Mapping of Capsular Side Effects by using Intraoperative Motor-Evoked Potentials during Asleep Deep Brain Stimulation Surgery of the Subthalamic Nucleus for Parkinson's Disease.

INTRODUCTION: The aim of this study was to present a novel technique for subthalamic nucleus (STN) deep brain stimulation (DBS) implantation under general anesthesia by using intraoperative motor-evoked potentials (MEPs) through direct lead stimulation and determining their correlation to the thresholds of postoperative stimulation-induced side effects. METHODS: This study included 22 consecutive patients with advanced Parkinson's disease who underwent surgery in our institution between January 2021 and September 2023. All patients underwent bilateral implantation in the STN (44 leads) under general anesthesia without microelectrode recordings (MERs) by using MEPs with electrostimulation directly through the DBS lead. No cortical stimulation was performed during this process. Intraoperative fluoroscopic guidance and immediate postoperative computed tomography were used to verify the electrode's position. The lowest MEP thresholds were recorded and were correlated to the postoperative stimulation-induced side-effect threshold. The predictive values of the MEPs were analyzed. Five DBS leads were repositioned intraoperatively due to the MEP results. RESULTS: A moderately strong positive correlation was found between the MEP threshold and the capsular side-effect threshold (RS = 0.425, 95% CI, 0.17-0.67, p = 0.004). The highest sensitivity and specificity for predicting a side-effect threshold of 5 mA were found to be at 2.4 mA MEP threshold (sensitivity 97%, specificity 87.5%, positive predictive value 97%, and negative predictive value 87.5%). We also found high sensitivity and specificity (100%) at 1.15 mA MEP threshold and 3 mA side-effect threshold. Out of the total 44 leads, 5 (11.3%) leads were repositioned intraoperatively due to MEP thresholds lower than 1 mA (4 leads) or higher than 5 mA (1 lead). The mean accuracy on postoperative CT was 1.05 mm, and there were no postoperative side-effects under 2.8 mA. CONCLUSION: Intraoperative MEPs with electrostimulation directly through the contacts of the DBS lead correlate with the stimulation-induced capsular side effects. The lead reposition based on intraoperative MEP may enlarge the therapeutic window of DBS stimulation.

Human cytomegalovirus DNA detection in a recurrent glioblastoma multiforme tumour, but not in whole blood: a case report and discussion about the HCMV latency and therapy perspectives.

In the current study, a 58-year-old male patient presented with recurrent glioblastoma multiforme (GBM). The patient underwent surgical resection, 4 months earlier, followed by radiotherapy and chemotherapy. During the second surgical intervention, tumour tissue and whole blood were sampled and analysed for human cytomegalovirus (HCMV) DNA, immediate early (IE) mRNA and pp65 mRNA. HCMV DNA was detected only in the recurrent tumour tissue but not in the whole blood. Neither IE mRNA nor pp65 mRNA was expressed. Our result suggests HCMV latency in the brain tumour with detectable level of viral DNA. More data are needed to understand the HCMV infection chronology in the brain tumours but our data could be important for further studies of HCMV antigens on the tumour surface and anti-GBM therapy.

Trends in pediatric epilepsy surgery in Europe between 2008 and 2015: Country-, center-, and age-specific variation.

OBJECTIVE: To profile European trends in pediatric epilepsy surgery (<16 years of age) between 2008 and 2015. METHODS: We collected information on volumes and types of surgery, pathology, and seizure outcome from 20 recognized epilepsy surgery reference centers in 10 European countries. RESULTS: We analyzed retrospective aggregate data on 1859 operations. The proportion of surgeries significantly increased over time (P < .0001). Engel class I outcome was achieved in 69.3% of children, with no significant improvement between 2008 and 2015. The proportion of histopathological findings consistent with glial scars significantly increased between the ages of 7 and 16 years (P for trend = .0033), whereas that of the remaining pathologies did not vary across ages. A significant increase in unilobar extratemporal surgeries (P for trend = .0047) and a significant decrease in unilobar temporal surgeries (P for trend = .0030) were observed between 2008 and 2015. Conversely, the proportion of multilobar surgeries and unrevealing magnetic resonance imaging cases remained unchanged. Invasive investigations significantly increased, especially stereo-electroencephalography. We found different trends comparing centers starting their activity in the 1990s to those whose programs were developed in the past decade. Multivariate analysis revealed a significant variability of the proportion of the different pathologies and surgical approaches across countries, centers, and age groups between 2008 and 2015. SIGNIFICANCE: Between 2008 and 2015, we observed a significant increase in the volume of pediatric epilepsy surgeries, stability in the proportion of Engel class I outcomes, and a modest increment in complexity of the procedures.

