Integrated care pathways in neurosurgery: A systematic review.

INTRODUCTION: Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success. METHODS: Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded. RESULTS: Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods. CONCLUSIONS: ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient's perspective.

Technical principles of direct bipolar electrostimulation for cortical and subcortical mapping in awake craniotomy.

INTRODUCTION: Intraoperative application of electrical current to the brain is a standard technique during brain surgery for inferring the function of the underlying brain. The purpose of intraoperative functional mapping is to reliably identify cortical areas and subcortical pathways involved in eloquent functions, especially motor, sensory, language and cognitive functions. MATERIAL AND METHODS: The aim of this article is to review the rationale and the electrophysiological principles of the use of direct bipolar electrostimulation for cortical and subcortical mapping under awake conditions. RESULTS: Direct electrical stimulation is a window into the whole functional network that sustains a particular function. It is an accurate (spatial resolution of about 5mm) and a reproducible technique particularly adapted to clinical practice for brain resection in eloquent areas. If the procedure is rigorously applied, the sensitivity of direct electrical stimulation for the detection of cortical and subcortical eloquent areas is nearly 100%. The main disadvantage of this technique is its suboptimal specificity. Another limitation is the identification of eloquent areas during surgery, which, however, could have been functionally compensated postoperatively if removed surgically. CONCLUSION: Direct electrical stimulation is an easy, accurate, reliable and safe invasive technique for the intraoperative detection of both cortical and subcortical functional brain connectivity for clinical purpose. In our opinion, it is the optimal technique for minimizing the risk of neurological sequelae when resecting in eloquent brain areas.

The clinical utility of QSM: disease diagnosis, medical management, and surgical planning.

Quantitative susceptibility mapping (QSM) is an MR technique that depicts and quantifies magnetic susceptibility sources. Mapping iron, the dominant susceptibility source in the brain, has many important clinical applications. Herein, we review QSM applications in the diagnosis, medical management, and surgical treatment of disease. To assist in early disease diagnosis, QSM can identify elevated iron levels in the motor cortex of amyotrophic lateral sclerosis patients, in the substantia nigra of Parkinson's disease (PD) patients, in the globus pallidus, putamen, and caudate of Huntington's disease patients, and in the basal ganglia of Wilson's disease patients. Additionally, QSM can distinguish between hemorrhage and calcification, which could prove useful in tumor subclassification, and can measure microbleeds in traumatic brain injury patients. In guiding medical management, QSM can be used to monitor iron chelation therapy in PD patients, to monitor smoldering inflammation of multiple sclerosis (MS) lesions after the blood-brain barrier (BBB) seals, to monitor active inflammation of MS lesions before the BBB seals without using gadolinium, and to monitor hematoma volume in intracerebral hemorrhage. QSM can also guide neurosurgical treatment. Neurosurgeons require accurate depiction of the subthalamic nucleus, a tiny deep gray matter nucleus, prior to inserting deep brain stimulation electrodes into the brains of PD patients. QSM is arguably the best imaging tool for depiction of the subthalamic nucleus. Finally, we discuss future directions, including bone QSM, cardiac QSM, and using QSM to map cerebral metabolic rate of oxygen. Copyright © 2016 John Wiley & Sons, Ltd.

Insinuating electronics in the brain.

There is an expanding interface between electronic engineering and neurosurgery. Rapid advances in microelectronics and materials science, driven largely by consumer demand, are inspiring and accelerating development of a new generation of diagnostic, therapeutic, and prosthetic devices for implantation in the nervous system. This paper reviews some of the basic science underpinning their development and outlines some opportunities and challenges for their use in neurosurgery.

[Intracerebral xanthogranuloma with specific MRI features: a case report].

We report a case of a 47-year-old male who had a left frontal lobe mass with specific magnetic resonance imaging (MRI). Four years previous to his admission to our hospital, he developed acute myelocytic leukemia and he was implanted with peripheral blood stem cell transplantation. One month before his admission, he was unable to walk due to right leg motor weakness. MRI revealed a round mass lesion at the left frontal lobe. Initial diagnosis was a brain abscess, so he was administered some antibacterial drug. However, his neurological symptoms kept getting worse with increase of mass size on MRI. T1-weighted MR images showed the mass as a low intensity lesion with incomplete ring-like Gd-enhancement. T2-weighted images showed the mass as a high intensity lesion with many linear shadows inside the mass. Diffusion weighted images showed the mass as a low intensity lesion. MR spectroscopy revealed an elevation of choline and lactate peak. Differential diagnosis was glioma or demyelinating disease. At the operation, the mass was light yellow and seen to be rich with vessels. The pathological diagnosis was xanthogranuloma in the brain. Postoperative course was uneventful. The frontal residual mass lesion decreased in size and Gd-enhancement.

