Search

Surgical targeting of the ventral intermediate nucleus of the thalamus (VIM) has been historically done using indirect strategies. Here we depict the cerebello-thalamo-cortical tract (CTCT) through 3 T proton density (PD) in a cohort of patients who underwent high-intensity focus ultrasound (HIFUS) thalamotomy. Forty-seven patients treated in our institution with MR-guided HIFUS VIM thalamotomy were included in this study. PD weighted 3 T MRI used for presurgical planning was compared with postoperative MRI obtained 1 month after surgery. Images were processed with ISTX software (Brain lab, Munich, Germany). The coordinates of the VIM lesion concerning the inter-commissural line (ICL) were annotated. Deterministic tractographies using three ROIs were used to verify the different tracts. The triangle seen in the 3 T PD sequence at the level of the mesencephalic-diencephalic junction was systematically recognized. The posterior angle of this triangle at the junction of the CTCT and the ZI was denominated as "point P." The area of this triangle corresponds to the posterior subthalamic area (PSA) harboring the Raprl fibers. The CTCT was visible from 1 to 2.5 mm below the ICL. The average center of the final HIFUS lesion (point F) was 11 mm from the medial thalamic border of the thalamus (14.9 mm from the midline), 6.4 mm anterior to PC, and 0.6 mm above the ICL. The FUS point was consistently 1-2 mm directly above point P. The anterior border of the external angle of this triangle (point P) can be used as an intraparenchymal point for targeting the ventral border of the VIM. Three ROIs placed in a single slice around this triangle are a fast way to originate tractography of the CTCT, lemniscus medialis, and pyramidal tract.

Flow diverters have become a critical instrument for complex aneurysms treatment. However, limited data are currently available regarding short and long-term outcomes for the Silk flow diverter. The objective of the study is to determine neurological prognosis and mortality rates for the Silk flow diversion device used in intracranial aneurysms. A systematic review with meta-analysis was performed using databases. The following descriptors were used for the search: “SILK”, “Flow Diverter”, “Mortality”, and “Prognosis”. The following data were extracted: mortality, good functional outcome, Glasgow outcome scale, complete or near-complete occlusion rates, rate of retreatment, and complications (thromboembolic and hemorrhagic complications). A total of 14 studies were selected. Among the 14 studies, 13 were retrospective observational cohort studies and 1 was a prospective observational cohort study. The mortality rate was 2.84%. The clinical good outcomes rate was 93.3%. The poor outcome rate was 6.6%. The overall thromboembolic complication rate was 6.06% (95% confidence interval [CI] 0.00–6.37, P=0.12, I2=3.13%). The total hemorrhagic complication rate was 1.62% (95% CI 0.00–5.34, P=0.28, I2=1.56%). The complete aneurysm occlusion rate was 80.4% (95% CI 8.65–9.38, P

Introduction Transcorporeal anterior cervical microforaminotomy is a motion-preserving surgery. It addresses directly to the prolapsed disc in contrast to posterior laminoforaminotomy and does not affect facet joints; in the transuncal approach, there is a chance of vertebral artery injury and it also decreases disc height; hence, may alter the motion of that segment. Objective Aim is to assess the outcome of surgery and its effectiveness. Methods A total of 40 patients were observed retrospectively of which 33 were male and 7 were female. A single study of transcorporeal anterior cervical microforaminotomy was analyzed in a private hospital (Comfort Hospital), Dhaka, Bangladesh. Patients having pure brachialgia who were not relieved by conservative treatment over 6–8 weeks in cervical disc prolapse were included in the study. Patients having more than one level of disease, features of myelopathy, or instability were excluded from the study. Results All patients were pain-free postoperatively, although after one to two months 2 out of 40 patients developed brachialgia and required anterior cervical discectomy and fusion. Conclusion Transcorporeal microforaminotomy for brachialgia is a safe and effective approach that is motion preserving and minimally invasive as well.

The authors have requested that this preprint be removed from Research Square.

An important feature of hydrocephalus is the alteration of the cerebral spinal fluid (CSF) homeostasis. New insights in the understanding of production, secretion, and absorption of CSF, along with the discovery of the glymphatic system (GS), can be useful for a better understanding and treatment of hydrocephalus in disorders with CSF overproduction. A 1-year-old patient was diagnosed with communicating hydrocephalus; ventricle peritoneal shunt (VPS) is installed and ascites developed. VPS is exposed, yielding volumes of 1000-1200ml/day CSF per day. MRI is performed showing generalized choroidal plexus hyperplasia. Bilateral endoscopic coagulation of thechoroid plexus was performed in 2 stages (CPC) however the high rate of CSF production persisted, needing a bilateral plexectomy through septostomy, which finally decreased the CSF outflow. New knowledge about the CSF physiology will help to propose better treatment depending on the cause of the hydrocephalus. The GS is becoming an additional reason to better study and develop new therapies focused of the modulation of alternative CSF reabsorption. Despite the current knowledge about hydrocephalus, we remain without a complete understanding of the pathophysiology of this condition. GS could be more important than conventional concept of reabsorption of CSF in the arachnoid villi, therefore GS could be a new key point, which will guide future investigations.