Three-dimensional neuronavigation in SEEG-guided epilepsy surgery.

OBJECTIVES: Epilepsy surgery is mainly cortical surgery and the precise definition of the epileptogenic zone on the complex cortical surface is of paramount importance. Stereoelectroencephalography (SEEG) may delineate the epileptogenic zone even in cases of non-lesional epilepsy. The aim of our study was to present a technique of 3D neuronavigation based on the brain surface and SEEG electrodes reconstructions using FSL and 3DSlicer software. PATIENTS AND METHODS: Our study included 26 consecutive patients operated on for drug-resistant epilepsy after SEEG exploration between January 2015 and December 2017. All patients underwent 1.5 T pre-SEEG MRI, post-SEEG CT, DICOM data post-processing using FSL and 3DSlicer, preoperative planning on 3DSlicer, and intraoperative 3D neuronavigation. Accuracy and precision of 3D SEEG reconstruction and 3D neuronavigation was assessed. RESULTS: We identified 125 entry points of SEEG electrodes during 26 operations. The accuracy of 3D reconstruction was 0.8 mm (range, 0-2 mm) with a precision of 1.5 mm. The accuracy of 3D SEEG neuronavigation was 2.68 mm (range, 0-6 mm). The precision of 3D neuronavigation was 1.48 mm. CONCLUSION: 3D neuronavigation for SEEG-guided epilepsy surgery using free software for post-processing of common MRI sequences is possible and a reliable method even with navigation systems without a brain extraction tool.

Bilateral pallidotomy for Meige syndrome.

Meige syndrome (MS) is usually described as a combination of blepharospasm with oromandibular dystonia. There are a large number of case reports of deep brain stimulation (DBS) of the globus pallidus internus (GPI) for MS and only one report of unilateral pallidotomy (PT). We report the first case of staged bilateral PT for treatment of a patient with MS using intraoperative high-frequency stimulation in order to predict and prevent postoperative deficit. There was a significant improvement of the Burk-Fahn-Marsden dystonia rating scale from 26 to 3. There were no adverse postoperative neurological and neuropsychological events.

Cells isolated from human glioblastoma multiforme express progesterone-induced blocking factor (PIBF).

Glioblastoma multiforme (GBM) is the most common and malignant tumor in the central nervous system. One of the contemporary hypotheses postulates that its pathogenesis is associated with the cancer stem cells (CSCs) which originate from mutations in the normal neural stem cells residing in their specific "niches." Simultaneously with its aggressive development the tumor suppresses the local immune system by different secreted and/or cell expressed factors. Progesterone-induced blocking factor (PIBF) is an immunomodulatory protein with known role in the regulation of the immune response in the reproductive system. Expression of PIBF has been described in some tumors as one of the factors suppressing the anti-tumor immunity. The aim of the present study was to check for the expression of PIBF from cells isolated from six GBMs. To characterize the cultured cells and to study the PIBF expression confocal microscopy, flow cytometry, ELISA, and real-time PCR were used. The results obtained showed expression of markers typical for cancer CSCs and secretion of interleukin 6 by the GBM-derived cultured cells. The results convincingly prove that PIBF is intracellularly expressed by the cultured cells from the all six GBM samples, and this fact is confirmed by three different methods-flow cytometry, confocal microscopy, and real-time PCR. This paper reports for the first time the expression of PIBF by GBM-derived cells cultured in vitro and reveals a new aspect of the immunosuppressive mechanism used by GBM in escaping the immune control.

