Stereotactic radiosurgery for cerebellopontine meningiomas: a systematic review and meta-analysis.

OBJECTIVE: To (1) measure surgical outcomes associated with stereotactic radiosurgery treatment of cerebellopontine angle meningiomas, and (2) determine if differences in radiation dosages or preoperative tumor volumes affect surgical outcomes. METHODS: A systematic search was performed on the PubMed, Medline, Embase and Cochrane Library databases searching for patients under stereotactic radiosurgery for meningiomas of the cerebellopontine angle. After data extraction and Newcastle-Ottawa scale quality assessment, meta-analysis of the data was performed with Review Manager 3.4.5. RESULTS: In total, 6 studies including 406 patients were included. Postprocedure, patients had minimal cranial nerve complications while having an overall tumor control rate of 95.6%. Complications were minimal with facial nerve deficits occurring in 2.4%, sensation deficits of the trigeminal nerve in 4.0%, hearing loss in 5.9%, hydrocephalus in 2.0% and diplopia in 2.6% of all patients. Individuals with tumors extending into the internal auditory canal extension did not have significantly increases in hearing loss. There was a higher likelihood of tumor regression on postprocedure imaging in studies with a median prescription dose of >13 Gy (RR 1.27 [95% CI 1.04-1.56, p = 0.0225). There was no evidence of publication bias detected. CONCLUSIONS: Radiosurgery is an effective modality for offering excellent tumor control of CPA meningiomas while allowing for only minimal complications postprocedure. A higher prescription dose may achieve higher tumor regression at follow up. Future studies should aim at establishing and optimizing accurate dosimetric guidelines for this patient population.

Ventriculopleural shunt: Review of literature and novel ways to improve ventriculopleural shunt tolerance.

Cerebrospinal fluid (CSF) diversion is among the most commonneurosurgical procedures that are performed worldwide. It is estimated thatapproximately 30,000 ventriculostomies are performed annually in the United States.Ventriculoperitoneal (VP) shunt malfunction rate within the first year of initialimplantation has been reported to be as high as 11-25%. In patients with abdominaladhesions, infections or multiple failed VP shunts, another bodily compartment shouldbe utilized as a substitute for the peritoneal cavity for distal shunt catheter placement.Ventriculopleural (VPL) shunting for hydrocephalus was first introduced by Heile in1914. Since the inception of this idea, VPL shunts have been utilized in select patientswith varying degrees of success. There have been a number of case reports andseries documenting unique complications with VPL shunting, with pleural effusion andpneumothorax being the most common complications. In our review article, we soughtto review the development of VPL shunting, pleuropulmonary physiology, insertiontechniques for VPL shunt, complications associated with VPL shunts, and uniquestrategies to improve VPL shunt tolerance.

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review.

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Lateral Myelotomy for Resection of a Ruptured Intramedullary Cervico-Thoracic Cavernous Malformation.

BACKGROUND AND IMPORTANCE: Intramedullary spinal cord cavernous malformations represent 5% to 12% of spinal vascular disease. Most patients present with acute or progressive neurological symptoms, including motor weakness or sensory loss. Surgical resection is the only definitive management and is recommended for symptomatic lesions that are surgically accessible. CLINICAL PRESENTATION: A 35-yr-old woman presented with a sudden onset of pain and temperature sensation loss in the left lower extremity. Magnetic resonance imaging of the spine showed a hemorrhage located ventral and slightly lateral to the right of the midline of the spinal cord from C7 through T3. Ultimately, a right lateral myelotomy between the ventral and dorsal roots was performed, and the cavernous malformation was removed. Postoperative imaging confirmed gross total resection of the cavernous malformation. CONCLUSION: In this article, we report a highly unusual case of a multisegment, ruptured intramedullary cavernous malformation that was ultimately resected through a lateral myelotomy approach. This case demonstrates that a lateral approach to the spinal cord substance can be utilized for ruptured cavernous malformation, especially if there is hemorrhage at the surface of the spinal cord. This can be used as an entry into the anterolateral compartment of the spinal cord, which would otherwise be regarded as a highly morbid approach due to the sensory deficits induced. We believe this entry point to the spinal cord is feasible in highly select cases such as this.

