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• Chronic subdural hematoma (cSDH) is a common neurosurgical disease of increasing prevalence. • Middle meningeal artery embolization (MMAE) is a newer option for the treatment of chronic subdural hematoma. • The addition of MMAE to surgery in the treatment of cSDH seems to improve neurologic outcomes. • The addition of MMAE to surgery in the treatment of cSDH reduces overall healthcare burden by decreasing resource utilization. Outcomes after surgical treatment of chronic subdural hematoma (cSDH) remain undesirable in a significant proportion of patients. We aimed to show the role of middle meningeal artery (MMA) embolization and to demonstrate its benefits. Thirty-five patients with symptomatic cSDH were enrolled in a prospective randomized trial following evacuation surgery. Participants were randomized to embolization or control group (expectant management following surgical evacuation without embolization). Patients were followed throughout their hospitalization and outpatient follow-ups. The main goals of this planned interim analysis were to assess neurological outcome and resource utilization. The groups were comparable in terms of sex, age and follow-up retention rates. Side(s) of intervention(s) and hematoma size were similar. There was no statistical difference in neurological examination improvement at discharge, but at follow-up, we observed a decline in neurologic exam in the control group (p = 0.03). Control group participants required more re-interventions (p = 0.02) and were followed in clinic and during related readmissions for longer (p = 0.02). The number of imaging studies obtained in relation to the disease management was higher in the control group (p = 0.01). Our results suggest a beneficial role for the addition of MMA embolization to surgical intervention in the treatment of symptomatic chronic subdural hematoma. Neurological outcomes were significantly better in the embolization group. This contributed to less need for follow-up, re-interventions, and imaging studies. [ABSTRACT FROM AUTHOR]

Purpose: A novel software algorithm combining non-invasive EEG and resting state functional MRI data to map networks of cortex correlated to epileptogenic tissue was used to map an epilepsy network non-invasively. The relationship between epilepsy network connectivity and outcomes after surgery was investigated using this non-invasive and non-concurrent modeling algorithm.Method: Scalp EEG and resting state functional MRI were acquired for nineteen patients with temporal lobe epilepsy. The hypothetical irritative zone was mapped, and resting state functional MRI data was used to model regions functionally correlated with the irritative zone. Epilepsy network connectivity was measured in patient with temporal lobe epilepsy (n = 19) both pre- and post-operatively. Temporal networks were also mapped in healthy control participants (n = 6).Results: Thirteen of nineteen patients (68 %) were seizure free after 20.3 ± 4.8 months. Epilepsy network connectivity within the temporal lobe was significantly higher among patients with temporal lobe epilepsy compared to the healthy control patients (p < 0.05). Disconnection of the epilepsy network was significantly higher in patients who were seizure free. Using spearman rho analyses, neuropsychological function after surgery was found to be relatively better in patients with higher degree of epilepsy network disconnection.Conclusions: The magnitude of network disconnection after surgery was strongly associated with increased rates of seizure freedom and relatively better neuropsychological measures of memory and naming function. It was shown that seizure-free outcomes and relatively improved neuropsychological function correlated with surgical disconnection of a highly synchronous epilepsy network. [ABSTRACT FROM AUTHOR]

