Prediction of Early Postoperative Language Function by Quantitative Evaluation with Visual and Auditory Naming Tasks during Awake Craniotomy for Brain Tumor Resection: Significance of Auditory Naming Task.

Language tasks for monitoring intraoperative language symptoms have not yet been established. This study aimed to examine whether the quantitative evaluation of language function with visual and auditory naming during awake craniotomy predicts early postoperative language function in patients. Thirty-seven patients with brain tumors in the language-dominant hemisphere were included. They underwent visual and auditory naming preoperatively and at the end of tumor resection for intraoperative evaluation. Using the Western Aphasia Battery, their overall language functions were evaluated preoperatively, early postoperatively (within 1 week), and late postoperatively (after 1 month). The preoperative and intraoperative changes in the visual and auditory naming scores were significantly correlated with most of the Western Aphasia Battery score changes between the preoperative and early postoperative evaluations, which was more remarkable for auditory naming. Multiple linear regression analysis showed that changes in the auditory naming score predicted the preoperative to early postoperative changes in the aphasia quotient of the Western Aphasia Battery. Receiver operating characteristics analysis showed a higher area under the curve or discriminative power for auditory than visual naming in predicting the development or exacerbation of aphasia in the early postoperative period. Considering the analyses applied separately for low- and high-grade glioma, auditory naming, which taps into a wider range of linguistic functions, may be more informative than visual naming as language evaluation in awake craniotomy for the early postoperative development of aphasia, especially for patients with high-grade glioma.

Left Sylvian Fissure Epidermoid Cyst Presenting with Progressive Aphasia.

INTRODUCTION: Epidermoid cysts within the sylvian fissure are extremely rare. Expressive aphasia and neurocognitive dysfunction because of mass effect have never been reported previously. CASE PRESENTATION: We discuss the case of a 53-year-old male who presented with an acute episode of expressive aphasia and vision changes along with progressive headaches and cognitive slowing over the 2.5 years prior to presentation. A detailed neurologic examination revealed subtle conductive aphasia, as well as mild short-term memory dysfunction. Magnetic resonance imaging revealed a cystic mass consistent with epidermoid cyst within the left sylvian fissure. High-definition fiber tractography showed that the arcuate fasciculus was stretched by the tumor. A left frontotemporal craniotomy allowed for near-total excision of the cyst and led to rapid and complete resolution of symptoms. CONCLUSION: Although rare, epidermoid cysts of the dominant sylvian fissure can present with progressive aphasia due to mass effect on the arcuate fasciculus. Despite the long-standing symptoms, surgical resection can lead to their complete resolution.

Recurring Thalamic Symptoms Due to Intracranial Dural Arteriovenous Fistula: Report of Unusual Case and Treatment Outcome.

BACKGROUND: Initial clinical presentation of dural arteriovenous fistula (DAVF) with predominantly thalamic symptoms is rare and has not been reported until now. CASE DESCRIPTION: A young child presenting with complaints of tinnitus and mild right hemiparesis was evaluated with an initial magnetic resonance imaging, which revealed a Borden type 2 DAVF in the right transverse sinus with retrograde venous drainage and cortical venous reflux. Flow-related small aneurysms were also noted in the left basal vein of Rosenthal (BVR). Two days later, his motor power deteriorated and he developed right hemisensory loss and severe thalamic pain. Aphasia was atypical and mimicked the transcortical type. Repeat imaging revealed expanding thrombosed aneurysm of BVR with mass effect and edema on thalamocapsular region. Initial antiedema measures reversed the neurologic deficits; however, they recurred, necessitating an urgent endovascular intervention. Angiogram revealed an extensive high-flow DAVF in the right transverse-sigmoid sinus and torcula with preferential retrograde venous drainage into deep veins and left BVR. He underwent staged embolization of DAVF, resulting in significant obliteration of shunt. Neurologic deficits improved in the postoperative period, and the patient remained clinically asymptomatic at 6 months of follow-up. CONCLUSIONS: DAVF presenting with recurrent predominantly thalamic symptoms is rare. Atypical transcortical aphasia rather than fluent aphasia is an unusual clinical manifestation of thalamic pathology and could result from the involvement of specific thalamic nuclei. Preferential high flow into BVR in the presence of venous anomalies could potentially induce architectural weakness of the venous wall and precipitate aneurysm formation. Embolization of the DAVF can potentially reverse this unusual neurologic condition.

The Occipital Artery as an Alternative Donor for Low-Flow Bypass to Anterior Circulation After Internal Carotid Artery Occlusion Failure prior to Exenteration for an Atypical Cavernous Sinus Meningioma.