Pott's puffy tumor in children.

INTRODUCTION: Pott's puffy tumor is characterized by subperiosteal abscess associated with osteomyelitis of frontal bone. Reports are limited for this rare entity in the antibiotics era but increase during past decade. METHODS: We had clinical analysis of a series with six consecutive pediatric patients of Pott's puffy tumor during 20 years in a tertiary medical center via retrospective chart review. One case was described in detail. RESULTS: Male-to-female ratio was 5:1. The mean age at the time of diagnosis was 13 years-3 months. The risk factors were acute sinusitis in two (33%), chronic sinusitis in two (33%), recent head trauma in two (33%), and acupuncture therapy on skull in one (17%). The commonest presenting symptoms were fever, headache, forehead tenderness, vomiting, and fatigue/malaise (100%). Pott's puffy tumor was diagnosed on average the seventh day after fever, and half had intracranial involvement at diagnosis. All had intracranial infections, and most of them had subdural empyema. The most often involved sinus was frontal sinus (100%). The frontal lobe was the most common site of intracranial infection (100%), two thirds of which are polymicrobial from two or more sites. The initial operation was performed on average on the 5.8th days after diagnosis. Half of the patients underwent reoperation. The mortality rate was 17% (one of six). CONCLUSION: The symptoms of Pott's puffy tumor are inconspicuous even though early intracranial involvement often occurred. The importance of early diagnosis and aggravated and prompt treatment with prolonged antibiotic therapy is emphasized for better outcome.

Neurosurgical applications of laser technology.

Although lasers have been used in clinical neurosurgery for over 40 years, technological advancements have expanded their use and improved technical application. Originally applied to brain tumors to confer destructive oncolysis, lasers have been used over the last few decades to incise, fenestrate, and repair tissues and now are being used for cerebrovascular bypass techniques. In this chapter, a brief history on the evolution of lasers in neurosurgery will be discussed, and technical and clinical aspects of current applications will presented. Such applications include: laser scalpel for spinal cord tumors and lipomas, fenestration of arachnoid cysts, cerebrovascular bypass with the ELANA device, laser-induced interstitial thermotherapy for brain tumors, laser tissue soldering for dural repair, and percutaneous laser disc decompression.

Mirthful gelastic seizures with ictal involvement of temporobasal regions.

Ictal laughter is the cardinal clinical sign of gelastic seizures in hypothalamic hamartomas and may also occur in extrahypothalamic epilepsies. Laughing consists of an affective and a motor component. It has been suggested that the affective component may result from an involvement of temporobasal structures, whereas the motor part is related to an involvement of the mesial frontal cortex. So far, evidence is based on a limited number of cases with spontaneously recorded seizures or in whom electrical stimulation of invasive intracranial EEG recordings has been performed. We report a patient who suffered from epigastric psychic auras, complex partial seizures with a gelastic component and secondarily generalized seizures. To evaluate a possible epileptogenic role of the hippocampus and dysplastic region in the right mid-temporal gyrus, intracranial monitoring with subdural electrodes over the temporobasal and temporolateral regions, as well as a deep brain electrode in the hippocampus, were performed. During the intial part of the seizure, consisting of an intense retrosternal ascending feeling with sexual connotation, rhythmic spikes in temporolateral contacts were detected. Concomitant with the development of smiling and laughter, a rhythmic activity over the temporobasal regions evolved. The patient became seizure-free following right temporal lobe resection. This case supports the assumption that ictal involvement of temporobasal structures is crucial for gelastic seizure components in patients with temporal lobe epilepsy. Progression to temporobasal regions was associated with the feeling of happiness whereas motor components of laughter occurred later. These findings are in accordance with the interpretation of surface recordings by Dericioglu and co-workers in a similar previous case. [Published with video sequences].

Pediatric-onset gelastic seizures: clinical data and outcome.

