Search

During the past decades, improving patient neurological recovery following spinal cord injury (SCI) has remained a challenge. An effective treatment for SCI would not only reduce fractured elements and isolate developing local glial scars to promote axonal regeneration but also ameliorate secondary effects, including inflammation, apoptosis, and necrosis. Three-dimensional (3D) scaffolds provide a platform in which these mechanisms can be addressed in a controlled manner. Polymer scaffolds with favorable biocompatibility and appropriate mechanical properties have been engineered to minimize cicatrization, customize drug release, and ensure an unobstructed space to promote cell growth and differentiation. These properties make polymer scaffolds an important potential therapeutic platform. This review highlights the recent developments in polymer scaffolds for SCI engineering. STATEMENT OF SIGNIFICANCE: How to improve the efficacy of neurological recovery after spinal cord injury (SCI) is always a challenge. Tissue engineering provides a promising strategy for SCI repair, and scaffolds are one of the most important elements in addition to cells and inducing factors. The review highlights recent development and future prospects in polymer scaffolds for SCI therapy. The review will guide future studies by outlining the requirements and characteristics of polymer scaffold technologies employed against SCI. Additionally, the peculiar properties of polymer materials used in the therapeutic process of SCI also have guiding significance to other tissue engineering approaches.

Peripheral nerve blockade is an important perioperative intervention for pain management. However, this management always results in a limited analgesia effect due to the rapid elimination of local anesthetic drugs after a single injection, while continuous infusion leads to multiple side effects associated with catheter insertion. In this study, three thermosensitive hydrogels, i.e., Pluronic F127, and poly(l-alanine)-block-poly(ethylene glycol)-block-poly(l-alanine) (PAla-PEG-PAla), and poly(lactic-co-glycolic acid)-block-poly(ethylene glycol)-block-poly(lactic-co-glycolic acid) (PLGA-PEG-PLGA), with distinct properties were applied to encapsulate bupivacaine (BUP) for prolonged analgesia with one single injection. All three hydrogel platforms exhibited a homogeneous three-dimensional structure with thermosensitive properties and high BUP encapsulation efficiency. The BUP loaded in PAla-PEG-PAla showed a sustained drug release profile, which was advantageous over those from Pluronic F127 and PLGA-PEG-PL...

Background Optic pathway gliomas (OPGs) are low-grade tumors of the white matter of the visual system with a highly variable clinical course. The aim of the study was to generate a magnetic resonance imaging (MRI)-based predictive model of OPG tumor progression using advanced image analysis and machine learning techniques. Methods We performed a retrospective case–control study of OPG patients managed between 2009 and 2015 at an academic children’s hospital. Progression was defined as radiographic tumor growth or vision decline. To generate the model, optic nerves were manually highlighted and optic radiations (ORs) were segmented using diffusion tractography tools. For each patient, intensity distributions were obtained from within the segmented regions on all imaging sequences, including derivatives of diffusion tensor imaging (DTI). A machine learning algorithm determined the combination of features most predictive of progression. Results Nineteen OPG patients with progression were matched to 19 OPG patients without progression. The mean time between most recent follow-up and most recently analyzed MRI was 3.5 ± 1.7 years. Eighty-three MRI studies and 532 extracted features were included. The predictive model achieved an accuracy of 86%, sensitivity of 89%, and specificity of 81%. Fractional anisotropy of the ORs was among the most predictive features (area under the curve 0.83, P < 0.05). Conclusions Our findings show that image analysis and machine learning can be applied to OPGs to generate a MRI-based predictive model with high accuracy. As OPGs grow along the visual pathway, the most predictive features relate to white matter changes as detected by DTI, especially within ORs.

Ossification of the posterior longitudinal ligament (OPLL) often leads to cervical myelopathy. Although multiple procedures have been shown to be effective in the treatment of OPLL, outcomes are less predictable than in degenerative cervical myelopathy, and surgery is associated with high rates of complications and reoperation, which affect quality of life. In this study, we performed a decision analysis using postoperative complication data and health-related quality of life (HRQoL) utility scores to assess the average expected health utility and 5-year quality-adjusted life years (QALYs) associated with the most common surgical approaches for multilevel cervical OPLL.We searched Medline, EMBASE, and the Cochrane Library for relevant articles published between 1990 and October 2017. Meta-analytically pooled complication data and HRQoL utility scores associated with each complication were evaluated in a long-term model.The overall incidence of perioperative complications ranged from 6.2% for laminectomy alone to 11.0% for anterior decompression and fusion. Revision surgery for hardware/fusion failure or progression was highest for laminectomy alone (3.0%) and lowest for laminectomy and fusion (1.6%). Laminoplasty resulted in the highest 5-year QALYs gained, compared with laminectomy and anterior approaches (P0.001). There was no significant difference in QALY gained between laminectomy-fusion and laminoplasty.The results suggest that owing to the higher rates of complications associated with anterior cervical approaches, laminoplasty may result in improved long-term outcomes from an HRQoL standpoint. These findings may guide surgeons in cases where either procedure is a reasonable option.