Timing of Surgical Intervention for Dysphagia in Patients With Diffuse Idiopathic Skeletal Hyperostosis: A Systematic Review and Meta-Analysis.

STUDY DESIGN: This was a systematic review and meta-analysis. OBJECTIVE: The objective was (1) to measure rates of successful resolution of dysphagia in patients after undergoing surgical intervention for diffuse idiopathic skeletal hyperostosis (DISH); and (2) to determine if older age, longer duration of preoperative symptoms, or increased severity of disease was correlated with unsuccessful surgical intervention. SUMMARY OF BACKGROUND DATA: DISH, also known as Forestier disease, is an enthesopathy affecting up to 35% of the elderly population. Many patients develop osteophytes of the anterior cervical spine, which contribute to chronic symptoms of dysphagia causing debilitating weight loss and possibly resulting in the placement of a permanent gastrostomy feeding tube. For patients that fail conservative medical management, an increase in surgical interventions have been reported in the literature in the last 2 decades. MATERIALS AND METHODS: A systematic search was performed on PubMed, Medline, Cochrane Library, and Embase. Studies measuring outcomes after surgical intervention for patients with dysphagia from DISH were selected for inclusion. Two independent reviewers screened and assessed all literature in accordance with Cochrane systematic reviewing standards. RESULTS: In total, 22 studies reporting 119 patients were selected for inclusion. Successful relief of dysphagia was obtained in 89% of patients after surgical intervention. Failure to relieve dysphagia was associated with increased length of symptoms preoperatively (P<0.01) using logistic regression. Patients with more severe preoperative symptoms also seem to have an increased risk for treatment failure (risk ratio, 2.86; 95% confidence interval, 1.19-6.85; P=0.02). Treatment failure was not associated with patient age, use of intraoperative tracheostomy, implementation of additional fusion procedures, level of involved segments, or number of involved segments. CONCLUSIONS: Patients undergoing surgical intervention have a higher likelihood of failing surgery with increasing preoperative symptom length and increased preoperative symptom severity. LEVEL OF EVIDENCE: Level III.

Intrathecal and intracerebroventricular dopamine for Parkinson's disease.

While CDD directly to the CSF can provide a constant delivery of the dopaminergic drug resulting in a more stable treatment effect without the limitations of traditional oral therapy without peripheral effects, it is still young and longitudinal data is lacking. These experimental therapies show promise and further investigation into their efficacy and safety could extend the frontiers for management of PD.

Presentation, Surgical Management, and Postoperative Outcome of a Fourth Ventricular Cavernous Malformation: Case Report and Review of Literature.

BACKGROUND: Brainstem cavernous malformations (CMs) represent dangerous clinical entities associated with high rates of rebleeding and morbidity compared with those in other locations. Particularly rare are those located within the fourth ventricle. Although fourth ventricular CMs are favorable from a surgical standpoint, there are no defined guidelines on definitive indications and optimal timing of surgery. In addition, the surgical approaches, anatomic considerations, and general observations regarding these lesions are not well reported in the literature. CASE PRESENTATION: A 27-year-old man with a known history of a CM on the floor of the fourth ventricle presented with new cranial nerve deficits and signs of increased intracranial pressure. Imaging revealed acute bleeding from a fourth ventricular CM. The patient was urgently taken to surgery for resection. Despite a noneventful surgery which resulted in gross total resection, the patient developed a unique constellation of cranial nerve deficits postoperatively, most notably of which was eight-and-a-half syndrome. CONCLUSIONS: CMs of the fourth ventricle are rare clinical entities that can be treated successfully with surgery. The indications for surgery may not always be clear-cut; therefore, the neurosurgeon's decision to proceed with surgery must reside on a case-by-case basis using a multifactorial approach. The location of these lesions presents unique challenges given their proximity to vital structures and the technical difficulty required. For these reasons, the resection of these lesions often results in new or persistent neurologic deficits. However, despite the associated risks, the potential benefits of surgery oftentimes outweigh the risks of the alternative.

