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Purpose Intradural spinal hemangioblastomas are rare highly hypervascularized benign neoplasms. Surgical resection remains the treatment of choice, with a significant risk of postoperative neurological deterioration. Due to the tumor infrequency, scientific evidence is scarce and limited to case reports and small case series. Methods We performed a retrospective multicenter study including five high-volume neurosurgical centers analyzing patients surgically treated for spinal hemangioblastomas between 2006 and 2021. We assessed clinical status, surgical data, preoperative angiograms, and embolization when available. Follow-up records were analyzed, and logistic regression performed to assess possible risk factors for neurological deterioration. Results We included 60 patients in Germany and Austria. Preoperative angiography was performed in 30% of the cases; 10% of the patients underwent preoperative embolization. Posterior tumor location and presence of a syrinx favored gross total tumor resection (93.8% vs. 83.3% and 97.1% vs. 84%). Preoperative embolization was not associated with postoperative worsening. The clinical outcome revealed a transient postoperative neurological deterioration in 38.3%, depending on symptom duration and preoperative modified McCormick grading, but patients recovered in most cases until follow-up. Conclusion Spinal hemangioblastoma patients significantly benefit from early surgical treatment with only transient postoperative deterioration and complete recovery until follow-up. The performance of preoperative angiograms remains subject to center disparities.

Background Dumbbell tumors present challenging cases, with either an incomplete tumor resection or a need to sacrifice nerve roots. Published literature suggests encouraging neurological outcomes after nerve root amputation. Objective To determine the incidence of postoperative neurological deficits after amputating the parent nerve root. Methods A retrospective consecutive analysis of all patients treated for dumbbell nerve sheet tumors with a reported amputation of the functional relevant parent nerve roots C5-Th1 and L3-S1. Results Among 21 evaluated patients, minor postoperative neurological motor function deterioration occurred in 4 patients (19%). Most patients recovered to the preoperative level at the follow-up examination, and only one patient retained a new Medical Research Council (MRC) scale of 4/5 for deltoid weakness. The majority of tumors were resected at the lumbar level (nerve root L3: 28.6%, L5: 19%). Gross total resection was achieved in 90.5% of patients. Neuropathic pain was reported in one third of the patients during the long-term follow-up. Conclusion Amputating critical parent nerve roots during the dumbbell tumor resections seems to result in a low incidence of postoperative motor deficits and may offer an acceptable sacrifice in otherwise only incompletely resectable dumbbell tumors. The cross-innervation of neighboring nerve roots and its, probably, per-se-reduced functionality may be a possible mechanism for maintaining motor function.

Spinal dural arterio-venous fistulas (SDAVF) are rare vascular pathologies. Degree of symptom improvement after surgery remains unclear. We evaluated surgically treated SDAVF patients for functional outcome and symptom improvement. Retrospective inclusion of consecutive patients treated surgically in our department between 2007&ndash, 2019. We measured functional outcome using the McCormick Scale and modified Japanese Orthopaedic Association (mJOA) score. We included 27 patients with a median follow-up of 8.8 months (IQR 27.8). Mean age was 61.8 years (SD 8.4), 40.7% were female. Most frequent location was the thoracic spine in 15 (55.6%) followed by lumbar in 8 (29.6%), cervical in 3 (11.1%) and sacral spine in one patient (3.7%). Most common presenting symptom was progressive myelopathy (24/27 patients, 88.9%). In all patients the SDAVF was completely resected, however, four patients (14.8%) required a second surgery. Six patients (22.2%) deteriorated immediately after surgery with five recovering to baseline upon discharge. On discharge, presenting symptoms had improved in 17 patients (63%), 8/25 patients (32%) had a McCormick score of 1. Twenty (74.1%) continued to improve on follow-up. In total 23/27 patients (85.2%) improved. In the univariable analysis mJOA score on admission was associated with mJOA score on follow-up (coefficient 0.6, 95%CI 0.4&ndash, 0.81, p &lt, 0.001), whereas age was inversely associated (coefficient &minus, 0.1, 95%CI &minus, 0.19&ndash, 0.01, p = 0.08). Untreated SDAVF leads to progressive myelopathy which may result in considerable disability. Surgical disconnection and resection provides a safe treatment option with low perioperative morbidity and excellent chances for symptom improvement or progression prevention.