BACKGROUND: In skull base tumors involving the cavernous sinus, indications for aggressive resection are sparse and must be carefully examined because of their invasiveness. With careful evaluation, techniques including internal carotid artery sacrifice with or without extracranial-intracranial bypass may still be an option in some cases. Moreover, previous surgery with the sacrifice of potential donor vessels requires adjusting the revascularization strategy. We describe an occipital artery-middle cerebral artery bypass before skull base tumor resection. CASE DESCRIPTION: A 47-year-old woman with a recurrent cavernous sinus meningioma was referred to our department. Because of tumor recurrence after radiotherapy and its rapid progression, radical resection, including part of the cavernous sinus, was planned. A balloon test occlusion was performed and showed good tolerance. An endovascular internal carotid artery occlusion was performed. The patient eventually experienced motor deficits and aphasia after surgery. Therefore, bypass surgery using an occipital artery-middle cerebral artery anastomosis was performed. The patient showed no exacerbation of symptoms after bypass surgery and subsequently underwent tumor resection. CONCLUSIONS: The reliability of balloon test occlusion in the management of giant aneurysms may not be similarly applicable to skull base tumors. If hypoperfusion symptoms occur after occlusion of the internal carotid artery, a surgical revascularization procedure should be considered because of the risk of ischemic stroke following tumor resection. For patients whose superficial temporal artery is not available, the occipital artery can be a valuable alternative donor for low-flow bypass.

Overcoming End-to-End Vessel Mismatch During Superficial Temporal Artery-Radial Artery-M2 Interposition Grafting for Cerebral Ischemia: Tapering Technique.

Cerebral revascularization procedures, such as the external carotid-internal carotid bypass, have been used in the clinical management of cerebral ischemic states. Among the most commonly performed bypasses is the superficial temporal artery-middle cerebral artery (STA-MCA) bypass to restore cerebral blood flow. In cases of a foreshortened STA donor vessel, a radial artery (RA) graft is often used as an interposition graft between the STA and MCA. However, addressing the vessel size mismatch between the radial artery and donor can be problematic and challenging. We present the case of an 80-year-old male presenting with positional-onset expressive aphasia and right-sided hemiparesis. Computed tomography perfusion demonstrated a diffusion-perfusion mismatch in a left MCA distribution. Angiography showed a complete left internal cerebral artery occlusion and poor distal filling of the STA. We performed an external carotid artery-to-internal carotid artery bypass through interposing an RA graft to the STA proximally with an end-to-end anastomosis and to the MCA distally using an end-to-side anastomosis. The mismatch between 2 bypass vessel sizes was corrected by removing a small piece from the RA graft at 1 margin and suturing it to itself to reduce the size of the RA vessel diameter opening on the side used to sew to the STA. The patient did well clinically with improved right-sided strength, a patent graft, and no postoperative complications. Addressing vessel mismatch when using RA interposition grafts for bypass is challenging. Various operative approaches to address mismatch should be individualized on the basis of the particular vascular anatomy and needs of the case. Nevertheless, our method of cutting and suturing 1 side of the RA graft into a semiblind end to match donor vessel diameter may be of use to cerebrovascular surgeons in select cases.

Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter?

OBJECTIVE: To report our experience in POEM vs. LHM, with particular focus on myotomy extension. BACKGROUND: POEM has been adopted worldwide as a treatment for achalasia. While resolution of dysphagia is above 90%, postoperative reflux ranges from 10 to 57%. Myotomy length has been a controversial topic. METHODS: Thirty-five cases of POEM were prospectively analyzed and compared retrospectively to the last 35 patients that underwent LHM, from December 2010 to August 2016. Mean follow-up was 10 months (6/32) for POEM and 20 months (6/68) for LHM. All patients with LHM had a myotomy extension ≥3 cm on the gastric side. In POEM cases, extension was defined by direct vision (Hill type II) and never exceeded 2 cm. RESULTS: Follow-up was completed in 100% of patients. Efficacy (ES ≤ 3) was 33/35 (94.2%) for POEM and 32/35 (91.4%) for LHM in a short-term follow-up (p = 1.000) and 31/35 (88.6%) and 27/35 (77.1%), respectively, in a long-term follow-up (p = 1.000), with average ES drop from 9 to 1.2 (p = 0.0001) in POEM vs. 9.2 to 1.3 (p = 0.0001) in LHM. Major Postoperative complications occurred in 1 patient (leak) for LHM and 1 patient (massive capnothorax) in POEM. Hospital stay was shorter for POEM than for LHM (1.3 vs. 2.1, respectively) (p = 0.0001). Symptomatic reflux cases included 7/35 POEM (20%) vs. 6/35 LHM (17.1%) (p = 0.4620). Esophagitis signs in endoscopy appeared in 1/21 POEM (4.7%) vs. 1/22 LHM (4.5%) (p = 1.000). Patients requiring PPI included 8/35 POEM (22.8%) vs. 7/35 LHM (20%) (p = 0.6642). Further treatment (endoscopic dilation) was performed in 10/35 POEM (28.5%) vs. 8/35 LHM (22.8%). CONCLUSIONS: A shorter myotomy on the gastric side in POEM may contribute to an acceptable reflux rate with comparable relief of dysphagia. Although our follow-up for POEM is shorter than for LHM, the trends are promising and warrant future prospective studies to address this topic.

