A technique for reconstruction of a giant extracranial internal carotid artery aneurysm: A technical note.

Background: Surgery is effective for extracranial internal carotid artery (EICA) aneurysms. However, the risk of cranial nerve injury associated with surgical repair, such as graft-assisted resection and extracranial-intracranial bypass techniques, is relatively high. Here, we report two cases of surgical treatment for EICA aneurysms and describe the surgical techniques and strategies to avoid cranial nerve injury. Methods: Two patients presented to our facility with an increasing cervical pulsatile mass and no neurological symptoms. Angiography showed a large aneurysm in the cervical internal carotid artery. Surgical treatment was performed to prevent rupture of the aneurysm. In both patients, the aneurysm was strongly attached to the vagus nerve. The aneurysm and vagus nerve were carefully dissected using a low-power bipolar (20 Malis; 3 watts), leaving connective tissue on the vagus nerve side. Results: The aneurysm was detached from the vagus nerve without injury. Based on intraoperative findings, one patient underwent clipping, and the other underwent aneurysmectomy and primary closure for aneurysm obliteration and angioplasty. Both patients were discharged without any cranial nerve dysfunction. Conclusion: The selection of a strategy based on intraoperative findings and low-power bipolar cutting is important for the treatment of extracranial carotid artery aneurysms to preserve cranial nerves.

Frontal Sinus Mucosa Bacteriological Features: Evaluation after Unintentional Opening in Neurosurgery.

Objectives The bacteriological features of the frontal sinus mucosa may impose significant complications in neurosurgery, when breached unintentionally. This study aimed to investigate the bacterial flora in patients undergoing frontal craniotomy for cerebrovascular substrate surgery. Design This is a single-center prospective study. Setting When mucosal laceration occurred, the patients underwent frontal sinus reconstruction with mucosa reconstruction, preserving the nasofrontal duct. Participants We enrolled eight consecutive patients who underwent bifrontal craniotomy associated with frontal sinus mucosa laceration. Main Outcome Measures A portion of the mucosa was extracted during the reconstructive procedure and was sent for microbiological analysis. Results None of the patients presented with the bacterial flora in the mucosal cultures. No patient experienced postoperative cerebrospinal fluid leakage or meningitis. One patient with a clinical history of chronic maxillary sinusitis presented with a subcutaneous abscess around the forehead at 9 months postoperatively. The patient rapidly recovered after receiving oral administration of antibiotics. Conclusions Our findings demonstrated that the frontal sinuses were maintained in an aseptic environment in all cases. The results may encourage the development and wider use of transfrontal sinus approaches.

Effect of revascularization surgery on cerebral hemodynamics in adult moyamoya disease.

OBJECTIVE: Few studies have reported local hemodynamic changes after revascularization surgery. This study aimed to identify regional hemodynamic changes after combined revascularization surgery for moyamoya disease using single-photon emission computed tomography with N-isopropyl-p-123I-iodoamphetamine. METHODS: A total of 46 adults with moyamoya disease who underwent combined revascularization surgery from August 2009 to July 2021 at our facility were enrolled. The combined bypass procedure comprised a single direct bypass to the motor area and encephalo-duro-arterio-myo-synangiosis. The preoperative and postoperative cerebral blood flow (CBF) and cerebral vascular reserve (CVR) in the genu; precentral, central, parietal, angular, temporal, and posterior regions; splenium; hippocampus; and cerebellum were measured. To modify the examination variability, the cerebral-to-cerebellar activity ratio (CCR) was calculated by dividing the counts in the region by those in the cerebellum (CBF-CCR and CVR-CCR). RESULTS: Postoperatively, asymptomatic cerebral infarction occurred in three (6.5%) patients. The CBF-CCR and CVR-CCR improved in the precentral, parietal, and temporal regions and in the overall middle cerebral artery (MCA) territory. Sub-analysis of anterior cerebral artery (ACA) and posterior cerebral artery (PCA) territory hemodynamics revealed that patients with normal preoperative hemodynamics showed no changes in the CBF-CCR and CVR-CCR postoperatively, whereas patients with preoperative perfusion impairment exhibited improved CVR-CCR in the ACA territory (0.13-0.3, p=0.019) and CBF-CCR in the PCA territory (0.93-0.96, p=0.0039). CONCLUSION: Combined revascularization surgery with single bypass to the motor area improved hemodynamics in the primary targeted MCA territory and in the ACA and PCA territories among patients with preoperative hemodynamic impairment.

The use of advanced technology for preoperative planning in cranial surgery - A survey by the EANS Young Neurosurgeons Committee.