Is PDQ-39 a reliable measure of quality of life of patients at advanced stages of Parkinson's disease considered for Deep Brain Stimulation.

Purpose: Parkinson's disease (PD) significantly impedes, especially at its advanced stages, the health-related quality of life (QoL) of patients. The Parkinson's disease questionnaire (PDQ-39) is a widely-used measure assessing the impact of the disease on the patients' QoL. To date, the reliability of PDQ-39 has not been selectively evaluated for patients at a particular delineated stage of the PD progression. Against this backdrop, the study aimed firstly to evaluate comprehensively the internal consistency reliability of PDQ-39 and the constituent scales specifically for patients at the advanced stages of PD who were candidates for Deep Brain Stimulation (DBS) surgery, and secondly, to compare the Cronbach's alpha coefficients with those reported in other studies conducted with patients across all stages of the PD progression. Methods: The sample included 36 Bulgarian patients (29 men and 7 women) at advanced stages of PD (Hoehn and Yahr stage 4), PD duration, M = 11.06, SD = 3.50). The internal consistency reliability of the questionnaire and the constituent scales was assessed using three criteria: Cronbach's alpha coefficients, inter-item and item-total correlations. Results: The internal consistency reliability indicators were satisfactory for the entire instrument and for most of the scales and similar to those reported in previous studies. None of the scales had low internal consistency reliability results across the three criteria. Except for the Communication scale, seven of the eight scales had Cronbach's alpha values that were satisfactory or marginally below the cut off score. All scales had acceptable inter-item correlations. Three of the scales (Emotional Well-Being, Cognition and Communication) contained more than one item with non-satisfactory item-total correlations. With minor exceptions, the removal of the items with low item-total correlations either did not improve or improved marginally or even decreased the Cronbach's alpha coefficients of the respective scale. The Communication scale was the only scale with a Cronbach's alpha coefficient that was both low and comparatively different to other studies and had as well low item-total correlations for all constituent items, thus showing non-satisfactory results on two of the three internal consistency reliability estimates. In contrast, the Mobility scale met all three internal consistency reliability criteria. Conclusion: PDQ-39 is a reliable tool for assessing the QoL of patients at advanced stages of PD across multiple health-related domains. The questionnaire can be recommended for inclusion in the best practice guidelines for evaluating DBS candidacy and the efficacy of DBS treatment for patients' QoL.

Monopolar stereoelectroencephalography-guided radiofrequency thermocoagulation.

OBJECTIVE: Stereoelectroencephalography (SEEG)-guided radiofrequency thermocoagulation (RFTC) has the advantage of producing a lesion in the epileptogenic zone (EZ) at the end of SEEG. The majority of published SEEG-guided RFTCs have been bipolar and usually performed between contiguous contacts of the same electrode. In the present study, the authors evaluate the safety, efficacy, and benefits of monopolar RFTC at the end of SEEG. METHODS: This study included a series of 31 consecutive patients who had undergone RFTC at the end of SEEG for drug-resistant focal epilepsy in the period of January 2013-December 2019. Post-RFTC seizure control was assessed after 2 months and at the last follow-up visit. Twenty-one patients underwent resective epilepsy surgery after the SEEG-guided RFTC, and the postoperative seizure outcome among these patients was compared with the post-RFTC seizure outcome. RESULTS: Four hundred forty-six monopolar RFTCs were done in the 31 patients. Monopolar RFTCs were performed in all cortical areas, including the insular cortex in 11 patients (56 insular RFTCs). There were 31 noncontiguous lesions (7.0%) because of vascular constraints. The volume of one monopolar RFTC, as measured on T2-weighted MRI immediately after the procedure, was between 44 and 56 mm3 (mean 50 mm3). The 2-month post-RFTC seizure outcomes were as follows: seizure freedom in 13 patients (41.9%), ≥ 50% reduced seizure frequency in 11 (35.5%), and no significant change in 7 (22.6%). Seizure outcome at the last follow-up visit (mean 18 months, range 2-54 months) showed seizure freedom in 2 patients (6.5%) and ≥ 50% reduced seizure frequency in 20 patients (64.5%). Seizure freedom after monopolar RFTC was not significantly associated with the number or location of coagulated contacts. Seizure response after monopolar RFTC had a high positive predictive value (93.8%) but a low negative predictive value (40%) for seizure outcome after subsequent resective surgery. In this series, the only complication (3.2%) was a limited intraventricular hematoma following RFTC performed in the hippocampal head, with spontaneous resolution and no sequelae. CONCLUSIONS: The use of monopolar SEEG-guided RFTC provides more freedom in terms of choosing the SEEG contacts for thermocoagulation and a larger thermolesion volume. Monopolar thermocoagulation seems particularly beneficial in cases with an insular EZ, in which vascular constraints could be partially avoided by making noncontiguous lesions within the EZ.

