Predictors of Functional Independence in Children with Spinal Cord Tumors After Surgery: From Physiotherapist Perspective.

Knowledge of the factors affecting functional outcomes has an important role in the development of the care plan in children with spinal cord tumors. Retrospective study was planned to determine predictors of functional independence in children with spinal cord tumors. Data from 80 children treated for spinal cord tumors over 2001-2020-year period was analyzed. Results showed that key predictors such as younger age, higher KPS, and better initial WeeFIM scores were strongly associated with improved functional outcomes. Further multicenter prospective studies are recommended to validate these findings and explore long-term functional outcomes to enhance rehabilitation strategies for this patient population.

Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent Cushing's disease: safety, feasibility, and success.

PURPOSE: The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients. METHODS: A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission. RESULTS: Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission. CONCLUSION: Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.

Quantitative assessment and objective improvement of the accuracy of neurosurgical planning through digital patient-specific 3D models.

Objective: Neurosurgical patient-specific 3D models have been shown to facilitate learning, enhance planning skills and improve surgical results. However, there is limited data on the objective validation of these models. Here, we aim to investigate their potential for improving the accuracy of surgical planning process of the neurosurgery residents and their usage as a surgical planning skill assessment tool. Methods: A patient-specific 3D digital model of parasagittal meningioma case was constructed. Participants were invited to plan the incision and craniotomy first after the conventional planning session with MRI, and then with 3D model. A feedback survey was performed at the end of the session. Quantitative metrics were used to assess the performance of the participants in a double-blind fashion. Results: A total of 38 neurosurgical residents and interns participated in this study. For estimated tumor projection on scalp, percent tumor coverage increased (66.4 ± 26.2%-77.2 ± 17.4%, p = 0.026), excess coverage decreased (2,232 ± 1,322 mm2-1,662 ± 956 mm2, p = 0.019); and craniotomy margin deviation from acceptable the standard was reduced (57.3 ± 24.0 mm-47.2 ± 19.8 mm, p = 0.024) after training with 3D model. For linear skin incision, deviation from tumor epicenter significantly reduced from 16.3 ± 9.6 mm-8.3 ± 7.9 mm after training with 3D model only in residents (p = 0.02). The participants scored realism, performance, usefulness, and practicality of the digital 3D models very highly. Conclusion: This study provides evidence that patient-specific digital 3D models can be used as educational materials to objectively improve the surgical planning accuracy of neurosurgical residents and to quantitatively assess their surgical planning skills through various surgical scenarios.

Extracellular-Vesicle-Based Cancer Panels Diagnose Glioblastomas with High Sensitivity and Specificity.

Glioblastoma is one of the most devastating neoplasms of the central nervous system. This study focused on the development of serum extracellular vesicle (EV)-based glioblastoma tumor marker panels that can be used in a clinic to diagnose glioblastomas and to monitor tumor burden, progression, and regression in response to treatment. RNA sequencing studies were performed using RNA isolated from serum EVs from both patients (n = 85) and control donors (n = 31). RNA sequencing results for preoperative glioblastoma EVs compared to control EVs revealed 569 differentially expressed genes (DEGs, 2XFC, FDR < 0.05). By using these DEGs, we developed serum-EV-based biomarker panels for the following glioblastomas: wild-type IDH1 (96% sensitivity/80% specificity), MGMT promoter methylation (91% sensitivity/73% specificity), p53 gene mutation (100% sensitivity/89% specificity), and TERT promoter mutation (89% sensitivity/100% specificity). This is the first study showing that serum-EV-based biomarker panels can be used to diagnose glioblastomas with a high sensitivity and specificity.

Endonasal endoscopic approach for sellar metastatic pathologies: a national observation.

PURPOSE: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions. METHODS: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes. RESULTS: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients. CONCLUSION: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Development and Validation of a Novel Methodological Pipeline to Integrate Neuroimaging and Photogrammetry for Immersive 3D Cadaveric Neurosurgical Simulation.

