Showing papers in "Neurosurgery in 2013"

Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update.

Abstract: In 2002, an author group selected and sponsored by the Joint Section on Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons published the first evidence-based guidelines for the management of patients with acute cervical spinal cord injuries (SCIs). In the spirit of keeping up with changes in information available in the medical literature that might provide more contemporary and more robust medical evidence, another author group was recruited to revise and update the guidelines. The review process has been completed and is published and can be once again found as a supplement to Neurosurgery. The purpose of this article is to provide an overview of the changes in the recommendations as a result of new evidence or broadened scope.

Stereoelectroencephalography: surgical methodology, safety, and stereotactic application accuracy in 500 procedures.

Abstract: BACKGROUND Stereoelectroencephalography (SEEG) methodology, originally developed by Talairach and Bancaud, is progressively gaining popularity for the presurgical invasive evaluation of drug-resistant epilepsies. OBJECTIVE To describe recent SEEG methodological implementations carried out in our center, to evaluate safety, and to analyze in vivo application accuracy in a consecutive series of 500 procedures with a total of 6496 implanted electrodes. METHODS Four hundred nineteen procedures were performed with the traditional 2-step surgical workflow, which was modified for the subsequent 81 procedures. The new workflow entailed acquisition of brain 3-dimensional angiography and magnetic resonance imaging in frameless and markerless conditions, advanced multimodal planning, and robot-assisted implantation. Quantitative analysis for in vivo entry point and target point localization error was performed on a sub--data set of 118 procedures (1567 electrodes). RESULTS The methodology allowed successful implantation in all cases. Major complication rate was 12 of 500 (2.4%), including 1 death for indirect morbidity. Median entry point localization error was 1.43 mm (interquartile range, 0.91-2.21 mm) with the traditional workflow and 0.78 mm (interquartile range, 0.49-1.08 mm) with the new one (P < 2.2 × 10). Median target point localization errors were 2.69 mm (interquartile range, 1.89-3.67 mm) and 1.77 mm (interquartile range, 1.25-2.51 mm; P < 2.2 × 10), respectively. CONCLUSION SEEG is a safe and accurate procedure for the invasive assessment of the epileptogenic zone. Traditional Talairach methodology, implemented by multimodal planning and robot-assisted surgery, allows direct electrical recording from superficial and deep-seated brain structures, providing essential information in the most complex cases of drug-resistant epilepsy.

The Comprehensive Anatomical Spinal Osteotomy Classification

Abstract: Background Global sagittal malalignment is significantly correlated with health-related quality-of-life scores in the setting of spinal deformity. In order to address rigid deformity patterns, the use of spinal osteotomies has seen a substantial increase. Unfortunately, variations of established techniques and hybrid combinations of osteotomies have made comparisons of outcomes difficult. Objective To propose a classification system of anatomically-based spinal osteotomies and provide a common language among spine specialists. Methods The proposed classification system is based on 6 anatomic grades of resection (1 through 6) corresponding to the extent of bone resection and increasing degree of destabilizing potential. In addition, a surgical approach modifier is added (posterior approach or combined anterior and posterior approaches). Reliability of the classification system was evaluated by an analysis of 16 clinical cases, rated 2 times by 8 different readers, and calculation of Fleiss kappa coefficients. Results Intraobserver reliability was classified as "almost perfect"; Fleiss kappa coefficient averaged 0.96 (range, 0.92-1.0) for resection type and 0.90 (0.71-1.0) for the approach modifier. Results from the interobserver reliability for the classification were 0.96 for resection type and 0.88 for the approach modifier. Conclusion This proposed anatomically based classification system provides a consistent description of the various osteotomies performed in spinal deformity correction surgery. The reliability study confirmed that the classification is simple and consistent. Further development of its use will provide a common frame for osteotomy assessment and permit comparative analysis of different treatments.

Pharmacological therapy for acute spinal cord injury.

Abstract: • Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is not Food and Drug Administration (FDA) approved for this application. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death. • Administration of GM-1 ganglioside (Sygen) for the treatment of acute SCI is not recommended.

The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort.

Abstract: BACKGROUND The SRS-Schwab classification of adult spinal deformity (ASD) is a validated system that provides a common language for the complex pathology of ASD. Classification reliability has been reported; however, correlation with treatment has not been assessed. OBJECTIVE To assess the clinical relevance of the SRS-Schwab classification based on correlations with health-related quality of life (HRQOL) measures and the decision to pursue operative vs nonoperative treatment. METHODS Prospective analysis of consecutive ASD patients (18 years of age and older) collected through a multicenter group. The SRS-Schwab classification includes a curve type descriptor and 3 sagittal spinopelvic modifiers (sagittal vertical axis, pelvic tilt, pelvic incidence/lumbar lordosis mismatch). Differences in demographics, HRQOL (Oswestry Disability Index, SRS-22, Short Form-36), and classification between operative and nonoperative patients were evaluated. RESULTS A total of 527 patients (mean age, 52.9 years; range, 18.4-85.1 years) met inclusion criteria. Significant differences in HRQOL were identified based on SRS-Schwab curve type, with thoracolumbar and primary sagittal deformities associated with greater disability and poorer health status than thoracic or double curve deformities. Operative patients had significantly poorer grades for each of the sagittal spinopelvic modifiers, and progressively higher grades were associated with significantly poorer HRQOL (P < .05). Patients with worse sagittal spinopelvic modifier grades were significantly more likely to require major osteotomies, iliac fixation, and decompression (P ≤ .009). CONCLUSION The SRS-Schwab classification provides a validated language to describe and categorize ASD. This study demonstrates that the SRS-Schwab classification reflects severity of disease state based on multiple measures of HRQOL and significantly correlates with the important decision of whether to pursue operative or nonoperative treatment.