Comaneci stent-angioplasty for the optimization of inadequately deployed flow diverter stents.

BACKGROUND AND PURPOSE: In endovascular procedures, inadequate deployment of a flow diverter stent is a highly concerning technical complication that can lead to acute parent vessel occlusion and ischaemic events. This study aimed to assess the off-label use of the Comaneci device in managing technical difficulties associated with flow diversion. MATERIALS AND METHODS: We conducted an analysis of all flow diverter procedures documented in our prospectively collected database. Our objective was to identify patients with inadequately deployed implants who underwent Comaneci stent-angioplasty. Both Comaneci 17 and Comaneci 21 devices were utilized to address and remediate technical complications related to stent deployment. We reviewed anatomical features, technical details, intraprocedural complications, as well as clinical and angiographic outcomes. RESULTS: Thirty-one Comaneci devices were employed to remediate 31 inadequately deployed flow diverter stents. Successful resolution of technical complications associated with flow diverter placement was achieved in all attempted cases. No clinically significant complications were attributed to the technique, and no mortality was observed during the study. CONCLUSION: Technical issues arising from flow diverter stent deployment are formidable complications. Familiarity with appropriate corrective manoeuvres is essential to achieve successful outcomes. The Comaneci device can be safely and effectively incorporated into the range of techniques used to rectify inadequately deployed stents.

Development and results of the epilepsy surgery in Armenia: hope for a better future.

Purpose: We present our experience with the national epilepsy surgery program in Armenia by tracing the development of epilepsy surgery in the largest pediatric neurology department at "Arabkir" Medical Center. This development was possible on the basis of a strong collaboration with the Epilepsy Surgery center at the University Hospital "Sofia St. Ivan Rilski," Sofia, Bulgaria. Materials and methods: Our material included 28 consecutive patients with lesional drug-resistant epilepsy evaluated. All patients underwent 3 T MRI and Video-EEG monitoring. Brain 18FDG-PET was done in 13 patients in St. Petersburg. Fifteen patients (53%) had preoperative neuropsychological examination before surgery. All operations were done by the same neurosurgical team on site in Arabkir Hospital. Results: The majority of the patients in our cohort benefited from the epilepsy surgery as 25 (89%) are free of disabling seizures (Engel class I) and three patients (11%) did not improve substantially (Engel class IV). Eleven patients (39%) are already ASM-free after surgery, 4 (14%) are on monotherapy, 11(39%) get two drugs, and 2(7%) are on polytherapy, one of them still continues having seizures. In 12 patients (43%), we were able either to withdraw therapy or to decrease one of the ASM. Conclusion: We believe that, although small, yet encompassing patients along the usual age spectrum and with the most frequent pathologies of drug-resistant epilepsies, our experience can serve as a model to develop epilepsy surgery in countries with limited resources.

Management of Mirror Middle Cerebral Artery Aneurysms: Surgical Results and Morphological Parameters.