Introduction: Technological advancements provided several preoperative tools allowing for precise preoperative planning in cranial neurosurgery, aiming to increase the efficacy and safety of surgery. However, little data are available regarding if and how young neurosurgeons are trained in using such technologies, how often they use them in clinical practice, and how valuable they consider these technologies. Research question: How frequently these technologies are used during training and clinical practice as well as to how their perceived value can be qualitatively assessed. Materials and methods: The Young Neurosurgeons' Committee (YNC) of the European Association of Neurosurgical Societies (EANS) distributed a 14-items survey among young neurosurgeons between June 1st and August 31st, 2022. Results: A total of 441 responses were collected. Most responders (42.34%) received "formal" training during their residency. Planning techniques were used mainly in neuro-oncology (90.86%), and 3D visualization of patients' DICOM dataset using open-source software was the most frequently used (>20 times/month, 20.34% of responders). Software for 3D visualization of patients' DICOM dataset was the most valuable technology, especially for planning surgical approach (42.03%). Conversely, simulation based on augmented/mixed/virtual reality was considered the less valuable tool, being rated below sufficiency by 39.7% of responders. Discussion and conclusion: Training for using preoperative planning technologies in cranial neurosurgery is provided by neurosurgical residency programs. Software for 3D visualization of DICOM datasets is the most valuable and used tool, especially in neuro-oncology. Interestingly, simulation tools based on augmented/virtual/mixed reality are considered less valuable and, therefore, less used than other technologies.

Managing Complications Related to Peripheral Nerve Surgery: Selected Illustrative Cases.

Peripheral nerve surgery mostly involves elective procedures; thus, the associated complications are of great clinical, social, and medicolegal importance. Apart from the general perioperative morbidity, complications during interventions on peripheral nerves are extremely rare. However, iatrogenic peripheral nerve injuries during unrelated surgical procedures performed by those not specialised in peripheral nerve surgery remain the most significant group of complications, accounting for up to approximately 17% of all cases. The aims of this review are to provide better insight into the multifaceted nature of complications related to peripheral nerve surgery-from the perspective of their causes, treatment, and outcome-and to raise surgeons' awareness of the risks of such morbidity. It should be emphasized that intraoperative complications in peripheral nerve surgery are largely "surgeon-related" rather than "surgery-related"; therefore, they have great potential to be avoided.

Disappearance of hemichorea as the initial presentation of moyamoya disease after revascularization surgery regardless of residual hypoperfusion evaluated by quantitative N-isopropyl-p-123I-iodoamphetamine SPECT.

BACKGROUND AND IMPORTANCE: Although hypoperfusion of the basal ganglia or the frontal subcortical matter is suspected, the pathology of chorea in moyamoya disease remains unclarified. Herein, we report a case of moyamoya disease presenting with hemichorea and evaluate pre- and postoperative perfusion using single photon emission computed tomography with N-isopropyl-p-123I-iodoamphetamine (123I-IMP SPECT). CLINICAL PRESENTATION: An 18-year-old woman presented with choreic movement of her left limbs. Magnetic resonance imaging revealed an ivy sign, and 123I-IMP SPECT demonstrated decreased cerebral blood flow (CBF) and cerebral vascular reserve (CVR) values in the right hemisphere. The patient underwent direct and indirect revascularization surgery to improve cerebral hemodynamic impairment. The choreic movements entirely resolved immediately after surgery. Although CBF and CVR values in the ipsilateral hemisphere demonstrated by quantitative SPECT increased, these did not reach the normal values threshold. CONCLUSION: Choreic movement in moyamoya disease may be related to cerebral hemodynamic impairment. Further studies are required to elucidate its pathophysiological mechanisms.

Reversible splenial lesion after surgery for distant arteriovenous malformation: a case report.

Isolated lesions of the corpus callosum are rare and may represent permanent but also transient responses to various pathology termed "reversible splenial lesion syndrome" (RESLES) when in light of relevant clinical presentation. We present the first case of the RESLES after elective surgery for distant arteriovenous malformation (AVM), followed by a slight speech disturbance and MRI verified small, oval, well-circumscribed area of apparent cytotoxic edema in the center of the corpus callosum splenium, which completely resolved within 15 days. Surgery for AVM is followed by the complex adaptation to a new vascular pattern, RESLES might develop, and should be suspected.

Distal nerve transfer (PT-AIN, SUP-PIN) for regaining hand function in C8, T1 root injury following extirpation of the right C8, T1 schwannoma.