Independently together: subthalamic theta and beta opposite roles in predicting Parkinson's tremor.

Tremor is a core feature of Parkinson's disease and the most easily recognized Parkinsonian sign. Nonetheless, its pathophysiology remains poorly understood. Here, we show that multispectral spiking activity in the posterior-dorso-lateral oscillatory (motor) region of the subthalamic nucleus distinguishes resting tremor from the other Parkinsonian motor signs and strongly correlates with its severity. We evaluated microelectrode-spiking activity from the subthalamic dorsolateral oscillatory region of 70 Parkinson's disease patients who underwent deep brain stimulation surgery (114 subthalamic nuclei, 166 electrode trajectories). We then investigated the relationship between patients' clinical Unified Parkinson's Disease Rating Scale score and their peak theta (4-7 Hz) and beta (13-30 Hz) powers. We found a positive correlation between resting tremor and theta activity (r = 0.41, P < 0.01) and a non-significant negative correlation with beta activity (r = -0.2, P = 0.5). Hypothesizing that the two neuronal frequencies mask each other's relationship with resting tremor, we created a non-linear model of their proportional spectral powers and investigated its relationship with resting tremor. As hypothesized, patients' proportional scores correlated better than either theta or beta alone (r = 0.54, P < 0.001). However, theta and beta oscillations were frequently temporally correlated (38/70 patients manifested significant positive temporal correlations and 1/70 exhibited significant negative correlation between the two frequency bands). When comparing theta and beta temporal relationship (r θ ß) to patients' resting tremor scores, we found a significant negative correlation between the two (r = -0.38, P < 0.01). Patients manifesting a positive correlation between the two bands (i.e. theta and beta were likely to appear simultaneously) were found to have lower resting tremor scores than those with near-zero correlation values (i.e. theta and beta were likely to appear separately). We therefore created a new model incorporating patients' proportional theta-beta power and r θ ßscores to obtain an improved neural correlate of resting tremor (r = 0.62, P < 0.001). We then used the Akaike and Bayesian information criteria for model selection and found the multispectral model, incorporating theta-beta proportional power and their correlation, to be the best fitting model, with 0.96 and 0.89 probabilities, respectively. Here we found that as theta increases, beta decreases and the two appear separately-resting tremor is worsened. Our results therefore show that theta and beta convey information about resting tremor in opposite ways. Furthermore, the finding that theta and beta coactivity is negatively correlated with resting tremor suggests that theta-beta non-linear scale may be a valuable biomarker for Parkinson's resting tremor in future adaptive deep brain stimulation techniques.

Minimally invasive trigeminal ablation in patients with refractory trigeminal neuralgia who are ineligible for intracranial intervention.

We describe the use of minimally invasive trigeminal ablation, an endoscopic ablative technique to treat trigeminal neuralgia in patients who are traditionally poor surgical candidates. We present 4 patients who presented with refractory unilateral trigeminal neuralgia. Three of the patients had previously failed stereotactic radiosurgery and three of them have multiple sclerosis. Due either to lack of neurovascular compression, minimally invasive trigeminal ablation was offered. Intraoperatively, an incision is made along the buccal mucosa or mid-brow and the tissue is endoscopically dissected in a plane towards the symptomatic nerve. Once isolated, the epineurium is partially ablated with thermocautery and the tissue surrounding the nerve is decompressed. All patients reported resolution of their pain post-operatively and were pain free at last follow up. Two patients had mild hypesthesia over the ablated nerve territory. Minimally invasive trigeminal ablation is a safe and effective technique for symptomatic control of trigeminal neuralgia. The efficacy, low risk, and relative ease of the procedure makes it ideal for use in patients who are refractory to medical management and have no neurovascular compression, are unable to tolerate traditional surgery or have failed other therapies.