AIM: To investigate the safety and applicability of two main methods for treating mirror intracranial aneurysms, based on correlations in their geometric characteristics. MATERIAL AND METHODS: We conducted a retrospective analysis on 125 patients who underwent 138 surgical interventions for MCA aneurysms and were treated with microsurgical clipping and endovascular embolization at the Department of Neurosurgery in the University Hospital "St. Iv. Rilski", Sofia, in 2013-2019. In six of these cases, we observed mirror MCA aneurysms. RESULTS: All six patients with "mirror" aneurysms were female. In one case, a third aneurysm was observed on the anterior communicating artery; hence, a total of 13 aneurysms were treated. The average age of the group was 48.16 years. All patients had known risk factors, such as high blood pressure and tobacco smoking. Four patients presented with aneurysmal subarachnoid hemorrhage (aSAH). All patients underwent surgical treatment in two stages-with obliteration of the intracranial aneurysm leading to subarachnoid bleeding in the first stage and planned surgical intervention within a month in the second stage to exclude unruptured aneurysms. During the one-month interval, there were no SAH incidents. However, we observed one patient with a postoperative neurological deficit and one with recanalization of the aneurysm on follow-up at 3 months, requiring re-embolization. In both cases, endovascular treatment was performed despite the unfavorable anatomical features (aspect ratio ≤1.5 and neck size ≥4 mm). The clinical outcome, in all operated patients, for "mirror" aneurysms of the MCA was reasonable (mRS: 0-2). CONCLUSION: The choice of treatment for "mirror" aneurysms should be determined on an individual basis by the clinical manifestations and morphological characteristics of intracranial aneurysms. In cases of aSAH, where "mirror" aneurysms are present, both can be treated safely via microsurgical clipping or endovascular embolization after thorough investigation and ensuring prioritization of the offending lesion.

Endovascular treatment of wide-necked intracranial aneurysms using the Nautilus Intrasaccular System: initial case series of 41 patients at a single center.

BACKGROUND: Endovascular treatment of intracranial wide-necked and bifurcation aneurysms (WNBA) is technically challenging. The Nautilus Intrasaccular System is designed to provide a mechanical barrier at the aneurysm neck to support coil embolization. We report the results of a single-center series of patients treated for intracranial aneurysms with the Nautilus. METHODS: Clinical and radiological data were retrospectively collected for all patients treated with the Nautilus for an unruptured or ruptured intracranial aneurysm at our center between March 2021 and March 2022. Clinical outcomes (modified Rankin Scale (mRS) scores), Raymond-Roy angiographic occlusion, recanalization, and complications were measured immediately post-procedure and at 3-6-month follow-up. RESULTS: A total of 41 patients of mean age 56.7 years (range 37-83 years) were treated with the Nautilus, with 41 saccular aneurysms (18 (43.9%) unruptured and 23 (56.1%) ruptured). The majority of aneurysms (39/41 (95.1%)) were located in the anterior circulation. We experienced no technical complications. One patient had an asymptomatic post-procedural minor stroke related to the procedure. Immediate Class I occlusion was achieved in 30 (73.1%) patients. The rate of all-cause mortality was 7.3% (3/41). One patient was lost to follow-up. At follow-up, 94.5% (35/37) of patients achieved Class I occlusion and 94.5% (35/37) had an mRS score of 0. There were no procedural-related deaths or permanent morbidities at discharge or follow-up. CONCLUSION: This study demonstrates good safety and effectiveness using the Nautilus Intrasaccular System to treat both ruptured and unruptured intracranial aneurysms. Larger studies are needed to confirm these findings.

Flow Diversion for the Management of Ruptured Intracranial Arterial Infudibular Dilatation: Proof of Principle and Therapeutic Protocol.

Thought to be benign anatomical variants, cerebral infundibular dilatations (ID) are most commonly encountered at the junction of the internal carotid artery (ICA) and the posterior communicating artery (PcomA). The true nature of this entity remains controversial, as some literature reports suggest they should be considered preaneurysmal lesions and a potential source of devastating subarachnoid hemorrhage. This report describes cases of presumably ruptured IDs and their therapeutic endovascular management. We retrospectively reviewed and analyzed patients with isolated subarachnoid hemorrhage (SAH) where the only potential cause was ruptured cerebral IDs, treated or not, between January 2012 and June 2021. Morphological and radiological features, treatment and procedural considerations, clinical and angiographic outcomes were also reviewed. Natural history of the ID is poorly understood, and its relation to SAH remains controversial. Ruptured cerebral IDs can be the suspected cause of bleeding if no other vascular lesion is present during multimodal examinations. Endovascular flow diversion stenting is safe and effective for the proper treatment of ruptured IDs. Pending further validations with longitudinal data are needed to legitimate the natural course of these mysterious lesions.