Gelastic seizures are an extremely rare form of epilepsy defined as automatic bouts of laughter without mirth commonly associated with a hypothalamic hamartoma. The objective was to survey all Israeli children found to develop recurrent gelastic seizures and report presenting symptoms, electroencephalographic and radiologic data, and response to either antiepileptic drugs or surgery. Ten children who developed gelastic seizures at the age of 1 week to 6.5 years (mean, 25 months) at a frequency from 3 bouts per week to >10 prolonged bouts per day were followed for a period of 1.3-12 years (mean, 6 years). Seven cases were defined as symptomatic: cortical magnetic resonance imaging revealed a hypothalamic hamartoma in four patients and cortical abnormalities in three others. Seizure control was achieved in four patients, including a neonate with status gelasticus and hypothalamic hamartoma, and partial control in one more. Five children remained resistant to polytherapy, including three with hypothalamic hamartoma even after two of them underwent hemartoma excision. Thus, children with gelastic seizures may respond relatively well to drug therapy. Four of the 10 patients became seizure free with drug therapy; in three intractable symptomatic cases, surgery was tried but failed in two of the three.

Gamma knife surgery for hypothalamic hamartomas accompanied by medically intractable epilepsy and precocious puberty: experience in Mexico.

OBJECT: Hypothalamic hamartoma is a nonneoplastic malformative mass of neurons and glia in the region of the hypothalamus. Because of its location, open surgery is associated with high morbidity and mortality rates. Gamma knife surgery (GKS) may be an efficient and safe treatment approach, which produces little morbidity. The authors describe the results of GKS in three patients with hypothalamic hamartomas. METHODS: All patients were male, aged 3, 12, and 15 years. The lesions were classified according to the Valdueza scale: one was Type IIb and two were Type IIa. The patients presented with gelastic seizures (15-20 per day), generalized epilepsy, behavioral abnormalities, and alterations of the sleep cycle. Precocious puberty was present in one patient. The Type IIb tumor had a volume of 1.8 cm3, and the Type IIa tumors were 597 mm3 and 530.1 mm3. The lesions received 12.5 Gy, 14 Gy, and 15 Gy, respectively, to the 50% isodose line. The patients were followed for 30 to 50 months. After 3 months, all patients showed improvement of their sleep, behavior, and epilepsy. At the present time, these patients are receiving low-dose antiepileptic agents and have achieved adequate social development and school integration. CONCLUSIONS: Gamma knife surgery appears to be a good, safe, and effective option for the treatment of selected hypothalamic hamartomas. No morbidity or mortality was associated with these three cases.

[Voluminous hypothalamic hamartoma in a 5-month-old boy: Epilepsy and surgery]. / Voluminoso hamartoma hipotalámico en un niño de 5 meses: epilepsia y cirugía.

The authors report the case of 5-month-old boy with a hypothalamic hamartoma and persistent gelastic seizures in spite of a wide combination of different antiepileptic drugs. It was decided to carry out only partial removal of the tumor for decompression and to decreasing the activity of the epileptogenic focus. Surgical therapy revealed as a valid option in the treatment of the uncontrollable gelastic seizures.

Management of hardware infections following deep brain stimulation.

OBJECTIVE: To report our experience on hardware-related infections following deep brain stimulation (DBS). METHODS: The present article presents the retrospective clinical notes review of gained in a two-centre, single-surgeon study experience of 108 consecutive DBS cases between 1996 and 2002. In all patients the minimum follow-up was six months. One hundred and eight patients received an intracerebral electrode implantation and 106 underwent internalization. RESULTS: In total 178 electrodes were implanted with a mean follow-up of 42.6 months and a cumulative follow-up of 367.7 patient-years. Four patients (3.8%) developed an infection related to the DBS-hardware and all were initially treated with antibiotics. Two patients eventually required additional surgical treatment. CONCLUSION: Infections due to DBS-hardware can result in considerable levels of morbidity. In certain cases antibiotic therapy may be adequate. In others, surgical intervention to externalise the electrodes may be necessary. In our experience, there was never a need to remove the electrodes.

[Dislocation and impaction of the brain after purgetive enema]. / Dislokatsiia i vklinenie mozga posle ochistitel'noi klizmy.

The paper describes a case of dislocation and impaction of the brain in a child with a large brain tumor, which developed after purgetive enema. It also discusses the management of patients with this complication and possible ways of its prevention.

Video EEG monitoring prior to vagal nerve stimulator implantation.

