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Introduction After the official announcement of the coronavirus disease-19 pandemic on March 11, 2020, the disease impacted most aspects of health care delivery, especially postgraduate education and training. Method A cross-sectional, online questionnaire-based assessment was performed. The study participants involved neurosurgery residents and program directors (PDs) across the country between May 16 and May 27, 2020. Results Approximately 74 of 95 (77.9%) of the residents experienced an impact on their training calendar. Before the pandemic, 51 residents (53.3%) were involved in 2–3 surgeries per week, but during the pandemic, 66 (69.5%) were attending 0–1 case per week. Fifty-three residents (55.8%) agreed that academic sessions were affected despite the helpful effort of online teaching sessions. Thirty-four (35.8%) residents graded their anxiety during coronavirus disease-19 times as high. Ten PDs (58.8%) confirmed spending 3–5 hours per week on educational activities normally, whereas during the pandemic, 15 PDs (88.2%) reduced their educational hours to 0–2 hours per week. Conclusion Our study showed that educational activities significantly decreased and shifted toward virtual teaching methods. Operative volume showed a substantial reduction for both junior and senior residents. Academic and clinical teaching was the main concern for PDs, and they faced challenges interviewing newly matched residents.

OBJECTIVE: Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality. METHODS: A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality. RESULTS: A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.67), 1 (1-24 h) (OR, 1.63; 95% CI, 1.10-2.41), and 4 (OR, 0.28; 95% CI, 0.19-0.42) showed significant differences. CONCLUSIONS: During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

The novel coronavirus disease (COVID-19) was first identified in Wuhan province of China in late December 2019.[1][1][⇓][2]–[3][3] COVID-19 is characterized by a rapid spread through respiratory droplets with human-to-human contact.[1][1][⇓][2]–[3][3] The virus has spread rapidly to more

Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty.The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multicenter, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is "Treatment Success": (i) occlusion or exclusion of the aneurysm using the allocated treatment modality; (ii) no intracranial hemorrhage during follow-up; (iii) no retreatment of the target aneurysm during follow-up, (iv) no residual aneurysm on angiographic follow-up; and (v) independence (mRS3) at 1 year. The trial tests 2 versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared with endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1-year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377.Patients with MCA aneurysms can be optimally managed within a care trial protocol.

Stroke is the second most common cause of death worldwide. It is a medical emergency demanding immediate recognition to provide time-sensitive acute management. The coronavirus disease 2019 (COVID-19) pandemic has challenged acute stroke care, and alternate models of treatment are needed. Telestroke is well proven as a valid tool for acute stroke assessment and has been utilized successfully to manage patients remotely in many parts of the world, though it is underutilized in the Middle East and North Africa region. Given the challenges associated with the COVID-19 pandemic, such as risk of physician exposure to infection, implementation of a telestroke system is critical to provide consultant stroke physician coverage. This article provides a proposed model for coordinated telestroke. Implementation of telestroke in the Middle East and North Africa region and other underdeveloped areas will optimize stroke management, especially during the COVID-19 era.

Objective: Young patients with intracerebral hemorrhage (ICH) make up a small but important subgroup of patients with ICH. This study investigated the clinical characteristics and outcomes of hypertensive ICH in very young (18-45 years) and young (46-55 years) patients. Methods: This was a retrospective study of patients aged 18-55 years with hypertensive ICH admitted to a hospital from April 2014 to April 2019. Clinical and radiologic features as well as long-term clinical outcomes were compared between 2 age groups: group 1 (18-45 years) and group 2 (46-55 years). Factors affecting the clinical outcome were investigated as well. Results: Of 63 patients with hypertensive ICH, 24 (38.1%) were in group 1 (mean ± SD age of 38 ± 4.6 years), and 39 (61.9%) were in group 2 (50 ± 2.5 years). The risk factor profile was similar except for diabetes, which was more prevalent in group 1 (odds ratio [OR] = 4.65; 95% CI, 1.4-15.2). Patients in group 1 had higher mean ± SD NIH Stroke Scale scores (15.7 ± 4.6, P = .044), had lower Glasgow Coma Scale (GCS) scores (OR = 3.33; 95% CI, 1.0-10.8), were at higher risk of intubation (OR = 2.79; 95% CI, 1.1-9.9), and had higher ICH volume (21 ± 18, P = .034). Worse clinical outcome was higher in group 1 (OR = 5.14; 95% CI, 1.0-26.1). Low GCS score, mean hematoma volume, and intraventricular extension were independently associated with worse outcome. Conclusions: Relatively young patients with hypertensive ICH have higher prevalence of diabetes and worse clinical outcome in comparison to older patients with hypertensive ICH. Such patients should be monitored and treated more aggressively.