OBJECTIVEMeningiomas are the most common primary tumor of the central nervous system. Complete resection can be curative, but intraoperative identification of dural tails and tumor remnants poses a clinical challenge. Given data from preclinical studies and previous clinical trials, the authors propose a novel method of localizing tumor tissue and identifying residual disease at the margins via preoperative systemic injection of a near-infrared (NIR) fluorescent contrast dye. This technique, what the authors call “second-window indocyanine green” (ICG), relies on the visualization of ICG approximately 24 hours after intravenous injection.METHODSEighteen patients were prospectively identified and received 5 mg/kg of second-window ICG the day prior to surgery. An NIR camera was used to localize the tumor prior to resection and to inspect the margins following standard resection. The signal to background ratio (SBR) of the tumor to the normal brain parenchyma was measured in triplicate. Gross tumor and margin specimens were qualitatively reported with respect to fluorescence. Neuropathological diagnosis served as the reference gold standard to calculate the sensitivity and specificity of the imaging technique.RESULTSEighteen patients harbored 15 WHO Grade I and 3 WHO Grade II meningiomas. Near-infrared visualization during surgery ranged from 18 to 28 hours (mean 23 hours) following second-window ICG infusion. Fourteen of the 18 tumors demonstrated a markedly elevated SBR of 5.6 ± 1.7 as compared with adjacent brain parenchyma. Four of the 18 patients showed an inverse pattern of NIR signal, that is, stronger in the adjacent normal brain than in the tumor (SBR 0.31 ± 0.1). The best predictor of inversion was time from injection, as the patients who were imaged earlier were more likely to demonstrate an appropriate SBR. The second-window ICG technique demonstrated a sensitivity of 96.4%, specificity of 38.9%, positive predictive value of 71.1%, and a negative predictive value of 87.5% for tumor.CONCLUSIONSSystemic injection of NIR second-window ICG the day before surgery can be used to visualize meningiomas intraoperatively. Intraoperative NIR imaging provides higher sensitivity in identifying meningiomas than the unassisted eye. In this study, 14 of the 18 patients with meningioma demonstrated a strong SBR compared with adjacent brain. In the future, reducing the time interval from dye injection to intraoperative imaging may improve fluorescence at the margins, though this approach requires further investigation.Clinical trial registration no.: NCT02280954 (clincialtrials.gov).

A decision analysis.To perform a decision analysis utilizing postoperative complication data, in conjunction with health-related quality of life (HRQoL) utility scores, to rank order the average health utility associated with various surgical approaches used to treat symptomatic thoracic disk herniation (TDH).Symptomatic TDH is an uncommon entity accounting for1% of all symptomatic herniated disks. A variety of surgical approaches have been developed for its treatment, which may be classified into 4 major categories: open anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benefit profiles, but there is still no set algorithm for choosing an approach in cases with multiple surgical options.We searched Medline, EMBASE, and the Cochrane Library for relevant articles on surgical approaches for TDHs published between 1990 and August 2014. Pooled complication data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to determine which surgical approach resulted in the highest average HRQoL.Posterior surgical approaches resulted in the highest average HRQoL, followed by thoracoscopic, lateral, and finally open anterolateral transthoracic procedures. The higher average HRQoL associated with posterior approaches over all others was highly significant (P0.001); conversely, the open anterolateral approach resulted in a lower average postoperative utility compared with all other approaches (P0.001).The results of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs, which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical trials, are necessary to ascertain whether novel surgical strategies have risk/benefit profiles that ultimately supersede those of traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.

Neurosurgeons are often asked to perform open biopsy for diagnosis of encephalitis after medical investigations are non-diagnostic. These patients may be critically ill with multiple comorbidities. Patients and their families often request data regarding the success rates and complication profile of biopsy, but minimal literature exists in this area. Retrospective chart review of all patients undergoing open brain biopsy (burr hole or craniotomy) for encephalitis refractory to medical diagnosis between January 2009 and December 2013 was undertaken. Pathology records and outpatient follow-up were reviewed to determine most recent clinical status of each patient. A total of 59 patients were included with mean follow up of 20 months. The average age at biopsy was 55 years. The most common unconfirmed diagnoses leading to biopsy were vasculitis (44%), neoplasm (27%), infection (12%), autoimmune (12%), amyloidosis (5%). Tissue pathology was diagnostic in 42% of all cases. Overall, biopsy confirmed the preoperative diagnosis in 46% of cases and refuted the preoperative leading diagnosis in 25% of cases. At last follow-up, the tissue pathology resulted in a medical treatment change in 25% of cases. There was a 14% major neurological complication rate (postoperative stroke, hemorrhage, or neurological deficit) and 9% cardiopulmonary complication rate (delayed extubation and re-intubation) attributable to surgical intervention. In this limited series, diagnostic utility of biopsy in patients with idiopathic encephalitis is less than 50% and the major complication rate is 23%. Patients and providers must be counseled accordingly and weigh the risks and benefits of open biopsy for encephalitis cautiously.

