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Background: Deficits in self are commonly described through different neuro-pathologies, based on clinical evaluations and experimental paradigms. However, currently available approaches lack appropriate clinical validation, making objective evaluation and discrimination of self-related deficits challenging. Methods: We applied a statistical standardized method to assess the clinical discriminatory capacity of a Self-Other Voice Discrimination (SOVD) task. This task, validated experimentally as a marker for self-related deficits, was administered to 17 patients eligible for neurosurgery due to focal hemispheric brain tumors or epileptic lesions. Results: The clinical discriminatory capacity of the SOVD task was evident in three patients who exhibited impairments for self-voice perception that could not be predicted by other neuropsychological deficits. Impairments in other-voice perception were linked to inhibitory neuropsychological deficits, suggesting a potential association with executive deficits in voice recognition. Conclusions: This exploratory study highlights the clinical discriminatory potential of the SOVD task and suggests that it could complement the standard neuropsychological assessment, paving the way for enhanced diagnoses and tailored treatments for self-related deficits.

Background: The primary co-occurrence of gonadal and extragonadal central nervous system (CNS) germ cell tumors (GCTs) has rarely been reported in the literature, and a common opinion on the underlying etiopathogenetic mechanism is lacking. Objective: We aim to investigate the pathophysiological mechanisms and genetic pathways underlying the primary co-occurrence of gonadal and CNS GCTs. Methods: We reviewed data from 29 consecutive patients with a diagnosis of CNS GCT, evaluated in our Hospital over the past 23 years, and searched for those who had at least a primary gonadal co-occurrence of GCT. A systematic review of the literature according to the PRISMA guidelines was also conducted. For a comprehensive and detailed search, PubMed, Ovid MEDLINE, and Ovid EMBASE databases have been consulted. Boolean operators and MeSH terms were used to find studies. Only articles published between 2000 and 2023 were considered. Results: Including our Institutional case report, a total of 7 patients with both testicular NGGCTs and CNS GCTs were identified (5 patients with metachronous tumors and patients with synchronous presentation). The average age at tumor diagnosis was 17 years. The cerebral histotypes reported were mixed GCTs (3 cases; 43%), pure germinomas (3 cases, 43%), and one yolk sac tumor (14%). Two out of seven cases (29%) were syndromic, one suffering from Down Syndrome and the other from Testicular Dysgenesis Syndrome. Regarding the etiology and molecular mechanism of GCT development, several gene mutations have been reported in the literature. Particularly, genetic alterations in the MAPK and/or PI3K/AKT/mTOR pathway, together with mutations of the KIT gene, have been shown to guarantee survival and transformation of mismigrated totipotent primordial germ cells, while suppressor genes allow their resistance against apoptotic death. Aberrant chromosomes have also been reported to be responsible for oncogenic transformation. It is also known that CNS and testicular GCTs share some genetic/epigenetic profiles. Conclusions: The primary co-occurrence of testicular NGGCT and extragonadal CNS GCTs is extremely rare. Genetic factors seem to play a paramount role in their etiopathogenesis. Additional research is needed to elucidate molecular mechanisms of oncogenesis in such patients.

Background Intracranial aneurysms (IAs) are more common in women than in men; however, there is still limited knowledge on sex‐dependent differences regarding aneurysm location, multiplicity, rupture risk, risk factors, and histopathology. Methods This cross‐sectional, consecutive cohort study examined whether IAs differ in multiplicity, location, geometry, rupture risk, risk factors, and histology between sexes. Results We included 982 patients (714 women, 268 men) totaling 1484 IAs (1056 unruptured, 397 ruptured). A total of 363 patients (36.97%) had multiple IAs, the proportion of which was significantly higher in women. In women, the internal carotid artery (40.79%) was the most frequent location for IAs, whereas in men most were found along the anterior carotid artery territory (32.86%). Men were significantly more often diagnosed with ruptured aneurysms. Aneurysm geometry did not differ between sexes; however, ruptured aneurysms in men presented with a significantly larger neck diameter than unruptured ones. Regarding risk factors for aneurysm rupture, blood pressure control was more effective in women, whereas the effect of smoking status did not show clear sex‐dependent differences. Histologically, wall‐type classification analysis showed significantly more severe aneurysm wall types in men. Conclusion IA prevalence in women is significantly higher than in men. Women more often present with multiple IAs, whereas men were more often diagnosed with ruptured IAs. Sex‐specific differences in IA location were identified, whereas geometry of IAs did not differ between sexes. IAs in men showed a more severe histological wall type. Further research is needed to unravel the molecular mechanisms underlying these important sex‐dependent manifestations in IAs.

Abstract In patients with drug‐resistant epilepsy who are considering surgery, intracranial EEG (iEEG) helps delineate the putative epileptogenic zone. In a minority of patients, iEEG fails to identify seizure onsets. In such cases, it might be worthwhile to reimplant more iEEG electrodes. The consequences of such a strategy for the patient are unknown. We matched 12 patients in whom the initially implanted iEEG electrodes did not delineate the seizure onset zone precisely enough to offer resective surgery, and in whom additional iEEG electrodes were implanted during the same inpatient stay, to controls who did not undergo reimplantation. Seven cases and eight controls proceeded to resective surgery. No intracranial infection occurred. One control suffered an intracranial hemorrhage. Three cases and two controls suffered from a post‐operative neurological or neuropsychological deficit. We found no difference in post‐operative seizure control between cases and controls. Compared to an ILAE score of 5 (ie, stable seizure frequency in the absence of resective surgery), cases showed significant improvement. Reimplantation of iEEG electrodes can offer the possibility of resective epilepsy surgery to patients in whom the initial iEEG investigation was inconclusive, without compromising on the risk of complications or seizure control.