There is a new focus on minimally invasive treatments for medically refractory mesial temporal lobe epilepsy (MTLE). MRI-guided laser interstitial thermal therapy (MRgLITT) is one such minimally invasive procedure, which utilizes MRI guidance and real-time feedback to ablate an epileptogenic focus. A total of 38 patients presenting exclusively with MTLE and no other lesions (including neoplasia), who underwent MRgLITT were reviewed. We evaluated a number of outcome measures, including seizure freedom, neuropsychological performance, complications, and other considerations. Eighteen (53%) had an Engel class I outcome, 10 patients had repeat procedures/operations, and 12 post-procedural complications occurred. Follow-up time ranged from 6 to 38.5 months. There was a decreased length of procedure time, hospitalization time, and analgesic requirement when compared to open surgery. In cases of well-localized MTLE this procedure may offer similar (albeit slightly lower) rates of seizure freedom versus traditional surgery. MRgLITT may be an alternative treatment option for high risk surgical patients and, more importantly, could increase referrals for surgery in patients with medically refractory MTLE. However, data is limited and long-term outcomes have not been evaluated. Further investigation is required to understand the potential of this minimally invasive technique for MTLE. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: High resolution MRI findings suggestive of mesial temporal sclerosis (MRI-MTS) correlate with good outcome after surgery. However, a large group of patients present with normal brain MRI (N-MRI) and temporal lobe epilepsy (TLE). We aim to compare pre-operative ictal EEG patterns in predicting surgical outcomes in the population with MRI-MTS vs. N-MRI after selective anterior-mesial temporal lobe (AMTL) resection. Methods: 241 patients with unilateral anterior ictal EEG findings underwent selective AMTL resection. 143 MRI-MTS and 98 N-MRI patients were identified. Outcome was based on the modified Engel classification, ictal EEG pattern at seizure onset, demographics and MRI findings. Results: Seizure-free outcome was seen in the MRI-MTS in 79% of patients, compared to 59.1% (p <.005) of the N-MRI group. No significant difference was identified in ictal EEG patterns at presentation between groups. Class I outcome was achieved in 78.9% of patients that had theta rhythm and MRI-MTS compared to 57.9% of patients that had theta rhythm and N-MRI (p <0.05). Discussion and conclusion: Surgical treatment for mesial TLE is effective. Positive MRI suggestive of mesial temporal sclerosis (MTS) predicts better seizure control after surgery. Theta rhythm is the most common ictal pattern and seems to carry the best prognosis for TLE. However, a well-selected group of patients with N-MRI will benefit from surgical intervention, and similar outcome to MRI-MTS patients can be achieved if delta ictal EEG pattern is presented at initial onset. Early referral to an epilepsy center cannot be emphasized enough, even in situations when high-resolution brain MRI is normal. [Copyright &y& Elsevier]

Abstract: Epilepsy surgery is a successful treatment for refractory temporal lobe epilepsy (TLE). Reports suggest fewer seizure-free outcomes for patients with TLE and who have a negative brain MRI (nMRI) for mesial temporal sclerosis. Data were collected prospectively from patients with nMRI who underwent temporal lobe surgery for TLE characterized by unilateral ictal temporal lobe seizure onset based on a scalp video electroencephalogram or invasive subdural electrode recordings. A total of 86 patients were followed for at least 24months after surgery. Outcome was evaluated using the Engel classification. Seizure control was obtained by 55% (47/86) of patients (Class [CL]-I), 27% (23/86) showed significant improvement (CL-II) and 19% (16/86) were deemed surgical failures. Shorter duration of epilepsy, later onset of seizures, and ictal theta rhythm (5–7Hz) were the most significant predictors of postoperative seizure control. Although hypometabolism on positron emission tomography scan and significant memory disparity (>2.5/8) were not significant prognosticators independently, cumulatively they were predictors for favorable outcome. [Copyright &y& Elsevier]

Abstract: Cerebrospinal fluid (CSF) rhinorrhea is the most common complication after transsphenoidal pituitary surgery. The authors compare their previous experience using an autologous fat graft and lumbar drain placement in 107 patients with their current technique of using a dural sealant and collagen matrix in 97 patients to prevent postoperative CSF leak after pituitary tumor resection. The failure rate for CSF leak repairs between the two groups was similar. The use of a dural sealant and collagen matrix, however, has the advantages of decreased length of hospital stay, decreased length of Intensive Care Unit stay, avoidance of the morbidity of an extra abdominal incision, and avoidance of the risks of lumbar CSF drainage. [Copyright &y& Elsevier]

Abstract: Objective: Adequate control of intractable epilepsy continues to be a challenge. Little is known about the role of VNS therapy in intractable epilepsy in patients who failed to respond to surgical management. The objective of the present study is to determine the efficacy of vagus nerve stimulation therapy in patients with intractable epilepsy who have failed surgical and medical therapy. Methods: All the patients who had persistent seizures after cranial surgery who subsequently underwent vagus nerve stimulator (VNS) placement at our institution from 1998 to 2008 were included in the study. Thirty-seven consecutive patients were enrolled and followed for the outcome measures of seizure burden, anti-epileptic drug (AED) burden and quality of life (QoL). Minimum follow-up was 18 months. Results: Overall, 24 (64.9%), 9 (24.3%), 4 (10.8%) patients reported less than 30%, between 30% and 60% and greater than 60% reduction in seizure frequency after VNS placement, respectively at a mean of 5 years follow-up period. Post-VNS anti-epileptic requirement exhibited a decreasing trend. 17 patients (45.9%) report an improvement in QoL (better or much better). Conclusion: VNS therapy in patients who have failed medical and surgical therapies only provides marginal improvement in seizure control but has greater likelihood to improve subjective QoL issues. In addition, VNS has the potential to reduce AED burden without adversely impacting seizure management. Given the low surgical risk of VNS placement, vagus nerve stimulation as a therapeutic modality should be individualized to achieve best clinical response and fewest side effects. [Copyright &y& Elsevier]

Summary: Purpose: While an abnormal pre-operative high-resolution brain MRI portends a favorable outcome in patients undergoing resective epilepsy surgery for medically intractable localization-related epilepsy (LRE), a normal MRI is less favorable. Ascertaining desirable pre-operative predictors for successful anterior temporal lobectomy (ATL) in LRE patients with a normal brain MRI is essential to better anticipate surgical outcome. Methods: Patients with LRE and normal temporal structures on MRI underwent ATL at two epilepsy centers in the southeastern US (FL and NC). Outcome was separated into those patients that were seizure free (SF), and those that were not seizure free (NSF), and those NSF were stratified in accordance with the Engel classification system. Those with a pre-operative history of clinical risk factors, unilateral anterior temporal interictal epileptiform discharges (IEDs), well localized scalp ictal EEG with rhythmic temporal theta at onset, localized PET/ictal SPECT, and Wada asymmetry with >2.5/8, were evaluated for the purpose of predicting outcome. Where appropriate, data is presented as a median (mean±S.D.). Results: Thirty-nine patients, median age 33 years, were followed up 2 years (3±1.2) after ATL. Overall, 22/39 (56.4%) patients were identified as SF, and 17/39 (43.6%) patients were NSF. Ictal EEG with rhythmic temporal theta at onset was the only predictive measure of seizure-free outcome (p =0.001, Fisher''s exact test), and also favorably correlated with seizure reduction (p =0.0001, r 2 =0.34, multiple regression analysis). None of the other predictors examined added greater predictive value. Conclusions: ATL is a favorable option for patients with LRE even when high-resolution brain MRI reveals normal temporal structures. Normal brain MRI patients with localizing pre-operative scalp ictal EEG, have better outcomes following ATL. [Copyright &y& Elsevier]

Abstract: Thoracic ossification of the posterior longitudinal ligament is a rare but debilitating condition. It is most commonly diagnosed in the Japanese population. If left untreated, significant myelopathy and weakness can ensue. Anterior decompression and stabilization is effective but technically demanding and is associated with high rate of complications. Posterior laminectomy appears to be an acceptable approach with lower risks. This work reviews the published literature on this topic and highlights the salient points. [Copyright &y& Elsevier]

Abstract: We present a 28-year-old man with neck pain, fevers, elevated acute-phase reactant levels and progressive quadraparesis. He had a history of intravenous drug abuse. Contrast-enhanced cervical spine MRI revealed a heterogeneously enhancing mass in the anterior atlantoaxial region with spinal cord compression. The patient was taken emergently to the operating room for decompression. Although the transoral approach for access to the ventral atlantoaxial complex for resection of compressive inflammatory and neoplastic lesions is well described, reports of evacuation of infectious lesions via this route are limited. Thus, we report drainage of a ventral high cervical abscess via the transoral approach. [Copyright &y& Elsevier]