Background: Visualizing and comprehending 3-dimensional (3D) neuroanatomy is challenging. Cadaver dissection is limited by low availability, high cost, and the need for specialized facilities. New technologies, including 3D rendering of neuroimaging, 3D pictures, and 3D videos, are filling this gap and facilitating learning, but they also have limitations. This proof-of-concept study explored the feasibility of combining the spatial accuracy of 3D reconstructed neuroimaging data with realistic texture and fine anatomical details from 3D photogrammetry to create high-fidelity cadaveric neurosurgical simulations. Methods: Four fixed and injected cadaver heads underwent neuroimaging. To create 3D virtual models, surfaces were rendered using magnetic resonance imaging (MRI) and computed tomography (CT) scans, and segmented anatomical structures were created. A stepwise pterional craniotomy procedure was performed with synchronous neuronavigation and photogrammetry data collection. All points acquired in 3D navigational space were imported and registered in a 3D virtual model space. A novel machine learning-assisted monocular-depth estimation tool was used to create 3D reconstructions of 2-dimensional (2D) photographs. Depth maps were converted into 3D mesh geometry, which was merged with the 3D virtual model's brain surface anatomy to test its accuracy. Quantitative measurements were used to validate the spatial accuracy of 3D reconstructions of different techniques. Results: Successful multilayered 3D virtual models were created using volumetric neuroimaging data. The monocular-depth estimation technique created qualitatively accurate 3D representations of photographs. When 2 models were merged, 63% of surface maps were perfectly matched (mean [SD] deviation 0.7 ± 1.9 mm; range -7 to 7 mm). Maximal distortions were observed at the epicenter and toward the edges of the imaged surfaces. Virtual 3D models provided accurate virtual measurements (margin of error <1.5 mm) as validated by cross-measurements performed in a real-world setting. Conclusion: The novel technique of co-registering neuroimaging and photogrammetry-based 3D models can (1) substantially supplement anatomical knowledge by adding detail and texture to 3D virtual models, (2) meaningfully improve the spatial accuracy of 3D photogrammetry, (3) allow for accurate quantitative measurements without the need for actual dissection, (4) digitalize the complete surface anatomy of a cadaver, and (5) be used in realistic surgical simulations to improve neurosurgical education.

Exogenous Amylase Reverses Cerebral Ischemia Induced by Selective Intraarterial Injection of Degradable Starch Microspheres: An Angiographic and Histological Study in a Novel in Vivo Animal Model.

AIM: To validate a new particulate embolization method using degradable starch microspheres (DSM) and intraarterial exogenous amylase administration, which allow for regulated temporary cerebral arterial embolization without compromising tissue perfusion. MATERIAL AND METHODS: Twenty-four male New Zealand rabbits were randomly divided into three groups. All animals underwent routine angiography. The control group received no additional intervention. In the ischemia group, 0.2ml DSM was administered to the animals via the right carotid artery with pulsed, gentle injections to induce ischemia in the cerebral microcirculation. Animals in the reperfusion group received 0.05 ml of exogenous amylase along with DSM administration. Six hours after the procedure, the animals were sacrificed and histopathological analysis was performed. RESULTS: The ischemia group was the most adversely affected group by embolization, with the highest number of pyknotic neurons. The reperfusion group, which received exogenous amylase, had lower pyknotic neurons than the ischemia group. The pyknotic neuron count was similar in some regions between reperfusion and control groups. CONCLUSION: Exogenous amylase can rapidly attenuate cerebral ischemia caused by microembolization with DSM.

Does Gross Total Resection Improve Progression-Free and Overall Survival in Pediatric Intracranial Ependymomas? Single-Center Clinical Experience Of 61 Cases.

OBJECTIVE: To share our clinical experience of 25 years and identify prognostic factors for progression-free and overall survival in pediatric intracranial ependymomas. METHODS: In total, 61 children who were treated between 1995 and 2020 in a single institution were included in the study. Medical records of the patients were retrospectively reviewed to obtain and analyze the following data: patient age at first surgery, sex, presenting symptoms, hydrocephalus and any invasive treatment, anatomic site, extent of resection, pathologic grade, time to progression, and time to death. Progression-free and overall survival rates and affecting factors were analyzed by Kaplan-Meier method. RESULTS: Dysphagia, number of surgeries, and spinal seeding were associated with progression free and overall survival in univariate analysis. The extent of resection, World Health Organization grade, and visual problems were also associated with progression whereas sex was associated with overall survival. Cox regression identified the extent of resection and single surgery as an independent prognostic factor for progression-free survival. No independent factor was found for overall survival. CONCLUSIONS: This single center experience of 25 years confirms the beneficial effect of gross total resection on disease progression. Although spinal seeding seems to affect survival rates, greater number of cases are needed to reveal its full effect.