A comparison of language mapping by preoperative navigated transcranial magnetic stimulation and direct cortical stimulation during awake surgery.

Abstract: Background Navigated transcranial magnetic stimulation (nTMS) is increasingly used in presurgical brain mapping. Preoperative nTMS results correlate well with direct cortical stimulation (DCS) data in the identification of the primary motor cortex. Repetitive nTMS can also be used for mapping of speech-sensitive cortical areas. Objective The current cohort study compares the safety and effectiveness of preoperative nTMS with DCS mapping during awake surgery for the identification of language areas in patients with left-sided cerebral lesions. Methods Twenty patients with tumors in or close to left-sided language eloquent regions were examined by repetitive nTMS before surgery. During awake surgery, language-eloquent cortex was identified by DCS. nTMS results were compared for accuracy and reliability with regard to DCS by projecting both results into the cortical parcellation system. Results Presurgical nTMS maps showed an overall sensitivity of 90.2%, specificity of 23.8%, positive predictive value of 35.6%, and negative predictive value of 83.9% compared with DCS. For the anatomic Broca's area, the corresponding values were a sensitivity of 100%, specificity of 13.0%, positive predictive value of 56.5%, and negative predictive value of 100%, respectively. Conclusion Good overall correlation between repetitive nTMS and DCS was observed, particularly with regard to negatively mapped regions. Noninvasive inhibition mapping with nTMS is evolving as a valuable tool for preoperative mapping of language areas. Yet its low specificity in posterior language areas in the current study necessitates further research to refine the methodology.

Spinal robotics: current applications and future perspectives.

Abstract: Even though robotic technology holds great potential for performing spinal surgery and advancing neurosurgical techniques, it is of utmost importance to establish its practicality and to demonstrate better clinical outcomes compared with traditional techniques, especially in the current cost-effective era. Several systems have proved to be safe and reliable in the execution of tasks on a routine basis, are commercially available, and are used for specific indications in spine surgery. However, workflow, usability, interdisciplinary setups, efficacy, and cost-effectiveness have to be proven prospectively. This article includes a short description of robotic structures and workflow, followed by preliminary results of a randomized prospective study comparing conventional free-hand techniques with routine spine navigation and robotic-assisted procedures. Additionally, we present cases performed with a spinal robotic device, assessing not only the accuracy of the robotic-assisted procedure but also other factors (eg, minimal invasiveness, radiation dosage, and learning curves). Currently, the use of robotics in spinal surgery greatly enhances the application of minimally invasive procedures by increasing accuracy and reducing radiation exposure for patients and surgeons compared with standard procedures. Second-generation hardware and software upgrades of existing devices will enhance workflow and intraoperative setup. As more studies are published in this field, robot-assisted therapies will gain wider acceptance in the near future.

The Acute Cardiopulmonary Management of Patients With Cervical Spinal Cord Injuries

Abstract: M anagement of patients with an acute cervical spinal cord injury in an intensive care unit or similar monitored setting is recommended. • Use of cardiac, hemodynamic, and respiratory monitoring devices to detect cardiovascular dysfunction and respiratory insufficiency in patients following acute spinal cord injury is recommended. • Correction of hypotension in spinal cord injury (systolic blood pressure , 90 mm Hg) when possible and as soon as possible is recommended. • Maintenance of mean arterial blood pressure between 85 and 90 mm Hg for the first 7 days following an acute spinal cord injury is recommended.

Proximal junctional kyphosis in primary adult deformity surgery: evaluation of 20 degrees as a critical angle

Abstract: BACKGROUND : Multiple studies have reported on the prevalence of proximal junctional kyphosis (PJK) following spinal deformity surgery; however, none have demonstrated its significance with respect to functional outcome scores or revision surgery. OBJECTIVE : To evaluate if 20° is a possible critical PJK angle in primary adult scoliosis surgery patients as a threshold for worse patient-reported outcomes. METHODS : Clinical and radiographic data of 90 consecutive primary surgical patients at a single institution (2002-2007) with adult idiopathic/degenerative scoliosis and 2-year minimum follow-up were analyzed. Assessment included radiographic measurements, but most notably sagittal Cobb angle of the proximal junctional angle at preoperation, between 1 and 2 months, 2 years, and ultimate follow-up. RESULTS : Prevalence of PJK ≥20° at 3.5 years was 27.8% (n = 25). Those with PJK ≥20° at ultimate follow-up were older (mean 56 vs 46 years), had lower number of levels fused (median 8 vs 11), and were proximally fused to the lower thoracic spine more often than upper thoracic spine (all P < .001). PJK ≥20° was associated with significantly higher body mass index and fusion to the sacrum with iliac screws (P < .016, P < .029, respectively). Scoliosis Research Society outcome score changes were lower for PJK patients, but not significantly different from those in the non-PJK group. CONCLUSION : PJK ≥20° in primary adult idiopathic/degenerative scoliosis does not lead to revision surgery for PJK, but is univariately associated with older age, shorter constructs starting in the lower thoracic spine, obesity, and fusion to the sacrum. The negative results, supported by Scoliosis Research Society outcome data, provide important guidance on the postoperative management of such PJK patients. ABBREVIATIONS : BMI, body mass indexLIV, lowest instrumented vertebraeODI, Oswestry Disability IndexPJ, proximal junctionalPJK, proximal junctional kyphosisSRS, Scoliosis Research SocietyUIV, upper instrumented vertebra.