Background: Decompressive craniectomy (DC) represents an effective method for intracranial pressure (ICP) reduction in cases of severe traumatic brain injury (TBI). However, little is known regardi...

Background COVID-19 pandemic has negatively impacted stroke care services at multiple levels. There was a decline in acute stroke admissions. Fewer interventions have been performed. Increased “door-to-needle times and “door-to-groin puncture” during this pandemic. These factors combined have led to declining in the favoured outcomes of stroke patients' globally. Yet this pandemic permits an opportunity for higher preparedness for future pandemics. Objectives and methods This paper aims to shed light on the main lessons learned in the field of stroke care during the first wave of COVID-19 pandemic. Here we are presenting proposals and initiatives for better preparedness in future similar emergencies. These proposals are based primarily on literature review of COVID-19 publications, as well as the first-hand experience gained during the first wave at the regional level. In addition to the consensus and collective ride of stroke experts in the Middle East North Africa Stroke and Interventional Neurotherapies Organization (MENA+-SINO) and interaction and collaboration with international stroke specialists from the Stroke World Organization (WSO), European Stroke Organization (ESO) and stroke and COVID-19 papers authors. Conclusion Stroke care is very complex, particularly in the initial hours after onset of symptoms. A successful outcome requires very close collaboration between clinical personnel from multiple specialties. Preparedness for future pandemics requires the improvement of care plans that allow for rapid assessment of stroke patients and ensuring that regular ‘mock exercises’ familiarize quintessential services that care for the stroke patients.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Highlights • All neurosurgical procedures decreased in number during the COVID-19 pandemic. • Surgical complication rates remained within the acceptable range. • Emergency procedures numbers remained the same throughout the study period. • Neurosurgical oncology cases were the highest in frequency. • There is a decline in hospital length of stay as we progressed during the study period., Objective This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. Methods We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. Results During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5–8). The number of cases declined from 72 in the first week and plateaued at the 30′s range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4–18) to 6 (IQR: 3–13) to 5 days (IQR: 2–8). There was no significant among-period difference with respect to institution type, complications, or mortality. Conclusion Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

COVID-19 pandemic has led to a change in the way we manage acute medical illnesses. This pandemic had a negative impact on stroke care worldwide. The World Stroke Organization (WSO) has raised concerns due to the lack of available care and compromised acute stroke services globally. The numbers of thrombolysis and thrombectomy therapies are declining. As well as, the rates and door-to treatment times for thrombolysis and thrombectomy therapies are increasing. The stroke units are being reallocated to serve COVID-19 patients, and stroke teams are being redeployed to COVID-19 centers. Covid 19 confirmed cases and deaths are rising day by day. This pandemic clearly threatened and threatening all stroke care achievements regionally. Managing stroke patients during this pandemic is even more challenging at our region. The Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) is the main stroke organization regionally. MENA-SINO urges the need to developing new strategies and recommendations for stroke care during this pandemic. This will require multiple channels of interventions and create a protective code stroke with fast triaging path. Developing and expanding the tele-stroke programs are urgently required. There is an urgent need for enhancing collaboration and cooperation between stroke expertise regionally and internationally. Integrating such measures will inevitably lead to an improvement and upgrading of the services to a satisfactory level.

