Longer survival of glioblastoma complicated by bacterial infections after surgery: what is known today.

INTRODUCTION: Glioblastoma is the most common primary brain tumor in adults with the worst overall survival. Post-craniotomy intracranial infections are not infrequent after surgery; however, their impact on overall survival of glioblastoma patients remains unclear. Here we report the case of an unusual longer survival of a glioblastoma patient affected by multiple infections and the review of the literature on this topic. EVIDENCE ACQUISITION: PubMed, Embase and Cochrane search engines were reviewed for papers describing outcome of patients suffering from glioblastoma and associated cerebral infections. EVIDENCE SYNTHESIS: Four papers accounting a total of 29 patients met the eligibility criteria. Staphylococcus aureus and Staphylococcus epidermidis resulted the most common bacteria causing post-craniotomy intracranial infections in brain tumor patients. The overall median survival rate was 18±18.12 months when adding all 29 patients. Only one study described a significant higher survival rate for the infected group. CONCLUSIONS: Glioblastoma is the most frequent malignant brain tumor with a very poor outcome/survival. In the literature few cases described an exceptional longer survival often associated with a postoperative infection. To date, the pathophysiology behind this longer survival remains unclear, but it seems that Staphylococcus species could have an influence on the progression of this aggressive brain tumor.

The Morphology of Somatosensory Evoked Potentials During Middle Cerebral Artery Aneurysm Clipping (MoSAC): A Pilot Study.

Somatosensory evoked potential (SEP) monitoring is a standard tool during clipping of aneurysms of the middle cerebral artery (MCA), and the parameter used to detect a state of cortical ischemia is amplitude. We think that the sensitivity of SEP can however be improved by using other parameters. Our study moves in this direction via SEP morphology. In this pilot preliminary study, involving a small sample without postoperative neurological deficit, we aimed at investigating the value of SEP morphology (in the 15- to 35-ms time frame), in comparison with SEP amplitude (N20 peak-to-peak), as a measure of sensitivity to blood flow reduction. The changes in the SEP morphology of 16 patients undergoing clipping of an unruptured MCA aneurysm was studied. We applied the Morph-Fréchet index for each recorded SEP (at 30-second intervals), quantifying the pattern shape change with regard to the average SEP recorded after dura opening (baseline). We also compared 3 measurements of the SEP morphology, without and with GARCH-derived filter. Filtered Morph-Fréchet never exceeded the individual's "normality" range in baseline but did so in 81% of the risk phase on average across the 16 subjects, which is more than that for amplitude (36%, P = .002). This pilot study indicates that a measurement derived from the networking nature of the brain was sensitive to blood flow reduction. The SEP morphology approach promises to improve SEP monitoring sensitivity during clipping of unruptured MCA aneurysms. New and Noteworthy. The higher sensitivity to blood flow reduction of SEP morphology than amplitude promises to improve the effectiveness of intraoperative monitoring during MCA aneurysm clipping procedures.

Intradiploic encephalocele of the primary motor cortex in an adult patient: electrophysiological implications during surgery.

Encephaloceles are herniations of brain parenchyma through congenital or acquired osseous-dural defects of the skull base or cranial vault. Different types of symptoms, due to CSF fistulas, meningitis, or seizures, are often associated with this condition. The authors present a rare case of spontaneous right frontal parasagittal encephalocele in a 70-year-old man who was experiencing a spastic progressive paresis of his left lower limb. Results of routine electrophysiological workup (motor evoked potentials, somatosensory evoked potentials, and electroneuromyography), as well as those of MRI of the spinal cord, were normal. A brain MRI study detected a partial herniation of the right precentral gyrus through a meningeal defect into the diploe, embedding corticospinal fibers. The patient underwent navigated craniotomy. Intraoperative neuromonitoring of motor function with transcranial electrical stimulation and direct cortical stimulation indicated the presence of motor cortex inside the encephalocele. Thus, the brain parenchyma was carefully released without resection to preserve motor function and, finally, a cranioplasty was performed. After a few months, the patient demonstrated considerable improvement in his left lower-limb function and, after 1 year, he had fully recovered. Intraoperative electrophysiological monitoring and mapping allowed for the determination of the best surgical strategy for the isolation of the encephalocele and correlated well with preoperative multimodal MRI.

Anterior communicating artery aneurysm clipping using standard small fronto-pterional approach, clipping with 3 Lazic clips.

An 80-year-old female presented 5 months previous for nonspecific gait disturbance, during which an MRI was performed. A large based anterior communicating artery aneurym was found independent of neurology. An interdisciplinary discussion favored surgical treatment, on which the patient insisted. Surgery was performed using standard anesthesia techniques with intraoperative burst supression during surgery, neuromonitoring with MEP and SEP, as well as ICG angiography, microdoppler and neuronavigation. Successful clipping was performed with 2 fenestrated straight and one bayoneted straight Lazic clip. Temporary clipping was 6.1 minutes. Postoperative angiography showed exclusion of the aneurysm, and there was no neurological deficit. The video can be found here: http://youtu.be/WKjOHG8irFo .