We present a rare case of a patient initially presenting with unilateral abdominal wall bulging and radicular pain caused by a lateral disc herniation at Th11/12, later suffering from a hernia recurrence with bilateral disc prolapse and motor deficits. The patient underwent sequesterectomy via a right hemilaminectomy at Th11, and after 8 weeks, a bilateral sequesterectomy with semirigid fusion Th11/12 was performed. Unilateral motor deficits at the thoracic level have been discussed in case reports; a bilateral disc protrusion with abdominal wall bulging occurring as a recurrent disc herniation has never been described before.

Chainsaw accidents are severe injuries, mostly work-related and concerning upper or lower extremities. Few suicidal chainsaw injuries are reported, all of them fatal. We report the case of a 23-year-old man who attempted suicide by sub-decapitation with a chainsaw, its successful (peri-) operative management, and clinical course along with a discussion of the contemporary management and body of evidence of such lesions. Chainsaw injuries are severe traumas. Stepwise surgery with maximal functional reconstruction is safe and optimal clinical outcome can be achieved.

Introduction: Adult spinal ependymoma presents a rare benign tumor entity. Due to its incidence peak in the fourth decade of life, it mostly affects patients during a professionally and physically active time of life.Methods: We performed a retrospective monocentric study, including all patients operated upon for spinal ependymoma between January 2009 and September 2020. We prospectively collected data on professional reintegration, physical activities and quality-of-life parameters using EQ-5D and SF-36. Issues encountered in returning to work and physical activities were assessed using existing spinal-cord-specific questionnaires and free-text questions.Results: In total, 65 of 114 patients operated on for spinal ependymomas agreed to participate. Most patients suffered from only mild pre- and postoperative impairment on the modified McCormick scale, but 67% confirmed difficulties performing physical activities in which they previously engaged due to pain, coordination problems and fear of injuries. We observed a shift from full- to part-time employment and patients unable to work, independently from tumor dignity and neurological function.Conclusion: Despite its benign nature and formal only mild neurological deficits occurring in patients suffering from spinal ependymoma, the studied population described severe difficulties returning to their preoperative physical activity and profession. Clinical scores such as the McCormick grade and muscle strength may not reflect the entire self-perceived impairment appropriately.

Introduction Spinal cord herniation (SCH) is a rare cause of progressive myelopathy and Brown-Sequard-Syndrome. Research question Evaluation of functional outcome after SCH treatment compared to conservatively treated patients. Material and methods We retrospectively analysed functional outcome in SCH patients treated between 2009 and 2020. We conducted a systematic search using PubMed, MEDLINE and EMBASE to perform a pooled analysis in SCH patients. Results Our hospital cohort included 17 patients of which 9 were treated surgically. Mean age was 51.9 years, 58.8% of the patients were female. In 4/9 patients (44.4%) the neurological state remained stable after surgery. Four patients improved (44.4%) and one deteriorated after surgery (11.1%). Conservatively treated patients had a higher deterioration rate on follow-up with 3/8 patients deteriorating (37.5%). In our pooled analysis, 109/145 (75.2%) of patients improved, 32/145 (22.1%) remained stable and 4/145 patients deteriorated (2.8%). Among the available data of nine cohorts, mean recovery rate measured by the JOA score was 36.6% (SD 14.4). In our pooled multivariable model lower preoperative JOA score was associated with worse functional outcome (OR 0.86, 95%CI 0.74–0.99, p ​= ​.04). Discussion and conclusion Our data shows that patients who are treated surgically have a higher improvement rate and acceptable perioperative morbidity compared to conservatively treated patients. Lower preoperative JOA score decreases chances of improved functional outcome on follow-up. We therefore advocate early surgery for symptomatic patients. Wait and see appears outdated due to progressive impairment and decreased chances of recovery. However, it is still an option in asymptomatic incidental SCH patients.