OBJECTIVE Fetal ventriculomegaly (FV), or enlarged cerebral ventricles in utero, is defined in fetal studies as an atrial diameter (AD) greater than 10 mm. In postnatal studies, the frontooccipital horn ratio (FOHR) is commonly used as a proxy for ventricle size (VS); however, its role in FV has not been assessed. Using image analysis techniques to quantify VS on fetal MR images, authors of the present study examined correlations between linear measures (AD and FOHR) and VS in patients with FV. METHODS The authors performed a cross-sectional study using fetal MR images to measure AD in the axial plane at the level of the atria of the lateral ventricles and to calculate FOHR as the average of the frontal and occipital horn diameters divided by the biparietal distance. Computer software was used to separately segment and measure the area of the ventricle and the ventricle plus the subarachnoid space in 2 dimensions. Segmentation was performed on axial slices 3 above and 3 below the slice used to measure AD, and measurements for each slice were combined to yield a volume, or 3D VS. The VS was expressed as the absolute number of voxels (non-normalized) and as the number of voxels divided by intracranial size (normalized). A Pearson correlation coefficient was used to measure the strength of the relationships between the linear measures and the size of segmented regions in 2 and 3 dimensions and over various gestational ages (GAs). Differences between correlations were compared using Steiger's z-test. RESULTS Fifty FV patients who had undergone fetal MRI between 2008 and 2014 were included in the study. The mean GA was 26.3 ± 5.4 weeks. The mean AD was 18.1 ± 8.3 mm, and the mean FOHR was 0.49 ± 0.11. When using absolute VS, the correlation between AD and 3D VS (r = 0.844, p < 0.0001) was significantly higher than that between FOHR and 3D VS (r = 0.668, p < 0.0001; p = 0.0004, Steiger's z-test). However, when VS was normalized, correlations were not significantly different between AD and 3D VS (r = 0.830, p < 0.0001) or FOHR and 3D VS (r = 0.842, p < 0.0001; p = 0.8, Steiger's z-test). For GAs of 24 weeks or earlier, AD correlated more strongly with normalized 3D VS (r = 0.902, p < 0.0001) than with FOHR (r = 0.674, p < 0.0001; p < 0.0001, Steiger's z-test). After 24 weeks, there was no difference in correlations between linear measures (AD or FOHR) and 3D VS (r > 0.9). Correlations of linear measures with VS in 2 and 3 dimensions were similar, and inclusion of the subarachnoid space did not significantly alter results. CONCLUSIONS Findings in the study support the use of AD as a measure of VS in fetal studies as it correlates highly with both absolute and relative VS, especially at early GAs, and captures the preferential dilation of the occipital horns in patients with FV. Compared with AD, FOHR similarly correlates with normalized VS and, after a GA of 24 weeks, can be reported in fetal studies to provide continuity with postnatal monitoring.

Meningiomas are the most common primary brain tumor of adults. The majority are benign (WHO grade I), with a mostly indolent course; 20% of them (WHO grade II and III) are, however, considered aggressive and require a more complex management. WHO grade II and III tumors are heterogeneous and, in some cases, can develop from a prior lower grade meningioma, although most arise de novo. Mechanisms leading to progression or implicated in de novo grade II and III tumorigenesis are poorly understood. RNA-seq was used to profile the transcriptome of grade I, II, and III meningiomas and to identify genes that may be involved in progression. Bioinformatic analyses showed that grade I meningiomas that progress to a higher grade are molecularly different from those that do not. As such, we identify GREM2, a regulator of the BMP pathway, and the snoRNAs SNORA46 and SNORA48, as being significantly reduced in meningioma progression. Additionally, our study has identified several novel fusion transcripts that are differentially present in meningiomas, with grade I tumors that did not progress presenting more fusion transcripts than all other tumors. Interestingly, our study also points to a difference in the tumor immune microenvironment that correlates with histopathological grade. Electronic supplementary material The online version of this article (10.1186/s40478-019-0690-x) contains supplementary material, which is available to authorized users.

Background Intracranial vasculopathy in adult patients with human-acquired immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a rare but increasingly recognized disease entity. Objective We aimed to contribute to and summarize the adult literature describing patients with HIV/AIDS who have intracranial vasculopathy. Methods A retrospective review of adult patients with HIV/AIDS undergoing diagnostic cerebral angiography at our institution from 2007–2013 was performed. A literature review of relevant existing studies was performed. Results Five adult patients with HIV-related aneurysmal and occlusive vasculopathy were diagnosed and/or treated at our institution. A comprehensive review of the literature yielded data from 17 series describing 28 adult patients with HIV/AIDS and intracranial vasculopathy. Our review suggests that low CD4 count, motor weakness, and meningismus may be associated with the sequelae of intracranial vasculopathy/vasculitis in patients with HIV/AIDS. Conclusion Patients with HIV/AIDS who have aneurysmal and stenotic vascular disease may benefit from earlier surveillance with the onset of neurological symptoms. The roles of medical, open surgical, and endovascular therapy in this unique entity will be further defined as the pathological basis of the disease is better understood.

Treatment following neurosurgical resection or biopsy of a central neurocytoma depends on the pathologic analysis and proliferative activity demonstrated, the extent of surgical resection, the neuroanatomic location and accessibility of residual tumor, and the patient's postoperative condition. The risks and benefits of additional surgery, radiation therapy, and/or chemotherapy should be weighed and individualized based on these factors and guided by the existing literature.

Myelomeningocele is one of the most common congenital malformations. A randomized controlled trial, known as the Management of Myelomeningocele Study (MOMS), demonstrated that closure during the fetal period can be performed relatively safely and be of significant benefit to patients. However, postnatally, patients can develop resultant symptoms from a tethered cord and inclusion cysts; this often requires surgical treatment. Repeat surgery in this population can be challenging due to the age of the patients, the extent of surgical exposure needed and the need for resection of dermal and epidermal tissues in the midline. We describe our approach for closure of these complex defects using lateral fasciocutaneous flaps with relaxing incisions made in the posterior axillary line, in order to minimize tension and maximize soft tissue coverage of the midline.

Background Alveolar soft part sarcoma (ASPS) is a rare, malignant soft-tissue neoplasm typically seen in young adults that possesses an unusual tendency to metastasize. Metastases to the intramedullary compartment of the spinal cord, however, are exceptionally rare and have not been described in the literature. Case Description We report the case of a 23-year-old woman with disseminated ASPS to the lung and brain who presented with progressive lower-extremity weakness and loss of sensation after radiation and chemotherapy. Magnetic resonance imaging revealed a 1.3-cm avidly enhancing lesion within the central thoracic spinal cord at T3. A T2–T4 laminectomy was undertaken and resulted in a gross total resection. Histopathologically, the mass was composed of organoid nests containing epithelioid cells with eosinophilic, granular cytoplasm separated by sinusoidal spaces. Immunohistochemistry demonstrated convincing positive TFE3 staining. Postoperative imaging confirmed the complete resection of the mass, and her examination was notable for intact sensation and impaired motor function that gradually improved. Conclusions A review of the literature found that the reported case represents the first instance of primary or metastatic ASPS in the spinal cord. Metastatic ASPS should thus be included in the differential diagnosis in patients with known disease and neurologic impairment or back pain. Imaging of the spine should then be considered.