Vessel wall magnetic resonance imaging identifies the site of rupture in patients with multiple intracranial aneurysms: proof of principle.

Abstract: BACKGROUND:: High-resolution magnetic resonance vessel wall imaging (MR-VWI) is increasingly used to study steno-occlusive cerebrovascular disease, but has not yet been applied to patients with aneurysmal subarachnoid hemorrhage (SAH) OBJECTIVE:: To study the ability of high-resolution MR-VWI to determine the site-of-rupture in patients with aneurysmal SAH METHODS:: Medical records of patients admitted with aneurysmal SAH between December 2011 and May 2012 were reviewed MR-VWI was routinely performed for patients treated in the IMRIS Neurovascular Suite immediately prior to definitive treatment of the ruptured aneurysm RESULTS:: We report for the first-time high-resolution MR-VWI in five patients with aneurysmal SAH Three patients harbored multiple intracranial aneurysms The ruptured aneurysms demonstrated thick vessel wall enhancement in all cases None of the associated unruptured aneurysms demonstrated this MR imaging finding CONCLUSION:: High-resolution MR-VWI identified the site-of-rupture in patients with aneurysmal SAH including those patients harboring multiple intracranial aneurysms It may represent a useful tool in the investigation of aneurysmal SAH

Magnetic resonance imaging-guided focused laser interstitial thermal therapy for intracranial lesions: single-institution series.

Abstract: Background Surgical treatments for deep-seated intracranial lesions have been limited by morbidities associated with resection. Real-time magnetic resonance imaging-guided focused laser interstitial thermal therapy (LITT) offers a minimally invasive surgical treatment option for such lesions. Objective To review treatments and results of patients treated with LITT for intracranial lesions at Washington University School of Medicine. Methods In a review of 17 prospectively recruited LITT patients (34-78 years of age; mean, 59 years), we report demographics, treatment details, postoperative imaging characteristics, and peri- and postoperative clinical courses. Results Targets included 11 gliomas, 5 brain metastases, and 1 epilepsy focus. Lesions were lobar (n = 8), thalamic/basal ganglia (n = 5), insular (n = 3), and corpus callosum (n = 1). Mean target volume was 11.6 cm, and LITT produced 93% target ablation. Patients with superficial lesions had shorter intensive care unit stays. Ten patients experienced no perioperative morbidities. Morbidities included transient aphasia, hemiparesis, hyponatremia, deep venous thrombosis, and fatal meningitis. Postoperative magnetic resonance imaging showed blood products within the lesion surrounded by new thin uniform rim of contrast enhancement and diffusion restriction. In conjunction with other therapies, LITT targets often showed stable or reduced local disease. Epilepsy focus LITT produced seizure freedom at 8 months. Preliminary overall median progression-free survival and survival from LITT in tumor patients were 7.6 and 10.9 months, respectively. However, this small cohort has not been followed for a sufficient length of time, necessitating future outcomes studies. Conclusion Early peri- and postoperative clinical data demonstrate that LITT is a safe and viable ablative treatment option for intracranial lesions, and may be considered for select patients.

The epidemiology of admissions of nontraumatic subarachnoid hemorrhage in the United States.

Abstract: Background Subarachnoid hemorrhage (SAH) is the cause of 5% to 10% of strokes annually in the United States. Objective To study the incidence and mortality trends of admissions of SAH from 1979 to 2008 using a nationally representative sample of all nonfederal acute-care hospitals in the United States: The National Hospital Discharge Survey. Methods The sample was obtained from the hospital discharge records according to the International Classification of Disease, 9th Revision, Clinical Modification code 430. Results We reviewed data on approximately 1 billion hospitalizations in the United States over a 30-year study period and identified 612,500 cases of SAH, which was more common in women (relative risk 1.71, 95% confidence interval 1.7-1.72) and nonwhite persons than white persons (relative risk 1.46, 95% confidence interval 1.4-1.5). The estimated incidence rate of admission after SAH was 7.2 to 9.0 per 100,000/year and did not significantly change over the study period. Overall, in-hospital mortality after SAH fell from 30% during the period from 1979 to 1983 to 20% during the subperiod from 2004 to 2008 (P = .03) and was lower in larger treating hospitals. The average days of care for SAH hospitalizations decreased, but the rate of discharge to long-term care facilities increased. Conclusion The incidence rate of admission after SAH has remained stable over the past 30 years. Total deaths and in-hospital mortality after SAH have decreased significantly. In-hospital mortality after SAH is lower in larger treating hospitals.

Flow-diverter devices for intracranial aneurysms: systematic review and meta-analysis.