Primary intracranial smooth muscle tumors are rare. Most cases are related to Epstein-Barr virus proliferation in immunocompromised patients such as organ solid recipients. Only a few cases have been reported in pediatric patients. The clinical features are very variable depending mainly on the location and size of the smooth muscle tumor (SMT) and the pathogenesis is poorly understood. We describe two cases of intracranial SMT localized in the temporal lobe and associated with EBV in immunosuppressed children. A review of the literature associated with intracranial leiomyomas was also done.

Background Collateral circulation is a vascular network which maintains the blood flow after the partial blockage of primary vascular pathways. This acts as potential vascular supplementary system and plays important role in the cerebral ischemia. Main body Collateral circulation has implications in the management especially related to cerebral endovascular treatment and thrombolytic therapy. It is considered as subsidiary network of vascular channels, which is highly variable. Insufficient arterial supply is due to the hemodynamic compromise because of thromboembolism. Apart from the collaterals, there is additional existence of a group of vessels known as venous collaterals. Their function is variable and they contribute to the augmentation of venous drainage in venous ischemias. Various pharmacological interventions are used to modulate the collaterals, these can prove to be a complementary alternative to the invasive intracerebral interventions. Conclusions The aim of this review article is to highlight the importance of cerebral collateral circulation and to discuss the various available pharmacological alternatives available and their current relevance in the management of various neurovascular pathologies.

Historically, obesity has been identified as one of the most important risk factors for developing cardiovascular diseases including stroke; however, a theory called “The Obesity Paradox” has been recently considered. The paradoxical theory is that obese or overweight patients (according to body mass index score) can have better outcomes compared to leaner or malnourished patients. The paradox was initially discovered in patients with heart failure. The purpose of this manuscript was to investigate whether this paradox also applies to stroke patients, according to information available in the current literature.

Recent studies have recognized similarities between the peptides involved in the neuropathology of Alzheimer’s disease and prions. The Tau protein and the Amyloid β peptide represent the theoretical pillars of Alzheimer’s disease development. It is probable that there is a shared mechanism for the transmission of these substances and the prion diseases development; this presumption is based on the presentation of several cases of individuals without risk factors who developed dementia decades after a neurosurgical procedure. : This article aims to present the role of Aβ and Tau, which underlie the pathophysiologic mechanisms involved in the AD and their similarities with the prion diseases infective mechanisms by means of the presentation of the available evidence at molecular (in-vitro), animal, and human levels that support the controversy on whether these diseases might be transmitted in neurosurgical interventions, which may constitute a wide public health issue.

Seizures in aneurysmal subarachnoid haemorrhage (aSAH) have been described secondary to SAH, changes in cortical function, vasospasm and as a result of treatment effects. Seizures are one of the important clinical determinants in neurological outcome of aSAH. Various studies support the notion of less risk of future seizures in endovascular treatment as compared to the microsurgical clipping, yet there is no conclusive evidence in favour or against the seizure occurrence in aSAH patients after endovascular treatment as compared to the microsurgical treatment. To carry out a systematic review and meta-analysis of the risk of seizures after endovascular management (coiling) of ruptured intracranial aneurysms. A literature search was performed in electronic database of PubMed, MEDLINE, Embase, and Scopus from inception to February 2020, using the terms Seizure, Intracranial aneurysms, embolization, with no constraints applied. Data were pooled using a random-effect model, results were abstracted as odds ratios (ORs) and 95% confidence interval (CI), and heterogeneity was reported as Chi-square. Five studies involving 3,077 patients were included in the meta-analysis. After endovascular management of aSAH, seizure risk was increased by a worse clinical severity (World Federation of Neurosurgery scale or Hunt and Hess) (OR, 3.34; 95% CI, 2.69–4.16; p