Introduction We sought to identify factors associated with increased length of stay (LOS) and morbidity in patients undergoing resection of pituitary macroadenomas. Methods We reviewed records of 203 consecutive patients who underwent endoscopic endonasal resection of a pituitary macroadenoma (mean age = 55.7 [16-88]) years, volume = 11.3 (1.0-134.3) cm3. Complete resection was possible in 60/29.6% patients. Mean follow-up was 575 days. Multivariate logistic regression was performed using MATLAB. Results Mean LOS was 4.67 (1-66) days and was associated with CSF leak (p = 0.025), lumbar drain placement (p = 0.041; n = 8/3.9% intraoperative, n = 20/9.9% postoperative), and any infection (p = 0.066). Age, diabetes insipidus (n = 17/8.37%), and syndrome of inappropriate antidiuretic hormone secretion (n = 12/5.9%) were not associated with increased LOS (p > 0.2). Postoperative CSF leak in the hospital (n = 21/10.3%) was associated with intraoperative CSF leak (p = 0.002; n = 82/40.4%) and complete resection (p = 0.012). There was no significant association (p > 0.1) between postoperative CSF leak in the hospital following surgery and the use of a fat graft (n = 61/30.1%), nasoseptal flap (155/76.4%), or perioperative lumbar drain placement (n = 8/3.94%). Conclusion Complete resection is associated with increased risk of CSF leak and LOS. Operative strategies including placement of fat graft, nasoseptal flap, or intraoperative lumbar drain placement may have limited value in reducing the risk of postoperative CSF leak.

Background Although real-time localization of gliomas has improved with intraoperative image guidance systems, these tools are limited by brain shift, surgical cavity deformation, and expense. Objective To propose a novel method to perform near-infrared (NIR) imaging during glioma resections based on preclinical and clinical investigations, in order to localize tumors and to potentially identify residual disease. Methods Fifteen patients were identified and administered a Food and Drug Administration-approved, NIR contrast agent (Second Window indocyanine green [ICG], 5 mg/kg) before surgical resection. An NIR camera was utilized to localize the tumor before resection and to visualize surgical margins following resection. Neuropathology and magnetic resonance imaging data were used to assess the accuracy and precision of NIR fluorescence in identifying tumor tissue. Results NIR visualization of 15 gliomas (10 glioblastoma multiforme, 1 anaplastic astrocytoma, 2 low-grade astrocytoma, 1 juvenile pilocytic astrocytoma, and 1 ganglioglioma) was performed 22.7 hours (mean) after intravenous injection of ICG. During surgery, 12 of 15 tumors were visualized with the NIR camera. The mean signal-to-background ratio was 9.5 ± 0.8 and fluorescence was noted through the dura to a maximum parenchymal depth of 13 mm. The best predictor of positive fluorescence was enhancement on T1-weighted imaging; this correlated with signal-to-background ratio (P = .03). Nonenhancing tumors did not demonstrate NIR fluorescence. Using pathology as the gold standard, the technique demonstrated a sensitivity of 98% and specificity of 45% to identify tumor in gadolinium-enhancing specimens (n = 71). Conclusion With the use of Second Window ICG, gadolinium-enhancing tumors can be localized through brain parenchyma intraoperatively. Its utility for margin detection is promising but limited by lower specificity. Abbreviations 5-ALA, 5-aminolevulinic acidEPR, enhanced permeability and retentionFDA, Food and Drug AdministrationGBM, glioblastomaICG, indocyanine greenNIR, near-infraredNPV, negative predictive valuePPV, positive predictive valueROC, receiver operating characteristicROI, region of interestSBR, signal-to-background ratioWHO, World Health Organization.

Simulated practice may improve resident performance in endoscopic endonasal surgery. Using the NeuroTouch haptic simulation platform, we evaluated resident performance and assessed the effect of simulation training on performance in the operating room. First- (N=3) and second- (N=3) year residents were assessed using six measures of proficiency. Using a visual analog scale, the senior author scored subjects. After the first session, subjects with lower scores were provided with simulation training. A second simulation served as a task-learning control. Residents were evaluated in the operating room over six months by the senior author-who was blinded to the trained/untrained identities-using the same parameters. A nonparametric bootstrap testing method was used for the analysis (Matlab v. 2014a). Simulation training was associated with an increase in performance scores in the operating room averaged over all measures (p=0.0045). This is the first study to evaluate the training utility of an endoscopic endonasal surgical task using a virtual reality haptic simulator. The data suggest that haptic simulation training in endoscopic neurosurgery may contribute to improvements in operative performance. Limitations include a small number of subjects and adjudication bias-although the trained/untrained identity of subjects was blinded. Further study using the proposed methods may better describe the relationship between simulated training and operative performance in endoscopic Neurosurgery.

