Comparison of direct MRI guided versus atlas-based targeting for subthalamic nucleus and globus pallidus deep brain stimulation.

PURPOSE: The subthalamic nucleus (STN) and globus pallidus internus (GPi) targets for deep brain stimulation (DBS) can be defined by atlas coordinates or direct visualisation of the target on MRI. The aim of this study was to evaluate geometric differences between atlas-based targeting and MRI-guided direct targeting. METHODS: One-hundred-nine Parkinson's disease or dystonia patients records who underwent DBS surgery between 2005 and 2016 were prospectively reviewed. MRI-guided direct targeting coordinates was used to implant 205 STN and 64 GPi electrodes and compared with atlas-based coordinates. RESULTS: The directly targeted coordinates (mean, SD, range) for STN were x: [9.9 ± 1.1 (7.1 - 13.2)], y: [-0.8 ± 1.1 (-4.2 - 2)] and z: [-4.7 ± 0.53 (-5.9 - -3.2)]. The mean value for the STN was 2.1 mm more medial (p < 0.0001), 1.2 mm more anterior (p < 0.0001) and 0.7 mm more ventral (p < 0.0001) than the atlas target. The targeted coordinates for GPi were x: [22.3 ± 2.0 (17.8 - 26.1)], y: [-0.2 ± 2.2 (-4.5 - 3.4)], z: [-4.3 ± 0.8 (-6.2 - -2.3)]. The mean value for the GPi was 2.2 mm (p < 0.001) more posterior and 0.3 mm (p < 0.01) more ventral than the atlas-based coordinates. CONCLUSION: MRI-guided targeting may be more accurate than atlas-based targeting due to individual variations in anatomy.

The neuroanatomical consequences and pathological implications of bilingualism.

In recent years, there has been a rise in the number of people who are able to speak two or more languages. This has been paralleled by an increase in research related to bilingualism. Despite this, much of the neuroanatomical consequences and pathological implications of bilingualism are still subject to discussion. This review aims to evaluate the neuroanatomical structures related to language and to the acquisition of a second language as well as exploring how learning a second language can alter one's susceptibility to and the progression of certain cerebral pathologies. A literature search was conducted on the Medline, Embase, and Web of Science databases. A total of 137 articles regarding the neuroanatomical or pathological implications of bilingualism were included for review. Following analysis of the included papers, this review finds that bilingualism induces significant gray and white matter cerebral changes, particularly in the frontal lobes, anterior cingulate cortex, left inferior parietal lobule and subcortical areas, and that native language and acquired language largely recruit the same neuroanatomical structures with however, subtle functional and anatomical differences dependent on proficiency and age of language acquisition. There is adequate evidence to suggest that bilingualism offsets the symptoms and diagnosis of dementia, and that it is protective against both pathological and age-related cognitive decline. While many of the neuroanatomical changes are known, more remains to be elucidated and the relationship between bilingualism and other neurological pathologies remains unclear.

Paediatric spinal trauma presenting to a UK major trauma centre.

PURPOSE: Paediatric spine trauma is uncommon and is managed differently from adults due to the anatomical differences of the paediatric spine. The paediatric spine is less ossified, with lax ligaments and a higher fulcrum in the c-spine which results in a different pattern of injuries. The aim of this study is to provide a contemporary audit of paediatric spinal trauma. METHODS: A retrospective review was conducted using the Trauma and Audit Research Network database at a major trauma centre (2011-2018). All patients < 18 years old with a spine injury underwent case note and radiology review. RESULTS: A total of 72 patients (37, 51.4% male with an average age of 13.3 (± 5.9) years old) were identified. The most common mechanism of injury was road traffic collisions (n = 39, 54.2%). The most common sporting cause was motocross accidents (n = 6, 8.3%), and a further 6 (8.3%) patients had a suspected inflicted injury. Eight patients (11.1%) sustained a spinal cord injury. Twenty-seven (37.5%) patients underwent surgical intervention to treat their spinal injury. CONCLUSION: This series demonstrates the profile of injury mechanisms causing paediatric spinal injuries. Paediatric spine injuries continue to have the potential for lifelong disability and require careful, specialist management. This series also highlights certain causes such as motocross accidents and suspected inflicted injury which are more frequent than expected and raise potential public health concerns.

Abolishing spontaneous epileptiform activity in human brain tissue through AMPA receptor inhibition.

OBJECTIVE: The amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) is increasingly recognized as a therapeutic target in drug-refractory pediatric epilepsy. Perampanel (PER) is a non-competitive AMPAR antagonist, and pre-clinical studies have shown the AMPAR-mediated anticonvulsant effects of decanoic acid (DEC), a major medium-chain fatty acid provided in the medium-chain triglyceride ketogenic diet. METHODS: Using brain tissue resected from children with intractable epilepsy, we recorded the effects of PER and DEC in vitro. RESULTS: We found resected pediatric epilepsy tissue exhibits spontaneous epileptic activity in vitro, and showed that DEC and PER inhibit this epileptiform activity in local field potential recordings as well as excitatory synaptic transmission. INTERPRETATION: This study confirms AMPAR antagonists inhibit epileptiform discharges in brain tissue resected in a wide range of pediatric epilepsies.