Abstract Background Klippel–Feil syndrome is a rare condition described in 1912 by Maurice Klippel and André Feil. It is defined as a congenital cervical fusion of at least two vertebrae, associated with a classical triad of clinical signs: short neck, low posterior hairline, and limited range of movement. However, Klippel–Feil syndrome manifests with a vast spectrum of phenotypes, ranging from no symptoms to complete triad, with or without other associated malformations. Most commonly, CCF results from sporadic mutations, even though autosomal recessive, autosomal dominant, or even X-linked inheritance can be detected. The ATP-binding cassette subfamily B member 4 is only expressed in the liver and is involved in biliary phospholipid secretion. The clinical spectrum includes various hepatobiliary pathologies, including low phospholipid-associated cholelithiasis, and has never been associated with musculoskeletal anomalies. Case presentation A 55-year-old male Caucasian patient presenting with low phospholipid-associated cholelithiasis syndrome with ATP-binding cassette subfamily B member 4 mutation and liver cirrhosis was referred to our clinic for a liver transplant. A period of 6 months before, the patient underwent a T7–T9 posterior fixation for a T8 osteoporotic fracture. Postoperatively, he was tetraparetic, whereas he was neurologically intact before the operation. At admission to our hospital, he was still tetraparetic and presented with clinical signs of cervical myelopathy. Moreover, he suffered a limitation of cervical range of motion in all directions, short neck, and low posterior hairline. Imaging showed multiple cervical and thoracic vertebral bodies fusion, as well as cervical spine stenosis. Based on the available data, we diagnosed a type 3 Klippel–Feil syndrome according to Samartzis’ classification. Conclusions The heterogeneity of KFS and the various potential hereditary links that are known indicate that it is important to highlight all potential cases related to known genetic defects. At present, no association between ATP-binding cassette subfamily B member 4 mutation and congenital cervical fusions has been reported. The other important clinical focus of this case is the appearance of spontaneous tetraparesis after thoracic spine surgery. This mechanism remains unclear, but considering different spinal anatomy it might have been due to difficult intubation and patient’s positioning during his previous operation.

Studying the development of brain network disruptions in epilepsy is challenged by the paucity of data before epilepsy onset. Here, we used the unilateral, kainate mouse model of hippocampal epilepsy to investigate brain network changes before and after epilepsy onset and their stability across time.Using 32 epicranial electrodes distributed over the mouse hemispheres, we analyzed EEG epochs free from epileptic activity in 15 animals before and 28 days after hippocampal injection (group 1) and in 20 animals on two consecutive days (d28 and d29, group 2). Statistical dependencies between electrodes were characterized with the debiased-weighted phase lag index. We analyzed: a) graph metric changes from baseline to chronic stage (d28) in group 1; b) their reliability across d28 and d29, in group 2; c) their correlation with epileptic activity (EA: seizure, spike and fast-ripple rates), averaged over d28 and d29, in group 2.During the chronic stage, intra-hemispheric connections of the non-injected hemisphere strengthened, yielding an asymmetrical network in low (4–8 Hz) and high theta (8–12 Hz) bands. The contralateral hemisphere also became more integrated and segregated within the high theta band. Both network topology and EEG markers of EA were stable over consecutive days but not correlated with each other.Altogether, we show reproducible large-scale network modifications after the development of focal epilepsy. These modifications are mostly specific to the non-injected hemisphere. The absence of correlation with epileptic activity does not allow to specifically ascribe these network changes to mechanisms supporting EA or rather compensatory inhibition but supports the notion that epilepsy extends beyond the sole repetition of EA and impacts network that might not be involved in EA generation.

Introduction: Surgical training traditionally adheres to the apprenticeship paradigm, potentially exposing trainees to an increased risk of complications stemming from their limited experience. To mitigate this risk, augmented and virtual reality have been considered, though their effectiveness is difficult to assess. Research question: The PASSION study seeks to investigate the improvement of manual dexterity following intensive training with neurosurgical simulators and to discern how surgeons' psychometric characteristics may influence their learning process and surgical performance. Material and methods: Seventy-two residents were randomized into the simulation group (SG) and control group (CG). The course spanned five days, commencing with assessment of technical skills in basic procedures within a wet-lab setting on day 1. Over the subsequent core days, the SG engaged in simulated procedures, while the CG carried out routine activities in an OR. On day 5, all residents' technical competencies were evaluated. Psychometric measures of all participants were subjected to analysis. Results: The SG demonstrated superior performance (p