Early Cerebral Blood Flow Changes, Cerebrovascular Reactivity and Cortical Spreading Depolarizations in Experimental Mild Traumatic Brain Injury Model.

AIM: To investigate the spatiotemporal dynamics of early cerebral blood flow (CBF) changes, cerebrovascular reactivity (CVR), and vascular responses to cortical spreading depolarization (CSD) in an experimental mild traumatic brain injury (mTBI) model with laser speckle contrast imaging (LSCI) technique. MATERIAL AND METHODS: The weight-drop model was used to induce blunt head trauma. The mice were divided into two groups as mild TBI (n=12), and sham (n=6). The animals underwent continuous LSCI before and for 1 hour after trauma to evaluate the regional CBF changes, CVR in response to CO2, and CSD-associated vascular responses induced by pinprick. RESULTS: Our minor blunt head trauma protocol induced CSD in only 2 (16.7%) animals, which were excluded from further analyses. Of the remaining animals, 30% showed slight hyperemia following trauma, with mild ipsilateral hemisphere oligemia (15%?20% decrease in CBF) on average compared to baseline (p=0.027) and contralateral hemisphere (p=0.029). Maximal CBF decrease was measured in the peri-impact area (24.1% ± 5.1%). No significant difference was found between the sham and mTBI groups and two hemispheres of the mTBI group or pre/post-CSD periods of CO2 reactivity, as well as the characteristics of vascular CSD responses (net ischemia: 52.3% ± 2.6% vs. 56.3% ± 1.9% and prolonged oligemia duration 44.8 ± 1.8 min vs. 49.8 ± 2.3 min). CONCLUSION: The ipsilateral hemisphere, particularly in the peri-impact area, had mild hypoperfusion, within the first hour of minor blunt head trauma in mice. Nonetheless, mTBI does not alter CVR and vascular responses to an induced CSD, thus the overall CVR is largely preserved in mTBI without significant structural damage despite a mildly decreased CBF in the hyperacute phase.

Group-Level Ranking-Based Hubness Analysis of Human Brain Connectome Reveals Significant Interhemispheric Asymmetry and Intraparcel Heterogeneities.

Objective: Graph theory applications are commonly used in connectomics research to better understand connectivity architecture and characterize its role in cognition, behavior and disease conditions. One of the numerous open questions in the field is how to represent inter-individual differences with graph theoretical methods to make inferences for the population. Here, we proposed and tested a simple intuitive method that is based on finding the correlation between the rank-ordering of nodes within each connectome with respect to a given metric to quantify the differences/similarities between different connectomes. Methods: We used the diffusion imaging data of the entire HCP-1065 dataset of the Human Connectome Project (HCP) (n = 1,065 subjects). A customized cortical subparcellation of HCP-MMP atlas (360 parcels) (yielding a total of 1,598 ROIs) was used to generate connectivity matrices. Six graph measures including degree, strength, coreness, betweenness, closeness, and an overall "hubness" measure combining all five were studied. Group-level ranking-based aggregation method ("measure-then-aggregate") was used to investigate network properties on population level. Results: Measure-then-aggregate technique was shown to represent population better than commonly used aggregate-then-measure technique (overall rs: 0.7 vs 0.5). Hubness measure was shown to highly correlate with all five graph measures (rs: 0.88-0.99). Minimum sample size required for optimal representation of population was found to be 50 to 100 subjects. Network analysis revealed a widely distributed set of cortical hubs on both hemispheres. Although highly-connected hub clusters had similar distribution between two hemispheres, average ranking values of homologous parcels of two hemispheres were significantly different in 71% of all cortical parcels on group-level. Conclusion: In this study, we provided experimental evidence for the robustness, limits and applicability of a novel group-level ranking-based hubness analysis technique. Graph-based analysis of large HCP dataset using this new technique revealed striking hemispheric asymmetry and intraparcel heterogeneities in the structural connectivity of the human brain.

A simple and effective modified technique of twist drill craniostomy for bedside drainage and irrigation of chronic subdural hematoma: Technical and clinical study.

