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The occurrence of a symptomatic post-infectious intrathecal to prevertebral fistula is rare. We report the presentation and management of a 38-year-old chronically paraplegic male with longstanding thoracic osteomyelitis and epidural infection who developed a cerebrospinal fluid (CSF) fistula causing symptomatic intracranial hypotension (IH). During an interventional radiology (IR)-guided aspiration of what was thought to be residual abscess, pulsatile, clear fluid was observed. A subsequent CT myelogram showed air in the spinal canal and a CSF fistula between the thecal sac and the pre-vertebral space. Upon intraoperative exploration, a large ventral dural defect was identified with insufficient native dura for primary closure and the thecal sac was tied off cranial to the level of the fistula. Given the large ventral dural defect, the fistula was likely the result of longstanding infection in the epidural space rather than the IR guided aspiration. The aspiration likely transgressed an existing fistula and may have exacerbated the symptoms of IH by providing another route for CSF egress. The patient's postural headaches completely resolved post-operatively. Thecal sac ligation is a viable treatment option in select circumstances with symptomatic CSF fistula.

COVID-19 patients are increasingly understood to develop multisystem manifestations, including neurologic involvement. We report the case of a 42-year old COVID-19 positive patient with a fatal intracerebral hemorrhage (ICH). The patient presented with fever and dyspnea, requiring intubation due to medical complications. After prolonged sedation and anticoagulation, the patient suddenly developed bilaterally fixed and dilated pupils, caused by a right-sided intracranial hemorrhage with uncal herniation. The course of this case illustrates the delicate balance between hypercoagulability and coagulation factor depletion; especially in the intubated and sedated patient, in whom regular neurological assessments are impeded. As we expand our understanding of the neurological ramifications of COVID-19, clinicians need to be increasingly aware of the precarious coagulation balance.

Background: Sellar arachnoid cysts (SACs) are rare lesions and incidentally found on brain imaging. The pathophysiology is poorly understood. Some authors suggested that SACs develop as a herniation of arachnoid membrane through the diaphragma sellae followed by cyst formation. Furthermore, Meyer et al. postulated that SACs are formed by splitting of the arachnoid layers. Symptomatic SACs present with headache, visual field deficit, or pituitary dysfunction. The data are limited on the indications and timing for intervention. We present a case of symptomatic SAC that was fenestrated using orbitofrontal approach. Case Description: A 64-year-old female presented with chronic headaches and blurriness of vision. She was previously diagnosed with diabetes insipidus (DI) that was treated with desmopressin, magnetic resonance imaging (MRI) of her brain at that time was normal. Later on, she developed severe headaches that were managed medically. A year later, she had an episode of generalized seizure that led to the discovery of SAC on brain MRI. On examination, she had a left-sided monocular temporal hemianopia. The patient underwent an orbitofrontal craniotomy for fenestration of the SAC. At 6-month follow-up, her headaches had significantly improved with the resolution of the visual deficit. In addition, the DI had resolved, and the desmopressin was discontinued. Conclusion: SACs are rare with no consensus on the indications for surgery. Our experience suggests that fenestration of SAC through transcranial approach is a valid option for patients with visual deficit and/or pituitary dysfunction.

Stereotactic frames have been in neurosurgical practice for more than half a century. Since the earliest models, these instruments have seen several iterative improvements, from the first rectilinear frame to arc-centric frames and finally to “frameless” or mini-frame techniques. Each iteration has aimed at improving accuracy while providing increased patient comfort and versatility. Today, the fluidity of modern imaging, robotics, and rapid manufacture techniques have enabled a new host of stereotactic systems. In this chapter, we describe the theoretical basis behind each system and its workflow for DBS lead placement. We compare the advantages and disadvantages of these systems.

BACKGROUND Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time. OBJECTIVE To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study. METHODS We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018. RESULTS The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3). CONCLUSION Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

Introduction Despite being one of the most common neurological diseases, it is unknown whether there may be a genetic basis to temporal lobe epilepsy (TLE). Whole genome analyses were performed to test the hypothesis that temporal cortical gene expression differs between TLE patients with high vs. low baseline seizure frequency. Methods Baseline seizure frequency was used as a clinical measure of epileptogenicity. Twenty-four patients in high or low seizure frequency groups (median seizures/month) underwent anterior temporal lobectomy with amygdalohippocampectomy for intractable TLE. RNA was isolated from the lateral temporal cortex and submitted for expression analysis. Genes significantly associated with baseline seizure frequency on likelihood ratio test were identified based on >0.90 area under the ROC curve, P value of Results Expression levels of forty genes were significantly associated with baseline seizure frequency. Of the seven most significant, four have been linked to other neurologic diseases. Expression levels associated with high seizure frequency included low expression of Homeobox A10, Forkhead box A2, Lymphoblastic leukemia derived sequence 1, HGF activator, Kelch repeat and BTB (POZ) domain containing 11, Thanatos-associated protein domain containing 8 and Heparin sulfate (glucosamine) 3-O-sulfotransferase 3A1. Conclusions This study describes novel associations between forty known genes and a clinical marker of epileptogenicity, baseline seizure frequency. Four of the seven discussed have been previously related to other neurologic diseases. Future investigation of these genes could establish new biomarkers for predicting epileptogenicity, and could have significant implications for diagnosis and management of temporal lobe epilepsy, as well as epilepsy pathogenesis.