OBJECTIVE Cranioplasty (CP) is a crucial procedure after decompressive craniectomy and has a significant impact on neurological improvement. Although CP is considered a standard neurosurgical procedure, inconsistent data on surgery-related complications after CP are available. To address this topic, the authors analyzed 502 patients in a prospective multicenter database (German Cranial Reconstruction Registry) with regard to early surgery-related complications. METHODS Early complications within 30 days, medical history, mortality rates, and neurological outcome at discharge according to the modified Rankin Scale (mRS) were evaluated. The primary endpoint was death or surgical revision within the first 30 days after CP. Independent factors for the occurrence of complications with or without surgical revision were identified using a logistic regression model. RESULTS Traumatic brain injury (TBI) and ischemic stroke were the most common underlying diagnoses that required CP. In 230 patients (45.8%), an autologous bone flap was utilized for CP; the most common engineered materials were titanium (80 patients [15.9%]), polyetheretherketone (57 [11.4%]), and polymethylmethacrylate (57 [11.4%]). Surgical revision was necessary in 45 patients (9.0%), and the overall mortality rate was 0.8% (4 patients). The cause of death was related to ischemia in 2 patients, diffuse intraparenchymal hemorrhage in 1 patient, and cardiac complications in 1 patient. The most frequent causes of surgical revision were epidural hematoma (40.0% of all revisions), new hydrocephalus (22.0%), and subdural hematoma (13.3%). Preoperatively increased mRS score (OR 1.46, 95% CI 1.08–1.97, p = 0.014) and American Society of Anesthesiologists Physical Status Classification System score (OR 2.89, 95% CI 1.42–5.89, p = 0.003) were independent predictors of surgical revision. Ischemic stroke, as the underlying diagnosis, was associated with a minor rate of revisions compared with TBI (OR 0.18, 95% CI 0.06–0.57, p = 0.004). CONCLUSIONS The authors have presented class II evidence–based data on surgery-related complications after CP and have identified specific preexisting risk factors. These results may provide additional guidance for optimized treatment of these patients.

Transsphenoidal surgery provides a minimal invasive treatment for pituitary adenoma. Our aim is to evaluate the endocrinological outcomes after adenoma resection focusing on the corticotroph function, and to identify prognostic factors for an impaired hypothalamic-pituitary-adrenal-axis function (HPA) and the reliability of postoperative early morning serum cortisol measurements. We performed a retrospective analysis of all patients treated for pituitary adenoma from April 2006 to January 2019 in our neurosurgical department. Pituitary function was assessed pre- and postoperatively as well as at 6 weeks to 12 weeks and at 1-year follow-up. Two hundred eleven patients were included. Nine percent of the patients recovered from a preoperative adrenal insufficiency, 10.4% developed a new need for hormone substitution, and a long-term deficiency of the hypothalamic-pituitary-adrenal-axis was observed in 30.9%. Cortisol measurements 5 days after surgery had a lower area under the curve (AUC) than cortisol levels detected after 6 to 12 weeks (AUC 0.740 vs. AUC 0.808) in predicting an intact corticotrope function. The cut-off value determined for cortisol measured after 6 weeks was 6.95 µg/dl (sensitivity of 94%, specificity of 68%). Postoperative early morning cortisol levels seem to be less sensitive and specific in predicting long-term corticotroph function than measurements after 6 weeks and 1 year, emphasizing the importance of endocrine follow-up testing.

Transsphenoidal surgery provides a minimal invasive treatment for pituitary adenoma. Our aim is to evaluate the endocrinological outcomes after adenoma resection focusing on the corticotroph function, and to identify prognostic factors for an impaired hypothalamic–pituitary–adrenal-axis function (HPA) and the reliability of postoperative early morning serum cortisol measurements. We performed a retrospective analysis of all patients treated for pituitary adenoma from April 2006 to January 2019 in our neurosurgical department. Pituitary function was assessed pre- and postoperatively as well as at 6 weeks to 12 weeks and at 1-year follow-up. Two hundred eleven patients were included. Nine percent of the patients recovered from a preoperative adrenal insufficiency, 10.4% developed a new need for hormone substitution, and a long-term deficiency of the hypothalamic–pituitary–adrenal-axis was observed in 30.9%. Cortisol measurements 5 days after surgery had a lower area under the curve (AUC) than cortisol levels detected after 6 to 12 weeks (AUC 0.740 vs. AUC 0.808) in predicting an intact corticotrope function. The cut-off value determined for cortisol measured after 6 weeks was 6.95 µg/dl (sensitivity of 94%, specificity of 68%). Postoperative early morning cortisol levels seem to be less sensitive and specific in predicting long-term corticotroph function than measurements after 6 weeks and 1 year, emphasizing the importance of endocrine follow-up testing.

