Efficacy of routine post-operative head computed tomography on cranial surgery patients outcome.

OBJECTIVE: To identify the role of routine postoperative head CT in changing postoperative management after elective craniotomies. METHODS: We conducted a retrospective study on adult patients who underwent cranial surgery. Exclusion criteria includes cranial CTs done postoperatively for urgent clinical indications, pediatric patients, CSF diversion procedures and sedated patients. Patients were placed into "positive" group if the physical assessment changed from the baseline in the form of clinical deterioration, and the "negative" group if the exam did not change. The data then were analyzed to identify which patients needed further medical or surgical management based on CT findings only with "negative" physical examination. RESULTS: Total of 222 were included in the study. 151 patients had negative physical examination. Only 8 out of 151 patients had positive CT findings. Two patients out of 222 (0.9%) had a negative physical exam and positive CT findings that required additional action that wouldn`t be done urgently without routine postoperative brain CT. Only one patient out of 222 (0.4%) who was re-operated urgently based CT findings only and negative physical examination. CONCLUSION: Routine postoperative routine brain CT did not alter the course of medical management, even in the presence of significant radiological findings.

Analgesia in Neurocritical Care: An International Survey and Practice Audit.

OBJECTIVE: To characterize analgesic administration in neurocritical care. DESIGN: ICU pharmacy database analgesic delivery audits from five countries. A 31-question analgesic agent survey was constructed, validated, and e-distributed in four countries. SETTING: International multicenter neuro-ICU database audit and electronic survey. PATIENTS: Six ICUs provided individual, anonymized analgesic delivery data in primary neurological diagnosis patients. Prescriber surveys were disseminated by neurocritical care societies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Analgesic delivery data from 173 patients in French, Canadian, American, and Australian and New Zealand ICUs suggest that acetaminophen/paracetamol is the most common first-line analgesic (49.1% of patients); opiates are the "second line" in 31.5% of patients; however, 33% patients received no second agent. In the 2.3% with demyelinating disease, gabapentin was the most likely second analgesic (50.0%). Third-line analgesics were scarce across sites and neuropathologies. Few national or regional differences were found. The analgesic preference rankings noted by the 95 international physicians who completed the survey matched the audits. However, self-reported analgesic prescription rates were much higher than pharmacy records indicate, with self-reported prescribing of both acetaminophen/paracetamol and opiates in 97% of patients and gabapentin in 45% of patients. Third-line analgesic variability appeared to be driven by neuropathology; ibuprofen was preferred for traumatic brain injury, postcraniotomy, and thromboembolic stroke patients, whereas gabapentin/pregabalin were favored in subarachnoid hemorrhage, intracranial hemorrhage, spine, demyelinating disease, and epileptic patients. CONCLUSIONS: Opiates and acetaminophen are preferred analgesic agents, and gabapentin is a contextual third choice, in neurocritically ill patients. Other agents are rarely prescribed. The discordance in physician self-reports and objective audits suggest that pain management optimization studies are warranted.

"Brain Biopsy Revolution: Unveiling the Core Syringe Technique with Clinical Insights".

OBJECTIVES: Obtaining a definitive pathological diagnosis from brain tissue sampling was challenging due to the small, non-representative sample. This study introduced a novel syringe technique for brain biopsy aimed at enhancing diagnostic accuracy by obtaining core tissue samples that better represent the targeted tissue. METHODS: The ten patients with atypical brain lesions underwent the syringe biopsy. After meticulous preoperative planning with neuronavigation, a minimally invasive approach was used: a 3 cm skin incision and a 14 mm burr hole were created. A modified 3-cc syringe was used to create negative pressure and cannulate the brain tissue. The desired sample size (24 cm³) was obtained by controlling the syringe depth and withdrawal. Medical records were reviewed to assess sample analysis results and any complications RESULTS: The syringe technique successfully yielded adequate tissue samples in 9 out of 10 patients. In one case, the desired tissue could not be retrieved and required a microsurgical approach for removal. In all ten cases, a correct diagnosis was made without significant complications. CONCLUSION: The preliminary findings suggest that the syringe technique is both safe and effective for obtaining substantial volumes of brain tissue, facilitating accurate pathological evaluation in cases of complex neurological disorders.

The efficacy of wrapping the neurorrhaphy site utilizing dura substitute: A case series.

BACKGROUND: Different procedures have been developed to improve the surgical outcome of peripheral nerve injuries. The purpose of this study was to evaluate the efficacy of wrapping the neurorrhaphy site utilizing dura substitute graft as an alternative conduit in the management of peripheral nerve injury. METHODS: This retrospective clinical case series included 42 patients with a single peripheral nerve injury. The mean age was 26.8 ± 11 years, and the mean duration of symptoms was 3 ± 1.8 months. The visual analogue score (VAS) for pain and the Medical Research Council's (MRC) grading for motor power were used to evaluate the functional outcome among our patients. All patients were operated on for primary microscopic end-to-end repair, followed by wrapping the neurorrhaphy site with dura substitute graft as a conduit. Patients were followed in the outpatient clinic with regular visits for average of 6 months. RESULTS: Thirty-seven patients (83%), showed functional improvement in all aspects, the VAS for pain and the MRC for motor power, as well as the functional state. One patient (2.3%) developed a postoperative hematoma collection, which needed immediate evacuation. Superficial wound infection, reported in two patients (4.7%), was treated conservatively. No postoperative neuroma was observed among our patients during the follow-up period. CONCLUSION: Wrapping the neurorrhaphy site utilizing dura substitute as conduit appears to be safe and might prove effective in managing peripheral nerve injury.