OBJECTIVE: Chronic subdural hematoma (CSDH) is an important health problem observed mostly in elderly population. Here, we aimed to describe and validate a simple modified technique of twist-drill craniostomy (TDC) using easily accessible tools for effective and safe bedside CSDH drainage. METHODS: A detailed description of the new modified TDC technique which allows for sequential drainage and irrigation under physiological conditions is provided. Clinical and radiological characteristics as well as surgical results of the patients undergoing this procedure are also presented. RESULTS: A total of 55 patients (30 M, 25 F) underwent this modified TDC. Mean age was 61.7 ±â€¯12.3 years. Medical comorbidities were common (76.4 %). Subdural hematoma was mostly unilateral (83.6 %). Maximum width of hematoma was 21 ±â€¯4 mm on average (range: 9-38 mm). In total, patients underwent 1.6 ±â€¯0.9 subdural tappings on average (median: 1, range: 1-5). Repeat tappings were performed in 43.6 % of the patients. No mortality, serious morbidity or infectious complications were noted. Pneumocephalus was either absent or minimal in most cases (96.4 %). Mean length of hospital stay was 4.9 ±â€¯4.0 days (median: 3; range: 2-20 days). The clinical outcomes were favorable in 92.7 % of the patients (no craniotomy required and no symptomatic recurrence detected). CONCLUSION: This modified technique of TDC utilizes easily available tools, yields satisfactory radiological and clinical results, allows repeated tappings even in outpatient settings and can thus be readily applied in every neurosurgical unit across the world. It can be an effective alternative to existing procedures for patients with multiple co-morbidities and/or high anesthesia risk, in emergency conditions and busy neurosurgical centers.

Long-Term Outcomes of Pediatric Meningioma Surgery: Single Center Experience with 23 Patients.

AIM: To evaluate the long-term outcomes and prognostic variables in a surgical cohort of pediatric meningiomas treated in a single institution. MATERIAL AND METHODS: Medical records and follow-up notes of 23 pediatric patients aged < 18 years (12 male and 11 female; mean age on presentation, 13.1 ± 4.4 years) harboring 27 meningiomas operated between 1994 and 01/2019 at Hacettepe University Ihsan Dogramaci Children’s Hospital were evaluated. RESULTS: One patient had neurofibromatosis (NF) type 1, and five patients had NF2. Tumors were most commonly located in the convexity (n=6) and parasagittal or falcine (n=6). Gross total resection was performed in 70.4% of cases. WHO grade I tumors accounted for 56% of all cases, whereas high-grade meningiomas accounted for 44% (33% grade II, 11% grade III). The mean follow-up duration was 10.3 ± 7.7 years. Three patients (13%) died during follow-up, and 76.2% of the patients had favorable outcome (Glasgow Outcome Scale > 3) during the last follow-up assessment. Ten patients (43.5%) had relapse. In univariate analysis, low histological grade (p=0.030) and gross total resection (p=0.024) were associated with favorable outcome. The 10-year overall survival rate was 86%. CONCLUSION: Meningiomas in the pediatric age group are surgically treatable tumors with fairly good outcomes. However, relapses are common even for low-grade tumors; therefore, long-term surveillance and aggressive treatment are needed.

The Effect of Training, Used-Hand, and Experience on Endoscopic Surgery Skills in an Educational Computer-Based Simulation Environment (ECE) for Endoneurosurgery Training.

Today, virtual simulation environments create alternative hands-on practice opportunities for surgical training. In order to increase the potential benefits of such environments, it is critical to understand the factors that influence them. This study was conducted to determine the effects of training, used-hand, and experience, as well as the interactions between these variables, on endoscopic surgery skills in an educational computer-based surgical simulation environment. A 2-hour computer-based endoneurosurgery simulation training module was developed for this study. Thirty-one novice- and intermediate-level resident surgeons from the departments of neurosurgery and ear, nose, and throat participated in this experimental study. The results suggest that a 2-hour training during a 2-month period through computer-based simulation environment improves the surgical skills of the residents in both-hand tasks, which is necessary for endoscopic surgical procedures but not in dominant hand tasks. Based on the results of this study, it can be concluded that computer-based simulation environments potentially improve surgical skills; however, the scenarios for such training modules need to consider especially the bimanual coordination of hands and should be regularly adapted to the individual skill levels and progresses.

Survival Benefit with Gross Total Resection and Adjuvant Radiotherapy in Childhood Atypical Teratoid/Rhabdoid Tumors: Results of a Single-Center Cohort of 27 Cases.

