence and outcomes for emergency non-elective neurosurgical cases in COVID-19-negative patients across Austria and the Czech Republic. The primary analysis was focused on incidence and 30-day mortality in emergency neurosurgical cases compared to four preceding years (2017-2020). A total of 5077 neurosurgical emergency cases were reviewed. The year 2021 compared to the years 2017-2019 was not significantly related to any increased odds of 30 day mortality in Austria or in the Czech Republic. Recently, there was a significant propensity toward increased incidence rates of emergency non-elective neurosurgical cases during the third COVID-19 pandemic wave in Austria, driven by their lower incidence during the first COVID-19 wave in 2020. Selected neurosurgical conditions commonly associated with traumatic etiologies including TBI, and CSDH roughly reverted to similar incidence rates from the previous non-COVID-19 years. Further resisting the major deleterious effects of the continuing COVID-19 pandemic, it is edifying to notice that the neurosurgical community´s demeanor to the recent third pandemic culmination keeps the very high standards of non-elective neurosurgical care alongside with low periprocedural morbidity. This also reflects the current state of health care quality in the Czech Republic and Austria.

Video-EEG monitoring: safety and adverse events in 507 consecutive patients.

PURPOSE: Video-electroencephalography (EEG) monitoring plays a central role in the presurgical evaluation of medically refractory epilepsies and the diagnosis of nonepileptic attack disorders (NEADs). The aim of this study was to analyze safety and adverse events (AEs) during video-EEG monitoring. METHODS: We retrospectively evaluated 596 video-EEG sessions in 507 patients (233 men, mean age 36 years, standard deviation = 14, range 9-80 years) within a 6-year period. AEs were examined in detail and their risk factors were assessed using multiple logistic regression analysis. KEY FINDINGS: Forty-four patients (9%) experienced 53 AEs: 20 had psychiatric events (17 postictal psychosis, 2 panic attacks, 1 interictal psychosis), 15 had injuries (14 falls with minor injuries, 2 falls with fractures, 2 fractures without fall, 1 fall with epidural hematoma), 10 patients had 13 episodes of status epilepticus (SE), and one AE was treatment-related (valproic acid--induced encephalopathy). Patients with AEs were older (p = 0.036) and had a longer duration of epilepsy (p = 0.019). All AEs resulted in a prolonged hospital stay (p < 0.001). Ninety-one percent of the AEs occurred within the first 4 days of monitoring. Independent risk factors were duration of epilepsy >17 years [odds ratio (OR) 3.096; 95% confidence interval (CI) 1.548-6.189], a previous history of psychiatric illness (OR 16.882; 95% CI 5.469-52.110), a history of seizure-related injuries (OR 3.542; 95% CI 1.069-11.739), or a history of SE (OR 3.334; 95% CI 1.297-8.565). SIGNIFICANCE: The most common AEs were postictal psychosis, falls, and SE. Patients with an older age, long disease duration, psychiatric comorbidity, history of injuries, and SE have a higher risk.

Cranial nerve monitoring during subpial dissection in temporomesial surgery.

OBJECTIVE: Cranial nerves (CNs) crossing between the brainstem and skull base at the level of the tentorial hiatus may be at risk in temporomesial surgery involving subpial dissection and/or tumorous growth leading to distorted anatomy. We aimed to identify the surgical steps most likely to result in CN damage in this type of surgery. METHODS: Electromyographic responses obtained with standard neuromonitoring techniques and a continuous free-running EMG were graded as either contact activity or pathological spontaneous activity (PSA) during subpial resection of temporomesial structures in 16 selective amygdalohippocampectomy cases. Integrity of peripheral motor axons was tested by transpial/transarachnoidal electrical stimulation while recording compound muscle action potentials from distal muscle(s). RESULTS: Continuous EMG showed pathological activity in five (31.2%) patients. Nine events with PSA (slight activity, n = 8; strong temporary activity, n = 1) were recorded. The oculomotor nerve was involved three times, the trochlear nerve twice, the facial nerve once, and all monitored nerves on three occasions. Surgical maneuvers associated with PSA were the resection of deep parts of the hippocampus and parahippocampal gyrus (CN IV, twice; CN III, once), lining with or removing cotton patties from the resection cavity (III, twice; all channels, once) and indirect exertion of tension on the intact pia/arachnoid of the uncal region while mobilizing the hippocampus and parahippocampal gyrus en bloc (all channels, once; III, once). CMAPs were observed at 0.3 mA in two patients and at 0.6 mA in one patient, and without registering the exact amount of intensity in three patients. CONCLUSION: The most dangerous steps leading to cranial nerve damage during mesial temporal lobe surgery are the final stages of the intervention while the resection is being completed in the deep posterior part and the resection cavity is being lined with patties. Distant traction may act on nerves crossing the tentorial hiatus via the intact arachnoid.

A simple electrical approach to diagnosing a suspected lead break in patients with implanted vagus nerve stimulators - Technical note.