Introduction: The surgical procedure for severe, drug-resistant, unilateral hemispheric epilepsy is challenging. Over the last decades the surgical landscape for hemispheric disconnection procedures changed from anatomical hemispherectomy to functional hemispherotomy with a reduction of complications and stable good seizure outcome. Here, a task force of European epilepsy surgeons prepared, on behalf of the EANS Section for Functional Neurosurgery, a consensus statement on different aspects of the hemispheric disconnection procedure. Research question: To determine history, indication, timing, techniques, complications and current practice in Europe for hemispheric disconnection procedures in drug-resistant epilepsy. Material and methods: Relevant literature on the topic was collected by a literature search based on the PRISMA 2020 guidelines. Results: A comprehensive overview on the historical development of hemispheric disconnection procedures for epilepsy is presented, while discussing indications, timing, surgical techniques and complications. Current practice for this procedure in European epilepsy surgery centers is provided. At present, our knowledge of long-term seizure outcomes primarily stems from open surgical disconnection procedures. Although minimal invasive surgical techniques in epilepsy are rapidly developing and reported in case reports or small case series, long-term seizure outcome remain uncertain and needs to be reported. Discussion and conclusion: This is the first paper presenting a European consensus statement regarding history, indications, techniques and complications of hemispheric disconnection procedures for different causes of chronic, drug-resistant epilepsy. Furthermore, it serves as the pioneering document to report a comprehensive overview of the current surgical practices regarding this type of surgery employed in renowned epilepsy surgery centers across Europe.

Introduction: Despite changes in regulations, boxing-related injuries and fatalities are still occurring. The numbers available in the literature regarding mortality and long-term consequences may not accurately represent the actual situation. Indeed, the real extent of this phenomenon remains poorly known. Research question: Delineating the spectrum of acute and chronic consequences of boxing-related traumatic brain injuries (TBI). Material and methods: Narrative review of the literature concerning acute and chronic boxing-related TBI. Keywords such as mortality, boxing, subdural hematoma were used to search in PubMed and Google scholar. An updated analysis of the Velazquez fatalities collection in boxing was undertaken. Results: The Velazquez collection includes 2076 fatalities from 1720 to the present with a death rate of 10 athletes per year. More than half of the deaths (N = 1354, 65.2%) occurred after a knock-out, and nearly 75% happened during professional bouts. In Australia, from 1832 to 2020, 163 fatalities were recorded (75% professional). In Japan, from 1952 to 2016, 38 deaths were recorded with a mean age of 23.9 years. Up to 40% of retired professional boxers in the United States were diagnosed with symptoms of chronic brain injury. Clinical dementia is far more prevalent among professional boxers than in amateurs with an incidence of 20%. Discussion and conclusions: A concerted effort to raise awareness and shed light on boxing-related neuro-trauma is required. Similar considerations can be made for other combat sports or contact sports. A call to action to address this knowledge gap, decrease and prevent this phenomenon is advocated.

Arterial spin labeling (ASL) has emerged as a promising noninvasive tool for the evaluation of both pediatric and adult arteriovenous malformations (AVMs). This paper reviews the advantages and challenges associated with the use of ASL in AVM assessment. An assessment of the diagnostic workup of AVMs and their variants in both adult and pediatric populations is proposed. Evaluation after treatments, whether endovascular or microsurgical, was similarly examined. ASL, with its endogenous tracer and favorable safety profile, offers functional assessment and arterial feeder identification. ASL has demonstrated strong performance in identifying feeder arteries and detecting arteriovenous shunting, although some studies report inferior performance compared with digital subtraction angiography (DSA) in delineating venous drainage. Challenges include uncertainties in sensitivity for specific AVM features. Detecting AVMs in challenging locations, such as the apical cranial convexity, is further complicated, demanding careful consideration due to the risk of underestimating total blood flow. Navigating these challenges, ASL provides a noninvasive avenue with undeniable merits, but a balanced approach considering its limitations is crucial. Larger-scale prospective studies are needed to comprehensively evaluate the diagnostic performance of ASL in AVM assessment.

In this paper, we discuss how the clustering analysis technique can be applied to analyze functional magnetic resonance imaging (fMRI) time-series data in the context of glioblastoma (GBM), a highly heterogeneous brain tumor. The precise characterization of GBM is challenging and requires advanced analytical approaches. We have synthesized the existing literature to provide an overview of how clustering algorithms can help identify unique patterns within the dynamics of GBM. Our review shows that the clustering of fMRI time series has great potential for improving the differentiation between various subtypes of GBM, which is pivotal for developing personalized therapeutic strategies. Moreover, this method proves to be effective in capturing temporal changes occurring in GBM, enhancing the monitoring of disease progression and response to treatment. By thoroughly examining and consolidating the current research, this paper contributes to the understanding of how clustering techniques applied to fMRI data can refine the characterization of GBM. This article emphasizes the importance of incorporating cutting-edge data analysis techniques into neuroimaging and neuro-oncology research. By providing a detailed perspective, this approach may guide future investigations and boost the development of tailored therapeutic strategies for GBM.

BackgroundChronic subdural hematoma (cSDH) is a disease affecting mainly elderly individuals. The reported incidence ranges from 2.0/100,000 to 58 per 100,000 person-years when only considering patients who are over 70 years old, with an overall incidence of 8.2–14.0 per 100,000 persons. Due to an estimated doubling of the population above 65 years old between 2000 and 2030, cSDH will become an even more significant concern. To gain an overview of cSDH hospital admission rates, treatment, and outcome, we performed this multicenter national cohort study of patients requiring surgical treatment of cSDH.MethodsA multicenter cohort study included patients treated in 2013 in a Swiss center accredited for residency. Demographics, medical history, symptoms, and medication were recorded. Imaging at admission was evaluated, and therapy was divided into burr hole craniostomy (BHC), twist drill craniostomy (TDC), and craniotomy. Patients' outcomes were dichotomized into good (mRS, 0–3) and poor (mRS, 4–6) outcomes. A two-sided t-test for unpaired variables was performed, while a chi-square test was performed for categorical variables, and a p-value of

