Separation of conjoined spinal cords in symmetrical pygopagus twins using intraoperative neuromonitoring: pearls and pitfalls.

Pygopagus twin is a rare congenital malformation with a worldwide incidence of 1in 200,000. Few literature reports are published regarding the matter. In some cases, neuromonitoring is essential for safe surgical separation. We believe it is important to share our challenges and nuances in order to minimize obstacles one might encounter. We utilized neuromonitoring during our separation of both twins, and we planned a multidisciplinary approach and efficient communication system with the other teams in order to plan a successful, safe, and timely separation of the twins. We seek to highlight not our success but rather the obstacles and challenges we encountered during the separation of pygopagus twins in our institute using neuromonitoring for future reference.

Subtotal Resection Followed by Adjuvant Radiosurgery for Large Vestibular Schwannomas: Outcomes with Regard to the Timing and Regimen of Irradiation.

OBJECTIVE: To evaluate the results of combined management of large vestibular schwannomas (VS) with initial subtotal resection (STR) followed by adjuvant stereotactic radiosurgery (SRS), with a particular emphasis on the timing and regimen of irradiation. METHODS: Seventeen patients underwent STR of a VS followed by SRS, whereas five others were observed after STR. Early SRS (<6 months after surgery) and late SRS (>6 months after surgery) were done in 8 and 9 patients, respectively. Single- and multisession SRS treatments were administered in 10 and 7 patients, respectively. The mean follow-up durations after surgery and SRS were 40 and 28 months, respectively. RESULTS: The rates of radiological and oncological tumor control after SRS were 82% and 100%, respectively. The tumor volume at the last follow-up and its relative changes after SRS did not differ significantly on the basis of the irradiation timing (early versus late) or on the basis of the irradiation regimen (single-session versus multisession). In no patient who was observed after STR of a VS was tumor regrowth noted during a mean follow-up period of 49 months. At 12 months after surgery, motor function of the ipsilateral facial nerve corresponded to House-Brackmann grades I, II, III, and IV in 16 patients (73%), 3 patients (14%), 1 patient (5%), and 2 patients (9%), respectively. Facial nerve function at the last follow-up did not differ significantly on the basis of the irradiation timing (early versus late) or on the basis of the irradiation regimen (single-session versus multisession). CONCLUSION: The combination of initial STR followed by adjuvant SRS is an effective treatment strategy for patients with a large VS. Although the optimal timing and regimen of postoperative irradiation of the residual lesion should be defined further, our preliminary data suggest that either early or late SRS after surgery may provide good tumor control and optimal functional results.

Combined Unilateral Posteroventral Pallidotomy and Ventral Intermediate Nucleus Thalamotomy in Tremor-Dominant Parkinson's Disease versus Posteroventral Pallidotomy Alone: A Prospective Comparative Study.

BACKGROUND: The optimum target in surgery for Parkinson's disease (PD) is still controversial, especially in patients with tremor-dominant PD. We aim to compare results in tremor-dominant patients undergoing pallidotomy vs. those undergoing simultaneous posteroventral pallidotomy (PVP) and ventral intermediate nucleus (VIM) thalamotomy. METHODS: Twenty-four patients with tremor-dominant PD were included in this study. Twelve patients received unilateral PVP contralateral to the most affected side. The other 12 patients received simultaneous unilateral PVP and VIM thalamotomy contralateral to the most affected side. Assessment of results in both groups was achieved using both UPDRS "off" motor scores and UPDRS rest tremor subscores. RESULTS: The mean UPDRS off motor score improved in the pallidotomy group from 61.3 preoperatively to 36.8 at 12 months. In the combined group, it improved from 59.6 to 35.2 at 12 months, with no statistically significant difference between both groups. On the other hand, while the mean tremor subscore in the pallidotomy group improved from a mean of 2.3-0.8, the tremors were abolished in all of the patients in the combined group except for 1 patient who showed slight infrequent tremors at 12 months. CONCLUSION: Patients with tremor-dominant PD achieve more improvement in tremor control after combined PVP and VIM thalamotomy.

Spinal schistosomiasis: Cases in Egyptian population.