Impact of COVID-19 on Saudi Neurosurgery Residency: Trainers' and Trainees' Perspectives.

INTRODUCTION: After the official announcement of the coronavirus disease-19 pandemic on March 11, 2020, the disease impacted most aspects of health care delivery, especially postgraduate education and training. METHOD: A cross-sectional, online questionnaire-based assessment was performed. The study participants involved neurosurgery residents and program directors (PDs) across the country between May 16 and May 27, 2020. RESULTS: Approximately 74 of 95 (77.9%) of the residents experienced an impact on their training calendar. Before the pandemic, 51 residents (53.3%) were involved in 2-3 surgeries per week, but during the pandemic, 66 (69.5%) were attending 0-1 case per week. Fifty-three residents (55.8%) agreed that academic sessions were affected despite the helpful effort of online teaching sessions. Thirty-four (35.8%) residents graded their anxiety during coronavirus disease-19 times as high. Ten PDs (58.8%) confirmed spending 3-5 hours per week on educational activities normally, whereas during the pandemic, 15 PDs (88.2%) reduced their educational hours to 0-2 hours per week. CONCLUSION: Our study showed that educational activities significantly decreased and shifted toward virtual teaching methods. Operative volume showed a substantial reduction for both junior and senior residents. Academic and clinical teaching was the main concern for PDs, and they faced challenges interviewing newly matched residents.

A potential new brainstem reflex: The oculoglossal phenomenon.

BACKGROUND: A synchronized involuntary movement of the tongue to the same side as voluntary movements of the eyes, termed the oculoglossal phenomenon, has been observed. A description of the hypothesized pathway of this phenomenon could guide the development of a rapid clinical evaluation of the long segment of the brainstem and help facilitate further studies to establish a new reflex, if possible. The aim of this study is to describe and propose the simple concept of this pathway/phenomenon, the oculoglossal phenomenon. METHODS: This is an observational study. Of a newly observe brainstem phenomenon evaluated on a subject at the National Neuroscience Institute in king Fahad Medical City (KFMC), Riyadh, Saudi Arabia. After being observed incidentally in a single patient, 60 participants were tested between January and March 2020 to confirm the presence of the phenomenon. Each subject was instructed to protrude the tongue and then move their eyes horizontally to the side. If the tongue simultaneously and involuntarily moved to the same side as the eyes, the test was deemed confirmatory. A literature review was performed, and possible anatomical pathway was proposed. RESULTS: The oculoglossal reflex was present in most (50/60, 83.3%) of the subjects. Our proposed pathway begins at the frontal cortex, followed by a projection to the paramedian pontine reticular formation, then to the contralateral medial longitudinal fasciculus and bilaterally to the hypoglossal nuclei. CONCLUSION: An accurate description of this phenomenon could lead to additional studies and possibly establishing it as a legitimate reflex, thus conceivably adding a new tool in the neurological examination to evaluate the brainstem's integrity.

Neuromodulation Options and Patient Selection for Parkinson's Disease.

Neuromodulation therapies, including deep brain stimulation (DBS) and pump therapies, are currently the standard of care for PD patients with advanced disease and motor complications that are difficult to control with medical management alone. The quest for alternate lesser invasive approaches led to the development of several novel therapies like intrajejunal levodopa infusions (IJLI), continuous subcutaneous apomorphine infusions (CSAI) and Magnetic Resonance guided Focused Ultrasound (MRgFUS) in recent years. To achieve good outcomes with any of these therapeutic modalities, careful patient selection, multidisciplinary evaluation and technical expertise are equally important. In this review, we will provide an overview of the neuromodulation strategies currently available for PD, emphasizing on patient selection and choosing among the various strategies.

Supratentorial Craniotomies with or without Dural Closure-A Comparison.

BACKGROUND: Dural closure is a routine surgical step in neurosurgery. The benefit of suturing the dura to achieve watertight closure-with or without the use of dural substitutes-has been questioned in supratentorial craniotomy. We performed a retrospective study to examine the possible benefits and harms of suturing the dura compared with no dural closure and the occurrence of postoperative infection, cerebrospinal fluid (CSF) leak, and postcraniotomy headaches. METHODS: We performed a retrospective study to compare the incidence of CSF leak, infection, surgical site swelling, and postcraniotomy headaches between patients with watertight dural closure (closed group) and patients without watertight dural closure (open group). Any method used to close the dura and to achieve watertight closure was included, whether primary or secondary closure (with or without using suturable dural substitute). RESULTS: Overall, 216 patients were included in the present study, with 112 patients in the open group and 114 in the closed group. The open group experienced a greater incidence of infection and CSF leak (6 in the open group vs. 2 in the closed group), but without statistical significance (P = 0.15). We found no difference in surgical site swelling (P = 0.29). However, the closed group showed a greater association with the development of postcraniotomy headaches (P = 0.001). CONCLUSION: We found no difference in the occurrence of CSF leak, infection, or surgical site swelling between the closed and open groups. The incidence of postcraniotomy headaches was greater in the closed group, and the difference was statistically significant.