Abstract: BACKGROUND Although the introduction of flow-diverter devices (FDDs) has aroused great enthusiasm, the level of evidence supporting their use has not been systematically evaluated. OBJECTIVE To report a systematic review of medical literature up to May 2012 on FDDs to assess the morbidity, case fatality rate, and efficacy of FDDs for intracranial aneurysms. METHODS The literature was searched by using MEDLINE, Embase, and all Evidence-Based Medicine in the OVID database. Eligibility criteria were studies including at least 10 patients, reporting duration of follow-up and number of patients lost to follow-up, and documenting the rate of aneurysm occlusion and death and neurological complications. The endpoints were angiographic success, early and late mortality, and neurological morbidity. RESULTS Fifteen studies were analyzed consisting of 897 patients with 1018 aneurysms. The mean value of methodological quality score was 14.4 using the STROBE score. The early mortality rate was 2.8% (95% confidence interval [CI]: 1.7-3.8; I(2) = 93.4%) and the late mortality rate was 1.3% (95% CI: 0.2-2.3; I(2) = 36.9%). The early neurological morbidity rate was 7.3% (95% CI: 5.7-9; I(2) = 91.8%) and the late morbidity rate was 2.6% (95% CI: 1.1-4; I(2) = 81.3%). The Egger test for early and late morbidity and aneurysm occlusion was <0.001. CONCLUSION With the available data from the studies, both heterogeneity and publication biases imply that the current clinical use of FDDs is not supported by high-quality evidence. In the absence of reliable evidence, the use of FDDs in patients eligible for more conventional treatments should be restricted to controlled clinical trials.

Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes.

Abstract: Paul A. Gardner, Matthew J. Tormenti, Harshita Pant, Juan C. Fernandez-Miranda, Carl H. Snyderman, Michael B. Horowitz

Current management of middle cerebral artery aneurysms: surgical results with a "clip first" policy.

Abstract: Background One response to randomized trials like the International Subarachnoid Aneurysm Trial has been to adopt a "coil first" policy, whereby all aneurysms be considered for coiling, reserving surgery for unfavorable aneurysms or failed attempts. Surgical results with middle cerebral artery (MCA) aneurysms have been excellent, raising debate about the respective roles of surgical and endovascular therapy. Objective To review our experience with MCA aneurysms managed with microsurgery as the treatment of first choice. Methods Five hundred forty-three patients with 631 MCA aneurysms were managed with a "clip first" policy, with 115 patients (21.2%) referred from the Neurointerventional Radiology service and none referred from the Neurosurgical service for endovascular management. Results Two hundred eighty-two patients (51.9%) had ruptured aneurysms and 261 (48.1%) had unruptured aneurysms. MCA aneurysms were treated with clipping (88.6%), thrombectomy/clip reconstruction (6.2%), and bypass/aneurysm occlusion (3.3%). Complete aneurysm obliteration was achieved with 620 MCA aneurysms (98.3%); 89.7% of patients were improved or unchanged after therapy, with a mortality rate of 5.3% and a permanent morbidity rate of 4.6%. Good outcomes were observed in 92.0% of patients with unruptured and 70.2% with ruptured aneurysms. Worse outcomes were associated with rupture (P = .04), poor grade (P = .001), giant size (P = .03), and hemicraniectomy (P Conclusion At present, surgery should remain the treatment of choice for MCA aneurysms. Surgical morbidity was low, and poor outcomes were due to an inclusive policy that aggressively managed poor-grade patients and complex aneurysms. This experience sets a benchmark that endovascular results should match before considering endovascular therapy an alternative for MCA aneurysms.

Long-term outcomes of deep brain stimulation for neuropathic pain.

Abstract: Background Deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy has reported variable outcomes and has gained United Kingdom but not USA regulatory approval. Objective To prospectively assess long-term efficacy of DBS for chronic neuropathic pain in a single-center case series. Methods Patient reported outcome measures were collated before and after surgery, using a visual analog score, short-form 36-question quality-of-life survey, McGill pain questionnaire, and EuroQol-5D questionnaires (EQ-5D and health state). Results One hundred ninety-seven patients were referred over 12 years, of whom 85 received DBS for various etiologies: 9 amputees, 7 brachial plexus injuries, 31 after stroke, 13 with spinal pathology, 15 with head and face pain, and 10 miscellaneous. Mean age at surgery was 52 years, and mean follow-up was 19.6 months. Contralateral DBS targeted the periventricular gray area (n = 33), the ventral posterior nuclei of the thalamus (n = 15), or both targets (n = 37). Almost 70% (69.4%) of patients retained implants 6 months after surgery. Thirty-nine of 59 (66%) of those implanted gained benefit and efficacy varied by etiology, improving outcomes in 89% after amputation and 70% after stroke. In this cohort, >30% improvements sustained in visual analog score, McGill pain questionnaire, short-form 36-question quality-of-life survey, and EuroQol-5D questionnaire were observed in 15 patients with >42 months of follow-up, with several outcome measures improving from those assessed at 1 year. Conclusion DBS for pain has long-term efficacy for select etiologies. Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.

Prognostic value of residual fluorescent tissue in glioblastoma patients after gross total resection in 5-aminolevulinic Acid-guided surgery.