PURPOSE: Vagus nerve stimulation (VNS) is an effective adjunctive treatment for patients with drug-resistant epilepsy (DRE) or difficult-to-treat depression (DTD). The implanted system consists of a titanium-cased generator and a lead with platinum electrodes, placed around the cervical vagus nerve. In rare cases a lead may break, causing the patient to receive insufficient therapy or no therapy at all, with potentially dangerous consequences. In order to confirm a suspected lead breakage, physicians have the option to perform x-rays. However, x-rays often do not show a clear, unmistakable lead break. In this technical note an additional method to verify lead integrity electrophysiological is described in detail to provide the highest degree of certainty on the integrity of the lead when a broken lead is suspected before proceeding to revision surgery. METHODS: When patients introduce themselves with symptoms indicating a suspected lead breakage, a systematic lead break management is required. This includes, beside the clinical anamneses, performing VNS Therapy® System Diagnostics (SD). If an unacceptable HIGH lead impedance is observed, performing x-rays (anteroposterior and lateral views) may help to confirm a lead breakage. Additionally, EMG recording equipment can be used to analyse the VNS stimulus waveform from the neck for verification of an electrical discontinuity. RESULTS: A differentiated VNS waveform with narrowed pulses or no waveform at all can confirm lead discontinuity. CONCLUSION: This Technical Note describes an easy but underused electrophysiological procedure to be included in the standardized protocol for identifying VNS lead breakage.

Asymmetric seizure termination in primary and secondary generalized tonic-clonic seizures.

PURPOSE: In temporal lobe epilepsies an asymmetric termination (AST) of the clonic phase of secondary generalized tonic-clonic seizures (sGTCS) reliably lateralizes the side of seizure onset. The last clonic activity occurs ipsilateral to the side of the seizure onset zone. We compared the prevalence and lateralizing value of AST in sGTCS of frontal and temporal lobe origin as well as in primary generalized tonic-clonic seizures (pGTCS). METHODS: We analyzed 177 seizures in 84 consecutive patients. Forty-one patients had temporal lobe epilepsy (TLE), 24 frontal lobe epilepsy (FLE), and 19 had nonfocal (primary) generalized epilepsies (GE). All patients underwent intensive video-EEG (electroencephalography) monitoring, high-resolution magnetic resonance imaging (MRI), neuropsychological testing, and single photon emission computed tomography/positron emission tomography (SPECT/PET) when feasible. Two investigators blinded for diagnosis, EEG, and imaging data assessed frequency and side of the last clonic jerk. RESULTS: AST occurred in 63% of patients with TLE (47% of seizures), in 71% with FLE (60% of seizures), and in 42% with GE (21% of seizures). These results were not significant for patients, but significant for seizures in TLE versus GE and in FLE versus GE (p < 0.001). The positive predictive value (PPV) for the side of seizure onset was 74% (p = 0.003) in TLE and 75% (p = 0.008) in FLE. DISCUSSION: AST in sGTCS lateralizes the side of seizure onset in TLE and in FLE to the ipsilateral hemisphere with a high PPV. However, AST was also observed in GE. Therefore, asymmetric clinical signs should not inevitably lead to the assumption of focal epilepsy syndromes.

Successful surgery in late onset epilepsy with tuberous sclerosis complex.

[Case records of Epileptic Disorders. Anatomo-electro clinical correlations. Case 01-2009]. Tuberous sclerosis complex (TSC) is a multisystem genetic disorder with variable phenotypic expression, caused by mutations in one of the two tumor suppressor genes, TSC1 or TSC2. Epilepsy is the most common neurological presentation and seizures are often medically intractable. Definition of the epileptogenic zone during presurgical evaluation is challenging given the multiple potentially epileptogenic lesions visible on MRI. However, TSC patients may nevertheless achieve seizure freedom, when preoperative evaluation yields concordant results. The strategies used in these patients vary substantially among different epilepsy surgery centres. We present a 21-year-old right-handed, intellectually not impaired woman with TSC and medically intractable seizures since the age of 15 years. Careful multi-stage presurgical evaluation, including prolonged video-EEG-monitoring, cerebral high resolution MRI, ictal and interictal [99m Tc]HMPAO-SPECT, [18 F]FDG-PET and further invasive recordings with subdural and depth electrodes led to the identification of an epileptogenic tuber with concordant seizure onset zone in the right neocortical temporal lobe. A tailored resection was performed leading to excellent surgical outcome (follow-up 12 months, Engel class I).