Movement Disorders and Deep Brain Stimulation in the Middle East.

BACKGROUND: Deep brain stimulation (DBS) is a well-established neuromodulation therapy for advanced Parkinson disease, essential tremor and dystonia. In as much as this therapy is being developed in the Middle East, a better understanding of the incidence and prevalence of movement disorders, health care, and social framework is required for the region. METHODS: We reviewed current literature on the incidence and prevalence of various movement disorders in the Middle East amenable to DBS surgery. We also assessed recent efforts to develop DBS in the region. RESULTS: Available data on incidence and prevalence of movement disorders in the Middle East are old, inconclusive, and conflicting. We identify key areas such as cultural background, availability of accessible information, training, infrastructure, and public support groups in the region that may pose challenges. CONCLUSIONS: The Middle East is projected to be a growing market for neuromodulation. The available data on incidence and prevalence of movement disorders is from studies that were small, partial, and old, with inconsistent results, highlighting the need for newer, better-designed, and larger studies. DBS in the Middle East will need assessment of incidence and prevalence of movement disorders, existing challenges to its application, and focused efforts on key opportunities to foster development of DBS for this underserved region. This article is an attempt to identify and explore these challenges and propose solutions in anticipation.

Safety and Efficacy of Gamma Knife Radiosurgery for the Management of Koos Grade 4 Vestibular Schwannomas.

BACKGROUND: Gamma Knife radiosurgery (GKRS) is commonly used in treating small vestibular schwannomas; however, its use for larger vestibular schwannomas is still controversial. OBJECTIVE: To assess the long-term safety and efficacy of treating eligible Koos grade 4 vestibular schwannomas with GKRS. METHODS: We conducted a single-center, retrospective evaluation of patient undergoing GKRS for Koos grade 4 vestibular schwannomas. We evaluated clinical, imaging, and treatment characteristics and assessed treatment outcome. Inclusion criteria were tumor size of ≥4 cm and follow-up of at least 6 months. Patients with neurofibromatosis type 2 were excluded. Primary outcomes measured were tumor control rate, hearing and facial function preservation rate, and complications. All possible factors were analyzed to assess clinical significance. RESULTS: Sixty-eight patients met inclusion criteria. Median follow-up was 47 months (range, 6-125 months). Baseline hearing was serviceable in 60%. Median tumor volume at radiosurgery was 7.4 cm (range, 4-19 cm). The median marginal dose used was 12 Gy at the 50% isodose line. Actuarial tumor control rates were 95% and 92% at 2 and 10 years, respectively. Actuarial serviceable hearing preservation rates were 89% and 49% at 2 and 5 years, respectively. Facial nerve preservation was 100%. Clinical complications included balance disturbance (11%), facial pain (10%), facial numbness (5%), and tinnitus (10%). Most complications were mild and transient. Hydrocephalus occurred in 3 patients, requiring ventriculoperitoneal shunt insertion. Larger tumor size was significantly associated with persisting symptoms post-treatment. CONCLUSION: Patients with Koos grade 4 vestibular schwannomas and minimal symptoms can be treated safely and effectively with GKRS.

Neuronavigation using susceptibility-weighted venography: application to deep brain stimulation and comparison with gadolinium contrast.

Careful trajectory planning on preoperative vascular imaging is an essential step in deep brain stimulation (DBS) to minimize risks of hemorrhagic complications and postoperative neurological deficits. This paper compares 2 MRI methods for visualizing cerebral vasculature and planning DBS probe trajectories: a single data set T1-weighted scan with double-dose gadolinium contrast (T1w-Gd) and a multi-data set protocol consisting of a T1-weighted structural, susceptibility-weighted venography, and time-of-flight angiography (T1w-SWI-TOF). Two neurosurgeons who specialize in neuromodulation surgery planned bilateral STN DBS in 18 patients with Parkinson's disease (36 hemispheres) using each protocol separately. Planned trajectories were then evaluated across all vascular data sets (T1w-Gd, SWI, and TOF) to detect possible intersection with blood vessels along the entire path via an objective vesselness measure. The authors' results show that trajectories planned on T1w-SWI-TOF successfully avoided the cerebral vasculature imaged by conventional T1w-Gd and did not suffer from missing vascular information or imprecise data set registration. Furthermore, with appropriate planning and visualization software, trajectory corridors planned on T1w-SWI-TOF intersected significantly less fine vasculature that was not detected on the T1w-Gd (p < 0.01 within 2 mm and p < 0.001 within 4 mm of the track centerline). The proposed T1w-SWI-TOF protocol comes with minimal effects on the imaging and surgical workflow, improves vessel avoidance, and provides a safe cost-effective alternative to injection of gadolinium contrast.