Persistent hemiplegia with normal intraoperative neurophysiological monitoring in supratentorial neurosurgery: a case report and review of literature.

Intraoperative neurophysiological monitoring (IONM) is needed for evaluating and demonstrating the integrity of the central and peripheral nervous system during surgical manoeuvres that take place in proximity to eloquent motor and somatosensory nervous structures. The integrity of the monitored motor pathways is not always followed by consistent clinical normality, particularly in the first hours/days following surgery, when surgical resection involves brain structures such as the supplementary motor areas (SMA). We report the case of a patient who underwent surgical excision of a right frontal glioblastoma with normal preoperative, intraoperative (IONM), and postoperative central motor conduction, but with persistent postoperative hemiplegia (> 6 months). The literature regarding SMA syndrome and its diagnosis and prognosis is reviewed.

Phase I clinical trial of intracerebroventricular transplantation of allogeneic neural stem cells in people with progressive multiple sclerosis.

We report the analysis of 1 year of data from the first cohort of 15 patients enrolled in an open-label, first-in-human, dose-escalation phase I study (ClinicalTrials.gov: NCT03282760, EudraCT2015-004855-37) to determine the feasibility, safety, and tolerability of the transplantation of allogeneic human neural stem/progenitor cells (hNSCs) for the treatment of secondary progressive multiple sclerosis. Participants were treated with hNSCs delivered via intracerebroventricular injection in combination with an immunosuppressive regimen. No treatment-related deaths nor serious adverse events (AEs) were observed. All participants displayed stability of clinical and laboratory outcomes, as well as lesion load and brain activity (MRI), compared with the study entry. Longitudinal metabolomics and lipidomics of biological fluids identified time- and dose-dependent responses with increased levels of acyl-carnitines and fatty acids in the cerebrospinal fluid (CSF). The absence of AEs and the stability of functional and structural outcomes are reassuring and represent a milestone for the safe translation of stem cells into regenerative medicines.

A Combined One-Staged Robot-Assisted Sacral Chordoma Resection.

BACKGROUND: The robotic surgery is an advanced modern minimally invasive technology, widely used in urologic oncology, and it has become useful in particular conditions. Over time, different surgical specialties made use of the robotic properties to minimize complications for high-risk procedures. A combined 1-staged robot-assisted multidisciplinary surgery with intraoperative neurophysiological monitoring can be a safe procedure to remove a sacral chordoma with low morbidity rates. CASE DESCRIPTION: A 64-year-old woman complained of a few months of drug-resistant low back and abdominal pain. The subsequent development of constipation brought the patient to undergo an abdominal computed tomography scan and magnetic resonance imaging. Radiologic investigations revealed a large size sacral mass associated with a partial destruction of the sacrum and posterior compression of the rectum. The tumor was en bloc removed by a combined 1-staged anterior laparoscopic robot-assisted and posterior open lumbosacral approach with continue intraoperative neurophysiological monitoring of sacral and pudendal plexuses. The histological diagnosis was of chordoma. After surgery, the patient reported pain relief and the total recovery of bowel dysfunction with good 11-month follow-up outcome. CONCLUSIONS: This combined technique represents a promising treatment option in selected cases. The robotic technology combined with the experience of highly qualified staff can improve the surgical result by minimizing complications. However, longer follow-up is necessary to confirm the long-term effects in terms of recurrence and survival.

Lower trunk of brachial plexus injury in the neonate rat: effects of timing repair.

OBJECTIVE: After lesion of a peripheral nerve in neonatal mammals, motoneurons undergo a cell death. We wanted to ascertain if early surgery could influence such post-axotomy motoneuronal death and improve the functional outcome. In this study, we investigated the functional and anatomical results after immediate and delayed repair of the lower trunk of brachial plexus (BP) sectioned at birth in rats. METHODS: In neonate rats, the lower trunk of the left BP was cut. This nerve trunk was repaired either immediately [immediately-reconstructed group of rats (IR), or 30 days after, tardy reconstructed group of rats (TR)]; in the third group of animals, the nerve was not repaired (noreconstructed group of rats, NoR). In each group of animals, functional studies were performed at 90 days of age using the grooming test and the walking tracks analysis. Histologic studies of the C7-T1 spinal cord and lower trunk of BP were performed at 30 and 90 days of age; the numbers of motoneuron and axon were counted. RESULTS: Functional recovery was related to the difference in motoneuron number between the injured and the uninjured sides of the spinal cord of the operated animals. On the one side, only in the rats in which the inferior trunk was immediately repaired, the difference in motoneuron number between the two sides of the spinal cord was not statistically significant; these animals showed a good axonal regeneration and function recovery. On the other side, in the rats in which the inferior trunk was left unrepaired or tardy repaired, the decrease in motoneuron number in the injured side compared with the uninjured side of the spinal cord was statistically significant; these animals showed no axonal regeneration and no function recovery. DISCUSSION: The results cited above suggest that an important role in restoration of good neurological function after section of the lower trunk of BP in neonate rats is played by early nerve repair. Good neurological function was related more to a quite numerical balance of motoneurons between the two anterior gray horns of spinal cord than to the absolute number of rescued motoneurons.