Straight to the point: an updated technique for performing lumbar puncture safely in obese patients.

Introduction: Lumbar puncture is an essential tool in any medical practitioner's repertoire - both surgeon and physician alike. With a rising trend in obesity, the procedure can be technically challenging.Methods: Here we present 12 cases where an updated version of lumbar puncture using an introducer is used for patients with a large body habitus.Results: The procedure was successful in all 12 patients with only one patient requiring a second attempt. All 12 patients gave positive feedback for the procedure.Conclusion: Performing lumbar puncture in obese patients using this updated technique is a safe, successful and cost-effective technique.

Transtemporal approach to hypothalamic hamartomas in children: report of 3 cases.

The surgical approach to hypothalamic hamartomas (HHs) associated with medically refractory epilepsy is challenging because of these lesions' deep midline or paramedian location. Whether the aim is resection or disconnection, the surgical corridor dictates how complete a procedure can be achieved. Here, the authors report a transtemporal approach suitable for Delalande type I, inferior extraventricular component of type III, and type IV lesions. This approach provides optimal visualization of the plane between the hamartoma and the hypothalamus with no manipulation to the pituitary stalk and brainstem, allowing for extensive disconnection while minimizing injury to adjacent neurovascular structures.Through a 1-cm corticectomy in the middle temporal gyrus, a surgical tract is developed under neuronavigational guidance toward the plane of intended disconnection. On reaching the mesial temporal pia-arachnoid margin, it is opened, providing direct visualization of the hamartoma, which is then disconnected or resected as indicated. Critical neurovascular structures are generally not exposed through this approach and are preserved if encountered.Three patients (mean age 4.9 years) with intractable epilepsy were treated using this technique as part of the national Children's Epilepsy Surgery Service. Following resection, the patient in case 1 (Delalande type I) is seizure free off medication at 3 years' follow-up (Engel class IA). The patient in case 2 (Delalande type III) initially underwent partial disconnection through a transcallosal interforniceal approach and at first had significant seizure improvement before the seizures worsened in frequency and type. Complete disconnection of the residual lesion was achieved using the transtemporal approach, rendering this patient seizure free off medication at 14 months postsurgery (Engel class IA). The patient in case 3 (Delalande type IV) underwent incomplete disconnection with a substantial reduction in seizure frequency at 3 years' follow-up (Engel class IIIC). There were no surgical complications in any of the cases.The transtemporal approach is a safe and effective alternative to more conventional surgical approaches in managing HHs with intractable epilepsy.

Consent in paediatric neurosurgery: adequacy of documentation and parental perspectives.

INTRODUCTION: Consenting paediatric patients for surgical procedures remains inherently unique in that it is underpinned by principles such as parental responsibility, assessment of the child's capacity to consent, and adherence to national/legal guidelines. Quality record keeping is an important objective evidence to demonstrate the highest standards of medical care provided to our patients. The consent form is a crucial medical record encapsulating the attainment of informed consent from a parent/guardian for performing a procedure on their child. We aimed to prospectively evaluate the consenting process in our department to assess adequacy of documentation and parental perspectives. METHODS: A prospective study using qualitative descriptive design was conducted with parents of 50 children requiring neurosurgical procedures over a 3-month period. RESULTS: All patients understood the primary diagnosis and type of surgery. Procedure-specific risks were understood by 98% and 84% could remember the mentioning of general risks of surgery. Only a minority of parents (24%) could recollect that alternative options of management including no treatment were discussed. In cases where relevant, laterality was only documented in 56% of consent forms. All patients felt that an informed decision regarding consent to surgery was made. However, 12% suggested areas where further improvement could be made in the timing of consent and the way information could be better provided. DISCUSSION: Consent is more than a signature on a form. It provides objective evidence of a shared decision-making process between the surgeon, patient, and their parent/guardian. Our initial study highlights multiple areas for improvement.

Paediatric intracranial aneurysms: a British institutional review.