Background Deep brain stimulation (DBS) has emerged as a safe and efficacious surgical intervention for several movement disorders; however, the 30-day all-cause readmission rate associated with this procedure has not previously been documented. Object To perform a retrospective cohort study to estimate the 30-day all-cause readmission rate associated with DBS. Methods We reviewed medical records of patients over the age of 18 who underwent DBS surgery at Pennsylvania Hospital of the University of Pennsylvania between 2009 and 2014. We identified patients who were readmitted to an inpatient medical facility within 30 days from their initial discharge. Results Over the study period, 23 (6.6%) of 347 DBS procedures resulted in a readmission to the hospital within 30 days. Causes of readmission were broadly categorized into surgery-related (3.7%): intracranial lead infection (0.6%), battery-site infection (0.6%), intracranial hematoma along the electrode tract (0.6%), battery-site hematoma (0.9%), and seizures (1.2%); and nonsurgery-related (2.9%): altered mental status (1.8%), nonsurgical-site infections (0.6%), malnutrition and poor wound healing (0.3%), and a pulse generator malfunction requiring reprogramming (0.3%). Readmissions could be predicted by the presence of medical comorbidities ( P .15). Conclusion All-cause 30-day readmission for DBS is 6.6%. This compares favorably to previously studied neurosurgical procedures. Readmissions frequently resulted from surgery-related complications, particularly infection, seizures, and hematomas, and were significantly associated with the presence of medical comorbidities ( P

OBJECTIVE Tarlov cysts (TCs) occur most commonly on extradural components of the sacral and coccygeal nerve roots. These lesions are often found incidentally, with an estimated prevalence of 4%–9%. Given the low estimated rates of symptomatic TC and the fact that symptoms can overlap with other common causes of low-back pain, optimal management of this entity is a matter of ongoing debate. Here, the authors investigate the effects of surgical intervention on symptomatic TCs and aim to solidify the surgical criteria for this disease process. METHODS The authors performed a retrospective review of data from consecutive patients who were surgically treated for symptomatic TCs from September 2011 to March 2013. Clinical evaluations and results from surveying pain and overall health were used. Univariate statistical analyses were performed. RESULTS Twenty-three adults (4 males, 19 females) who had been symptomatic for a mean of 47.4 months were treated with laminectomy, microsurgical exposure and/or imbrication, and paraspinous muscle flap closure. Eighteen patients (78.3%) had undergone prior interventions without sustained improvement. Thirteen patients (56.5%) underwent lumbar drainage for an average of 8.7 days following surgery. The mean follow-up was 14.4 months. Univariate analyses demonstrated that an advanced age (p = 0.045), the number of noted perineural cysts on preoperative imaging (p = 0.02), and the duration of preoperative symptoms (p = 0.03) were associated with a poor postoperative outcome. Although 47.8% of the patients were able to return to normal activities, 93.8% of those surveyed reported that they would undergo the operation again if given the choice. CONCLUSIONS This is one of the largest published studies on patients with TCs treated microsurgically. The data suggest that patients with symptomatic TCs may benefit from open microsurgical treatment. Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study is warranted and underway.

Digital subtraction angiography (DSA) is the gold standard for radiographic diagnosis of blunt cerebrovascular injury (BCVI), but use of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) has increased dramatically in BCVI screening. This study explores the utility, effectiveness, and cost of noninvasive CTA and MRA screening for BCVI.Medical records of 2,025 consecutive adults evaluated for acute blunt neck trauma and BCVI were reviewed retrospectively. The incidence of BCVI, level(s) of cervical injury, involvement of foramina transversaria and internal carotid canals, presence of bony dislocation or subluxation, and subsequent treatment received were assessed. Asymptomatic patients were analyzed based on fracture and injury patterns. The cost effectiveness of CTA compared with DSA and the effects of CTA sensitivity and screening yield were determined.Of reviewed patients, 196 received CTA or MRA. Thirty-eight patients (19.4%) were diagnosed with BCVI. Screening yield in patients symptomatic at presentation was 48.8%. Large-vessel internal carotid, vertebral, anterior spinal, and basilar artery occlusion were associated with a positive screen, as were concurrent stroke and spinal cord injury (p0.01). Of patients with injuries found with noninvasive imaging, 50.0% of BCVI involved C1-3 fracture, 34.2% involved subluxation, and 65.8% involved foramina transversaria. In both symptomatic and asymptomatic patients, CTA screening was more cost effective than DSA.Noninvasive imaging is a safe, accurate, and cost-effective tool for BCVI screening. Symptomatic presentation was the best predictor of BCVI. Significant cost savings were realized using CTA rather than DSA, with similar effectiveness and patient outcomes.Diagnostic study, level III; economic analysis, level IV.

Object The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective. Methods A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with “routine care,” in which Brain Trauma Foundation guidelines are not followed. A “comfort care” category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age. Results For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds. Conclusions When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.

Due to the rare occurrence of chordomas extra-axially, these lesions have not earned a great deal of consideration in the clinical and radiographic differential diagnoses of extra-axial paraspinal lesions. We describe a case of a patient with a surgically resected extra-axial chordoma and review the radiologic characteristics of chordomas as an entity in the spectrum of extra-axial lesions. A 47-year-old man presented to our institution with four months of intermittent parethesias, pain, and subjective weakness in the left leg. MR imaging of the lumbar spine demonstrated a large heterogeneously- enhancing paraspinal lesion extending from the left L3-4 neural foramen into the psoas muscle. The patient underwent a CT-guided needle biopsy demonstrating features consistent with a chordoma. He then underwent a left retroperitoneal approach and en bloc resection of the lesion from the vertebral column. Pathology confirmed chordoma as the diagnosis. EACs are a rare but important consideration in the diagnosis of extra-axial lesions of the central nervous system.