Progressive volume reduction and long-term aneurysmal collapse following flow diversion treatment of giant and symptomatic cerebral aneurysms.

Background: The primary goal of conventional endovascular and microvascular approaches is the clinical and radiological resolution of the symptomatic aneurysm-induced mass effect. This study assessed the volume changes and mass effect reduction due to sac shrinkage after treatment with flow diverter stents (FD) for unruptured cerebral aneurysms. Methods: We analyzed retrospectively 36 symptomatic aneurysms that were larger or equal to 25 mm in diameter in patients treated at our center from January 2016 to April 2022. Radiological and clinical outcomes were analyzed, including aneurysmal volume changes and resolution of aneurysm-related symptoms. Results: At 6 months, 25 aneurysms decreased in size, 2 remained unchanged, and 9 aneurysms demonstrated a post-treatment dimensional increase. At 12 months, 30 aneurysms showed a progressive radiological volume reduction. Either no change or negligible shrinkage was observed in the remaining six aneurysms. At 24 months, 32 aneurysms showed aneurysmal shrinkage by a mean 47% volume loss with respect to baseline. At the last follow-up, all 13 patients who had presented with third cranial nerve palsy showed improvements. Complete reversal of the pretreatment edematous changes was confirmed in all cases. The overall post-treatment complication rate was 8.3%, as 3 patients experienced non-fatal delayed rupture of their aneurysm. There was no mortality in this study. Conclusion: Flow diversion could effectively induce progressive aneurysmal shrinkage and resolution of the mass effect associated with giant symptomatic cerebral aneurysms.

Diagnostic value of MRI in the presurgical evaluation of patients with epilepsy: influence of field strength and sequence selection: a systematic review and meta-analysis from the E-PILEPSY Consortium.

MRI is a cornerstone in presurgical evaluation of epilepsy. Despite guidelines, clinical practice varies. In light of the E-PILEPSY pilot reference network, we conducted a systematic review and meta-analysis on the diagnostic value of MRI in the presurgical evaluation of epilepsy patients. We included original research articles on diagnostic value of higher MRI field strength and guideline-recommended and additional MRI sequences in detecting an epileptogenic lesion in adult or paediatric epilepsy surgery candidates. Lesion detection rate was used as a metric in meta-analysis. Eighteen studies were included for MRI field strength and 25 for MRI sequences, none were free from bias. In patients with normal MRI at lower-field strength, 3T improved lesion detection rate by 18% and 7T by 23%. Field strengths higher than 1.5T did not have higher lesion detection rates in patients with hippocampal sclerosis (HS). The lesion detection rate of epilepsy-specific MRI protocols was 83% for temporal lobe epilepsy (TLE) patients. Dedicated MRI protocols and evaluation by an experienced epilepsy neuroradiologist increased lesion detection. For HS, 3DT1, T2, and FLAIR each had a lesion detection rate at around 90%. Apparent diffusion coefficient indices had a lateralizing value of 33% for TLE. DTI fractional anisotropy and mean diffusivity had a localizing value of 8% and 34%. A dedicated MRI protocol and expert evaluation benefits lesion detection rate in epilepsy surgery candidates. If patients remain MRI negative, imaging at higher-field strength may reveal lesions. In HS, apparent diffusion coefficient indices may aid lateralization and localization more than increasing field strength. DTI can add further diagnostic information. For other additional sequences, the quality and number of studies is insufficient to draw solid conclusions. Our findings may be used as evidence base for developing new high-quality MRI studies and clinical guidelines.

Theoretical stereoelectroencephalography density on the brain convexity.

