Non-invasive prehabilitation to foster widespread fMRI cortical reorganization before brain tumor surgery: lessons from a case series.

PURPOSE: The objective of this prospective, single-centre case series was to investigate feasibility, clinical outcomes, and neural correlates of non-invasive Neuromodulation-Induced Cortical Prehabilitation (NICP) before brain tumor surgery. Previous studies have shown that gross total resection is paramount to increase life expectancy but is counterbalanced by the need of preserving critical functional areas. NICP aims at expanding functional margins for extensive tumor resection without functional sequelae. Invasive NICP (intracranial neuromodulation) was effective but characterized by elevated costs and high rate of adverse events. Non-invasive NICP (transcranial neuromodulation) may represent a more feasible alternative. Nonetheless, up to this point, non-invasive NICP has been examined in only two case reports, yielding inconclusive findings. METHODS: Treatment sessions consisted of non-invasive neuromodulation, to transiently deactivate critical areas adjacent to the lesion, coupled with intensive functional training, to activate alternative nodes within the same functional network. Patients were evaluated pre-NICP, post-NICP, and at follow-up post-surgery. RESULTS: Ten patients performed the intervention. Feasibility criteria were met (retention, adherence, safety, and patient's satisfaction). Clinical outcomes showed overall stability and improvements in motor and executive function from pre- to post-NICP, and at follow-up. Relevant plasticity changes (increase in the distance between tumor and critical area) were observed when the neuromodulation target was guided by functional neuroimaging data. CONCLUSION: This is the first case series demonstrating feasibility of non-invasive NICP. Neural correlates indicate that neuroimaging-guided target selection may represent a valid strategy to leverage neuroplastic changes before neurosurgery. Further investigations are needed to confirm such preliminary findings.

Giant Pseudoaneurysm as a delayed Surgical Complication in a Patient Operated on a Giant Neuroma of the Vagus Nerve: Case Report and Management Considerations / Pseudoaneurisma gigante como complicação cirúrgica em paciente operado com neuroma gigante do nervo vago: relato de caso e considerações

The vertebral artery has four segments. The horizontal portion of the V3 segment is the most exposed portion of the vertebral artery to potential iatrogenic injuries during surgical approaches to the posterior fossa.We present an unusual case of a patient who was operated on a giant neuroma of the left vagus nerve, with incidental vertebral artery iatrogenic injury, the development of a delayed giant pseudoaneurysm, and the treatment for this complication. We conclude that endovascular treatment may be a good option for the management of this serious surgical complication.

A artéria vertebral tem quarto segmentos. A porção horizontal do segmento V3 é a mais exposta a potenciais lesões iatrogênicas durante procedimento cirúrgico de acesso à fossa posterior. Apresentamos caso incomum de paciente submetido à cirurgia para neuroma gigante no nervo vago esquerdo, com acidental lesão da artéria vertebral iatrogênica, desenvolvimento de posterior pseudoaneurisma gigante e tratamento para esta complicação. Concluímos que o tratamento endovascular pode ser uma boa opção para o cuidado desta grave complicação cirúrgica.