Background Diffuse low-grade gliomas (DLGGs) represent several pathological entities that infiltrate and invade cortical and subcortical structures in the brain. Objective To describe methods for rapid prototyping of DLGGs and surgically relevant anatomy. Methods Using high-definition imaging data and rapid prototyping technologies, we were able to generate 3 patient DLGGs to scale and represent the associated white matter tracts in 3 dimensions using advanced diffusion tensor imaging techniques. Results This report represents a novel application of 3-dimensional (3-D) printing in neurosurgery and a means to model individualized tumors in 3-D space with respect to subcortical white matter tract anatomy. Faculty and resident evaluations of this technology were favorable at our institution. Conclusion Developing an understanding of the anatomic relationships existing within individuals is fundamental to successful neurosurgical therapy. Imaging-based rapid prototyping may improve on our ability to plan for and treat complex neuro-oncologic pathology.

Object Brainstem hemangioblastomas are frequently encountered in patients with von Hippel-Lindau (VHL) disease. These tumors can cause significant morbidity, and their optimal management has not been defined. To better define the outcome and management of these tumors, the authors analyzed the long-term results in patients who underwent resection of brainstem hemangioblastomas. Methods Consecutive patients with VHL disease who underwent resection of brainstem hemangioblastomas with a follow-up of 12 months or more were included in this study. Serial functional assessments, radiographic examinations, and operative records were analyzed. Results Forty-four patients (17 male and 27 female) underwent 51 operations for resection of 71 brainstem hemangioblastomas. The most common presenting symptoms were headache, swallowing difficulties, singultus, gait difficulties, and sensory abnormalities. The mean follow-up was 5.9 ± 5.0 years (range 1.0–20.8 years). Immediately after 34 operations (66.7%), the patients remained at their preoperative functional status; they improved after 8 operations (15.7%) and worsened after 9 operations (17.6%) as measured by the McCormick scale. Eight (88.9%) of the 9 patients who were worse immediately after resection returned to their preoperative status within 6 months. Two patients experienced functional decline during long-term follow-up (beginning at 2.5 and 5 years postoperatively) caused by extensive VHL disease–associated CNS disease. Conclusions Generally, resection of symptomatic brainstem hemangioblastomas is a safe and effective management strategy in patients with VHL disease. Most patients maintain their preoperative functional status, although long-term decline in functional status may occur due to VHL disease–associated progression.

BACKGROUND Few studies have established surgical landmarks for endoscopic endonasal dissection of the intraconal orbital apex (OA). OBJECTIVE We describe the optic nerve (ON) anatomy and its relationships, as seen during a fully endoscopic, endonasal approach to the medial intraconal OA. METHODS The study question was approached through a cadaver dissection and a radiographic study. Four formalin-fixed, latex-injected cadaver heads were dissected using transnasal endoscopic techniques. Dissection was performed using 0 degree and 30 degree nasal endoscopes and standard endoscopic sinus surgical instrumentation. A bi-nostril 4-handed technique was used. The anatomy of 8 medial OAs was evaluated and recorded. As the radiographic portion, 100 consecutively enrolled patient magnetic resonance images were evaluated, with particular attention given to the relationship of the ON to the medial rectus muscle (MRM) in 200 orbits. RESULTS Intraconally, the ON consistently coursed along the superior half of the MRM. Interestingly, the nerve was more easily identified from a superior approach after retracting the MRM inferiorly. With the identification of the nerve at the OA, carrying the dissection of the medial OA was easily accomplished with the ON as the guiding landmark. The radiographic portion of this study revealed a consistent relationship between the superior edge of the ON and the MRM. This relationship was maintained in the orbital apex in 98.4%-100% of the orbits examined. CONCLUSION The superior edge of the optic nerve is consistently found coursing along the superior half of the MRM, facilitating facile identification and further dissection navigation.

Currently, a substantial amount of effort is focused on developing actively targeted, receptor-specific nanoparticles for the delivery of anticancer drugs and diagnostic imaging contrast agents.[1–7] Receptor-targeted nanoparticles hold much promise and are often shown to provide nanoparticle delivery beyond that seen with the enhanced permeability and retention (EPR) effect alone. However, these nanoparticles still face considerable challenges as a result of the significant heterogeneity in receptor expression, not only between patients and tumor types, but also within individual tumors.[8] In many cases, the overexpressed receptor may also be present on normal tissues leading to detrimental off-target effects. Perhaps even more troubling is that several recent studies have shown that cancer stem cells may not even possess any known up-regulated receptor.[9] Therefore, targeting strategies that are more generalizable across a broad range of tumors than receptor-specific targeting are highly desirable.

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas. Case Descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility. Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

Following resection of a brain metastasis, stereotactic radiosurgery (SRS) to the cavity is an emerging alternative to postoperative whole-brain radiation therapy (WBRT). This approach attempts to achieve local control without the neurocognitive risks associated with WBRT. The authors aimed to report the outcomes of a large patient cohort treated with this strategy.A retrospective review identified 91 patients without a history of WBRT who received Gamma Knife (GK) SRS to 96 metastasis resection cavities between 2007 and 2013. Patterns of intracranial control were examined in the 86 cases with post-GK imaging. Survival, local failure, and distant failure were estimated by the Kaplan-Meier method. Prognostic factors were tested by univariate (log-rank test) and multivariate (Cox proportional hazards model) analyses.Common primary tumors were non-small cell lung (43%), melanoma (14%), and breast (13%). The cases were predominantly recursive partitioning analysis Class I (25%) or II (70%). Median preoperative metastasis diameter was 2.8 cm, and 82% of patients underwent gross-total resection. A median dose of 16 Gy was delivered to the 50% isodose line, encompassing a median treatment volume of 9.2 cm(3). Synchronous intact metastases were treated in addition to the resection bed in 43% of cases. Patients survived a median of 22.3 months from the time of GK. Local failure developed in 16 cavities, for a crude rate of 18% and 1-year actuarial local control of 81%. Preoperative metastasis diameter ≥ 3 cm and residual or recurrent tumor at the time of GK were associated with local failure (p = 0.04 and 0.008, respectively). Distant intracranial failure occurred in 55 cases (64%) at a median of 7.3 months from GK. Salvage therapies included WBRT and additional SRS in 33% and 31% of patients, respectively. Leptomeningeal carcinomatosis developed in 12 cases (14%) and was associated with breast histology and infratentorial cavities (p = 0.024 and 0.012, respectively).This study bolsters the existing evidence for SRS to the resection bed. Local control rates are high, but patients with larger preoperative metastases or residual/recurrent tumor at the time of SRS are more likely to fail at the cavity. While most patients develop distant intracranial failure, an SRS approach spared or delayed WBRT in the majority of cases. The risk of leptomeningeal carcinomatosis does not appear to be elevated with this strategy.