Objective To evaluate ChatGPT‘s performance in brain glioma adjuvant therapy decision-making.Methods We randomly selected 10 patients with brain gliomas discussed at our institution’s central nervous system tumour board (CNS TB). Patients’ clinical status, surgical outcome, textual imaging information and immuno-pathology results were provided to ChatGPT V.3.5 and seven CNS tumour experts. The chatbot was asked to give the adjuvant treatment choice, and the regimen while considering the patient’s functional status. The experts rated the artificial intelligence-based recommendations from 0 (complete disagreement) to 10 (complete agreement). An intraclass correlation coefficient agreement (ICC) was used to measure the inter-rater agreement.Results Eight patients (80%) met the criteria for glioblastoma and two (20%) were low-grade gliomas. The experts rated the quality of ChatGPT recommendations as poor for diagnosis (median 3, IQR 1–7.8, ICC 0.9, 95% CI 0.7 to 1.0), good for treatment recommendation (7, IQR 6–8, ICC 0.8, 95% CI 0.4 to 0.9), good for therapy regimen (7, IQR 4–8, ICC 0.8, 95% CI 0.5 to 0.9), moderate for functional status consideration (6, IQR 1–7, ICC 0.7, 95% CI 0.3 to 0.9) and moderate for overall agreement with the recommendations (5, IQR 3–7, ICC 0.7, 95% CI 0.3 to 0.9). No differences were observed between the glioblastomas and low-grade glioma ratings.Conclusions ChatGPT performed poorly in classifying glioma types but was good for adjuvant treatment recommendations as evaluated by CNS TB experts. Even though the ChatGPT lacks the precision to replace expert opinion, it may serve as a promising supplemental tool within a human-in-the-loop approach.

Objective: The goal of this study was to investigate the diagnostic utility of electric source imaging (ESI) in the presurgical evaluation of children with focal cortical dysplasia (FCD) and to compare it with other imaging techniques. Methods: Twenty patients with epilepsy onset before 18 years, surgically treated focal epilepsy with a minimal follow-up of 2 years, and histologically proven FCD were retrospectively selected. All patients underwent MRI, positron emission tomography (PET), and 16 patients also had ictal single-photon emission computed tomography (iSPECT). ESI, using EEG with 64 electrodes or more (HD-ESI), was performed in all 20 patients. We determined sensitivity, specificity and accuracy of ESI, and compared its yield to that of other imaging techniques. Results: Twelve patients were seizure-free post-operatively (60%). Among all patients, highest localization accuracy (80%) was obtained with ESI, followed by PET and iSPECT (75%). When results from ESI and SPECT were concordant 100% of patients achieved Engel I outcome. If ESI and PET showed concordant localization, 90% of patients achieved postoperative seizure freedom. Conclusions: Our findings demonstrate that HD-ESI allows accurate localization of the epileptogenic zone in patients with FCD. Significance: In combination with other imaging modalities, ESI helps with planning a more accurate surgery and therefore, the chances of postoperative seizure control are higher. Since it is based on EEG recordings, it does not require sedation, which is particularly interesting in pediatric patients. ESI represents an important imaging tool in focal epilepsies due to cortical dysplasia, which might be difficult to detect on standard imaging.

Introduction Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord impairment. Unfortunately, the condition remains poorly recognised and underdiagnosed. To better identify patients, screening tests that target individuals at high risk would be helpful. One group in particular known to have a high prevalence of DCM consists of patients with lumbar degenerative disease (LDD), with the combined presentation referred to as tandem stenosis. Given that LDD is one of the most common presentations in neurosurgical practice and primary care, it is the objective of the proposed study to administer a screening test to these patients as well as those with risk factors or symptoms which raise the suspicion of underlying DCM.Methods and analysis A screening test based on clinical signs/symptoms and known risk factors of DCM was designed. Screening will be performed in neurosurgical consultations for patients with LDD or those with any suspicion of myelopathy. Points are attributed based on the presence of signs/symptoms of DCM (eg, Hoffmann sign, hyper-reflexia) and for comorbidities that predispose or are frequently associated with cervical myelopathy (eg, rheumatoid arthritis, carpal tunnel syndrome). Patients with ≥3 points undergo cervical MRI examination. Patients with positive MRIs will be consulted and receive assessment via modified Japanese Orthopedic Association and Neck Disability Index scores, and subsequent clinical management will be based on practice guidelines. An exploratory multivariate analysis of the effectiveness and efficiency of this proposed screening test will be evaluated after positively screening 50 patients for DCM.Ethics and dissemination This study has received research ethics approval from the Swiss Association of Research Ethics Committees (ID: 2020-02785). The results of this study will be disseminated in a journal targeting physicians commonly encountering patients with LDD.