OBJECTIVE Healthcare digitization has led to increasing tablet-based apps to improve diagnostics, self-discipline, and well-being in patients. Moreover, patient-reported outcome measures are crucial for optimized treatment, with superior applicability if independent from patient visits. Whereas most uses cover health maintenance, only a few studies have focused on cognitive testing in neurosurgical patients despite its nature as one of the most integrative outcome measures in neurooncology. METHODS The authors performed a prospective single-center feasibility study including neurosurgical patients affected by intraaxial tumors and healthy subjects, testing cognitive function by using a digitized app-based approach and conventional paper-and-pencil (PP) tests. Healthy subjects underwent follow-up testing for retest reliability. RESULTS The authors included 24 patients with brain tumor and 10 healthy subjects, all of whom completed both tests. Equivalent mean performance results were found in the tablet-based digital app and PP counterparts; whereas the digital approach had shorter test duration in patients (29.9 minutes for PP vs 21.9 minutes for app, p = 0.019) and in the healthy cohort (23.2 minutes for PP vs 16.4 minutes for app, p = 0.003), patients with brain tumor scored lower when both test strategies were applied. Results were consistent in healthy subjects after a median of 3 months. CONCLUSIONS Cognitive function assessment is feasible using a digitized tablet-based app, with equivalent results to those of PP tests in healthy subjects and patients with brain tumor. Thus, this approach allows much closer follow-up independent of patient visits and might provide a viable option to improve patient follow-ups.

Purpose Spinal diseases requiring urgent surgical treatment are rare during pregnancy. Evidence is sparse and data are only available in the form of case reports. Our aim is to provide a comprehensive guide for spinal surgery on pregnant patients and highlight diagnostic and therapeutic aspects. Methods The study included a cohort of consecutive pregnant patients who underwent spinal surgery at five high-volume neurosurgical centers between 2010 and 2017. Perioperative and perinatal clinical data were derived from medical records. Results Twenty-four pregnant patients were included. Three underwent a preoperative cesarean section. Twenty-one patients underwent surgery during pregnancy. Median maternal age was 33 years, and median gestational age was 13 completed weeks. Indications were: lumbar disk prolapse (n = 14; including cauda equina, severe motor deficits or acute pain), unstable spine injuries (n = 4); intramedullary tumor with paraparesis (n = 1), infection (n = 1) and Schwann cell nerve root tumor presenting with high-grade paresis (n = 1). Two patients suffered transient gestational diabetes and 1 patient presented with vaginal bleeding without any signs of fetal complications. No miscarriages, stillbirths, or severe obstetric complications occurred until delivery. All patients improved neurologically after the surgery. Conclusion Spinal surgical procedures during pregnancy seem to be safe. The indication for surgery has to be very strict and surgical procedures during pregnancy should be reserved for emergency cases. For pregnant patients, the surgical strategy should be individually tailored to the mother and the fetus.

Background: Navigated repetitive transcranial magnetic stimulation (nrTMS) is effective therapy for stroke patients. Neurorehabilitation could be supported by low-frequency stimulation of the non-damaged hemisphere to reduce transcallosal inhibition. Objective: The present study examines the effect of postoperative nrTMS therapy of the unaffected hemisphere in glioma patients suffering from acute surgery-related paresis of the upper extremity (UE) due to subcortical ischemia. Methods: We performed a randomized, sham-controlled, double-blinded trial on patients suffering from acute surgery-related paresis of the UE after glioma resection. Patients were randomly assigned to receive either low frequency nrTMS (1 Hz, 15 min) or sham stimulation directly before physical therapy for 7 consecutive days. We performed primary and secondary outcome measures on day 1, on day 7, and at a 3-month follow-up (FU). The primary endpoint was the change in Fugl-Meyer Assessment (FMA) at FU compared to day 1 after surgery. Results: Compared to the sham stimulation, nrTMS significantly improved outcomes between day 1 and FU based on the FMA (mean [95% CI] +31.9 [22.6, 41.3] vs. +4.2 [-4.1, 12.5]; P = .001) and the National Institutes of Health Stroke Scale (NIHSS) (−5.6 [-7.5, −3.6] vs. −2.4 [-3.6, −1.2]; P = .02). To achieve a minimal clinically important difference of 10 points on the FMA scale, the number needed to treat is 2.19. Conclusion: The present results show that patients suffering from acute surgery-related paresis of the UE due to subcortical ischemia after glioma resection significantly benefit from low-frequency nrTMS stimulation therapy of the unaffected hemisphere. Clinical trial registration: Local institutional registration: 12/15; ClinicalTrials.gov number: NCT03982329