Abstract: Background There is evidence in the literature supporting that fluorescent tissue signal in fluorescence-guided surgery extends farther than tissue highlighted in gadolinium in T1 sequence magnetic resonance imaging (MRI), which is the standard to quantify the extent of resection. Objective To study whether the presence of residual fluorescent tissue after surgery carries a different prognosis for glioblastoma (GBM) cases with complete resection confirmed by MRI. Methods A retrospective review in our center found 118 consecutive patients with high-grade gliomas operated on with the use of fluorescence-guided surgery with 5-aminolevulinic acid. Within that series, the 52 patients with newly diagnosed GBM and complete resection of enhancing tumor (CRET) in early MRI were selected for analysis. We studied the influence of residual fluorescence in the surgical field on overall survival and neurological complication rate. Multivariate analysis included potential relevant factors: age, Karnofsky Performance Scale, O-methylguanine methyltransferase methylation promoter status, tumor eloquent location, preoperative tumor volume, and adjuvant therapy. Results The median overall survival was 27.0 months (confidence interval = 22.4-31.6) in patients with nonresidual fluorescence (n = 25) and 17.5 months (confidence interval = 12.5-22.5) for the group with residual fluorescence (n = 27) (P = .015). The influence of residual fluorescence was maintained in the multivariate analysis with all covariables, hazard ratio = 2.5 (P = .041). The neurological complication rate was 18.5% in patients with nonresidual fluorescence and 8% for the group with residual fluorescence (P = .267). Conclusion GBM patients with CRET in early MRI and no fluorescent residual tissue had longer overall survival than patients with CRET and residual fluorescent tissue.

The Pipeline Embolization Device: learning curve and predictors of complications and aneurysm obliteration.

Abstract: BACKGROUND The Pipeline Embolization Device (PED) has emerged as a promising treatment for intracranial aneurysms. OBJECTIVE To assess the safety and efficacy of the PED, to analyze the effect of operator experience on the complication rate, and to identify predictors of complications and obliteration. METHODS A total of 109 patients with 120 aneurysms were treated with PED at our institution. The patient population was divided into 3 consecutive equal groups to assess whether overall and major complication rates decreased over time: group 1, patients 1 through 37; group 2, patients 38 through 73; and group 3, patients 74 through 109. RESULTS The number of PEDs used was 1.40 per aneurysm. Symptomatic and major procedure-related complications occurred in 11% and 3.7% of patients, respectively. The rate of complications decreased from 16.2% in group 1 to 5.6% in group 3, and the rate of major complications fell dramatically from 10.8% in group 1 to 0% in groups 2 and 3 (P < .05). Procedure time significantly decreased over time (P = .04). In multivariate analysis, previously treated aneurysms were predictive of procedural complications (P = .02). At the latest follow-up, 65.8% of aneurysms were completely occluded, 9.6% were nearly completely occluded, and 24.6% were incompletely occluded. In multivariate analysis, fusiform aneurysms (P = .05) and shorter angiographic follow-up (P = .03) were negative predictors of aneurysm obliteration. CONCLUSION PED therapy may have an acceptable safety-efficacy profile. The risk of complications appears to decrease dramatically with physician experience, supporting the existence of a learning curve. Patients with previously treated aneurysms have higher complication rates, whereas fusiform aneurysms achieve lower obliteration rates.

Cranioplasty with custom-made titanium plates-14 years experience

Abstract: BACKGROUND: There is no consensus on which material is best suited for repair of cranial defects. OBJECTIVE: To investigate the outcomes following custom-made titanium cranioplasty. METHODS: The medical records for all patients who had titanium cranioplasty at 2 major neurosurgical centers in Western Australia were retrieved and analyzed for this retrospective cohort study. RESULTS: Altogether, 127 custom-made titanium cranioplasties on 113 patients were included. Two patients had 3 titanium cranioplasties and 10 patients had 2. Infected bone flap (n = 61, 54%), either from previous craniotomy or autologous cranioplasty, and contaminated bone flap (n = 16, 14%) from the initial injury were the main reasons for requiring titanium cranioplasty. Complications attributed to titanium cranioplasty were common (n = 33, 29%), with infection being the most frequent complication (n = 18 patients, 16%). Complications were, on average, associated with an extra 7 days of hospital stay (interquartile range 2-17). The use of titanium as the material for the initial cranioplasty (P = .58), the presence of skull fracture(s) (P . .99) or scalp laceration (s) (P = .32) at the original surgery, and proven local infection before titanium cranioplasty (P = .78) were not significantly associated with an increased risk of infection. Infection was significantly more common after titanium cranioplasty for large defects (hemicraniectomy [39%] and bifrontal craniectomy [28%]) than after cranioplasty for small defects (P = .04). CONCLUSION: Complications after using titanium plate for primary or secondary cranioplasty were common (29%) and associated with an increased length of hospital stay. Infection was a major complication (16%), and this suggested that more vigorous perioperative infection prophylaxis is needed for titanium plate cranioplasty.

Intraoperative seizures during awake craniotomy: incidence and consequences: analysis of 477 patients.