Treatment of Persistent Hemiballism with Deep Brain Stimulation of the Globus Pallidus Internus: Case Report and Literature Review.

BACKGROUND: Hemiballism is a rare hyperkinetic movement disorder characterized by involuntary, high-amplitude, unilateral flailing of upper or lower extremities or both. In the case of hemiballism refractory to pharmaceutical interventions, deep brain stimulation (DBS) is an effective primary neurosurgical treatment. DBS targets for hemiballism include the thalamus, subthalamic nucleus, and globus pallidus internus (GPi). CASE DESCRIPTION: We present a case of a patient who sustained a posterior cerebral artery ischemic stroke that eventually led to uncontrolled hemiballism, which was then successfully treated by unilateral GPi stimulation. We include a video depicting the patient preoperatively, intraoperatively with stimulation off, and intraoperatively with stimulation on. We also review published cases of hemiballism treated by GPi-DBS, which support the claim that GPi-DBS is an effective method for treating hemiballism. CONCLUSIONS: Evidence gathered from the literature indicates that GPi-DBS is an effective treatment for hemiballism, especially after neuroleptics have failed. Results from various case studies of GPi-DBS used to treat hemiballism reveal improved motor ability and decreased dyskinesia, although degree of improvement may vary. More studies are required to establish which DBS target requires the least amount of stimulation to treat hemiballism.

The Educational Quality of Neurosurgical Resources on YouTube.

BACKGROUND: YouTube has rapidly become one of the most widely accessed educational platforms of our time. Over 1 billion hours of YouTube content are viewed every day, including neurosurgical videos. To date, there has never been a qualitative analysis of neurosurgical content on YouTube. METHODS: By evaluating the search interest of neurosurgical terms via Google Trends, we selected 8 search terms to assess on YouTube. For each term, we selected the top 20 videos, 10 when sorting by view count and 10 when sorting by relevance. Using the DISCERN criteria, we evaluated 131 unique YouTube videos to assess bias and overall educational quality. In addition, we categorized each video based on its intended utility and the credentials of the video's commentator. The number of views, average DISCERN scores, and bias scores were compared between search terms and between video categories. RESULTS: There were 131 unique and 29 duplicate videos. The videos received 143,538,363 combined views (1,104,141 average). The average video age was 4.6 years (range, 66 days to 12.5 years). The term "brain surgery" received the most total views (62,339,885), with an average DISCERN score of 1.65 overall and 2 for bias. The average DISCERN score was 2.02 overall and 2.39 for bias. There were 45 advertisements for either hospitals, physicians, or companies, totaling 18,052,873 views and averaging a DISCERN score of 2.04. CONCLUSIONS: YouTube is a frequently viewed but biased source for neurosurgical information. Advertisements are frequently disguised as educational material, and few videos provide references or sources for their information.

Risk Factors Associated with Lead Migration Requiring Revision in Dorsal Root Ganglion Stimulation.

BACKGROUND: Neuromodulation is an evolving therapy for chronic pain. Aiming to meet the limitations of traditional spinal cord stimulation, dorsal root ganglion (DRG) stimulation targets pain in a dermatomal distribution at the site of pain transmission. Despite these advantages, lead migration is a significant complication that hinders the long-term efficacy of DRG stimulation. This study aims to identify risk factors for lead migration requiring revision in DRG stimulation. METHODS: We performed a retrospective review of all subjects who had DRG stimulators implanted at T10-S2 by a single physician over a 2-year period. Their history was reviewed for the following: age, sex, diagnosis, lead placement, reported symptom relief, complications, and postoperative activity. RESULTS: In total, 19 cases of DRG stimulator implantation were identified. All patients reported pain relief, with 84.2% (16/19) describing >50% relief. In total, 31.6% of patients (6/19) developed lead migration and 15.8% of total implanted leads (9/57) migrated. Of the migrated leads, 4% (4/9) occurred at S1 and 33.3% (3/9) occurred at L4. The underlying etiology of lead migration was clear and preventable in 66.7% of patients (4/6). All patients who developed lead migration were women. CONCLUSIONS: Premature activity, hardware manipulation, and female sex appear to be associated with an increased risk for lead migration. Leads on the S1 and L4 locations may be more likely to migrate. Large trials are necessary to gain a more conclusive understanding of these risk factors for lead migration.