Neuro-behçet’s disease (NBD) is an uncommon, serious presentation of behçet’s disease (BD) causing long-term morbidity and mortality. Cerebral aneurysms are rare in BD, with only a handful of cases reported worldwide. A 39-year-old female experienced slurring of speech, numbness, and reduced sensation in the left face, arm, and leg 90 minutes prior to presentation. She provided a history of recurrent oral and genital ulcers associated with intermittent joints pain and blurring of vision. erythrocyte sedimentation rate was elevated, but all other autoimmune workup was negative. Neuro-behçet’s disease was diagnosed. Brain magnetic resonance imaging demonstrated acute right periventricular infarction. Magnetic resonance angiogram revealed M1 segment stenosis and right internal carotid artery saccular aneurysm. Catheter angiography confirmed its presence measuring 4.8 mm×6.1 mm. She was stabilized after coiling of the aneurysm and was started on medical therapy. Brain imaging should be carried out in young patients with BD presenting with an ischemic event, and intervention may be lifesaving.

Objectives: To explore the perspective on Decompressive craniectomy (DH) of each of these specialties to establish common grounds for improved clinical practice. Method: An electronic survey was distributed via email and social media groups to members of these specialties in Kingdom of Saudi Arabia and the Gulf countries. Local practices, common triggers for referral for DH, perceived outcomes of these procedures, individual impression of what constitutes good clinical outcomes were explored. Results: There are 89 physicians participated: 41 (46.1%) neurologists, 34 (38.2%) neurosurgeons, and 14 (15.7%) intensivests. Participants are mostly practicing in intermediate volume centers or high volume centers. Half of the neurosurgeons preferred to be consulted immediately on candidates with large middle cerebral artery (MCA) strokes. The most important referral trigger for DH was clinical changes. The modified Rankin Scale (mRS) cutoff for good clinical outcome was 3 for 73.6% of respondents. There was agreement that DH only improves survival (64.4%). A third of the neurologists considered it to improve functional outcome compared to 15.4% of intensivests and 14.8% of neurosurgeons. There was agreement (66.7%) that patients older than 60 years with involvement of more than one territory should be excluded from DH. Only 7.7% of neurosurgeons excluded patients with dominant hemispheric strokes. Conclusion: Our physicians’ views are variable in what’s called acceptable outcome, and further studies are needed to to test the characteristics that helps in decision making such as hemisphere dominancy, time onset of stroke and vital radiological signs. This is seen despite the literature being full of data that supports the DC over medical management in malignant MCA infarction. Better multidisciplinary education initiatives are needed to unify the understanding and help improve the practices in this challenging subset of patients.

a b s t r a c t Objective: Posterior fossa arteriovenous malformations (pAVMs) are rare and because of their location at or close to vital structures, their treatment remains challenging despite overall improvements in the management of cerebrovascular lesions. We reviewed our recent series of ruptured pfAVMs in search of guiding principles in the management of these complex lesions. Methods: This is a retrospective series of consecutive patients admitted for a ruptured pfAVM from 2002 to 2013. We analyzed clinical and radiological data, as well as initial and definitive management. Outcome was assessed using the modified Rankin Scale (mRS) at 6 months. Results: The study included 34 patients (19 women and 15 men). Upon admission, 79% of patients pre- sented with an intra-cerebellar hematoma, 42% of which required urgent drainage. Hydrocephaly was also present in 82% of patients, 56% of which required emergency ventriculostomy. There was an aneurysm associated with the AVM in 47% of cases. In 38% of the cases, the aneurysm was the source of the hemor- rhage. Only 68% of patients were amenable to undergo treatment of the AVM: 24% exclusively by surgery, 9% by embolization, 3% by radiosurgery, and 32% using combined means. Five patients died within the first week: one as a direct result of the severity of the hemorrhage, and the other four due to re-bleeding before treatment. Outcome was favorable (mRS 0-2) in 71% of patients. Conclusion: Patients with a ruptured pfAVM are often comatose upon admission, requiring emergency live-saving surgical treatment. An associated aneurysm is often the source of bleeding which if dealt with immediately, offers time to plan the most appropriate strategies to eliminate the AVM. Nevertheless, early re-bleeding is frequent, and a cause of concern as it often leads to death. Despite the gravity of the clinical condition upon admission, outcome is favorable for those amenable to treatment.