Abstract The world currently faces the novel severe acute respiratory syndrome coronavirus 2 pandemic. Little is known about the effects of a pandemic on non-elective neurosurgical practices, which have continued under modified conditions to reduce the spread of COVID-19. This knowledge might be critical for the ongoing second coronavirus wave and potential restrictions on health care. We aimed to determine the incidence and 30-day mortality rate of various non-elective neurosurgical procedures during the COVID-19 pandemic. A retrospective, multi-centre observational cohort study among neurosurgical centres within Austria, the Czech Republic, and Switzerland was performed. Incidence of neurosurgical emergencies and related 30-day mortality rates were determined for a period reflecting the peak pandemic of the first wave in all participating countries (i.e. March 16th–April 15th, 2020), and compared to the same period in prior years (2017, 2018, and 2019). A total of 4,752 emergency neurosurgical cases were reviewed over a 4-year period. In 2020, during the COVID-19 pandemic, there was a general decline in the incidence of non-elective neurosurgical cases, which was driven by a reduced number of traumatic brain injuries, spine conditions, and chronic subdural hematomas. Thirty-day mortality did not significantly increase overall or for any of the conditions examined during the peak of the pandemic. The neurosurgical community in these three European countries observed a decrease in the incidence of some neurosurgical emergencies with 30-day mortality rates comparable to previous years (2017–2019). Lower incidence of neurosurgical cases is likely related to restrictions placed on mobility within countries, but may also involve delayed patient presentation.

Posterior fossa atypical teratoid rhabdoid tumor (ATRT) is a rare childhood tumor usually associated with a dismal prognosis. Although upfront surgical gross total resection (GTR) has classically been the first line of treatment, new multimodal treatments, including two-stage surgery, are showing promising results in terms of overall survival (OS) and complication rate. We present a case of a 9-month-old child treated with two-staged surgery and chemotherapy. When deemed risky, multimodal treatments, including staged surgeries, can be a safe alternative to reduce surgical mortality and morbidity. At 23 months old, the patient had normal global development and no major impact on quality of life. We, therefore, discuss the most recent advancements from a treatment perspective, including molecular targeting.

Objective The patient-reported outcome measure (PROM)-based evaluation in lumbar degenerative disc disease (DDD) is today’s gold standard but has limitations. We studied the impact of lower extremity motor deficits (LEMDs) on PROMs and a new objective outcome measure. Methods We evaluated patients with lumbar DDD from a prospective 2-center database. LEMDs were graded according to the British Medical Research Council (BMRC; 5 [normal] –0 [no movement]). The PROM-based evaluation included pain (visual analogue scale), disability (Oswestry Disability Index [ODI] & Roland-Morris Disability Index [RMDI]), and health-related quality of life (HRQoL; Short-Form 12 physical component summary/mental component summary & EuroQol-5D index). Objective functional impairment (OFI) was determined as age- and sex-adjusted Timed-Up and Go (TUG) test value. Results One hundred five of 375 patients (28.0%) had a LEMD. Patients with LEMD had slightly higher disability (ODI: 52.8 vs. 48.2, p = 0.025; RMDI: 12.6 vs. 11.3, p = 0.034) but similar pain and HRQoL scores. OFI T-scores were significantly higher in patients with LEMD (144.2 vs. 124.3, p = 0.006). When comparing patients with high- (BMRC 0–2) vs. low-grade LEMD (BMRC 3–4), no difference was evident for the PROM-based evaluation (all p > 0.05) but patients with high-grade LEMD had markedly higher OFI T-scores (280.9 vs. 136.0, p = 0.001). Patients with LEMD had longer TUG test times and OFI T-scores than matched controls without LEMDs. Conclusion Our data suggest that PROMs fail to sufficiently account for LEMD-associated disability, which is common and oftentimes bothersome to patients. The objective functional evaluation with the TUG test appears to be more sensitive to LEMD-associated disability. An objective functional evaluation of patients with LEMD appears reasonable.

Voluntary action and free will have been associated with cortical activity, referred to as “the readiness potential” that precedes self-initiated actions by about 1 s. Here, the authors show that the involuntary and cyclic motor act of breathing is coupled with voluntary action and the readiness potential.

Introduction: Women continue to be underrepresented in the majority of surgical specialties, including neurosurgery. Research question: In this multinational survey, we aimed to assess current gender disparities in neurosurgery focusing on job satisfaction and inequity/discrimination at work. Material and methods: Female and male members of the European Association of Neurosurgical Societies were asked to complete an electronic survey (Google Forms, Mountain View) containing demographic baseline data and questions on attitudes regarding gender disparity, personal experience with gender inequity and career satisfaction/work-life balance. Quantitative analyses were performed to analyse the responses, including summary and comparative statistics. Results: We received 168 responses from 40 different countries. Survey responders had a mean age of 40.8 ​± ​11.5 years; 29.8% were female. There were significant more male than female residents and attending surgeons per department. Eighty-eight percent of female and 38.1% of male responders experienced gender inequity or discrimination at work (adjusted OR 10.8, 95%CI 4.2–27.8, p