AIM: To share a single center experience with 27 atypical teratoid/rhabdoid tumor (AT/RT) cases, and to determine the effect of gross total tumor resection and other clinical characteristics on the overall survival rate of AT/RT. MATERIAL AND METHODS: We included 27 patients-with a histopathologically confirmed primary intracranial childhood AT/ RT-who were operated in our clinic between January 2000 and December 2017. Age, sex, tumor location, disseminated disease, the presence of hydrocephalus, symptom duration till diagnosis, the extent of resection, and adjuvant radiotherapy were evaluated for their influence on overall survival. RESULTS: Median age at diagnosis for 27 patients was 19.1 months (7.2 months-5 years). Gross total resection was possible in 13 (48.72%) patients. Except for three patients who died of perioperative complications, all patients received chemotherapy and 11 received radiotherapy. In univariate analysis, male sex, older age at diagnosis (≥24 months), gross total resection, and radiotherapy were associated with overall longer survival; however, radiotherapy remained the only significant parameter in multivariate analysis. CONCLUSION: AT/RT is a rare and dreadful brain tumor that has low survival rates despite contemporary treatment. Radiotherapy seems to prolong survival; however, large-scale studies are needed to establish prognostic factors.

Radiological and Clinical Comparison of Posterolateral Fusion and Transforaminal Interbody Fusion Techniques in Degenerative Lumbar Stenosis.

OBJECTIVE: Fusion surgery for lumbar degenerative stenosis is an established treatment mode. Despite comparable patient-related outcomes and radiologic results, the necessity of adding interbody fusion to posterolateral fusion remains controversial. We aimed to compare the clinical and radiologic outcomes of posterolateral fusion and transforaminal interbody fusion techniques in degenerative lumbar stenosis with or without spondylolisthesis. METHODS: We retrospectively evaluated the clinical and radiologic outcomes of 48 patients who underwent decompression plus either posterolateral fusion (PLF; n = 23) or transforaminal interbody fusion (TLIF) plus PLF (TLIF+PLF; n = 25) procedures, which incorporated 71 segments for degenerative lumbar stenosis with or without spondylolisthesis. RESULTS: The median follow-up duration for the PLF and TLIF groups were 26 and 31 months, respectively. Both procedures significantly improved the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores; however, the postoperative ODI and VAS scores were unaffected by the procedure type. Postoperative disc heights and percent changes in disc heights did not change by operation type; however, the percent change in the foramen areas was significantly greater in the TLIF group. The addition of TLIF to the PLF procedure resulted in significantly longer operating time and more intraoperative blood loss. Cerebrospinal fluid fistula was the only major complication noted. The radiologic fusion rates were similar between both study groups. CONCLUSIONS: Both PLF and TLIF+PLF procedures were effective in ameliorating the symptoms of degenerative lumbar stenosis and spondylolisthesis. Although some radiologic parameters favor TLIF, this was not reflected in the clinical outcomes.

A potential non-invasive glioblastoma treatment: Nose-to-brain delivery of farnesylthiosalicylic acid incorporated hybrid nanoparticles.

New drug delivery systems are highly needed in research and clinical area to effectively treat gliomas by reaching a high antineoplastic drug concentration at the target site without damaging healthy tissues. Intranasal (IN) administration, an alternative route for non-invasive drug delivery to the brain, bypasses the blood-brain-barrier (BBB) and eliminates systemic side effects. This study evaluated the antitumor efficacy of farnesylthiosalicylic acid (FTA) loaded (lipid-cationic) lipid-PEG-PLGA hybrid nanoparticles (HNPs) after IN application in rats. FTA loaded HNPs were prepared, characterized and evaluated for cytotoxicity. Rat glioma 2 (RG2) cells were implanted unilaterally into the right striatum of female Wistar rats. 10days later, glioma bearing rats received either no treatment, or 5 repeated doses of 500µM freshly prepared FTA loaded HNPs via IN or intravenous (IV) application. Pre-treatment and post-treatment tumor sizes were determined with MRI. After a treatment period of 5days, IN applied FTA loaded HNPs achieved a significant decrease of 55.7% in tumor area, equal to IV applied FTA loaded HNPs. Herewith, we showed the potential utility of IN application of FTA loaded HNPs as a non-invasive approach in glioblastoma treatment.