BACKGROUND: Spinal cord involvement by schistosomiasis is considered to be rare. Clinical presentation of spinal schistosomiasis ranges from radicular pain to myelopathy causing flaccid paraplegia, bladder incontinence, and dysesthesia. We reported six cases with spinal schistosomiasis. METHODOLOGY: We did a retrospective analysis of the records in our department from March 1995 to March 2015, and we found that six cases of proved spinal schistosomiasis were documented, with follow-up period more than a year, aiming to find an assumption for a guideline for this ambiguous issue. RESULTS: We found five cases from six were males and average age group was 26 years old (14-43). All had motor deficit (100%) which was variable, only two (33.33%) had dense weakness (G0) at time of presentation, three (50%) patients had sphincter disturbance also, and 50% of the patients presented with back pain as initial symptom. Only one of six patients had a positive history of the infestation. All patients went through surgical intervention, which was decompression laminectomy then biopsy or excision. Total excision was feasible only in two cases (33.33%), which had a well-defined lesion in imaging, while in others, lesion was ill defined and adherent, so biopsy was done. Steroids up to 2-month duration were used in all patients (100%) and praziquantel in repeated cycles after surgical excision or biopsy was used in all patients (100%). CONCLUSION: History of travelling to endemic areas should raise the suspicion which may be the cornerstone of diagnosis, particularly in conus/epiconus intramedullary lesions. Surgical excision and spinal canal decompression are the best line of treatment in cases of schistosomiasis even if this excision was not total but to confirm and exclude other forms of pathology. Steroids and oral Praziquantel in repeated cycles are the best medication regimen in case of myelitis and in postoperative treatment.

Image guided surgery in the management of craniocerebral gunshot injuries.

BACKGROUND: A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed. Surgical options for bullet extraction span from conventional craniotomy, through C-arm-guided surgery to minimally invasive frame or frameless stereotaxy. But what is the best surgical option? METHODS: We prospectively followed up a cohort of 28 patients with cranio-cerebral gunshot injury (CCHSI) managed from January to December 2012 in our department of neurosurgery. The missiles were extracted via stereotaxy (frame or frameless), C-arm-guided, or free-hand-based surgery. Cases managed conservatively were excluded. The Glasgow Outcome Score was used to assess the functional outcome on discharge. RESULTS: Five of the eight "stereotactic cases" had an excellent outcome after missile extraction while the initially planned stereotaxy missed locating the missile in three cases and were thus subjected to free hand craniotomy. Excellent outcome was obtained in five of the nine "neuronavigation cases, five of the eight cases for free hand surgery based on the bony landmarks, and five of the six C-arm-based surgery. CONCLUSION: Conventional craniotomy isn't indicated in the extraction of isolated, retained, intracranial firearm missiles in civilian injury but could be useful when the missile is incorporated within a surgical lesion. Stereotactic surgery could be useful for bullet extraction, though with limited precision in identifying small pellets because of their small sizes, thus exposing patients to same risk of brain insult when retrieving a missile by conventional surgery. Because of its availability, C-arm-guided surgery continues to be of much benefit, especially in emergency situations. We recommend an extensive long-term study of these treatment modalities for CCGSI.

Perspectives on the immunologic microenvironment of astrocytomas.

BACKGROUND: The microenvironment of astrocytomas includes infiltrative inflammatory cells that are dynamic in nature, possibly reflecting tumor biology. We evaluated the inflammatory cell infiltrate in astrocytic tumors aiming for a better understanding of their immunobiology. METHODS: Immunohistochemical expression of CD68, CD3, and CD20 was investigated in 21 glioblastomas, 21 anaplastic astrocytomas, 13 diffuse astrocytomas, and 18 pilocytic astrocytomas. The inflammatory infiltrate was classified based on microanatomic location as perivascular and intratumoral, and subsequently graded semiquantitatively. RESULTS: Perivascularly, CD68-positive infiltrate was noted in 71.4% of glioblastomas compared with 14.3% of anaplastic astrocytomas (P = 0.0001), 7.7% of diffuse astrocytomas (P = 0.0001), and 33.3% of pilocytic astrocytomas (P = 0.017). Intratumorally, 85.7% of glioblastomas exhibited CD68-positive infiltrate compared with 42.9% of anaplastic astrocytomas (P = 0.004), 38.5% of diffuse astrocytomas (P = 0.008), and 33.3% of pilocytic astrocytomas (P = 0.001). Among diffusely infiltrating astrocytomas, intratumoral CD3-positive infiltrate was only associated with glioblastoma. A CD20-positive infiltrate was only detected in the perivascular space of a single case of diffuse astrocytoma. CONCLUSION: These data indicate a distinct immune profile in the glioblastoma microenvironment primarily related to the prevalence of macrophages. Thus, novel glioblastoma therapies should address this key CD68-positive population and its possible role in generating an antitumor immune response.