A 64-year-old man presented to the trauma bay with metallic objects protruding from his right scalp following presumed assault. Clinical examination demonstrated an unresponsive, moderately hypertensive patient with reactive pupils, intact corneal and gag reflexes, and no movement to noxious stimuli (Glasgow Coma Scale1 3T). Neuroimaging demonstrated multiple linear metallic foreign bodies extending deep into the bilateral thalami and brain parenchyma (figure 1). The patient underwent a right decompressive hemicraniectomy and removal of seven 10-inch nails through the skull via the right frontal and temporal cortices (figure 2). The patient recovered and remains in a persistent vegetative state, likely from his diencephalic injury.2

A common cause of local tumor recurrence in brain tumor surgery results from incomplete surgical resection. Adjunctive technologies meant to facilitate gross total resection have had limited efficacy to date. Contrast agents used to delineate tumors preoperatively cannot be easily or accurately used in the real-time operative setting. Although multimodal imaging contrast agents are developed to help the surgeon discern tumor from normal tissue in the operating room, these contrast agents are not readily translatable. This study has developed a novel contrast agent comprised solely of two Food and Drug Administration approved components, indocyanine green (ICG) and superparamagnetic iron oxide (SPIO) nanoparticles-with no additional amphiphiles or carrier materials, to enable preoperative detection by magnetic resonance (MR) imaging and intraoperative photoacoustic (PA) imaging. The encapsulation efficiency of both ICG and SPIO within the formulated clusters is ≈100%, and the total ICG payload is 20-30% of the total weight (ICG + SPIO). The ICG-SPIO clusters are stable in physiologic conditions; can be taken up within tumors by enhanced permeability and retention; and are detectable by MR. In a preclinical surgical resection model in mice, following injection of ICG-SPIO clusters, animals undergoing PA-guided surgery demonstrate increased progression-free survival compared to animals undergoing microscopic surgery.

A 26-year-old woman gave a 2-year history of intermittent and worsening headaches. MR scan of brain showed a 1.1 cm cystic, peripherally enhancing lesion in the third ventricle, causing obstructive hydrocephalus at the interventricular foramen of Monro (figure 1A, B). She underwent endoscopic intraventricular resection through a left frontal burr hole. Pathological examination confirmed a colloid cyst. Figure 1 (A, B) Preoperative MRI, T1 with …

Common complications related to CT-guided percutaneous thoracic bone biopsy procedures include pneumothorax and muscular hematoma. Serious, but rare complications include paralysis, nerve injury, CSF leak, and aortic injury. Device failure has not been well documented in the literature. We discuss our experience with biopsy needle breakage during retrieval of a core specimen and the technique used to help retrieve an embedded needle using a CT fluoroscopic-guided, needle-in-needle approach. A 43 year-old man with Stage IIIa NSCLC was found to have a T11 vertebral body lesion as seen on PET, CT, and MR imaging. The patient underwent a CT-guided biopsy in the prone position. The T11 vertebral body was localized and cannulated using the percutaneous Bonopty® (Apriomed, Upsala, Sweden) needle device. After fine needle aspiration samples were obtained, a core needle biopsy was attempted with a 16-gauge device. The needle fractured 4 cm deep to the skin during removal of a sclerotic lesion, leaving a retained portion within the pedicle and vertebral body. Using CT-guided fluoroscopy, a large diameter Murphy M2 needle was advanced over the distal portion of the fractured Bonopty needle. The Murphy M2 needle was advanced distal to the tip of the Bonopty needle and removed, capturing the broken Bonopty penetration needle along with a core specimen. Larger-bore biopsy needle systems and/or a coaxial system should be used to perform core biopsies in sclerotic lesions to prevent device fracture. If there is device fracture, a larger-bore needle may be used to help capture the fractured needle and prevent open surgery.

Microsurgical Treatment of a Complex Sacral Perineural Cyst Using Paraspinous Muscle Flap: Technical Note Dr. I.M. Tarlov first described perineural (Tarlov) cysts in 1938. Symptomatic Tarlov cysts are common incidental findings yet uncommon clinical/pathologic entities. Microsurgical treatment of Tarlov cysts is even more rare. We report the microsurgical treatment of a symptomatic complex Tarlov cyst as a case. The patient presented with sacral pain, bilateral sciatica (S1-type), urinary retention, rectal pain with intercourse, gluteal heaviness, and intermittent burning in the S2-4 dermatome. MR imaging revealed a complex sacral Tarlov cyst with bony erosion. The patient was treated microsurgically and had a paraspinous muscle flap advancement procedure performed in conjunction with Plastic Surgery. The patient experienced a positive clinical outcome.