Traumatic intracranial pseudoaneurysm is a rare complication of blunt trauma. It is even more rare when it presents as epistaxis. Massive epistaxis of a ruptured intracranial internal carotid artery pseudoaneurysm is a major cause of mortality, which requires emergency intervention. We report a case of traumatic intracranial internal carotid artery pseudoaneurysm secondary to skull base fracture, which presented with delayed onset of epistaxis. This was successfully treated by primary endovascular coil embolization. We discuss endovascular treatment options and review the literature.

Background:Superficial anastomotic veins (SAVs) have been studied extensively but little attention has been paid to clinical studies. The aim of this study is to provide variations in the drainage patterns of SAVs depending on the intraoperative findings.Methods:A total of 251 craniotomies due to intractable temporal lobe epilepsy were performed between 1972 and 1987 at the Montreal Neurological Institute. The courses of the three largest SAVs including the vein of Trolard (VT), vein of Labbe (VL) and superficial Sylvian vein (SSV) were studied.Results:All three veins showed variable courses. The most common predominant vein was the combination of the VL + SSV. The VT and VL were frequently coursed at the level of the central vein and middle temporal vein, respectively. On the right hemisphere the SSV was the predominant type while the VL tended to be predominant on the left hemisphere. A combination of VL and SSV was predominant in patients with right and/or left hemispheric dominance.Conclusions:The SAVs showed considerable variation in their courses and it is difficult to define an exact pattern although some courses showed constant directions. Attention should be paid not to damage these veins since in a considerable number of cases a single dominant vein may be responsible for draining a majority of the lateral surface of cerebral hemisphere.

Background Decompressive hemicraniectomy (DhC) is a life-saving surgical procedure being increasingly employed for malignant middle cerebral artery strokes. We examined the incidence of hemorrhagic transformation following DhC. Methods We retrospectively reviewed the charts and radiological images of patients who underwent DhC for malignant middle cerebral artery strokes. We classified the hemorrhagic events and assessed the short-term 30-day outcome associated with these events. Results A total of 23 DhCs were performed for supratentorial ischemic strokes in 22 patients. There were 16 males and 6 females with an average age of 47 years (21-69 years). Of the 22 patients, 13 (59%) developed a new hemorrhage following DhC. There were 3 mortalities (14%). Of the survivors, 6 (27%) were discharged home with a modified Rankin Scale (mRS) score of 2. The remaining 13 patients (59%) recovered to a degree wherein they were discharged to a rehabilitation center (mRS score 3-4). No patient persisted in a vegetative or semivegetative state (mRS score 5). Conclusions In this study, the rate of hemorrhagic transformation following DhC for ischemic stroke was 59%. This is much higher than that reported in the stroke thrombolysis literature. The presence of any type of new hemorrhagic transformation in this patient population does not appear to alter the natural history of their ischemic strokes in terms of Glasgow outcome scores or destination of disposition.

Arteriovenous malformation (AVM)-related aneurysms have been described in the literature. Their behavior varies based on their location in relation to and the activity of the shunting through the index AVM. The intuitive expectation supported by numerous reports is that these aneurysms should regress if the AVM is excluded from the circulation. We describe a case of 46-year-old man who presented with a posterior fossa AVM with an aneurysm on the posterior inferior cerebellar artery feeding the AVM. The nidus of the AVM was successfully excluded by glue embolization, with initial regression of the PICA aneurysm on serial imaging. Five years after the endovascular treatment, the aneurysm showed significant re-growth necessitating endovascular coiling. This case presents the re-growth of an AVM-related aneurysm and emphasizes the importance of long-term follow-up of such aneurysms even if the AVM is completely excluded.