Transsphenoidal surgery (TSS) represents the gold standard of pituitary adenoma resection, providing a safe and minimal invasive treatment for patients suffering from symptoms of mass effect. The aim of this study is to analyze the postoperative improvement of visual function after adenoma resection and to identify prognostic factors for the postoperative clinical recovery. We performed a retrospective analysis of all consecutive patients treated via a transsphenoidal approach for pituitary adenomas from April 2006 to December 2019 in a high-volume neurosurgical department. Our primary outcome was postoperative visual acuity and visual field impairment; the clinical findings were followed up to 3 months after surgery and correlated with clinical and radiographic findings. In total, 440 surgeries were performed in our department for tumors of the sella region in a time period of 13 years via transsphenoidal approach, and 191 patients included in the analysis. Mean age was 55 years, and 98% were macroadenomas. Mean preoperative visual acuity in patients with preoperative impairment (n = 133) improved significantly from 0.64/0.65 to 0.72/0.75 and 0.76/0.8 (right eye R/left eye L) postoperatively and at 3 months follow-up (p

Combined scalp and skull deficiency due to malignant scalp tumors or sequelae of intracranial surgery present challenging entities for both neurosurgeons and reconstructive treatment. In complex cases, an interdisciplinary approach is needed between neurosurgeons and cranio-maxillofacial surgeons. We present a considerably large series for which we identify typical complications and pitfalls and provide evidence for the importance of an interdisciplinary algorithm for chronic wound healing complications and malignomas of the scalp and skull. We retrospectively reviewed all patients treated by the department of neurosurgery and cranio-maxillofacial surgery at our hospital for complex scalp deficiencies and malignant scalp tumors affecting the skull between 2006 and 2019, and extracted data on demographics, surgical technique, and perioperative complications. Thirty-seven patients were treated. Most cases were operated simultaneously (n: 32) and 6 cases in a staged procedure. Nineteen patients obtained a free flap for scalp reconstruction, 15 were treated with local axial flaps, and 3 patients underwent full thickness skin graft treatment. Complications occurred in 62% of cases, mostly related to cerebrospinal fluid (CSF) circulation disorders. New cerebrospinal fluid (CSF) disturbances occurred in 8 patients undergoing free flaps and shunt dysfunction occurred in 5 patients undergoing local axial flaps. Four patients died shortly after the surgical procedure (perioperative mortality 10.8%). Combined scalp and skull deficiency present a challenging task. An interdisciplinary treatment helps to prevent severe and specialty-specific complications, such as hydrocephalus. We therefore recommend a close neurological observation after reconstructive treatment with focus on symptoms of CSF disturbances.

Background Abnormalities and pathologies of the craniovertebral junction as well as space-occupying lesions of the odontoid process can result in myelopathy symptoms. A staged procedure with posterior stabilization and anterior transnasal endoscopic decompression is recently considered a less invasive alternative to the transoral approach. We present a considerably large case series focused on the operative technique and the long-term neurological clinical outcome. Objective To determine the safety and efficacy of odontoidectomy performed via an endoscopic transnasal approach. Methods We retrospectively reviewed all patients treated in our neurosurgical department from January 2009 to January 2020. Demographics, pre- and postoperative clinical status, and operative technique and complications were extracted and analyzed. Results In total, 22 transnasal operations were performed in 19 patients from January 2009 to January 2020. All but one patient underwent posterior C1-C2 instrumentation prior to the anterior transnasal computed tomography (CT)-navigated full-endoscopic decompression. The median duration of symptoms before surgery was 3 mo. Complications occurred in 1 patient who died from septic organ failure because of his initial diagnosis of osteomyelitis. Postoperative CT imaging showed sufficient decompression in 16 patients, and 3 patients underwent a transnasal endoscopic re-decompression (16%). Conclusion Transnasal endoscopic odontoidectomy presents a safe procedure with a satisfying clinical and radiological postoperative outcome.