Background We present a rare case of an intraparenchymal nonmissile penetrating spinal injury (NMPSI) occurring at the T11 level in a patient presenting without neurological deficit. Case description The patient sustained a knife wound that penetrated the lamina without incurring bony injury and entered the spinal cord at the T11 level. During surgery, the intramedullary penetration of the cord was confirmed, and following surgical removal of the knife, the patient fully recovered without losing any neurological function. Conclusions The surgical management of NMPSI in patients who are neurologically intact is controversial. Here, we report surgical excision of a knife that penetrated the spinal cord at the T11 level, without the patient incurring further neurological deterioration.

Background The recent expansion of three-dimensional (3D) printing technology into the field of neurosurgery has prompted a widespread investigation of its utility. In this article, we review the current body of literature describing rapid prototyping techniques with applications to the practice of neurosurgery. Methods An extensive and systematic search of the Compendex, Scopus, and PubMed medical databases was conducted using keywords relating to 3D printing and neurosurgery. Results were manually screened for relevance to applications within the field. Results Of the search results, 36 articles were identified and included in this review. The articles spanned the various subspecialties of the field including cerebrovascular, neuro-oncologic, spinal, functional, and endoscopic neurosurgery. Conclusions We conclude that 3D printing techniques are practical and anatomically accurate methods of producing patient-specific models for surgical planning, simulation and training, tissue-engineered implants, and secondary devices. Expansion of this technology may, therefore, contribute to advancing the neurosurgical field from several standpoints.

Elderly patients with glioblastoma represent a clinical challenge for neurosurgeons and oncologists. The data available on outcomes of patients greater than 80 undergoing resection is limited. In this study, factors linked to increased survival in patients over the age of 80 were analyzed. A retrospective chart review of all patients over the age of 80 with a new diagnosis of glioblastoma and who underwent surgical resection with intent for maximal resection were examined. Patients who had only stereotactic biopsies were excluded. Immunohistochemical expression of oncogenic drivers (p53, EGFR, IDH-1) and a marker of cell proliferation (Ki-67 index) performed upon routine neuropathological examination were recorded. Stepwise logistic regression and Kaplan Meier survival curves were plotted to determine correlations to overall survival. Fifty-eight patients fit inclusion criteria with a mean age of 83 (range 80-93 years). The overall median survival was 4.2 months. There was a statistically significant correlation between Karnofsky Performance Status (KPS) and overall survival (P < 0.05). There was a significantly longer survival among patients undergoing either radiation alone or radiation and chemotherapy compared to those who underwent no postoperative adjuvant therapy (p < 0.05). There was also an association between overall survival and lack of p53 expression (p < 0.001) and lack of EGFR expression (p

Object There is considerable variation in the use of adjunctive technologies to confirm pedicle screw placement. Although there is literature to support the use of both neurophysiological monitoring and isocentric fluoroscopy to confirm pedicle screw positioning, there are no studies examining the cost-effectiveness of these technologies. This study compares the cost-effectiveness and efficacy of isocentric O-arm fluoroscopy, neurophysiological monitoring, and postoperative CT scanning after multilevel instrumented fusion for degenerative lumbar disease. Methods Retrospective data were collected from 4 spine surgeons who used 3 different strategies for monitoring of pedicle screw placement in multilevel lumbar degenerative disease. A decision analysis model was developed to analyze costs and outcomes of the 3 different monitoring strategies. A total of 448 surgeries performed between 2005 and 2010 were included, with 4 cases requiring repeat operation for malpositioned screws. A sample of 64 of these patients was chosen for structured interviews in which the EuroQol-5D questionnaire was used. Expected costs and quality-adjusted life years were calculated based on the incidence of repeat operation and its negative effect on quality of life and costs. Results The decision analysis model demonstrated that the O-arm monitoring strategy is significantly (p < 0.001) less costly than the strategy of postoperative CT scanning following intraoperative uniplanar fluoroscopy, which in turn is significantly (p < 0.001) less costly than neurophysiological monitoring. The differences in effectiveness of the different monitoring strategies are not significant (p = 0.92). Conclusions Use of the O-arm for confirming pedicle screw placement is the least costly and therefore most cost-effective strategy of the 3 techniques analyzed.

Object Anterior temporal lobectomy (ATL) and selective amygdalohippocampectomy (SelAH) are the preferred surgical approaches for the treatment of medically refractory epilepsy involving the nondominant and dominant temporal lobes, respectively. Both techniques provide access to mesial structures—with the ATL providing a wider surgical corridor than SelAH. Because the extent of mesial temporal resection potentially impacts seizure outcome, the authors examined mesial resection volumes, seizure outcomes, and neuropsychiatric test scores in patients undergoing either ATL or transcortical SelAH at a single institution. Methods A retrospective study was conducted in 96 patients with medically refractory mesial temporal lobe epilepsy. Fifty-one patients who had nondominant temporal lobe epilepsy underwent standard ATL, and 45 patients with language-dominant temporal lobe epilepsy underwent transcortical SelAH. Volumetric MRI analysis was used to quantify the mesial resection in both groups. In addition, the authors examined seizure outcomes and the change in neuropsychiatric test scores. Results Seizure-free outcome in the entire patient cohort was 94% at a mean follow-up of 44 months. There was no significant difference in the seizure outcome between the 2 groups. The extent of resection of the mesial structures following ATL was slightly higher than for SelAH (98% vs 91%, p < 0.0001). The change in neuropsychiatric test scores largely reflected the side of surgery, but overall IQ and memory function did not change significantly in either group. Conclusions Transcortical SelAH provides adequate access to the mesial structures, and allows for a resection that is nearly as extensive as that achieved with standard ATL. Seizure outcomes and neuropsychiatric sequelae are similar in both procedures.