INTRODUCTION: Invasive electroencephalography (EEG) remains the "gold standard" for diagnosing the epileptogenic zone in patients with drug-resistant epilepsy and discrepancies between seizure semiology, video-EEG and magnetic resonance imaging (MRI) findings. However, the possibilities of stereoelectroencephalography (SEEG) to explore the brain surface remain a matter of debate and subdural EEG (SDEEG) is still preferred in some centers for cases when the supposed epileptogenic zone is on the brain convexity. The aim of our study was to evaluate the theoretical safe SEEG coverage on the brain convexity and to compare the theoretical SEEG cortical density with the usual SDEEG density. MATERIALS AND METHODS: Our material included 10 hemispheres in 5 patients, who had been already investigated with SEEG for drug-resistant epilepsy. We translated our previously described technique in a theoretical model in an attempt to calculate the maximal number of avascular windows for each cerebral hemisphere. The distance between every entry point and the other entry points for each hemisphere was calculated using a mathematical formula. Subsequently, the theoretical SEEG coverage on the brain convexity was described using the maximal, minimal and average distances between each entry point and the closest 4 neighboring points. This type of measurement allows a direct comparison between SEEG and SDEEG in their ability to explore the brain convexity. RESULTS: Ten hemispheres had 1328 safe entry points with a safety margin of 2.5 mm and a minimal distance of 2.5 mm between 2 entry points (average number of entry points: 132.8 (SD ± 5). The number of entry points in the explored 10 hemispheres varied from 104 to 156. The average distance between each entry point and its 4 neighbors was 11.47 mm. The maximal distance between two entry points in these 10 hemispheres was ranging from 20.28 to 27.23 mm (average: 24.67 mm). The closest entry points for the explored hemispheres were at an average distance of 4.67 mm (range: 2.82 - 5.96 mm). The average convexity surface was 223.68 cm2 (range: 204.63-238.77 cm2). The safe electrode density without electrode collision on the cortical surface was ranging from 0.46 to 0.69 electrodes per cm2 (average: 0.59 electrodes per cm2) (SD ± 0.023). CONCLUSION: The theoretical SEEG cortical density is comparable with the usual SDEEG density. These findings, combined with the better safety profile of SEEG and the possibilities to explore deep cortical structures, explain the progressive shift from SDEEG to SEEG during the last years.

Awake Epilepsy Surgery in Patients with Focal Cortical Dysplasia.

BACKGROUND: Awake craniotomy (AC) and direct electric stimulation emerged together with epilepsy surgery >80 years ago. The goal of our study was to evaluate the benefits of awake surgery in patients with drug-resistant epilepsy caused by focal cortical dysplasia (FCD) affecting eloquent areas. METHODS: Our material included 95 patients with drug-resistant epilepsy and FCD, who were operated on between January 2009 and December 2018. These 95 patients were assigned into 3 groups: AC; general anesthesia (GA) with intraoperative neuromonitoring; and GA without intraoperative neuromonitoring. We investigated the following variables: age at surgery, lesion side, eloquent cortex involvement, brain mapping success rate, epilepsy surgery success rate, intraoperative complications, postoperative complications, and intraoperative changes of the preoperative resection plan according to results of the brain mapping by direct electric stimulation. RESULTS: We found statistically significant differences between the AC and GA groups in the mean age at operation, lesion side, eloquent localization, and postoperative transient neurologic deficit. Seizure outcome in the AC was satisfactory (71% complete seizure control) and comparable to the seizure outcome in the GA groups. Our preoperative plan was changed because of functional constraints in 6 patients (43%) operated on during AC. CONCLUSIONS: AC during epilepsy surgery for FCD in eloquent areas may change the preoperative plan. The good rate of postoperative seizure control and the absence of permanent postoperative neurologic deficit in our series is the main proof that AC is a useful tool in patients with FCD involving the eloquent cortex.

Transvenous Embolization of a Ruptured Arteriovenous Malformation.