A Correction to this paper has been published: 10.1007/s00701-021-04898-w

Introduction Primary malignant spinal astrocytomas present rare oncological entities with limited median survival and rapid neurological deterioration. Evidence on surgical therapy, adjuvant treatment, and neurological outcome is sparse. We aim to describe the treatment algorithm and clinical features on patients with infiltrating intramedullary astrocytomas graded WHO II–IV. Methods The following is a multicentered retrospective study of patients treated for spinal malignant glioma WHO II–IV in five high-volume neurosurgical departments from 2008 to 2019. Pilocytic astrocytomas were excluded. We assessed data on surgical technique, perioperative neurological status, adjuvant oncological therapy, and clinical outcome. Results 40 patients were included (diffuse astrocytoma WHO II n = 11, anaplastic astrocytoma WHO III n = 12, WHO IV n = 17). Only 40% were functionally independent before surgery, most patients presented with moderate disability (47.5%). Most patients underwent a biopsy (n = 18, 45%) or subtotal tumor resection (n = 15, 37.5%), and 49% of the patients deteriorated after surgery. Patients with WHO III and IV tumors were treated with combined radiochemotherapy. Median overall survival (OS) was 46.5 months in WHO II, 25.7 months in WHO III, and 7.4 months in WHO IV astrocytomas. Preoperative clinical status and WHO significantly influenced the OS, and the extent of resection did not. Conclusion Infiltrating intramedullary astrocytomas WHO II–IV present rare entities with dismal prognosis. Due to the high incidence of surgery-related neurological impairment, the aim of the surgical approach should be limited to obtaining the histological tissue via a biopsy or, tumor debulking in cases with rapidly progressive severe preoperative deficits.

Calcified thoracic disc herniations present a rare and challenging entity. Due to the close proximity to the spinal cord and relative narrowing of the spinal canal, the optimal approach remains a matter of debate. While the transthoracic approach is usually preferred, we adapted a new technique described in 2012: the transdural posterior approach. Our aim was to evaluate its benefits in patients with giant thoracic disc protrusions. We retrospectively reviewed all patients treated in our neurosurgical department from July 2012 to March 2020. Demographics, pre- and postoperative clinical status, and operative technique and complications were extracted and analyzed. In total, 12 patients underwent a posterior transdural resection of giant calcified thoracic hard discs between 2012 and 2020. All patients underwent a posterior decompression (laminectomy, hemilaminectomy, or laminoplasty). The median duration of surgery was 152 min. Transient postoperative neurological deterioration occurred in 4 patients, with complete recovery until time of discharge. No patient underwent a surgical revision. The transdural resection of giant calcified thoracic hard discs through a posterior approach provides an excellent decompression with sufficient visualization of the spinal cord and a satisfying postoperative outcome. Electronic supplementary material The online version of this article (10.1007/s10143-020-01413-0) contains supplementary material, which is available to authorized users.

OBJECTIVEAutologous bone graft reimplantation remains the standard treatment after decompressive hemicraniectomy. Unfortunately, some patients present with signs of bone resorption without any visible signs of infection; the reasons remain unknown. Contamination with Propionibacterium acnes has been discussed as a potential source of the osteolytic process. The aim of this study was to investigate the microbial spectrum detected in samples of grafts from patients with aseptic bone resorption and compare them to septic bone graft infections in order to identify P. acnes as the specific pathogen of aseptic bone resorption.METHODSThe authors retrospectively reviewed all patients treated for aseptic bone resorption between 2012 and 2017 in their neurosurgical department. Septic infections were used as a control group to gain information on the present bacterial spectrum. Perioperative data such as demographics, number of surgeries, and complications were assessed and compared with the microbiological analyses conducted in order to detect differences and potential sources for aseptic bone resorption and possible differences in bacterial contamination in septic and aseptic bone infection.RESULTSIn total, 38 patients underwent surgery between 2012 and 2017 for septic bone infection—14 for aseptic bone resorption. In 100% of the septic bone infection cases in which bone flap removal was needed, bacteria could be isolated from the removed bone flap (55% Staphylococcus aureus, 13.2% Enterococcus faecalis, and 18.4% Staphylococcus epidermidis). The microbial spectrum from samples of aseptic bone flaps with resorption was examined in 10 of 14 patients and revealed contamination with P. acnes in 40% (n = 4, the other 6 bone grafts were sterile), especially in sonication analysis, whereas visible septic bone infection was mainly caused by S. aureus without detection of P. acnes.CONCLUSIONSAseptic bone resorption may be caused by low-grade infections with P. acnes. However, further analysis needs to be conducted in order to understand its clinical relevance and treatment perspective.