Vagal nerve stimulation (VNS) is a safe alternative therapy for epilepsy but may have rare significant complications. There is no consensus regarding the necessity of video-EEG monitoring to characterize events before the VNS implantation. The authors discuss four patients who were inappropriately referred for or implanted with VNS without any previous video-EEG monitoring, in the context of their entire case experience.

Alternative uses for the subgaleal shunt in pediatric neurosurgery.

The subgaleal shunt has been used for the temporary bypass of the normal cerebrospinal fluid (CSF) pathways. We retrospectively reviewed all subgaleal shunts placed at the Children's Hospital, Birmingham, Ala., USA, from 1997 to the present and examined all uses (e.g. indication, length of follow-up) of the subgaleal shunt outside its use for temporary CSF diversion in premature infants with intraventricular hemorrhage and subsequent hydrocephalus. The average length of survival of the primary subgaleal shunt in this population was 32.2 days. We have had good success with subgaleal shunts in children with malignant brain tumors, intraventricular abscesses, chronic truncal wounds, chronic subdural hygromas and meningitis. However, the greatest utility has been in those scenarios in which the peritoneal cavities were not currently, but with time would be, candidates for distal shunt implantation. Examples of these instances are patients with hydrocephalus and necrotizing enterocolitis or hydrocephalus and preoperative abdominal wall pathology such as omphalocele.

Hypothalamic hamartomas: seven cases and review of the literature.

Hypothalamic hamartomas constitute rare developmental lesions associated with gelastic epilepsy and/or precocious puberty (PP). We elected to review cases encountered at our center (7 patients) and the existing literature (277 patients) to obtain a better understanding of the clinical aspects, pathogenesis, and treatment of this entity. Evidence suggests that gelastic seizures are due to intrinsic epileptogenicity. The cause of the subsequent development of other seizure types, cognitive decline, and diffuse spike-and-wave pattern remains unresolved and is addressed. Anticonvulsants often fail to control seizures and different surgical options are available. Available evidence suggests that a resection through a subtemporal approach is best for lesions that are pedunculated or with a significant prepontine component, while a transcallosal approach is more appropriate for sessile lesions with an intraventricular component. Gamma knife surgery may be especially useful for small sessile lesions, failed partial resections, or patients not appropriate or refusing open surgery.

Morphometry of the anterior third ventricle region as a guide for the subfrontal (translaminaterminalis) approach.

The anterior third ventricle region acquires clinical significance in benign and malignant tumors and cyst formations, of which craniopharyngiomas and gliomas are the most common. The subfrontal approach is one of the most preferred approaches for removing these tumors. In this study, the microsurgical anatomy of 81 Turkish, adult cadaveric hemispheres was examined to provide morphometric data of the region. These measurements from the anterior third ventricle region serve as a guide for neurosurgeons during surgical approach for removing anterior third ventricle tumors.

CT-guided neurosurgery: preliminary experience.

BACKGROUND: With the possibility of CT systems becoming more handy and sophisticated, intraoperative CT was introduced in a few neurosurgical Centres with better results in lesion removal and surgical outcome. METHOD: At our Institution a mobile CT scanner was recently used for intraoperative evaluation (Philips Tomoscan M). For 27 tumour resections performed with a neuronavigation system, and 23 deep brain electrode positioning examinations, an intraoperative CT was employed. In addition the CT scanner was used in the recovery room for a postoperative control in 198 patients. FINDINGS: Our preliminary experience used for a real time evaluation of the treated patients, permitted to verify an incomplete removal in 23/27 cases. Evaluation of stereotactic electrode position in relation to the planned target was also possible and demonstrated a correct position in 21 cases. INTERPRETATION: Intraoperative CT scan is a useful system that permits to modify neuronavigation planning and is able to give information to the surgeon for better tumour removal, rule out possible hemorrhagic complications, and suitable deep brain electrode positioning.

Functional MR imaging: paradigms for clinical preoperative mapping.

Clinical applications of functional MR imaging include mapping of brain functions in relationship to intracranial tumors, seizure foci, or vascular malformations to determine the risk for performing surgical excision, the need for intraoperative mapping during excision, and selecting the optimal surgical approach to a lesion. A variety of paradigms are used to produce a blood-oxygen-level-dependent response in various brain regions, which can be identified with functional MR imaging. The paradigms used include active motor, language, or cognitive tasks, and passive tactile, auditory, or visual stimuli. Activation usually indicates the location of eloquent cortex. Lack of function in a region cannot be assumed when functional MR imaging shows absence of activation within the region.