Transvenous embolization is a not so widely used technique for treatment of arteriovenous malformations.1,2 However, in the reported cases and series in the literature, it is proven to be a safe and efficient method that can lead to total occlusion of the formation in 1 procedure.2-5 The transvenous approach is reserved for small, deeply localized formations with a single draining vein.2-4 In this video, we present a case of a successful single-session transvenous embolization of a ruptured arteriovenous malformation with Onyx. Prior to the injection of the liquid embolic agent, coils were deployed at the proximal part of the draining vein. A balloon was inflated at the arterial part to decrease the pressure inside the nidus, therefore ensuring better penetration of the embolic agent. Control angiogram at the end of the procedure showed total occlusion of the nidus of the arteriovenous malformation.

Early clinical experience with Cascade: a novel temporary neck bridging device for embolization of intracranial aneurysms.

BACKGROUND: Temporary placement of a retrievable neck bridging device, allowing parent vessel flow, is an attractive alternative to balloon remodeling for treatment of ruptured intracranial aneurysms. OBJECTIVE: To present, in a single-center study, our initial experience with Cascade (Perflow, Israel) in the treatment of ruptured intracranial aneurysms. METHODS: During a period of 1.5 months, 12 patients with aneurysmal subarachnoid hemorrhage underwent coil embolization in conjunction with Cascade in our center. Retrospective analysis of prospectively collected angiographic and clinical data was conducted to assess the safety and efficacy of the device. RESULTS: Among all treated patients, 41.7% (5/12) were female, the median age was 55 (47-77) years, the median aneurysm dome size was 5.75 mm (3-9.1), and the median neck size was 3.55 mm (2.3-7.9). Complete obliteration (Raymond 1) was achieved in 75% (9/12) of cases, and intentional residual neck (Raymond 2) was left in three cases (25%). None of the patients received any oral or intravenous antiplatelet therapy perioperatively. No thromboembolic complications, device-related spasm, vessel perforation, or coil entanglement were detected in any of the treated patients. CONCLUSIONS: In our initial experience, treatment of wide-neck ruptured intracranial aneurysms with Cascade is safe and effective, without the need for adjuvant antiplatelet therapy. Long-term follow-up data in larger cohorts are needed to confirm these preliminary findings.

Comaneci-Assisted Coiling as a Treatment Option for Acutely Ruptured Wide Neck Cerebral Aneurysm: Case Series of 118 Patients.

BACKGROUND: Wide-necked cerebral aneurysms in the setting of acute subarachnoid hemorrhage (SAH) remain difficult to treat with endovascular methods despite recent progress in the neuroendovascular field. OBJECTIVE: To evaluate the effectiveness and safety of the Comaneci device (Rapid Medical, Israel) in endovascular coil embolization of acutely ruptured, wide-necked sidewall, or bifurcation cerebral aneurysms. METHODS: We retrospectively reviewed 45 anterior communicating artery, 24 internal carotid artery, 21 middle cerebral artery bifurcation, 15 anterior cerebral artery, and 13 posterior circulation aneurysms, which were treated using Comaneci-assisted coil embolization from August 2017 to January 2019. We evaluated procedural complications, clinical outcomes, and mid-term angiographic follow-up. Immediate and 90 d-clinical outcome and radiological follow-up were obtained in all patients. RESULTS: Comaneci-assisted coil embolization was performed in 118 acutely ruptured aneurysms. The technique was carried out successfully in all cases. Simultaneous application of 2 separated Comaneci devices was performed in 8/118 cases (6.77%). Periprocedural thromboembolic complications related to the device were seen in 7/118 cases (5.93%) and severe vasospasm of the parent artery after manipulation of the Comaneci device occurred in 5/118 cases (4.2%). The procedural-related morbidity rate was 2.54%, and there was no procedural related mortality. Among the available survivors, angiographic follow-ups were obtained at 3 and 6 mo, and complete aneurysmal obliteration was confirmed in 81/112 (72.3%) and 75/112 (66.9%) cases, respectively. Mid-term follow-up reviewed total recanalization rate of 14.28%. CONCLUSION: Comaneci-assisted embolization of wide-necked intracranial aneurysms in patients presenting with acute SAH is associated with high procedural safety and adequate occlusion rates. Furthermore, dual antiplatelet therapy can be safely avoided in this patient group.