Abstract: BACKGROUND Awake craniotomy (AC) for removal of intra-axial brain tumors is a well-established procedure. However, the occurrence and consequences of intraoperative seizures during AC have not been well characterized. OBJECTIVE To analyze the incidence, risk factors, and consequences of seizures during AC. METHODS The database of AC at Tel Aviv Medical Center between 2003 to 2011 was reviewed. Occurrences of intraoperative seizures were analyzed with respect to medical history, medications, tumor characteristics, and postoperative outcome. RESULTS Of the 549 ACs performed during the index period, 477 with complete records were identified. Sixty patients (12.6%) experienced intraoperative seizures. The AC procedure failed in 11 patients (2.3%) due to seizures. Patients with intraoperative seizures were significantly younger than nonseizing patients (45 ± 14 years vs 52 ± 16 years, P = .003), had a higher incidence of frontal lobe involvement (86% vs % 57%, P < .0001), and had higher prevalence of a history of seizures (P = .008). Short-term motor deterioration developed postoperatively in a higher percentage of patients with intraoperative seizures (20% vs 10.1%, P = .02) with a longer hospitalization period (4.0 ± 3.0 days vs 3.0 ± 3.0 days, P = .045). CONCLUSION Although in most cases intraoperative seizures will not result in AC failure, the surgical team should be prepared to treat them promptly to avoid intractable seizures. Intraoperative seizures are more common in younger patients with a tumor in the frontal lobe and those with a history of seizures. Moreover, they are associated with a higher incidence of transient postoperative motor deterioration and protracted length of hospital stay.

Virtual reality simulation in neurosurgery: technologies and evolution.

Abstract: Neurosurgeons are faced with the challenge of learning, planning, and performing increasingly complex surgical procedures in which there is little room for error. With improvements in computational power and advances in visual and haptic display technologies, virtual surgical environments can now offer potential benefits for surgical training, planning, and rehearsal in a safe, simulated setting. This article introduces the various classes of surgical simulators and their respective purposes through a brief survey of representative simulation systems in the context of neurosurgery. Many technical challenges currently limit the application of virtual surgical environments. Although we cannot yet expect a digital patient to be indistinguishable from reality, new developments in computational methods and related technology bring us closer every day. We recognize that the design and implementation of an immersive virtual reality surgical simulator require expert knowledge from many disciplines. This article highlights a selection of recent developments in research areas related to virtual reality simulation, including anatomic modeling, computer graphics and visualization, haptics, and physics simulation, and discusses their implication for the simulation of neurosurgery.

Role of cranial and spinal virtual and augmented reality simulation using immersive touch modules in neurosurgical training.

Abstract: Recent studies have shown that mental script-based rehearsal and simulation-based training improve the transfer of surgical skills in various medical disciplines. Despite significant advances in technology and intraoperative techniques over the last several decades, surgical skills training on neurosurgical operations still carries significant risk of serious morbidity or mortality. Potentially avoidable technical errors are well recognized as contributing to poor surgical outcome. Surgical education is undergoing overwhelming change, as a result of the reduction of work hours and current trends focusing on patient safety and linking reimbursement with clinical outcomes. Thus, there is a need for adjunctive means for neurosurgical training, which is a recent advancement in simulation technology. ImmersiveTouch is an augmented reality system that integrates a haptic device and a high-resolution stereoscopic display. This simulation platform uses multiple sensory modalities, re-creating many of the environmental cues experienced during an actual procedure. Modules available include ventriculostomy, bone drilling, percutaneous trigeminal rhizotomy, and simulated spinal modules such as pedicle screw placement, vertebroplasty, and lumbar puncture. We present our experience with the development of such augmented reality neurosurgical modules and the feedback from neurosurgical residents.

Initial Closed Reduction of Cervical Spinal Fracture-Dislocation Injuries

Abstract: Standards There is insufficient evidence to support treatment standards Guidelines There is insufficient evidence to support treatment guidelines Early closed reduction of cervical spine fracture-dislocation injuries with craniocervical traction is recommended to restore anatomic alignment of the cervical spine in awake patients Closed reduction in patients with an additional rostral injury is not recommended Patients with cervical spine fracture-dislocation injuries who cannot be examined during attempted closed reduction, or before open posterior reduction, should undergo magnetic resonance imaging (MRI) before attempted reduction The presence of a significant disc herniation in this setting is a relative indication for a ventral decompression before reduction MRI study of patients who fail attempts at closed reduction is recommended Prereduction MRI performed in patients with cervical fracture dislocation injury will demonstrate disrupted or herniated intervertebral discs in one-third to one-half of patients with facet subluxation These findings do not seem to significantly influence outcome after closed reduction in awake patients; therefore, the usefulness of prereduction MRI in this circumstance is uncertain

Advanced 3-dimensional planning in neurosurgery.

Abstract: During the past decades, medical applications of virtual reality technology have been developing rapidly, ranging from a research curiosity to a commercially and clinically important area of medical informatics and technology. With the aid of new technologies, the user is able to process large amounts of data sets to create accurate and almost realistic reconstructions of anatomic structures and related pathologies. As a result, a 3-diensional (3-D) representation is obtained, and surgeons can explore the brain for planning or training. Further improvement such as a feedback system increases the interaction between users and models by creating a virtual environment. Its use for advanced 3-D planning in neurosurgery is described. Different systems of medical image volume rendering have been used and analyzed for advanced 3-D planning: 1 is a commercial "ready-to-go" system (Dextroscope, Bracco, Volume Interaction, Singapore), whereas the others are open-source-based software (3-D Slicer, FSL, and FreesSurfer). Different neurosurgeons at our institution experienced how advanced 3-D planning before surgery allowed them to facilitate and increase their understanding of the complex anatomic and pathological relationships of the lesion. They all agreed that the preoperative experience of virtually planning the approach was helpful during the operative procedure. Virtual reality for advanced 3-D planning in neurosurgery has achieved considerable realism as a result of the available processing power of modern computers. Although it has been found useful to facilitate the understanding of complex anatomic relationships, further effort is needed to increase the quality of the interaction between the user and the model.