A 48-year-old female was admitted to the authors' department due to hand weakness as a consequence of C8, T1 root injury. Eight months earlier, the patient had been treated by a pulmonary surgeon due to an expansive lesion near the apex of the right lung, which resulted in right lower brachial plexus palsy. Postoperative pathohistological findings indicated that the lesion was nerve schwannoma. The diagnostic process included physical examination, electromyoneurography, and MRI. A distal nerve transfer (pronator teres-anterior interosseus nerve [PT-AIN], supinator-posterior interosseus nerve [SUP-PIN]) was performed in order to restore hand function. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22110.

A Brief History of Peripheral Nerve Surgery in Serbia.

Peripheral nerve surgery in Serbia has become the most fruitful subsection of national neurosurgery, with international recognition of Serbian surgeons and institutions. We chronicle landmark events in the history of the field in Serbia, highlighting the development of the field over time and outlining future prospects. This manuscript provides an example of the development of peripheral nerve surgery and associated training in a challenging social, political, and economic context and may guide the development of peripheral nerve surgery care and training in other settings.

Quality of life and satisfaction in patients surgically treated for cubital tunnel syndrome.

OBJECTIVE: Cubital tunnel syndrome (CuTS) results from compression of the ulnar nerve at the elbow, resulting in pain, weakness, and numbness of the hand and forearm. This work describes the Quality of Life (QoL) and satisfaction after CuTS surgery and identifies the factors associated with those outcomes. METHODS: This cross-sectional study included patients surgically treated for CuTS from January 2011 to September 2021 at the Neurosurgery Clinic of the Clinic Center in Serbia. The questionnaires applied were the Short Form 36 (SF-36), EuroQol instrument (EQ-5D-5 L), Bishop's score and Patient-Rated Ulnar Nerve Evaluation (PRUNE). RESULTS: Sixty-two patients met the inclusion criteria. Bishop's score: The median score was 10 (7.75-11), 54.8% of the cases presented excellent results. PRUNE: The median score for symptoms was 19 (6-38.5); for functional, was 14 (0.75-38); and the total was 18.25 (5.87-34.12). SF-36: The subscale with the best result was social functioning (84.68 ± 22.79). The scale with the worst value was emotional well-being (49.35 ± 7.87). EQ-5D-5L: Over 50% patients did not present problems with mobility, self-care, activity, and anxiety. The average EQ-VAS was 72.77 ± 18.70; and 0.72 ± 0.21 of the EQ-index, revealing a good QoL. Models for QoL and satisfaction: Ten models showed statistical significance. The variables with major involvement were body mass index and time evolution of the symptoms. CONCLUSION: Surgical decompression has proved to diminish the symptoms, improving QoL and satisfaction. Many fixed and changeable factors can affect the satisfaction levels after surgery.

Useful functional recovery and quality of life after surgical treatment of peroneal nerve injuries.

Closed injuries to the peroneal nerve recover spontaneously in about a third of patients, but surgery may be needed in the remaining 2/3. The recovery after surgery is not always satisfactory and the patients may need an orthosis or a walking aid to cope with regular daily activities. This study aimed to evaluate the useful functional recovery and quality of life (QoL) in surgically treated patients with peroneal nerve (PN) injuries. The study involved 51 patients who have undergone surgical treatment due to PN injury in our department, within a 15-year period (2006-2020). Thirty patients (59%) were treated with neurolysis, 12 (23%) with nerve repair techniques, and 9 (18%) with tendon transfer (TT). Neurolysis is employed in the least extensive nerve injuries when nerve continuity is preserved and yields a motor recovery ratio of almost 80%. Nerve repairs were followed by 58.33% of patients achieving M3+ recovery, while 41.66% recovered to the useful functional state (M4 or M5) With the use of TTs, all patients recovered to the M3+, while 66.7% recovered to M4. All our results correspond to the results of previous studies. No statistically significant differences were found regarding the QoL of the groups. There is an apparent advantage of neurolysis, over nerve repair, over TT procedure, both in terms of useful functional recovery, and foot-drop-related QoL. However, when involving all aspects of QoL, these advantages diminish. The individual approach leads to optimal results in all groups of patients.

Peripheral nerve surgery in Serbia: "Think global, act local" and the privilege of service.