INTRODUCTION: Paediatric intracranial aneurysms are rare, with a differing natural history and thought to account for only up to 7% of all intracranial aneurysms. There is much uncertainty that surrounds the prevalence of unruptured intracranial aneurysms and it is estimated to be anywhere between 2 and 90 per 1000. This is the largest British single-centre analysis of paediatric intracranial aneurysms. We present the patient course from their initial presentations to the outcome of treatment and evaluate a serial assessment of adequacy of aneurysmal obliteration radiologically. RESULTS: Twenty-two paediatric cases were identified that required treatment. The median age of presentation was 11.3 years (mean 9.9, range 0 to 15.9), 68% (15/22) were male and 77% (17/22) were ruptured on presentation. The majority of aneurysms were located at the anterior circulation (77% (17/22)). The overall median aneurysm size (n = 21) was 7.4 mm (mean 5 mm, range 2.5-19 mm). Twenty patients survived the acute phase and 80% (16/20) underwent coil embolisation and the other patients' surgical clipping. The overall outcomes were available for the 20 patients; on discharge, 90% (18/20) had a favourable clinical outcome (GOS score of 3-5). Treatment-specific clinical favourable outcomes were 88% (14/16) for coil embolisation against 100% (4/4) after surgical clipping. Of the two patients that died in the acute phase, one had sickle cell anaemia. Aneurysm aetiology was unknown in all other cases. None of the patients had a family history of aneurysms. CONCLUSION: Paediatric intracranial aneurysms while rare should be considered a differential diagnosis of children presenting with unexplained loss of consciousness with or without focal neurological deficit and/or headache. There is a two to one preponderance for males with a larger proportion of aneurysms within the posterior circulation (25%). Coil embolisation is the preferred method of securing a paediatric intracranial aneurysm.

Patients' Expectations and Satisfaction in Subthalamic Nucleus Deep Brain Stimulation for Parkinson Disease: 6-Year Follow-up.

OBJECTIVE: Patients' expectations are considered to play an important role in subthalamic nucleus (STN) deep brain stimulation (DBS). We explored the relationship among expectations, satisfaction, and outcome 6 years after surgery. METHODS: Fifteen patients with Parkinson disease (9 males, mean age 60.5 ± 6.4 years) undergoing STN DBS completed a modified PDQ-39 questionnaire (incorporating an assessment of patients' expected changes in addition to the standard quality of life items) preoperatively and at 6 years postoperatively. A satisfaction questionnaire accompanied the postoperative questionnaire. RESULTS: At 6 years' follow-up, PDQ-39 scores were unchanged from preoperative scores except in the stigma domain, which showed significant improvement. There was no significant difference between the postoperatively rated expected PDQ-39 summary score and the postoperative actual PDQ-39 summary score. However, there was a significant difference between the preoperatively rated expected PDQ-39 summary score and the postoperative actual PDQ-39 summary score. Patients remained highly satisfied with the outcome of surgery (mean satisfaction score 83%). Satisfaction did not correlate with PDQ-39 summary scores, domain scores, or fulfilment of expectations. The more satisfied patients (satisfaction ≥80%) changed their expectations so that their postoperatively rated expectations reflected a less favorable condition, whereas no such change was seen in the less satisfied (satisfaction <80%) patients. CONCLUSIONS: Patients remain highly satisfied with STN DBS 6 years after surgery, although quality of life assessed by the PDQ-39 may return to baseline levels. Patients' expectations change over time and may influence patient satisfaction. Managing expectations before and after surgery plays an essential role in STN DBS.

Intracranial stimulation for children with epilepsy.

OBJECTIVES: To evaluate the efficacy of intracranial stimulation to treat refractory epilepsy in children. METHODS: This is a retrospective analysis of a pilot study on all 8 children who had intracranial electrical stimulation for the investigation and treatment of refractory epilepsy at King's College Hospital between 2014 and 2015. Five children (one with temporal lobe epilepsy and four with frontal lobe epilepsy) had subacute cortical stimulation (SCS) for a period of 20-161 h during intracranial video-telemetry. Efficacy of stimulation was evaluated by counting interictal discharges and seizures. Two children had thalamic deep brain stimulation (DBS) of the centromedian nucleus (one with idiopathic generalized epilepsy, one with presumed symptomatic generalized epilepsy), and one child on the anterior nucleus (right fronto-temporal epilepsy). The incidence of interictal discharges was evaluated visually and quantified automatically. RESULTS: Among the three children with DBS, two had >60% improvement in seizure frequency and severity and one had no improvement. Among the five children with SCS, four showed improvement in seizure frequency (>50%) and one chid did not show improvement. Procedures were well tolerated by children. CONCLUSION: Cortical and thalamic stimulation appear to be effective and well tolerated in children with refractory epilepsy. SCS can be used to identify the focus and predict the effects of resective surgery or chronic cortical stimulation. Further larger studies are necessary.

Spontaneous rupture of the popliteus tendon in a 74-year-old woman and review of the literature.

Spontaneous rupture of the popliteus tendon has not previously been reported. We report the case of a 74-year-old patient, discuss its diagnosis and management, and review the current literature on isolated popliteus lesions. A multi-database electronic literature review suggests that the injury is invariably traumatic and has essentially been reported only in young, active individuals. It should be suspected in a patient with acute lateral knee pain who, on examination, has a hemarthrosis and a stable, possibly locked knee. The diagnosis is readily made using arthroscopy. While both conservative treatment with physiotherapy and open repair have been advocated, we describe a successful outcome of arthroscopic resection in an elderly patient and propose that popliteus injury is not confined to a younger age group. The balance of opinion in the current literature is that acute traumatic rupture in the young patient is managed by primary surgical repair, but successful outcome is also reported with nonoperative treatment.