Background: Virtual Reality (VR) technologies have numerous beneficial applications for patients during hospitalization (through complete immersion in a virtual, distant place allowing to “escape” from the context of hospitalization). Their positive effects in pain and anxiety management, neurorehabilitation and psychotherapy have been demonstrated. Here, we evaluated the effects of VR on the quality of hospitalization and postoperative pain after neurosurgery.Methods: Patients hospitalized in our department between 2019 and 2020 were prospectively enrolled and divided into a group that received a personal, 30-minutes-long, VR session using an Oculus Go ™ VR headset (VR group) or not (non-VR group). Surgeries were classified in simple or complex spinal and simple or complex cranial. Patient‘s overall satisfaction was considered as primary outcome, with secondary outcomes encompassing duration of hospitalization, pain reduction and patients’ opinion regarding VR.Results: 161 patients were enrolled (77 in the VR group and 84 in the non-VR group). There was no statistical difference between the two groups regarding satisfaction. The VR group presented with a significantly longer duration of hospitalization and higher maximal pain. Interestingly, pain reduction during hospitalization was significantly higher in the VR group, particularly in simple surgeries and spine surgeries. A vast majority of the VR group patients appreciated their VR experience (89.2%) and advocated for its systematic use (83.8%).Conclusion: VR can improve pain reduction during hospitalization after neurosurgery, particularly for simple spine surgeries. Furthermore, patients experiencing VR appear to appreciate it and advocate for its systematic use in neurosurgery. Further research is warranted to identify patients for whom addition of VR during hospitalization might bring the most benefit.

Abstract Intraoperative electrocorticography (ECoG) captures neural information from the surface of the cerebral cortex during surgeries such as resections for intractable epilepsy and tumors. Current clinical ECoG grids come in evenly spaced, millimeter‐sized electrodes embedded in silicone rubber. Their mechanical rigidity and fixed electrode spatial resolution are common shortcomings reported by the surgical teams. Here, advances in soft neurotechnology are leveraged to manufacture conformable subdural, thin‐film ECoG grids, and evaluate their suitability for translational research. Soft grids with 0.2 to 10 mm electrode pitch and diameter are embedded in 150 µm silicone membranes. The soft grids are compatible with surgical handling and can be folded to safely interface hidden cerebral surface such as the Sylvian fold in human cadaveric models. It is found that the thin‐film conductor grids do not generate diagnostic‐impeding imaging artefacts (

Introduction: A connection clip to the ultrasonic aspirator handpiece was introduced for simultaneous resection and mapping of corticospinal motor tract (CST) (Kombos et al., 2001). Research question: To report retrospectively the use of this clip in cerebral surgery with CST mapping. Material and methods: Eight women and four men were included (mean: 55.8 years, SD 17.3 years). The ultrasonic aspirator handpiece was stimulated every second (5 biphasic pulses, 0.4 ​ms per phase, max 14 ​mA). Motor evoked potentials (MEPs) (Taniguchi et al., 1993), with transcranial and direct cortical stimulation, were alternated with CST mapping. The distances between the stimulus locations to the CST (diffusion tensor imaging based fibre tractography) were determined postoperatively. Muscle strength was evaluated pre-operatively, at discharge and 3 months. Results: Motor mapping thresholds ranged between 2 and 13 ​mA, in 12 consecutive patients (7 post-central, 5 insular). The distance of the stimulation site to the CST was fitted (y ​= ​0.63x+2.33, R2 ​= ​0.33; x, mA; y, mm), approximating the rule of thumb of 1 ​mA indicating 1 ​mm (R2 ​= ​0.22). One patient presented with a deterioration of motor function (wrist, M4+). No intraoperative seizures were observed. Discussion: The concept that 1 ​mA corresponds to 1 ​mm from the CST, was roughly observed within this low current range. This rule must be applied, integrating the confidence limits, when getting close to the CST, in conjunction with MEPs. Conclusion: The standardization of this clip, for continuous stimulation of the ultrasonic aspirator with simultaneous tissue resection, made the guided surgical flow smoother, more refined and very natural.

Introduction: Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies. Research question: What is the state of the art of cSDH management. Material and methods: Review. Results: Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13–15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9–22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9–33%), occurring more commonly with older age and bilateral cSDHs. Discussion and conclusion: While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment.

With the technical developments in neurosurgery, increasing numbers of neurosurgical implants are used in an increasingly aged population of patients with several comorbidities. Consequently, the number of neurosurgical implant-associated infections is continuously raising, resulting in significant morbidity and mortality, including disfiguring skull deformities and lack of brain protection. In this article we review infections associated with craniotomy, cranioplasty, neurostimulators, internal cerebrospinal fluid shunts, and external ventricular and lumbar cerebrospinal fluid drainages. In all implant-associated infections biofilms are involved, which are difficult to eradicate. A low number of microorganisms is sufficient to form a biofilm on the implant surface. In most infections, microorganisms of the skin flora are involved. Microorganisms reach the implant during surgery or immediately thereafter as a result of wound healing disturbances. In about two thirds of patients, implant-associated infections manifest early (within the first month after surgery), whereas the remaining infections present later as a result of low-grade infections or by direct extension from adjacent infections (per continuitatem) to the implants due to soft tissue damage. Except for ventriculo-atrial cerebrospinal fluid shunts, neurosurgical implants are rarely infected by the haematogenous route. In this article we review established and clinically validated concepts for the management of biofilm-associated infections in orthopaedic and trauma surgery, which can be extrapolated to other surgical disciplines that use implants. However, the evidence for the success of this extrapolation to neurosurgical patients is sparse and has not been evaluated in large patient populations. For favourable outcome, an optimised microbiological diagnosis including sonication of removed implants and prolonged incubation of cultures is required. Furthermore, a combined surgical and antimicrobial management strategy is needed. Surgery includes an appropriate debridement with or without implant exchange or removal, depending on the age of the biofilm and the soft tissue condition. Antimicrobial treatment includes a prolonged biofilm-active therapy, typically for 4–12 weeks. This concept is attractive, because in selected patients, implants can be retained or exchanged in a one-stage surgical procedure, which improves not only quality of life, but also decreases morbidity because every additional neurosurgical intervention can lead to secondary complications, including intracerebral bleeding or ischemia.