To assess the safety and effectiveness of lumbar drains as adjuvant therapy in severe bacterial meningitis, and compare it to standard treatment.A retrospective cohort study of all patients above the age of 18 years with bacterial meningitis and altered mental status admitted to the Montreal Neurological Hospital Intensive Care Unit from January 2000 to December 2010.Thirty-seven patients were identified using clinical and cerebrospinal fluid criteria. Patients were divided into lumbar drain (LD) (n = 11) and conventional therapy (no LD) (n = 26) groups.Outcomes were assessed using meningitis-related mortality and the Glasgow Outcome Scale (GOS) at 1 and 3 months.All patients received broad-spectrum antibiotic therapy, 84% received steroids. There was no significant difference in mean age, type of bacteria, or time from arrival in ER to initiation of therapy. There was significantly less co-morbidity (24% healthy vs. 18.1%) and coma (GCS8 34.6 vs. 54.5%) in the conventional therapy group, as well as a longer duration of symptoms prior to admission (mean 1.34 ± 1.24 vs. 2.19 ± 2.34 days). The mean opening pressure was high in all patients (20-55 cm H2O in the LD and 12-60 cm H2O in the no LD). Mean time from arrival in ER to insertion of the lumbar drain was 37 h. Lumbar drains were set for a maximum drainage of 10 cc/h and an ICP below 10 mmHg. Despite greater clinical severity, the LD group had 0% mortality and 91% of the patients achieved a GOS of 4-5. The non-LD group had 15.4% mortality and only 60% achieved a GOS of 4-5. No adverse events were associated with LD therapy.In this study, the use of lumbar drainage in adult patients with severe bacterial meningitis was safe, and likely contributed to the low mortality and morbidity.

The involvement of nuclear factor kappa B (NF-κB) in several processes in the postnatal and adult brain, ranging from neuronal survival to synaptogenesis and plasticity, has been documented. In contrast, little is known about the functions of NF-κB during embryonic brain development. It is shown here that NF-κB is selectively activated in neocortical neural progenitor cells in the developing mouse telencephalon. Blockade of NF-κB activity leads to premature cortical neuronal differentiation and depletion of the progenitor cell pool. Conversely, NF-κB activation causes decreased cortical neurogenesis and expansion of the progenitor cell compartment. These effects are antagonized by the proneuronal transcription factor Hes6, which physically and functionally interacts with RelA-containing NF-κB complexes in cortical progenitor cells. In turn, NF-κB exerts an inhibitory effect on the ability of Hes6 to promote cortical neuronal differentiation. These results reveal previously uncharacterized functions and modes of regulation for NF-κB and Hes6 during cortical neurogenesis.

Large tumors located on the upper surface of the tentorium, extending to the posterior edge of the tentorial incisura and affecting the posterior temporo-mesial region, are challenging to reach without damaging the surrounding brain. Typically, these lesions are approached through a subtemporal or a transcortical transtemporal corridor. To avoid temporal lobe transgression or retraction, and venous drainage compromise, we use a supracerebellar transtentorial (SCTT) approach which gives a direct exposure to the posterior temporo-medial region and the posterior incisural space. In this video, we demonstrate the surgical technique of the SCTT approach.The video can be found here: https://youtu.be/g3ilMO8vo4g.

Background:Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. Our hypothesis is that these two groups are distinct and the aim of this retrospective study is to evaluate the differences in order to better predict outcome after DC.Methods:Seventy patients had DC over a period of four years at our center. They were divided into two groups based on the timing of the DC. Primary DC (44 patients) was done within 24 hours of the injury for mass lesion evacuation. Secondary DC (26 patients) was done after 24 hours and purely for the treatment of refractory ICP. Pre-op characteristics and post-op outcomes were compared between the two groups.Results:There was a significant difference in the mechanism of injury, the pupil abnormalities and Marshall grade between primary and secondary DC. There was also a significant difference in outcome with primary DC showing 45.5% good outcome and 40.9% mortality and secondary DC showing 73.1% good outcome and 15.4% mortality.Conclusions:Primary and secondary DC have different indications and patients characteristics. Outcome prediction following DC should be adjusted according to the surgical indication.

Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for more than 40 years. Recent interest in the utilization of this technique stems from the many modifications of the original procedure and the refinement of the available hardware. This rendered the procedure less traumatic and more effective, and thus more widely accepted as a neuromodulation technique for the treatment of various chronic pain syndromes including post-traumatic and postsurgical neuropathy, occipital neuralgia, and complex regional pain syndromes, and in relatively new indications for neuromodulation, such as migraines and daily headaches, cluster headaches. We present a review of the principle and indications for the use of PNS, and review our single institution experience that comprises 24 peripheral nerve stimulators as well as 8 occipital nerve stimulators over 13 years. We review the protocol of our approach including the surgical nuances for our implantation technique. Collaborative efforts in future research will lead to a growth in our clinical experience with the utilization of PNS and will help in identifying the best candidates for it. This, along with the development and refinement of the available hardware would lead to a more specific patient selection for each modality of treatment, increasing the efficacy and success of the intended treatment.

AIM Electrical stimulation of the dorsal column of the spinal cord stands out as a major method of neuromodulation. Its popularity stems from the long lasting support to the "gate theory" in which electrical stimulation of the gate prevents passage of nociceptive impulses and reduces pain sensation. There is little known about the effect of the duration of intraoperative stimulation (IOS) trial on the success of the spinal cord stimulation trial. MATERIAL and METHODS We present our result on 58 patients with spinal cord stimulation implantation and their IOS trials and short-term follow up. RESULTS The major finding of this study is that the longer the IOS trial, the higher the chances for failure of SCS. Our study also suggests that tripolar spinal cord stimulation leads present a more reliable option for long-term success of the spinal cord stimulation (SCS). CONCLUSION The duration of IOS seems to influence the result of the initial trial of SCS. IOS should be between 30-60 minutes to optimize the placement of the lead for better correlation with the SCS trial.

Background:Scedosporial infections are usually encountered in the immunocompromised patients. However, they are now emerging in the immunocompetent population and have an affinity for the central nervous system. They represent a therapeutic challenge, since they are highly resistant to most antifungal medications.Methods:We report the case of an immunocompetent patient with multiple cerebral abscesses secondary toScedosporium apiospermumfollowing extracorporeal membrane oxygenation (ECMO) and review the literature about this challenging cerebral infection.Results:A previously healthy 33-year-old male admitted to the hospital for a community-acquired pneumonia requiring ECMO subsequently developed multiple cerebral abscesses. He was empirically treated with caspofungin, which was changed to voriconazole once surgical aspiration revealedScedosporium apiospermum.Despite multiple aspirations, decompressive craniectomy to alleviate intracranial pressure, and an appropriate antifungal agent, the patient did not survive this aggressive infection.Conclusion:Brain abscesses withScedosporium apiospermumpresent a therapeutic challenge. High clinical suspicion leading to early appropriate antifungal therapy and combined surgical interventions might improve the prognosis.

The aim of this paper is to provide functional results obtained from electrical cortical stimulation of the lower postcentral gyrus in patients who underwent either lesional or non-lesional epilepsy surgery. Group I (n = 393) included those patients with gliosis or normal tissue and Group II (n = 107) included patients with space-occupying lesions. For cortical stimulation, a unipolar voltage-controlled electrode was used. The tongue, lip, and hand/finger sequences over the lower postcentral gyrus lateromedially in both groups were in agreement with classic teaching. The presence of structural lesions, such as tumors and dysplasia, did not affect the vertical representation of the body parts on the lower sensory strip. Individual variations, which included mosaicism over the sensory strip, were frequent. Whether the functional variability and mosaicism within the sensory cortex result from a pathological condition or not remains to be elucidated in healthy humans using advanced non-invasive brain mapping techniques.

Spontaneous intracranial hypotension (SIH) is a syndrome of low pressure headache associated with low CSF pressure. The condition is generally considered benign but extreme cases of SIH can lead to changes in the level of consciousness. We describe a case in which alteration in the level of consciousness was prolonged and severe, and could not be explained solely by the presence of subdural collections. MRI of the brain showed evidence of impaired venous flow secondary to brain sagging causing distortion of deep venous structures.