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

PURPOSE: Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus. METHODS: A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus. RESULTS: The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms. CONCLUSION: A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Immediate Versus Delayed Surgical Treatment of Lumbar Disc Herniation for Acute Motor Deficits: The Impact of Surgical Timing on Functional Outcome.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of the study was to assess the impact of time to surgery in patients with motor deficits (MDs) on their functional outcome. The current single-center study presents results of emergency surgery for LDH in a group of patients with acute paresis in a "real-world" setting. SUMMARY OF BACKGROUND DATA: MDs are a frequent symptom of lumbar disc herniation (LDH). Although surgery within 48 hours has been recommended for cauda-equina syndrome, the best timing of surgery for acute MDs continues to be debated. The effect of early surgery has been proposed but remains to be unproven. METHODS: A total of 330 patients with acute paresis caused by LDH acutely referred to our department and surgically treated using microsurgical discectomy from January 2013 to December 2015 were included. Based on the duration of MD and surgical timing, all patients were classified into two categories: Group I included all patients with paresis <48 hours and Group II included all patients with paresis >48 hours. Patient demographics, LDH/clinical/treatment characteristics, and outcomes were collected prospectively.Severity of paresis [Medical Research Council (MRC) Grade 0-4], surgery-related complications, functional recovery of motor/sensory deficits, sciatica, retreatment/recurrence rates, and overall neurological outcome were analyzed. RESULTS: Group I showed significantly faster recovery of moderate/severe paresis (MRC 0-3) at discharge, and 6-weeks/3-months follow up (P ≤ 0.001), whereas there were no significant differences in recovery for mild paresis (MRC 4). Sensory deficits also recovered substantially faster in Group I at 6-weeks (P = 0.003) and 3-months follow up (P = 0.045). Body mass index, preoperative MRC-grade, and duration of MDs were identified as significant predictors for recovery of paresis at all follow ups with substantial impact on patient reported outcomes including sciatica and/or dermatomal sensory deficits. CONCLUSION: Given the superior rates of neurological recovery of acute moderate/severe MDs, immediate surgery should be the primary option. However, a prospective randomized clinical trial is needed to confirm the superiority of emergency surgery. LEVEL OF EVIDENCE: 3.

Functional imaging of semantic memory predicts postoperative episodic memory functions in chronic temporal lobe epilepsy.

Medial temporal (MTL) structures have crucial functions in episodic (EM), but also in semantic memory (SM) processing. Preoperative functional magnetic resonance imaging (fMRI) activity within the MTL is increasingly used to predict post-surgical memory capacities. Based on the hypothesis that EM and SM memory functions are both hosted by the MTL the present study wanted to explore the relationship between SM related activations in the MTL as assessed before and the capacity of EM functions after surgery. Patients with chronic unilateral left (n=14) and right (n=12) temporal lobe epilepsy (TLE) performed a standard word list learning test pre- and postoperatively, and a fMRI procedure before the operation using a semantic decision task. SM processing caused significant bilateral MTL activations in both patient groups. While right TLE patients showed asymmetry of fMRI activation with more activation in the left MTL, left TLE patients had almost equal activation in both MTL regions. Contrasting left TLE versus right TLE patients revealed greater activity within the right MTL, whereas no significant difference was observed for the reverse contrast. Greater effect size in the MTL region ipsilateral to the seizure focus was significantly and positively correlated with preoperative EM abilities. Greater effect size in the contralateral MTL was correlated with better postoperative verbal EM, especially in left TLE patients. These results suggest that functional imaging of SM tasks may be useful to predict postoperative verbal memory in TLE. They also advocate a common neuroanatomical basis for SM and EM processes in the MTL.

N-terminal pro-brain natriuretic peptide (NT-proBNP) release in children with vagus nerve stimulation. A prospective case series.

Brain natriuretic peptide(BNP) and the N-terminal pro-brain natriuretic peptide (NTproBNP)are important cardiac biomarkers secreted by the heart in response to increased ventricular wall stress associated with heart failure. The aim of our case series was to prospectively evaluate the influence of vagus nerve stimulation (VNS) on the release of NTproBNP.Three children with medically refractory epilepsy and scheduled for implantation of the VNS device were included. Pre-implantation,NT-proBNP measurements were taken at two different occasions after seizure-free periods of at least three days. After implantation,NT-proBNP measurements were taken every 2 to 4 weeks, immediately before and immediately after up-regulation of the VNS. After VNS implantation, the pattern of NT-proBNP increase was consistent for all children. In a 12 year-old girl, NT-proBNP concentrations reached a maximum of an almost 10-fold increase. Thereafter, NTproBNP concentrations returned continuously to baseline. In a three year-old boy, NT-proBNP concentrations reached a maximum of an almost 7-fold increase, accompanied by manifestation of side effects(voice alterations, snoring).Thereafter, NT-proBNP concentrations decreased to almost 4-fold those at baseline. In an 8 year-old girl, NT-proBNP concentrations increased slightly without yet reaching a plateau. This case series suggests that NT-proBNP concentrations increase in response to VNS-induced autonomic influences involving endocrinological stress-response mechanisms typically associated with cardiac injury.Especially in patients with pre-existing cardiovascular dysfunction,measurement of NT-proBNP concentrations may help to identify patients with high baseline concentrations and possibly at greater risk for cardiac side effects.