Glioblastoma is a dreadful disease with very poor prognosis, median overall survival being

Objective: Epilepsy diagnosis can be difficult in the absence of interictal epileptic discharges (IED) on scalp EEG. We used high-density EEG to measure connectivity in large‐scale functional networks of patients with focal epilepsy (Temporal and Extratemporal Lobe Epilepsy, TLE and ETLE) and tested for network alterations during resting wakefulness without IEDs, compared to healthy controls. We measured global efficiency as a marker of integration within networks. Methods: We analysed 49 adult patients with focal epilepsy and 16 healthy subjects who underwent high-density-EEG and structural MRI. We estimated cortical activity using electric source analysis in 82 atlas-based cortical regions based on the individual MRI. We applied directed connectivity analysis (Partial Directed Coherence) on these sources and performed graph analysis: we computed the Global Efficiency on the whole brain and on each resting state network. We tested these features in different group of patients. Results: Compared to controls, efficiency was increased in both TLE and ETLE (p

Objective: To diagnose and lateralise temporal lobe epilepsy (TLE) by building a classification system that uses directed functional connectivity patterns estimated during EEG periods without visible pathological activity. Methods: Resting-state high-density EEG recording data from 20 left TLE patients, 20 right TLE patients and 35 healthy controls was used. Epochs without interictal spikes were selected. The cortical source activity was obtained for 82 regions of interest and whole-brain directed functional connectivity was estimated in the theta, alpha and beta frequency bands. These connectivity values were then used to build a classification system based on two two-class Random Forests classifiers: TLE vs healthy controls and left vs right TLE. Feature selection and classifier training were done in a leave-one-out procedure to compute the mean classification accuracy. Results: The diagnosis and lateralization classifiers achieved a high accuracy (90.7% and 90.0% respectively), sensitivity (95.0% and 90.0% respectively) and specificity (85.7% and 90.0% respectively). The most important features for diagnosis were the outflows from left and right medial temporal lobe, and for lateralization the right anterior cingulate cortex. The interaction between features was important to achieve correct classification. Significance: This is the first study to automatically diagnose and lateralise TLE based on EEG. The high accuracy achieved demonstrates the potential of directed functional connectivity estimated from EEG periods without visible pathological activity for helping in the diagnosis and lateralization of TLE. Keywords: Temporal lobe epilepsy, Diagnosis, Lateralization, EEG, Machine learning

The present document represents the position of Swiss health-care associations, clinical and research centers, research-supporting foundations, and the association Alzheimer Switzerland regarding the care of persons with dementia and Alzheimer’s disease. We claim that dementia is not part of normal aging but a disease developing more frequently in old age; early diagnosis and treatment of dementia is paramount; all patients with dementia have the right to receive state-of-the-art treatments; more intense information, education, and counseling on dementia are necessary; media should provide balanced and fair reporting of scientific discoveries on Alzheimer’s and dementia; all patients with dementia have the right to be treated; anti-dementia drugs should be used and accompanied by listening, compassion, and understanding.

Despite the general acceptance of magnetic resonance imaging (MRI) as the gold standard for diagnostics of traumatic disco-ligamentous injuries in the subaxial cervical spine, clinical experience shows cases where no lesion is detected in MRI exams but obtained during surgery. The aim of this study was to compare intraoperative site inspection to preoperative imaging findings and to identify radiological features of patients having a risk for under- or over-estimating disco-ligamentous lesions. We performed a retrospective analysis of our clinical database, considering all patients who underwent surgical treatment of the cervical spine via an anterior approach after trauma between June 2008 and April 2018. Only patients with availability of immediate preoperative computed tomography (CT), 3-Tesla MRI scans, and information about intraoperative findings were considered. Results of preoperative imaging were set in context to intraoperative findings, and receiver operator characteristics (ROC) were calculated. Out of 144 patients receiving anterior cervical surgery after trauma, 83 patients (mean age: 59.4 ± 20.5 years, age range: 12–94 years, 63.9% males) were included in this study. Included patients underwent surgical treatment via anterior cervical discectomy and fusion (ACDF; 79 patients) or anterior cervical corpectomy and fusion (4 patients) with ventral plating. Comparing preoperative imaging findings to intraoperative site inspection, a discrepancy between imaging and surgical findings was revealed in 14 patients, leading to an overall specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of the cervical spine of 100%/77.4%. Yet, adding the existence of prevertebral hematoma and/or vertebral fractures according to preoperative imaging improved the sensitivity to 95.2%. Lack of sensitivity was most likely related to severe cervical spondylosis, rendering correct radiological reporting difficult. Thus, the risk of missing a traumatic disco-ligamentous injury of the cervical spine in imaging seems to be a particular threat in patients with preexisting degenerative cervical spondylosis. In conclusion, incorporating the existence of prevertebral hematoma and/or vertebral fractures can significantly improve diagnostic yield.