Posttraumatic immobilization in flexion of a congenital valgus elbow and cubital tunnel syndrome-case report.

BACKGROUND: Elbow trauma, cubitus valgus deformity, and prolonged flexion of the elbow are recognized risk factors for ulnar nerve entrapment. CASE DESCRIPTION: The 3 conditions coincided in the present case. In fact, a 36-year-old woman had a bilateral severe congenital cubitus valgus. A trauma of the right elbow caused luxation and supracondylar humeral fracture for which the joint was fixed in flexion at 90 degrees for 1 month. The patient developed a severe ulnar nerve entrapment syndrome that did not respond to several months of physiotherapy and active mobilization of the elbow. The symptoms recovered after surgical decompression and anterior subcutaneous transposition of the nerve. CONCLUSIONS: The present case illustrates how the development of a cubital tunnel syndrome should be considered as the expected outcome of a long immobilization in flexion of an elbow with a severe cubitus valgus. A simple subcutaneous anterior transposition of the ulnar nerve might be recommended before a long immobilization of a cubitus valgus elbow is performed.

Reducible and irreducible os odontoideum in childhood treated with posterior wiring, instrumentation and fusion. Past or present?

BACKGROUND: The aim of the study was to evaluate the results of instrumented rod and wire fusion in children with craniovertebral junction (CVJ) instability and os odontoideum. METHODS: We evaluated seven children (mean age 9.85 years) with Down and Morquio's syndromes and primary os odontoideum. X-ray, computerized tomography (CT) scan and magnetic resonance (MR) imaging of the CVJ showed reducible instability in all of the cases but one. All the children underwent surgical correction by means of posterior wiring, instrumentation, fusion and external orthosis. A posterior wiring technique was also utilized in the only child with irreducible preoperative atlantoaxial instability, which, however, proved to be reducible under general anesthesia. FINDINGS: At maximum follow-up (observation range 28 to 106 months, mean 59.42 months), the clinical picture was improved in all the patients. The postoperative neuroradiological investigations demonstrated satisfactory bony fusion with neural decompression in all patients. CONCLUSIONS: A wiring technique to correct atlantoaxial instabilities has been shown to be more relevant in these children with syndromic atlantoaxial dislocation and os odontoideum due to its simplicity, safety (continuous fluoroscopic assistance is not necessary and there is no risk of neuro-vascular injuries) and lower costs (no complex hardware devices; no neuronavigation systems are required). Preoperative irreducibility of the C1-C2 shift is not an absolute criterion for transoral decompression in children since os odontoideum can be reduced under general anesthesia.

Transcranial Doppler monitoring after embolization of an unruptured left paraclinoid aneurysm led to detection of subarachnoid hemorrhage.

A 46-year-old man who presented with an unruptured left paraclinoid aneurysm was treated via endovascular embolization using Guglielmi detachable coils, obtaining its complete exclusion. Within 5 hours, the patient developed a transient mild headache and moderate speech difficulty. CT scans revealed a left temporal ischemic area. Continuous transcranial Doppler monitoring was initiated. Eighteen hours after embolization, the patient developed a mild headache associated with a transient decrease in consciousness, while the diastolic blood flow velocity decreased and the pulsatility index increased in the left middle cerebral artery. These changes prompted us to perform CT, which revealed a subarachnoid hemorrhage. Angiograms demonstrated partial revascularization of the newly embolized aneurysm. The patient underwent a second embolization procedure with additional coils for complete exclusion of the aneurysm. His postoperative course was uneventful, with no additional neurological deficits. Although TCD monitoring is not recommended as a routine procedure in such cases, and experimental studies are needed to evaluate the possible risk of rebleeding in this specific setting, it could be used to detect the hemodynamic consequences of an acute increase in intracranial pressure, as in patients at risk of subarachnoid hemorrhage after endovascular treatment.