Introduction: The phrase "think globally, act locally", which has often been used to refer to conservation of the environment, highlights the importance of maintaining a holistic perspective and stipulates that each individual has a role to play in their community and larger world. Although peripheral nerve surgery has been largely unemphasized in global neurosurgical efforts, a wide disparity in peripheral nerve surgery is presumed to exist between high-income and low- and middle-income countries. Serbia is an upper middle-income country with a long history of peripheral nerve surgery. Research question: How can understanding the development of peripheral nerve surgery in Serbia advance global education and improve peripheral nerve surgery worldwide? Material and methods: An anecdotal and narrative review of recent advances in peripheral nerve surgery in Serbia was conducted. The World Federation of Neurosurgical Society (WFNS) Peripheral Nerve Surgery Committee discussions on improving peripheral nerve surgery education were summarized. Results: In this manuscript, we describe the application of "think globally, act locally" to peripheral nerve surgery by providing an account of the development of peripheral nerve surgery in Serbia. Then, we report measures taken by the WFNS Peripheral Nerve Surgery Committee to improve education on peripheral nerve surgery in LMICs. Discussion and conclusion: Viewing the development of peripheral nerve surgery in Serbia through the lens of "think globally, act locally" may guide the development of peripheral nerve surgery in LMICs.

A review of the diet, nutrients, and supplementation potential for the outcome augmentation in surgical treatment of peripheral nerve injuries.

Objective: Although the studies have shown the beneficial effects of diet, nutrition, and supplementation as an independent treatment modality, their roles are underestimated in the treatment of peripheral nerve injuries. This is in great part due to the development of efficient nerve repair techniques, combined with physical treatment and stimulation. To achieve the best possible functional recovery diet, nutrition, and supplementation should be implemented within a multidisciplinary approach. The aim of the study is to provide insight into the potentially beneficial effects of diet, nutrients, and supplementation, in the limitation of nerve damage and augmentation of the functional recovery after surgery in a review of human and animal studies. Methods: The data relating to the diet, nutrients, and supplementation effects on peripheral nerve injuries and their treatment was extracted from the previously published literature. Results: General balanced diet as well as obesity influence the initial nerve features prior to the injury. In the period following the injury, neuroprotective agents demonstrated beneficial effects prior to surgery, and immediately after the injury, while those potentiating nerve regeneration may be used after the surgical repair to complement the physical treatment and stimulation for improved functional recovery. Conclusions: Standardized diet, nutrition, and supplementation recommendations and protocols may be of great importance for better nerve regeneration and functional recovery as a part of the multidisciplinary approach to achieve the best possible results in surgically treated patients with peripheral nerve injuries in the future.

Etiological and epidemiological characteristics of surgically treated radial nerve lesions: A 20-year single-center experience.

Introduction: Radial nerve lesions present a clinical entity that may lead to disability, psychological distress, and job loss, and thus requires great attention. Knowledge of the etiology and exact mechanism of the nerve impairment is of great importance for appropriate management of these patients, and there are only a few papers that focused on these features in patients with surgically treated radial nerve lesions. The lack of studies presenting the etiology and injury mechanisms of surgically treated radial nerve lesions may be due to a relatively small number of specialized referral centers, dispersion to low-flow centers, and a greater focus on the surgical treatment outcomes. Aim: The aim of this study was to describe the etiological and epidemiological characteristics of patients with surgically treated radial nerve lesions of various origins. Methods: This retrospective study evaluated 147 consecutive patients with radial nerve lesion, treated in the department during the last 20 years, from January 1, 2001, until December 31, 2020. Results: The majority of patients belonged to the working population, and 70.1% of them were male. Most commonly, the etiology of nerve lesion was trauma (63.3%) or iatrogenic injury (28.6%), while the less common origin was idiopathic (4.1%) or neoplastic (4.1%). The most frequent location of the lesion was in the upper arm, followed by the elbow and forearm. Fracture-related contusion was the most common mechanism (29.9%), followed by postoperative fibrosis (17.7%), lacerations (17.7%), and compression (15.6%). Conclusion: Based on the fact that traumatic or iatrogenic injuries constitute the majority of cases, with their relevant mechanisms and upper arm predomination, it is crucial to raise awareness and understanding of the radial nerve injuries among orthopedic surgeons to decrease the numbers of these patients and properly preserve or treat them within the initial surgery.

Fatal Acute Pneumocephalus after Bilateral Drainage for Chronic Subdural Hematomas: Case Report.

BACKGROUND: Pneumocephalus is a well-known complication in the surgical treatment of chronic subdural hematomas; however, its influence remains controversial. The amount of subdural air may vary, and it may cause worsening of symptoms, increase reoccurrence rates, and worsen the outcomes. Lethal outcome following acute onset of massive pneumocephalus was not previously reported. CASE REPORT: An 81-year-old man with bilateral hematomas underwent surgery under local anesthesia. Both hematomas were approached in the same surgery, and the drains were placed subdurally. After initial improvement, severe hypertension developed, followed by vital function and neurologic deterioration. Massive pneumocephalus with subarachnoid and contralateral intracerebral hemorrhage was revealed, causing a severe midsagittal shift. Emergency irrigation to evacuate subdural air was performed. However, there was no improvement. Further computed tomography confirmed subdural air collection, but it also revealed hemorrhage progression and intraventricular propagation. No further surgery was indicated. CONCLUSION: Pneumocephalus is an underestimated but potentially devastating complication. Both intraoperative avoidance and postoperative prevention should be utilized to avoid subdural air ingress, and thus evade potentially fatal complications.