Traumatic brain injury is a common event where 70%-90% will be classified as mild TBI (mTBI). Among these, only 10% will have a brain lesion visible via CT scan. A triage biomarker would help clinicians to identify patients with mTBI who are at risk of developing a brain lesion and require a CT scan. The brain cells damaged by the shearing, tearing and stretching of a TBI event set off inflammation cascades. These cause altered concentrations of a high number of both pro-inflammatory and anti-inflammatory proteins. This study aimed to discover a novel diagnostic biomarker of mTBI by investigating a broad panel of inflammation biomarkers and their capacity to correctly identify CT-positive and CT-negative patients. Patients enrolled in this study had been diagnosed with mTBI, had a GCS score of 15 and suffered from at least one clinical symptom. There were nine patients in the discovery group, 45 for verification, and 133 mTBI patients from two different European sites in the validation cohort. All patients gave blood samples, underwent a CT scan and were dichotomised into CT-positive and CT-negative groups for statistical analyses. The ability of each protein to classify patients was evaluated with sensitivity set at 100%. Three of the 92 inflammation proteins screened-MCP-1, MIP-1alpha and IL-10 -were further investigated in the verification group, and at 100% sensitivity their specificities reached 7%, 0% and 31%, respectively. IL-10 was validated on a larger cohort in comparison to the most studied mTBI diagnostic triage protein to date, S100B. Levels of both proteins were significantly higher in CT-positive than in CT-negative patients (p < 0.001). S100B's specificity at 100% sensitivity was 18% (95% CI 10.8-25.2), whereas IL-10 reached a specificity of 27% (95% CI 18.9-35.1). These results showed that IL-10 might be an interesting and clinically useful diagnostic tool, capable of differentiating between CT-positive and CT-negative mTBI patients.

Mild traumatic brain injury (mTBI) patients may have trauma-induced brain lesions detectable using CT scans. However, most patients will be CT-negative. There is thus a need for an additional tool to detect patients at risk. Single blood biomarkers, such as S100B and GFAP, have been widely studied in mTBI patients, but to date, none seems to perform well enough. In many different diseases, combining several biomarkers into panels has become increasingly interesting for diagnoses and to enhance classification performance. The present study evaluated 13 proteins individually-H-FABP, MMP-1, MMP-3, MMP-9, VCAM, ICAM, SAA, CRP, GSTP, NKDA, PRDX1, DJ-1 and IL-10-for their capacity to differentiate between patients with and without a brain lesion according to CT results. The best performing proteins were then compared and combined with the S100B and GFAP proteins into a CT-scan triage panel. Patients diagnosed with mTBI, with a Glasgow Coma Scale score of 15 and one additional clinical symptom were enrolled at three different European sites. A blood sample was collected at hospital admission, and a CT scan was performed. Patients were divided into two two-centre cohorts and further dichotomised into CT-positive and CT-negative groups for statistical analysis. Single markers and panels were evaluated using Cohort 1. Four proteins-H-FABP, IL-10, S100B and GFAP-showed significantly higher levels in CT-positive patients. The best-performing biomarker was H-FABP, with a specificity of 32% (95% CI 23-40) and sensitivity reaching 100%. The best-performing two-marker panel for Cohort 1, subsequently validated in Cohort 2, was a combination of H-FABP and GFAP, enhancing specificity to 46% (95% CI 36-55). When adding IL-10 to this panel, specificity reached 52% (95% CI 43-61) with 100% sensitivity. These results showed that proteins combined into panels could be used to efficiently classify CT-positive and CT-negative mTBI patients.

Anaplastic meningioma is seldom encountered. Moreover, distant metastasis is extremely rare, with only a handful cases reported. Here, we report the case of a 74-year-old female patient who underwent a combined cranial and endonasal approach for an extensive spheno-orbital anaplastic meningioma (WHO grade III), followed by adjuvant radiotherapy. Although local tumor control was achieved, she presented with lung metastasis 2 years later. The patient then died from pulmonary complications related to chest metastasis. On the basis of this case, we discuss the available literature on metastatic meningiomas and radiologic follow-up strategies.

The majority of patients with mild traumatic brain injury (mTBI) will have normal Glasgow coma scale (GCS) of 15. Furthermore, only 5%-8% of them will be CT-positive for an mTBI. Having a useful biomarker would help clinicians evaluate a patient's risk of developing intracranial lesions. The S100B protein is currently the most studied and promising biomarker for this purpose. Heart fatty-acid binding protein (H-FABP) has been highlighted in brain injury models and investigated as a biomarker for stroke and severe TBI, for example. Here, we evaluate the performances of S100B and H-FABP for differentiating between CT-positive and CT-negative patients. A total of 261 patients with a GCS score of 15 and at least one clinical symptom of mTBI were recruited at three different European sites. Blood samples from 172 of them were collected ≤ 6 h after trauma. Patients underwent a CT scan and were dichotomised into CT-positive and CT-negative groups for statistical analyses. H-FABP and S100B levels were measured using commercial kits, and their capacities to detect all CT-positive scans were evaluated, with sensitivity set to 100%. For patients recruited ≤ 6 h after trauma, the CT-positive group demonstrated significantly higher levels of both H-FABP (p = 0.004) and S100B (p = 0.003) than the CT-negative group. At 100% sensitivity, specificity reached 6% (95% CI 2.8-10.7) for S100B and 29% (95% CI 21.4-37.1) for H-FABP. Similar results were obtained when including all the patients recruited, i.e. hospital arrival within 24 h of trauma onset. H-FABP out-performed S100B and thus seems to be an interesting protein for detecting all CT-positive mTBI patients with a GCS score of 15 and at least one clinical symptom.