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.

Revisión Estado actual de la cirugía de la epilepsia en España. Compendio y conciencia / Current status of epilepsy surgery in Spain. Compendium and awareness

INTRODUCCIÓN: La epilepsia refractaria al tratamiento médico afecta a entre un tercio y una cuarta parte de los pacientes con epilepsia. Dentro de este grupo, con peor calidad de vida y altos costes sanitarios, existe una considerable proporción de pacientes con causas de epilepsia potencialmente quirúrgicas, y la cirugía de la epilepsia es una opción terapéutica comprobada. En España no sabemos el número real de pacientes que llegan a tratarse en relación con el total de los casos con epilepsia refractaria que podrían beneficiarse del tratamiento quirúrgico. OBJETIVO: Analizar el número de cirugías de epilepsia realizadas y publicadas en relación con los potenciales casos de epilepsia refractaria candidatos a cirugía en nuestro país. MÉTODO: Se realizó una revisión mediante la búsqueda bibliográfica en PubMed y Cochrane de artículos publicados entre 1990 y 2020, combinando las siguientes palabras y operadores booleanos: epilepsy surgery IN Spain’. Se clasificaron las evidencias y recomendaciones según los criterios pronósticos del Oxford Center for Evidence Based Medicine (2001) y de la European Federation of Neurological Societies (2004) para actuaciones terapéuticas. RESULTADOS: El 75,6% de las publicaciones se originó en las comunidades autónomas de Madrid y Cataluña. El 46,4% de los artículos publicados son de series cortas. Contabilizamos 2.113 intervenciones quirúrgicas (resecciones, cirugías paliativas, implantación de electrodos profundos e implantación de neuroestimuladores), lo que representa el 8,7% de la población estimada con epilepsia refractaria. CONCLUSIÓN: La cirugía de la epilepsia en nuestro medio es una indicación terapéutica infrautilizada y que no se ofrece o no se administra a la mayoría de los potenciales beneficiarios

INTRODUCTION: Drug-resistant epilepsy affects between a third and a quarter of patients with epilepsy. Within this group, with a poorer quality of life and high healthcare costs, there is a considerable proportion of patients with potentially surgical causes of epilepsy, and epilepsy surgery is a proven therapeutic option. In Spain, we do not know the actual number of patients who are treated in relation to the total number of cases of refractory epilepsy that could benefit from surgical treatment. AIM: To analyse the number of epilepsy surgical interventions performed and published in relation to the potential cases of refractory epilepsy who are candidates for surgery in our country. METHOD: A review was carried out through a literature search in PubMed and Cochrane of articles published between 1990 and 2020, combining the following words and Boolean operators: epilepsy surgery IN Spain’. The evidence and recommendations were classified according to the prognostic criteria of the Oxford Centre for Evidence Based Medicine (2001) and of Neurological Societies (2004) for therapeutic actions. RESULTS: The majority (75.6%) of the publications came from the autonomous communities of Madrid and Catalonia and 46.4% of the articles published were short series. We counted 2,113 surgical interventions (resections, palliative interventions, implantation of deep electrodes and implantation of neurostimulators), which represents 8.7% of the estimated population with refractory epilepsy. CONCLUSION. Epilepsy surgery in our country is an underused therapeutic indication that is not offered or administered to the majority of potential beneficiaries

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.