Awake surgery in sitting position for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. METHOD: This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. RESULTS: Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. CONCLUSIONS: In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.

Surgical Treatment of Radial Nerve Injuries Associated With Humeral Shaft Fracture-A Single Center Experience.

Radial nerve injuries are often associated with humeral shaft fractures. The results of treatment of these injuries, by contemporary surgical approaches, remain diverse. In this paper we presented the outcomes and analyzed the patient, clinical, and surgical procedure related characteristics and factors that may influence the outcome overall, in 77 patients treated at Clinic for Neurosurgery, Clinical Center of Serbia during a 20 years period. The nerve injuries were verified by US and EMNG. The majority of patients were treated by neurolysis or sural nerve grafting, while only few were treated by direct suture. The final recovery was evaluated by muscle strength assessment and classified using MRC. We analyzed extension of the wrist, extension of the fingers including the thumb, and abduction of the thumb. There was a significant statistical difference in MRC grade following the treatment. The total rate of useful functional recovery was achieved in 69 (89.61%) out of all studied patients, out of whom 20 (28.99%) achieved excellent recovery, 26 (37.68%) achieved good recovery and 23 (33.33%) achieved fair recovery. Only 8 (10.39%) out of all studied patients achieved poor recovery. The injured nerves, that were preserved in continuity, acquired by a low-energy trauma, and treated earlier than the 6 months were associated with better functional outcome following the surgery. In addition, there was a trend of better functional improvement with aging, keeping in mind that the old were subjected to lower energy trauma. The expectant management followed by surgery of radial nerve injury associated with humeral shaft fracture should be around 3 months, and the surgical nerve repair should not be performed later than the 6 months after injury. The energy of trauma may be a factor predicting patient's final recovery following the treatment.

GIANT CAVERNOUS MALFORMATION WITH UNUSUALLY AGGRESSIVE CLINICAL COURSE: A CASE REPORT.

Giant cavernomas (GC) are rare lesions, with less than 50 cases reported so far. Clinical presentation usually involves epileptic seizures and less typically focal neurological deficit, due to repeated hemorrhages and GC mass effect and consequentially increased intracranial pressure. Although individual cases have been reported, due to the rarity and variable imaging appearance, GCs are usually not considered in the differential diagnosis of large hemorrhagic lesions, especially when significant mass effect is present. A 17-year-old boy presented due to severe headache, right-sided weakness, and slurred speech. Symptoms started three days before with occasional headaches, which intensified gradually. Emergency computed tomography revealed a left frontal massive heterogeneous lesion. Soon after, right-sided hemiparesis and speech impairment progressed, and the patient became drowsy with the slightly dilated left pupil. Emergency surgery was performed, and the lobed grayish lesion was entirely removed. Based on the macroscopic appearance, the surgeon assumed it was a metastasis of melanoma. Histopathologic analysis result was cavernoma. GC should be considered as an option in hemorrhagic lesions, especially in the young age population. Emergency surgery for mass lesions is not uncommon in neurosurgery; however, bleeding cavernomas are usually planned for elective surgery due to the specific approach and complications.

Peripheral Nerve Tumors as an Ongoing Challenge in Neuro-oncology: An Overview of Their Biological and Technical Nuances.

This paper aims to provide an overview of recent advances in the diagnosis and treatment of peripheral nerve tumors (PNTs) with regard to biological and technological nuances, and to highlight some recommendations for achieving better outcomes in the treatment of patients suffering from PNT. PNTs are probably the most challenging entity in the field of peripheral nervous system surgery. The goal of removing a nerve tumor while also preserving nerve function at the same time is often complicated, regardless of the surgeon's experience. Still, in most cases, high-quality results can be achieved upon carefully planned surgery. Clinical presentation, diagnosis, and indications for a specific type of treatment of PNTs still remain a topic of debate. Recent technological advances have led to an exponential improvement in the field with utilization of intraoperative ultrasound, neurostimulation devices, and intraoperative electrophysiological monitoring, along with the development of modern surgical techniques, whereby a multidisciplinary and individually shaped approach is necessary. CONCLUSION: These advances, however, still remain limited, and recent research is focused on the development of biological therapy. Biologically targeted therapies will emerge when there is a better understanding of the genetic and molecular mechanisms driving the development and growth of PNTs.