Retained catheter during placement of dorsal root ganglion stimulator: a case report.

Dorsal root ganglion (DRG) stimulation is a novel therapeutic option that is being increasingly utilized for patients with neuropathic pain. The potential complications during the placement of this device remain unknown. We describe a potential complication during DRG stimulator placement not previously reported in the literature. A 50-year-old male presented to the ED with lower back pain and right lower extremity radicular pain following placement of DRG stimulator at outside facility. A fragment of an introducer catheter was retained in the spinal canal and L2-L3 neural foramen. Patient underwent L2-L3 laminectomy for removal of the catheter without any complications. DRG stimulation is an effective option for intractable neuropathic pain, but the safety of the procedure and its long-term complications need to be further investigated.

Infection Incidence Associated with External Ventriculostomy Placement: A Comparison of Outcomes in the Emergency Department, Intensive Care Unit, and Operating Room.

BACKGROUND: External ventricular drain (EVD) placement is a common neurosurgical procedure used to control acute hydrocephalus and other neurosurgical complications. The infection and complication rates reported in the literature are highly variable, and iatrogenic factors determine the outcome of drain placement. We examined the impact of the setting of EVD placement (emergency department [ED] vs. intensive care unit [ICU] vs. operating room [OR]) and the experience of the operating surgeon on the infection rate, complication rate, EVD replacement, eventual placement of a ventriculoperitoneal shunt, and the need for further surgical intervention. METHODS: This was a retrospective, single-center study conducted at University Hospital in Newark, New Jersey. RESULTS: A total of 190 EVDs were placed in 163 patients. The infection rate was 6.13%, and the complication rate was 12.3%. Six out of the 10 patients with infection had the EVD placed in the ICU, but this was not significant (P = 0.1172). Patients with a Glasgow Outcome Scale score of 1 or 2 (dead or vegetative) after the procedure were significantly more likely to have an EVD placed in the ED or ICU (P = 0.0173). Although junior residents placed a greater number of drains than senior residents, the infection and complication rates were not significantly different between the 2 groups (P = 0.1142 and 0.8502, respectively). EVD infection also was not significantly correlated with patient sex, age, initial diagnosis, drain replacement, or duration of drain placement. The most common organisms cultured were coagulase-negative Staphylococcus spp. and Staphylococcus aureus. CONCLUSIONS: This study did not identify any significantly greater risk of infection or complications with EVDs placed in the OR or at the bedside, or with EVDs placed by less-experienced surgeons.

Repeat Intracranial Expansion After Skull Regrowth in Hyperostotic Disease: Technical Note.

OBJECTIVE AND IMPORTANCE: Camurati-Engelmann disease (CED) is a rare, autosomal-dominant genetic disorder resulting in hyperostosis of the long bones and skull. Patients often develop cranial nerve dysfunction and increased intracranial pressure secondary to stenosis of nerve foramina and hyperostosis. Surgical decompression may provide symptomatic relief in select patients; however, a small number of reports document the recurrence of symptoms due to bony regrowth. We present a patient who had been treated previously with bilateral frontal and parietal craniotomy who experienced recurrence of symptoms due to reossification of her cranial bones. This report underscores the progressive nature of CED and its influence on surgical management. Furthermore, we propose a novel surgical approach with multiple craniectomies and titanium mesh cranioplasties that could potentially offer long-term symptomatic relief. CLINICAL PRESENTATION: A 46-year-old female patient with CED who was treated with ventriculoperitoneal shunting, posterior fossa decompression, and multiple craniotomies 2 decades prior presented with signs and symptoms of increased intracranial pressure. Studies of the skull at presentation demonstrated rethickening of cranial bones that resulted in severely decreased intracranial volume. INTERVENTION: A radical craniectomy, requiring 4 separate bone flaps made up of bilateral frontal and parietal bones, was performed. The remaining coronal and sagittal bony struts were drilled to approximately 1 cm thick. Cranioplasties with 4 separate titanium meshes were performed to preserve the natural contour of the patient's skull. CONCLUSIONS: Although surgical decompression could provide some patients with CED symptomatic relief, clinicians should consider managing CED as a chronic condition. To the authors' knowledge, this is one of few case reports documenting the recurrence of symptoms in a patient with CED treated by surgical intervention. Furthermore, we propose that multiple craniectomies with titanium mesh cranioplasties confer more permanent symptomatic control, and, more importantly, lower the risk of recurrence secondary to cranial hyperostosis.