[Crossed Aphasia]. / Gekreuzte Aphasie.

Crossed aphasia (CA) is a rare acquired language disorder caused by a right-sided brain lesion in dextrals. Based on a case report, relevant aspects for the diagnosis of CA and differential diagnoses will be outlined. Relevant hypotheses concerning etiology, epidemiology, phenomenology and pathophysiology will be discussed with reference to the literature. The phenomenon of CA has contributed for decades to the development of hypotheses concerning lateralization of cognitive abilities.

Early effect of intra-arterial treatment in ischemic stroke on aphasia recovery in MR CLEAN.

OBJECTIVE: To investigate the effect of intra-arterial treatment (IAT) on early recovery from aphasia in acute ischemic stroke. We hypothesized that the early effect of IAT on aphasia is smaller than the effect on motor deficits. METHODS: We included patients with aphasia from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), in which 500 patients with a proximal anterior circulation stroke were randomized to usual care plus IAT (<6 hours after stroke, mainly stent retrievers) or usual care alone. We estimated the effect of IAT on the shift on the NIH Stroke Scale (NIHSS) item language and the NIHSS item motor arm at 24 hours and 1 week after stroke with multivariable ordinal logistic regression as a common odds ratio, adjusted for prognostic variables (acOR). Differences between the effect of IAT on aphasia and on motor deficits were tested in a multilevel model with a multiplicative interaction term. RESULTS: Of the 288 patients with aphasia, 126 were assigned to IAT and 162 to usual care alone. The acOR for improvement of language score at 24 hours was 1.65 (95% confidence interval [CI] 1.05-2.60), and at 1 week 1.86 (95% CI 1.18-2.94). The acOR for improvement of motor deficit at 24 hours was 2.44 (95% CI 1.54-3.88), and at 1 week 2.32 (95% CI 1.43-3.77). The effect of IAT on language deficits was significantly different from the effect on motor deficits at 24 hours and 1 week (p = 0.005 and p = 0.011). CONCLUSIONS: IAT results in better early recovery from aphasia than usual care alone. The early effect of IAT on aphasia is smaller than the effect on motor deficits. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for patients with acute ischemic stroke IAT increases early recovery from aphasia and that the early effect on aphasia, as measured by the NIHSS, is smaller than the effect on motor deficits.

A multimodal mapping study of conduction aphasia with impaired repetition and spared reading aloud.

The present study explores the functional neuroanatomy of the phonological production system in an Italian aphasic patient (SP) who developed conduction aphasia of the reproduction type following brain surgery. SP presented with two peculiar features: (1) his lesion was localized in the superior temporal gyrus, just posterior to the primary auditory cortex and anterior/inferior to and neighboring the Sylvian parietal temporal (Spt) area, and (2) he presented with severely impaired repetition and spelling from dictation of words and pseudowords but spared reading-aloud of words and pseudowords. Structural, functional, fiber tracking and intraoperative findings were combined to analyze SP's pattern of performance within a widely used sensorimotor control scheme of speech production. We found a dissociation between an interrupted sector of the arcuate fasciculus terminating in STG, known to be involved in phonological processing, and a part of the arcuate fasciculus terminating in MTG, which is held to be involved in lexical-semantic processing. We argue that this phonological deficit should be interpreted as a disorder of the feedback system, in particular of the auditory and somatosensory target maps, which are assumed to be located along the Spt area. In patient SP, the spared part of the left arcuate fasciculus originating in MTG may support an unimpaired reading performance, while the damaged part of the left arcuate fasciculus originating in STG may be responsible for his impaired repetition and spelling from dictation.

An unusual case of dysphasia and seizures.

Defects in the tegmen tympani can have serious consequences such as intracranial infection and seizures, however, they can be difficult to diagnose due to their subtlety on cross-sectional imaging and the non-specific way in which they can present. Repair of such defects can be undertaken via a middle fossa or transmastoid approach; both, however, usually necessitate a general anaesthetic and, furthermore, middle cranial fossa surgery carries the risk of epilepsy while transmastoid repair can result in the loss of hearing. We present a novel method of repair in a patient who would otherwise have been managed conservatively.

Endoscopic myotomy for achalasia.

POEM is an effective treatment of functional manometric esophageal outflow obstructive disorders with excellent relief of dysphagia. Reflux rates seem to be similar to that seen with traditional Heller myotomy with fundoplication. The POEM technique provides a true surgical esophageal myotomy without incisional pain. As such, POEM represents the first truly practical application of natural orifice surgery.

Is a lone right hemisphere enough? Neurolinguistic architecture in a case with a very early left hemispherectomy.

We studied the linguistic profile and neurolinguistic organization of a 14-year-old adolescent (EB) who underwent a left hemispherectomy at the age of 2.5 years. After initial aphasia, his language skills recovered within 2 years, with the exception of some word finding problems. Over the years, the neuropsychological assessments showed that EB's language was near-to-normal, with the exception of lexical competence, which lagged slightly behind for both auditory and written language. