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Introduction Spinal reflexes reorganize in cerebral palsy (CP), producing hyperreflexia and spasticity. CP is more common among male infants, and gender might also influence brain and spinal–cord reorganization. This retrospective study investigated the frequency of higher-graded EMG responses elicited by electrical nerve–root stimulation during selective dorsal rhizotomy (SDR), prior to partial nerve– root deafferentation, considering not only segmental level and body side, but also gender. Methods Intraoperative neuromonitoring (IOM) was used in SDR to pinpoint the rootlets most responsible for exacerbated stimulation-evoked EMG patterns recorded from lower-limb muscle groups. Responses were graded according to an objective response-classification system, ranging from no abnormalities (grade 0) to highly abnormal (grade 4+), based on ipsilateral spread and contralateral involvement. Non-parametric analysis of data with repeated measures was primarily used in investigating the frequency distribution of these various EMG response grades. Over 7000 rootlets were stimulated, and the results for 65 girls and 81 boys were evaluated, taking changes in the composition of patient groups into account when considering GMFCS levels. Results The distribution of graded EMG responses varied according to gender, laterality, and level. Higher-graded EMG responses were markedly more frequent in the boys and at lower segmental levels (L5, S1). Left-biased asymmetry in higher–graded rootlets was also more noticeable in the boys and in patients with GMFCS level I. A close link was observed between higher-grade assessments and left-biased asymmetry. Conclusions Detailed insight into the patient’s initial spinal-neurofunctional state prior to deafferentation suggests that differences in asymmetrical spinal reorganization might be attributable to a hemispheric imbalance.

Introduction Selective dorsal rhizotomy (SDR) consists of microsurgical partial deafferentation of sensory nerve roots (L1–S2). It is primarily used today in decreasing spasticity in young cerebral palsy (CP) patients. Intraoperative monitoring (IOM) is an essential part of the surgical decision-making process, aimed at improving functional results. The role played by SDR-IOM is examined, while realizing that connections between complex EMG responses to nerve–root stimulation and a patient’s individual motor ability remain to be clarified. Methods We conducted this retrospective study, analyzing EMG responses in 146 patients evoked by dorsal–root and rootlet stimulation, applying an objective response–classification system, and investigating the prevalence and distribution of the assessed grades. Part1 describes the clinical setting and SDR procedure, reintroduced in Germany by the senior author in 2007. Results Stimulation-evoked EMG response patterns revealed significant differences along the segmental levels. More specifically, a comparison of grade 3+4 prevalence showed that higher-graded rootlets were more noticeable at lower nerve root levels (L5, S1), resulting in a typical rostro-caudal anatomical distribution. Conclusions In view of its prophylactic potential, SDR should be carried out at an early stage in all CP patients suffering from severe spasticity. It is particularly effective when used as an integral part of a coordinated, comprehensive spasticity program in which a team of experts pool their information. The IOM findings pertaining to the anatomical grouping of grades could be of potential importance in adjusting the SDR-IOM intervention to suit the specific individual constellation, pending further validation. Trial registration ClinicalTrials.gov ID: NCT03079362

Purpose: The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis. Methods: We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex. Results: Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up. Conclusion: ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Berlin treasures a very specific sentiment. In contrast to other old but traditionally wealthy German cities like Munich or Hamburg, Berlin never settled and never have the city’s claims been staked. Although its importance ever increased, Berlin looks back to a rather checkered history of rise and fall, of unification, separation, and reunification. A flourishing trading city in the Middle Ages after merging the market towns Berlin and Coelln, it has experienced a first division and loss of independence in 1442. After reunification in 1470, Berlin until these days lived through an exhausting succession of political and economic crises causing repeated periods of substantial impoverishment and suppression, answered by organized resistance, civil unrest, and uprisings. A basic flavor of depression and desperation remained alive at all times and may very well be experienced today in the somewhat harsh and gruffy sense of humor of native Berliners, which at most encourages to take eventual blows of faith relaxed and with composure. Somewhat unaffected by adverse events and as if shrugging off the misery, Berlin continuously developed. It became an electoral residence, royal city, and imperial capital. Under Frederick the Great Berlin was the intellectual and cultural center of enlightenment. In 1909, the first German motor airport opened. In the golden 20s, personalities like the architect Walter Gropius; the physicist Albert Einstein; the painter George Grosz; writers like Arnold Zweig, Berthold Brecht, and Kurt Tucholsky, and actors and directors like Marlene Dietrich, Friedrich Wilhelm Murnau, and Fritz Lang turned Berlin into the cultural capital of Europe. The nightlife of that period found its most famous description in the film Cabaret. Four million inhabitants celebrated the opening of the first Autobahn in 1921. In 1924, the airport Tempelhof was opened, and the first public television was introduced in 1935. All this sounds very much like a success story if there had not happened the war of 30 years, halving the population, the occupation by Napoleon causing a sinister period of regression, followed by the first world war, bringing hunger and poverty, theWeimar Republic with harsh internal political hassles, followed by a galloping inflation and—after recovery by help of the allies—the word economic crisis, preparing the ground for national socialism and the second world war. Mutating into the capital of national socialism, Berlin experienced the horror of anti-Semitism, hardly suppressed during the Olympic Games of 1936. The city finally was destructed for the greater part between June 1940 and February 1945 by the most numerous allied bombing raids ever flown over a German City during the second world war. After a long period of vegetative survival, broken into pieces, and on the drip feed of the world powers, Berlin recovered slowly and only after the reunification in 1989 developed again into the current vibrant capital. This time, the traces of the past remained visible. The grounds of the former Berlin Wall, an only very tentatively built on fallow land, cut through the very city center, marking a virtually and very symbolic “broken heart”. Thus, the city center from the palace of tears down to Checkpoint Charly breathes a strange mix of bitter and sweet memories, loading the place with sentimentality. Alive but deeply marked by the fundamental crises of the past, Berlin continues its never ending journey towards a very distant and radiant goal. Berlin keeps on walking or rather strolling, admired, and accursed for this eternal status of a tramp poor but confident. Particularly in summer, drowsily drifting along in the sun, this very emotional city seems to just dream away, aimlessly self-absorbed in its narcissism. It is this specific mind setting which attracts—on the axis from Paris to Moscow—the shady world of glamour, illusion, gamble, fast wealth, and mass parties for any reason—be it the soccer world championship or the one mile high heels catwalk race—but as well creative potential, arts, and multiple scientific disciplines. Against this sparkling background, Culture meets Surgery was the title of the opening conference of the transdisciplinary research project‚ SchadelBasisWissen, directed by Sigrid Weigel and Hannes Haberl.

Debatable disadvantages of preset differential pressure valves in treating pediatric hydrocephalus are the inability to treat over- and underdrainage after implantation without further surgery. This survey aims to retrospectively determine whether adjustments were performed and effectively used for the individual adaptation of CSF drainage from the shunted patients' and families' perspective.In a series of 132 consecutive patients (59girls; 73boys, 0-29 years), families, caretakers, or the patients themselves were interviewed about their experiences after using the proGAV (Miethke-Aesculap, Germany) within a CSF-diverting shunt system. Thereby, the necessity and amounts of adjustments were evaluated. The subjective experiences of the adjustment process as well as the subsequent surgical interventions were documented with a follow-up period of 25.6 ± 9 months.In 87.9 % of the cases, clinical symptoms improved subjectively after valve implantation. A total of 103 adjustments in 69 patients were performed. In 30 % of patients, more than one readjustment was done. As subjective experience, the adjustment process was described by 85 % of patients as painless or merely uncomfortable. Symptoms improved in 91 % in connection to a new pressure setting. During the entire follow-up period, 61 % of all patients remained free of surgery.The recently used adjustable valves provide good clinical results and seem to lead to satisfactory treatment from the perspective of the affected patients or caretakers. Although a mechanical manipulation of the skin is necessary, the mechanism of the integrated adjustment unit was mostly well tolerated and allows for a noninvasive and MRI stable treatment of over- and underdrainage.

Neuroendoscopic procedures became essential in neurosurgical treatment of disturbed cerebrospinal fluid dynamics. While a vast number of papers report on the neuroendoscopic experience for adults and children, no series so far reported on techniques and indications for neonate infants. We present our experience for the feasibility of neuroendoscopic procedures in preterm and term newborn infants.All preterm and term infants who underwent an endoscopic neurosurgical intervention prior to the 28th day after the previously estimated date of delivery were identified by retrospective review. Surgical procedures and techniques, complications, and further follow-up data are reported.During the study period, 14 infants (median age at surgery, 36+(2)/7 weeks of gestation) underwent 20 endoscopic procedures. The performed procedures included endoscopic septostomy (n = 3), endoscopic shunt placement for multiloculated hydrocephalus (n = 4), endoscopic transaqueductal stenting for isolated fourth ventricle (n = 3), and endoscopic lavage for ventriculitis (n = 4) or for intraventricular hemorrhage (n = 6). No severe complications were seen, while two patients necessitating unexpected interventions during further follow-up (10 %).Despite the fragility of preterm and term newborn infants, neuroendoscopic procedures may play an important role in the treatment of disturbed cerebrospinal fluid (CSF) dynamics also in this patient population. The neuroendoscopic approach may be curative in conditions like isolated lateral ventricle, may facilitate simplified and effective CSF diversion in multiloculated hydrocephalus or isolated fourth ventricle, and may be beneficial in the course of ventriculitis and intraventricular hemorrhage. Further studies must verify our experience with a bigger cohort of patients and on a multicenter basis.

Convection-enhanced delivery using carboplatin in brainstem glioma models was reported to prolong survival. Functional impairment is of additional importance to evaluate the value of local chemotherapy. We established a neurological scoring system for the rat brainstem glioma model.In 46 male Fisher rats stereotactically 10(5) F-98 cells were implanted at 1.4-mm lateral to midline and at the lambdoid suture using guided screws. Following 4 days local delivery was performed using Alzet pumps (1 microl/h over 7 days) with either vehicle (5% dextrose) or carboplatin via one or two cannulas, respectively. All rats were subsequently tested neurologically using a specified neurological score. In 38 animals survival time was recorded. Representative MR imaging were acquired in eight rats, respectively, at day 12 after implantation. HE staining was used to evaluate tumor extension.Neurological scoring showed significantly higher impairment in the high dose carboplatin group during the treatment period. Survival was significantly prolonged compared to control animals in the high dose carboplatin-one cannula group as well as in both low dose carboplatin groups (18.6 +/- 3 versus 26.3 +/- 9, 22.8 +/- 2, 23.6 +/- 2 days; p0.05). Overall neurological grading correlated with survival time. MR imaging showed a focal contrast enhancing mass in the pontine brainstem, which was less exaggerated after local chemotherapy. Histological slices visualized decreased cellular density in treatment animals versus controls.Local chemotherapy in the brainstem glioma model showed significant efficacy for histological changes and survival. Our neurological grading enables quantification of drug and tumor-related morbidity as an important factor for functional performance during therapy.

Technical aspects of local chemotherapy in inoperable brainstem gliomas by convection-enhanced delivery (CED) are still under experimental considerations. In this study, we characterize the feasibility of multiple cannula placements in the rat brainstem.In 38 male Fisher rats, up to three guided screws were positioned in burr holes paramedian at 2.5 mm anterior and posterior to as well as at the lambdoid suture. Using Alzettrade mark pumps (1 microl/h flow rate over 7 days) either vehicle (5% dextrose) or 0.1 mg carboplatin was delivered via one, two, or three cannulas, respectively. During cannula insertion, electrocardiogram and respiratory rate was monitored. All rats were subsequently evaluated neurologically for 8 days. For drug distribution in coronal sections, the brain tissue concentration of platinum was measured. HE staining was used to evaluate the local site of drug delivery. Heart and respiratory rate remained within normal range during surgical procedure. Neurological scoring showed only mild neurological impairment in the groups receiving two or three cannulas, which resolved after vehicle delivery. However, after carboplatin delivery, this deficit remained unchanged. Drug distribution was more homogeneous in the three cannula group. Histological slices visualized edematous changes at the sight of cannula placement.The unilateral application of up to three cannulas in the brainstem of rats for local drug delivery studies is feasible. The remaining neurological deficit in carboplatin-treated animals underlines the need of low toxicity drugs for CED in the brainstem.