Surgery is the most common cause of spinal cord ischemia; it is also caused by hemodynamic changes, which disrupt the blood flow. Direct ligation of the spinal arteries, especially the Adamkiewicz artery is involved as well. Other causes of spinal cord ischemia include arteriography procedures, thoracic surgery, epidural and rachianesthesia, foraminal infiltration, arterial dissection, systemic hypotension, emboligenic heart disease, thoracic disc herniation, and compression. Understanding the vascular anatomy of the spinal cord is essential to develop optimal strategies for preventing ischemic injuries to the spinal cord. During ischemia, a rich network of intra and paraspinal collaterals allow enough blood flow to compensate the intensity of spinal cord ischemia. In case of interruption of flow of a main artery, the collateral artery increases its flow to maintain perfusion to the tissues. Avoiding spinal cord ischemia by using collateral circulation is necessary to prevent the establishment of hypovolemia, hyperthermia and elevations in venous pressures. The objective of this narrative review is to present the current concepts of spinal collateral circulation and its role in the setting of ischemic events, affecting the vascular supply of the spinal cord.

Cerebrospinal fluid (CSF) is largely (70-80%) produced by the choroids plexus of the ventricles and is considered as the plasma ultrafiltrate. While CSF formation, circulation, and composition appear to be physiological and physical, its absorption appears to be mainly physical. The formation, composition, circulation, absorption, and changes in pathological conditions of CSF are discussed briefly in this review article. The CSF pressure dynamics studies provide information about the tightness, elastance, or outflow resistance of the CSF in the CNS. We believe that the present study shall help to provide essential details of CSF physiology which are important to many disciplines including radiology, neurology, and neurosurgery.

Spinal cord trauma constitutes one of the main causes of mortality and morbidity in young adults around the world, with an estimated 2 to 3 new cases for every 100,000 population. Road traffic accidents, falls from high heights, sports injuries, and violent actions are common causes of spinal cord injuries. There is no “gold standard” for the diagnosis of spinal cord traumatic injuries; however, the rational use of conventional radiologic test, computed tomography scan, and magnetic resonance imaging (MRI) will allow to identify almost all clinically relevant injuries. MRI is recommended according to surgeon’s criteria, who after evaluating the specific characteristics of the injury will determine its usefulness. Therapeutic strategies need to be directed to maintain airway, breathing and circulation, maintenance of mean arterial pressure prevention of hypotension, and assessment of other associated injuries. Intensive treatment must be focused on the prevention and management of ventilatory and cardiovascular abnormalities related to muscle weakness and loss of autonomic innervation.

Background: Pituitary surgery is the most common surgery used to remove pituitary tumours. The use of mini doppler in surgical removal of an endonasal pituitary tumour has shown good short-term clinical outcomes and few complications in patients. Cavernous sinus invasion limits the surgical excision and still a challenge of gross total resection. Objective: The main objective of this study is to evaluate the outcome of surgical removal of an endonasal pituitary tumour using mini doppler. Method: A total of 12 patients were studied retrospectively from 2012 to 2018 in a single institution (Private hospital) in Dhaka, Bangladesh. The male and female ratio was 7:5. Results: 92% of cases of the total number of patients had satisfactory removal/ neurological improvement/hormonal improvement. Among 12 cases, 8 cases had transient diabetes insipidus and one patient had CSF leak. Conclusion: The intraoperative Doppler is a useful tool to localize the carotids, which provides safer resection of endonasal pituitary tumours. Thus, it is very safe and effective for laterosellar resection of recurrent pituitary tumours and for cavernous sinus invasions.

Today, traumatic brain injuries continue to be studied, increasingly investigating the pathophysiological mechanisms that contribute to the clinical presentation, severity, and possible sequelae, but despite this, the prognosis of these patients is sometimes poor. Mitochondrial dysfunction comprises a series of reactions that contribute to the inflammatory process in these patients that have an impact on the prognosis, since it is one of the pathophysiological mechanisms involved in secondary lesions after a traumatic brain injury; and therefore has opened a field of study in the search of possible biomolecular markers that allow us to establish a prognosis and prediction of mortality.