For the navigation of transcranial magnetic stimulation (TMS), various techniques are available. Yet, there are two basic principles underlying them all: electric-field-navigated transcranial magnetic stimulation (En-TMS) and line-navigated transcranial magnetic stimulation (Ln-TMS). The current study was designed to compare both methods. To explore whether there is a difference in clinical applicability, workflow, and mapping results of both techniques, we systematically compared motor mapping via En-TMS and Ln-TMS in 12 patients suffering from brain tumors. The number of motor-positive stimulation spots and the ratio of positive spots per overall stimulation numbers were significantly higher for En-TMS (motor-positive spots: En-TMS vs. Ln-TMS: 128.3 ± 35.0 vs. 41.3 ± 26.8, p

The resection of left-sided perisylvian brain lesions harbors the risk of postoperative aphasia. Because it is known that language function can shift between hemispheres in brain tumor patients, the preoperative knowledge of the patient's language dominance could be helpful. We therefore investigated the hemispheric language dominance by repetitive navigated transcranial magnetic stimulation (rTMS) and surgery-related deficits of language function.We pooled the bicentric language mapping data of 80 patients undergoing the resection of left-sided perisylvian brain lesions in our two university neurosurgical departments. We calculated error rates (ERs; ER = errors per stimulations) for both hemispheres and defined the hemispheric dominance ratio (HDR) as the quotient of the left- and right-sided ER (HDR1= left dominant; HDR1= right dominant). The course of the patient's language function was evaluated and correlated with the preoperative HDR.Only three of 80 patients (4%) presented with permanent surgery-related aphasia and 24 patients (30%) with transient surgery-related aphasia. The mean HDR (± standard deviation) of patients with new aphasia after five days was significantly higher (1.68±1.07) than the HDR of patients with no new language deficit (1.37±1.08) (p=0.0482). With a predefined cut-off value of 0.5 for HDR, we achieved a sensitivity for predicting new aphasia of 100%.A higher preoperative HDR significantly correlates with an increased risk for transient aphasia. Moreover, the intensive preoperative workup in this study led to a considerably low rate of permanent aphasia.

The resection of left-sided perisylvian brain lesions harbours the risk of postoperative language impairment. Therefore the individual patient’s language distribution is investigated by intraoperative direct cortical stimulation (DCS) during awake surgery. Yet, not all patients qualify for awake surgery. Non-invasive language mapping by repetitive navigated transcranial magnetic stimulation (rTMS) has frequently shown a high correlation in comparison with the results of DCS language mapping in terms of language-negative brain regions. The present study analyses the extent of resection (EOR) and functional outcome of patients who underwent left-sided perisylvian resection of brain lesions based purely on rTMS language mapping. Four patients with left-sided perisylvian brain lesions (two gliomas WHO III, one glioblastoma, one cavernous angioma) underwent rTMS language mapping prior to surgery. Data from rTMS language mapping and rTMS-based diffusion tensor imaging fibre tracking (DTI-FT) were transferred to the intraoperative neuronavigation system. Preoperatively, 5 days after surgery (POD5), and 3 months after surgery (POM3) clinical follow-up examinations were performed. No patient suffered from a new surgery-related aphasia at POM3. Three patients underwent complete resection immediately, while one patient required a second rTMS-based resection some days later to achieve the final, complete resection. The present study shows for the first time the feasibility of successfully resecting language-eloquent brain lesions based purely on the results of negative language maps provided by rTMS language mapping and rTMS-based DTI-FT. In very select cases, this technique can provide a rescue strategy with an optimal functional outcome and EOR when awake surgery is not feasible.