Prehospital cervical spinal immobilization after trauma.

Abstract: S pinal immobilization of all trauma patients with a cervical spine or spinal cord injury or with a mechanism of injury having the potential to cause cervical spinal injury is recommended. • Triage of patients with potential spinal injury at the scene by trained and experienced emergency medical services personnel to determine the need for immobilization during transport is recommended. • Immobilization of trauma patients who are awake, alert, and are not intoxicated; who are without neck pain or tenderness; who do not have an abnormal motor or sensory examination; and who do not have any significant associated injury that might detract from their general evaluation is not recommended.

Neurosurgery Simulation in Residency Training: Feasibility, Cost, and Educational Benefit

Abstract: BACKGROUND:The effort required to introduce simulation in neurosurgery academic programs and the benefits perceived by residents have not been systematically assessed.OBJECTIVE:To create a neurosurgery simulation curriculum encompassing basic and advanced skills, cadaveric dissection, cranial and sp

A novel data-driven approach to preoperative mapping of functional cortex using resting-state functional magnetic resonance imaging.

Abstract: An ongoing challenge in surgical resection of brain lesions is balancing the goal of maximizing resection with the need to preserve function. This is especially salient in the setting of epilepsy and glioma surgery where the lesions can be cortically based and intimately involved with eloquent regions. In both situations, resection around a seizure focus or maximizing tumor removal enhances clinical outcomes with regard to seizure freedom or survival, respectively.1-6 The benefits of a larger resection, however, must be weighed against the cost of deficits incurred in areas of eloquent cortex, particularly in motor and language areas.5 Because there is a high degree of individual variability in these areas, presurgical localization and intraoperative cortical mapping are often required to optimize the clinical outcome. Functional magnetic resonance imaging (fMRI) has played an important role in the preoperative assessment of patients with lesions adjacent to eloquent cortex. fMRI measures neuronal activity using the ratio of oxyhemoglobin to deoxyhemoglobin as a contrast mechanism (known as blood oxygen level-dependent [BOLD] fMRI). In a typical block-design application, the subject alternates between a passive resting state and performing a task. Clinical applications of task-based fMRI have focused on localizing areas of critical function for presurgical planning7 and have been shown to correlate with intraoperative electrophysiology,8 Wada testing,9 and prediction of loss of function postoperatively.10 Despite its utility, task-based fMRI has several disadvantages that limit its application for preoperative functional localization. First, the results are dependent on how well the patient can perform the prescribed task. In the setting of a brain tumor, cooperation and effective participation may be impaired due to neurological deficits or confusion.11 Second, because the patient must be awake during the imaging procedure, sedation cannot be used. This often limits effective imaging in pediatric populations for whom conscious sedation is frequently necessary. Finally, task-based fMRI can be lengthy if multiple functional sites are interrogated in a single imaging session. As an alternative to task-based fMRI, resting-state functional MRI (rs-fMRI) has been proposed as an imaging methodology for localizing critical sites independent of patient participation.12 This approach uses the endogenous brain activity detectable with BOLD MRI to identify areas that are interacting at rest. Spontaneous BOLD fluctuations are low-frequency (<0.1 Hz) oscillations in metabolic activity that are anatomically correlated within distinct functional networks.13 First reported by Biswal et al,14 there is strong coherence which is reproducibly present between the left and right somatomotor cortices,15 between language areas,16,17 and between numerous other functional regions in the absence of task performance. Using spontaneous activity, one can generate resting-state correlation maps that are similar to the functional maps obtained from task activations.18 This approach has a number of advantages. Most importantly, patient participation is not required. An additional advantage is that these methods are robust; spontaneous fluctuations have been shown to persist under conditions of sleep19-21 and anesthesia,22-25 as well as in the presence of tumors.12 Thus, resting state could potentially be widely applied irrespective of age and cognitive status. Although holding substantial promise, these advanced techniques have not yet entered routine clinical practice due to the high level of technical support necessary to create these resting-state maps. A common approach for network identification is the selection of a “seed region” in a characteristic location (such as the hand-motor area to identify the somatomotor network). This approach can be biased by the selection of seed regions and is technically labor intensive. Often multiple regions are tested until the optimal network is identified. Although this process is often successful in normal brains using standard atlas coordinates, it becomes more challenging in brains that are distorted due to disease (ie, tumors and cortical dysplasia). Finally, rs-fMRI has had limited comparison with the clinical gold standard of electrocortical stimulation (ECS). In this study, we evaluated the use of a novel methodology for identifying resting-state networks (RSNs) with fMRI as a potential tool for preoperative imaging. Using a multilayer neural network technique, we have developed an approach that enables the identification of multiple functional networks from a single task-independent dataset. Moreover, these networks are identified automatically in a purely data-driven approach independent of the need for an individual to pick seed regions. To assess the validity of the imaging findings as a potential clinical tool, language and motor networks were rigorously compared with the gold standard of ECS to localize essential eloquent cortex in patients with epilepsy. Additionally, to assess the robustness of our technique in the presence of lesions, the technique was applied to 7 patients with tumors. Taken together, these findings support the potential utility and augmented capability of rs-fMRI to enhance preoperative localization of functional regions.

Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study.

Abstract: BACKGROUND The endovascular treatment of middle cerebral artery (MCA) aneurysms with unfavorable anatomy (wide neck, unfavorable morphology) is frequently challenging. Flow disruption with the WEB is a potentially interesting endovascular treatment for this type of aneurysm. OBJECTIVE To report in a multicenter series the preliminary treatment experience of MCA aneurysms with flow disruption by the WEB. METHODS Thirty-three patients with 34 MCA aneurysms were treated with the WEB in 5 European centers. The ability to successfully deploy the WEB, procedure- and device-related adverse events, morbidity and mortality of the treatment, and short-term angiographic follow-up results were analyzed. RESULTS Most treated aneurysms were unruptured (85.3%) and were between 5 and 10 mm (85.3%) with a neck size ≥ 4 mm (88.2%). The treatment failed in 1 of the 34 aneurysms (2.9%) owing to a lack of appropriate device size. Treatment was performed exclusively with the WEB in 29 of 33 aneurysms (87.9%). Additional treatment (coiling and/or stenting) was used in 4 of 33 aneurysms (12.1%). Mortality of the treatment was 0.0% and morbidity was 3.1% (intraoperative rupture with modified Rankin Scale score of 3 at the 1-month follow-up). In short-term follow-up (range, 2-12 months), adequate occlusion (total occlusion or neck remnant) was observed in 83.3% of aneurysms. CONCLUSION WEB flow disruption seems to be a promising technique for the treatment of complex MCA aneurysms, particularly those with a wide neck or unfavorable dome-to-neck ratio.

Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients.

Abstract: BACKGROUND Cavernous malformations (CMs) in deep locations account for 9% to 35% of brain malformations and are surgically challenging. OBJECTIVE To study the clinical features and outcomes following surgery for deep CMs and the complication of hypertrophic olivary degeneration (HOD). METHODS Clinical records, radiological findings, operative details, and complications of 176 patients with deep CMs were reviewed retrospectively. RESULTS Of 176 patients with 179 CMs, 136 CMs were in the brainstem, 27 in the basal ganglia, and 16 in the thalamus. Cranial nerve deficits (51.1%), hemiparesis (40.9%), numbness (34.7%), and cerebellar symptoms (38.6%) presented most commonly. Hemorrhage presented in 172 patients (70 single, 102 multiple). The annual retrospective hemorrhage rate was 5.1% (assuming CMs are congenital with uniform hemorrhage risk throughout life); the rebleed rate was 31.5%/patient per year. Surgical approach depended on the proximity of the CM to the pial or ependymal surface. Postoperatively, 121 patients (68.8%) had no new neurological deficits. Follow-up occurred in 170 patients. Delayed postoperative HOD developed in 9/134 (6.7%) patients with brainstem CMs. HOD occurred predominantly following surgery for pontine CMs (9/10 patients). Three patients with HOD had palatal myoclonus, nystagmus, and oscillopsia, whereas 1 patient each had limb tremor and hemiballismus. At follow-up, 105 patients (61.8%) improved, 44 (25.9%) were unchanged, and 19 (11.2%) worsened neurologically. Good preoperative modified Rankin Score (98.2% vs 54.5%, P = .001) and single hemorrhage (89% vs 77.3%, P < .05) were predictive of good long-term outcome. CONCLUSION Symptomatic deep CMs can be resected with acceptable morbidity and outcomes. Good preoperative modified Rankin Score and single hemorrhage are predictors of good long-term outcome.

Management of Pediatric Cervical Spine and Spinal Cord Injuries

Abstract: DIAGNOSTIC STANDARDS There is insufficient evidence to support diagnostic standards. GUIDELINES In children who have experienced trauma and are alert, conversant, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury, and are not intoxicated, cervical spine x-rays are not necessary to exclude cervical spine injury and are not recommended. In children who have experienced trauma and who are either not alert, nonconversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. OPTIONS In children younger than age 9 years who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. In children age 9 years or older who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. Computed tomographic scanning with attention to the suspected level of neurological injury to exclude occult fractures or to evaluate regions not seen adequately on plain x-rays is recommended. Flexion/extension cervical x-rays or fluoroscopy may be considered to exclude gross ligamentous instability when there remains a suspicion of cervical spine instability after static x-rays are obtained. Magnetic resonance imaging of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis. TREATMENT STANDARDS There is insufficient evidence to support treatment standards. GUIDELINES There is insufficient evidence to support treatment guidelines. OPTIONS Thoracic elevation or an occipital recess to prevent flexion of the head and neck when restrained supine on an otherwise flat backboard may allow for better neutral alignment and immobilization of the cervical spine in children younger than 8 years because of the relatively large head in these younger children and is recommended. Closed reduction and halo immobilization for injuries of the C2 synchondrosis between the body and odontoid is recommended in children younger than 7 years. Consideration of primary operative therapy is recommended for isolated ligamentous injuries of the cervical spine with associated deformity.