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and life-threatening condition with high mortality and morbidity. Even though there is an association with intracranial pressure (ICP) raise and aSAH, there is a lack of recommendations regarding the indications for ICP monitoring in patients with aSAH. Defining what patients are at a higher risk to develop intracranial hypertension and its role in the functional outcome and mortality in patients with aSAH will be the purpose of the following systematic review and meta-analysis. The primary endpoint is to determine the prevalence and impact on mortality of ICP in patients with aSAH. Secondary endpoints aim to describe the variables related to the development of ICP and the relationship between traumatic and aneurysmal etiology of intracranial hypertension. PubMed, Embase, Central Cochrane Registry of Controlled Trials, and research meeting abstracts were searched up to August 2019 for studies that performed ICP monitoring, assessed the prevalence of intracranial hypertension and the mortality, in adults. Newcastle Ottawa scale (NOS) was used to assess study quality. The statistical analysis was performed using the Mantel-Haenszel methodology for the prevalence and mortality of intracranial hypertension for reasons with a randomized effect analysis model. Heterogeneity was assessed by I2. A total of 110 bibliographic citations were identified, 20 were considered potentially eligible, and after a review of the full text, 12 studies were considered eligible and 5 met the inclusion criteria for this review. One study obtained 7 points in the NOS, another obtained 6 points, and the rest obtained 5 points. Five studies were chosen for the final analysis, involving 793 patients. The rate of intracranial hypertension secondary to aSAH was 70.69% (95% CI 56.79–82.84%) showing high heterogeneity (I2 = 92.48%, p =

The "time is brain" concept denotes the importance of the expedited transfer of patients to stroke care centers. Helicopter emergency medical services (HEMS) can reduce the time to definitive care, which could improve neurologic prognosis and reduce mortality.Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a search for randomized controlled trials, nonrandomized controlled trials, and prospective and retrospective cohort studies was performed through specific databases from inception to February 2020. Helicopter, acute stroke, and their synonyms (according to Medical Subject Headings) were included in this search. The Newcastle-Ottawa Scale was used to assess the quality of the included studies, and the Egger test was used to assess for publication bias.A total of 8 studies matched the inclusion criteria and were included for meta-analysis. The overall number recruited for helicopter transportation was 1,372, and for emergency standard transportation, it was 8,587. The association among HEMS and mortality was not statistically significant (odds ratio [OR] = 0.7; 95% confidence interval [CI], 0.60-1.06; P = .12). There was a significant association between good outcomes and HEMS (OR = 2; 95% CI, 1.79-2.34; P ≤ .001), and the overall poor neurologic outcome was reduced (OR = 0.52; 95% CI, 0.46-0.60; P ≤ .001).A good neurologic outcome was higher with HEMS compared with emergency standard transportation. The mortality rate was less in the emergency standard transportation group after pooled analysis but was not significant; the reduction in a poor outcome was statistically significant.

The subarachnoid hemorrhage due to a ruptured brain aneurysm is a neurological emergency with high mobility and mortality. Hypertensive states are related to a bad prognosis and a higher risk of a ruptured aneurysm. However, the relationship between the blood pressure variability with the aneurysmal subarachnoid hemorrhage and its prognosis is quite unknown.A systematic review was performed across the databases. The following descriptors and related were used for the search: "blood pressure", "arterial pressure", variability, subarachnoid hemorrhage, hemorrhage, aneurysmal, aneurysmal subarachnoid hemorrhage. The following data were extracted: Glasgow Outcome Scale or Modified Rankin Scale, and blood pressure variabilities to categorize the prognosis.5 studies were selected. The blood pressure variability and the related outcome were assessed by mean systolic blood pressure and minimum systolic blood. The meta-analysis of mean systolic blood pressure (cut-off95.3 mmHg) showed an odds ratio of 11.23 (CI 95%: 4,423 to 28,537) (p=0.001), predicting the good outcome after the aneurysmal subarachnoid hemorrhage. The pooled analysis revealed AUC of the ROC predicting the good outcome was statistically significant (AUC:0.85, p0.001). The pooled data analysis of minimum systolic blood pressure revealed an odds ratio of 6.43 (CI 95%:2.834-14.589, P0,001) and AUC of the pooled ROC 0.931 (CI95%:0,851 to 1,000, P0,001) to predict poor outcome. The funnel plot through Egger's test for the analysis showed different grades of asymmetry.The blood pressure variability (mean and minimum systolic blood pressure) is a good predictor and parameter in the aneurysmal subarachnoid hemorrhage prognosis and outcome prediction.

Since its inception, medical training and practice are based primarily on the clinical experience provided by the mentors of each of the medical schools. In the 1990s, the first steps were taken for the construction of what we now know as evidence-based medicine. Evidence-based medicine is the set of studies, methods, and principles for the prevention of medical diseases, management guidelines, and algorithms used in sources of evidence. Neurosurgery based on evidence has emerged thanks to advances in neuroscience and information technology that allows the globalization of current scientific information. The results of important reviews on the levels of evidence in neurosurgery are low in percentages of high-quality evidence in this field of medicine. Based on the above, the objective of this manuscript is to describe the application of evidence in neurosurgery, the current state of the art in evidence-based medicine, and the steps needed to create evidence of the best quality in neurosurgery.