Schizophrenia and neurosurgery: A dark past with hope of a brighter future.

Schizophrenia is a chronic and progressive psychiatric disease that remains difficult to manage in the 21st century. Current medical therapies have been able to give reprieve and decrease incidence of psychotic episodes. However, as the disease progresses, patients can become ever more refractory to current pharmaceutical agents and the polypharmacy that is attempted in treatment. Additionally, many of these drugs have significant adverse effects, leaving the practitioner in a difficult predicament for treating these patients. The history of neurosurgery for schizophrenia, among other psychiatric diseases, has a very dark past. Therefore, this review examines peer-reviewed studies on the history of schizophrenia, its medical and surgical therapies, financial costs, and future directions for disease management. We highlight the historically poor relationship between neurosurgery and psychiatric disease and discuss current research in the understandings of schizophrenia. Guided by a strong code of ethics and new technology, including the use of stereotaxis and deep brain stimulation (DBS), the medical communities treating psychiatric disease are beginning to overcome the horrors of the past. DBS is currently being used with moderate success in the treatment of depression, obsessive compulsive disorder, Tourette's syndrome, and anorexia nervosa. With greater understanding of the neural circuitry of schizophrenia and the evolving role for DBS in psychiatric disease, the authors believe that schizophrenia, like other psychiatric diseases, can be treated with DBS.

First report of major vascular injury due to lateral transpsoas approach leading to fatality.

Extreme lateral interbody fusion (XLIF) has gained popularity among spine surgeons for treating multiple conditions of the lumbar spine. In contrast to the anterior lumbar interbody fusion (ALIF) approach, the minimally invasive XLIF approach affords wide access to the lumbar disc space without an access surgeon and causes minimal tissue disruption. The XLIF approach offers many advantages over other lumbar spine approaches, with a reportedly low complication profile. The authors describe the first fatality reported in the literature following an XLIF approach. They describe the case of a 50-year-old woman who suffered a fatal intraoperative injury to the great vessels during a lateral transpsoas approach to the L4-5 disc space.

Detection of atrial fibrillation using a modified microlife blood pressure monitor.

BACKGROUND: Hypertension is a major risk factor for the development of atrial fibrillation (AF) and for stroke due to AF. Asymptomatic AF can result in a stroke, in patients with risk factors, if it is not detected and treated appropriately. This study evaluated the sensitivity and specificity of an automatic oscillometric sphygmomanometer designed to detect AF. METHODS: The sphygmomanometer incorporates an algorithm for detecting AF while reducing false positive readings due to premature beats. A total of 405 unselected outpatients seen in two cardiology offices were evaluated by taking three sequential device readings and one electrocardiogram (EKG) on each patient. RESULTS: For detecting AF, the sensitivity was 95% and the specificity 86% with a positive predictive value of 68% and a negative predictive value of 98% for single device readings. For the three sequential device readings grouped together, the sensitivity was 97% and the specificity was 89%. The device correctly categorized most of the non-AF, abnormal rhythms. The specificity for those in sinus rhythm was 97%. CONCLUSIONS: This device is able to detect AF with high sensitivity and specificity. Use of this device by patients who monitor their blood pressure at home may help detect asymptomatic AF and allow for treatment prior to the development of a stroke.