A 48-yr-old female patient presented in our outpatients' clinic after an episode of speech arrest and seizures a week earlier. On physical examination, there were no neurological deficits. Cranial magnetic resonance imaging (MRI) revealed a contrast-enhancing tumor of the superior and middle frontal gyrus. A 18F-fluoroethyl-tyrosine positron emission tomography (FET-PET) showed a high tracer uptake, and we suspected the lesion to be a high-grade glioma. The tumor was located next to the cortical motor and language areas. We performed a left frontal craniotomy while the patient was asleep, and then conducted cortical and subcortical stimulation under an awake condition. The patient was asked to move her right upper extremity and to name objects. Based on MRI navigation, we achieved a complete tumor resection. Postoperative imaging confirmed gross total resection, and final histopathology revealed an anaplastic astrocytoma isocitrate dehydrogenase (IDH) mut, 1p19q noncodeleted WHO°III. The patient was discharged home on the fifth postoperative day with a supplementary motor area syndrome and diminishing word-finding difficulties. We safely achieved gross total tumor resection in a highly eloquent localization through awake craniotomy with direct cortical and subcortical stimulation and electrophysiological monitoring. Awake craniotomy remains the gold standard for tumor resection in eloquent language areas in our clinics. We obtained informed consent from the patient.

Introduction The resection of left-sided perisylvian brain lesions harbors the risk of postoperative aphasia. Because it is known that language function can shift between hemispheres in brain tumor patients, the preoperative knowledge of the patient’s language dominance could be helpful. Objective To investigate the correlation of hemispheric language dominance as measured by repetitive navigated transcranial magnetic stimulation (rTMS) and surgery-related deficits of language function. Patients & methods We pooled the bicentric language mapping data of 80 patients undergoing the resection of left-sided perisylvian brain lesions in our two university neurosurgical departments. We calculated error rates (ERs; ER = errors per stimulations) for both hemispheres and defined the hemispheric dominance ratio (HDR) as the quotient of the left- and right-sided ER (HDR > 1 = left dominant; HDR 1 = right dominant). The course of the patient’s language function was evaluated and correlated with the preoperative HDR. Result Only three of 80 patients (4%) presented with permanent surgery-related aphasia and 24 patients (30%) with transient surgery-related aphasia. The mean HDR (±standard deviation) of patients with new aphasia after five days was significantly higher (1.68 ± 1.07) than the HDR of patients with no new language deficit (1.37 ± 1.08) (p = 0.0482). With a predefined cut-off value of 0.5 for HDR, we achieved a sensitivity for predicting new aphasia of 100%. Conclusion A higher preoperative HDR significantly correlates with an increased risk for transient aphasia. Moreover, the intensive preoperative workup in this study led to a considerably low rate of permanent aphasia.

Introduction The resection of left-sided perisylvian brain lesions harbors the risk of postoperative language impairment. Therefore the individual patient’s language distribution is investigated by intraoperative direct cortical stimulation (DCS) during awake surgery. Yet, not all patients qualify for awake surgery. Non-invasive language mapping by repetitive navigated transcranial magnetic stimulation (rTMS) has frequently shown a high correlation in comparison with the results of DCS language mapping in terms of language-negative brain regions. Objective To analyze the oncological and functional outcome of patients who underwent left-sided perisylvian resection of brain lesions purely based on rTMS language mapping. Patients & methods Four patients with left-sided perisylvian brain lesions (2 gliomas WHO III, 1 glioblastoma, 1 cavernous angioma) underwent rTMS language mapping prior to surgery. Data from rTMS language mapping and rTMS-based diffusion tensor imaging fiber tracking (DTI-FT) were transferred to the intraoperative neuronavigation system. Preoperatively, 5 days after surgery (=POD5), and 3 months after surgery (=POM3) clinical follow-up examinations were performed. Results No patient suffered from a new surgery-related aphasia at POM3. Three patients underwent complete resection immediately, while one patient required a second rTMS-based resection some days later to achieve the final, complete resection. Conclusion The present study shows for the first time the feasibility of successfully resecting language-eloquent brain lesions purely based on the results of negative language maps provided by rTMS language mapping and rTMS-based DTI-FT. In very select cases this technique can provide a rescue strategy with an optimal functional and oncological outcome when awake surgery is not feasible.