BACKGROUND Several factors can influence the outcome of severe head injuries including the patient's hemoglobin levels. There has often been a dilemma regarding levels of hemoglobin at which red cell blood transfusion (RCBT) should be performed. OBJECTIVE To systematically review the literature to determine the usefulness of management protocols that have hemoglobin levels

COVID-19 has become an alarming pandemic for our earth. Worldwide, healthcare workers including neurosurgeons are facing challenges in prioritizing neurosurgical patients. Here we have tried to draw attention to the effective management of patients with limited resources. Prioritizing surgical cases in emergencies, overseeing triage framework for neurosurgeries, rebuilding of the inpatient service, should be of utmost priority. Neurosurgeons should point in the amendment as far as a good life for everybody, while still prioritizing equity in the distribution of services.

Cerebrovascular disease (CVD) has been studied for many years, representing a cause of high morbidity and mortality; it has a great impact at a social, economic, and psychological level in the young adult population. There are different etiological factors that we do not find in the adult population, for that it is important to know how to differentiate them. There is no definitive etiological factor in this population given that the epidemiologic profile fluctuates considerably throughout regions and provinces, even if the same country is considered to make comparisons. CVD in young adults is caused by many etiological factors, predominantly the rare ones, such as cardioembolic, small vessel disease, due to thrombophilias, and undetermined cause. Despite being the main cause, the undetermined etiology is overestimated because it deserves for a detailed investigation in search of one of the rare causes, also, because of the lack of more complex studies in centers worldwide. No atherosclerotic large vessels diseases, such as cervicocephalic artery dissection, moyamoya disease, systemic vasculitis, and other rare syndromes should be considered to make an accurate diagnosis approach.

Historically, brainstem gliomas have been one of the most difficult types of neoplasms to treat. They comprise 10%–20% of pediatric tumors of the central nervous system. The average age of diagnosis is 7–9 years, without a predilection for gender. The advent of magnetic resonance imaging and radiotherapy has significantly aided in the diagnosis and treatment of brainstem gliomas.

Objective To systematically review the medical literature to determine the utility of heart rate variability in predicting mortality for moderate to severe traumatic brain injury. Methods A search for randomized controlled trials, nonrandomized trials, and prospective and retrospective cohort studies was carried out using PubMed, SCOPUS, Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. Reference lists of included studies were also searched to identify potentially eligible studies. Results Five articles comprising 542 patients met inclusion criteria. Heart rate variability as low-frequency/high-frequency ratio (area under the curve [AUC] receiver operating characteristic [ROC]) for predicting mortality was found to be statistically significant (AUC ROC 0.810, P Conclusions This meta-analysis predicted high mortality based on odds ratio for variables low-frequency/high-frequency ratio, high-frequency peak, and TP. However, the statistical analysis was weakened owing to the high level of heterogeneity in the included studies. Further research is needed to generate high-quality recommendations regarding heart rate variability as a predictor of mortality after traumatic brain injury.

The changing temperatures are making an impact on health-related mortality outcomes with many studies on the role of temperature and mortality risks in cardiovascular and respiratory illnesses. Global warming a real phenomenon, progressing rapidly and producing changes in the ecosystem and have economic, social and public health implications.

Background Aspirin has been associated with a decreasing risk of subarachnoid hemorrhage due to its anti-inflammatory mechanism of action and potential protective properties against aneurysm growth. Objective To determine the association between aneurysmal subarachnoid hemorrhage and aspirin use. Methods A systematic review of the literature and a meta-analysis were performed across the PubMed database. The following keywords were used: “aspirin, acetylsalicylic acid, 2-acetyloxy-benzoic acid, ruptured intracranial aneurysm, aneurysmal subarachnoid hemorrhage, spontaneous subarachnoid hemorrhage, intracerebral hemorrhage, spontaneous aneurysmal hemorrhage, spontaneous intracerebral bleeding”. Studies that were performed with animals or analyzed patients with traumatic brain injury were excluded. A total of five studies were included in our meta-analysis, with a total of 19,222 patients evaluated. Statistical analysis was performed to determine the association between the use of aspirin and the risk of subarachnoid hemorrhage. Results Aspirin use reduce the risk of subarachnoid hemorrhage (odds ratio [OR] 0.51, 95 % confidence interval [CI] 0.34-0.76). Conclusion Although some previous studies suggested that aspirin may potentially reduce the risk of subarachnoid hemorrhage, our meta-analysis found an association between the reduction of risk of aneurysmal subarachnoid hemorrhage.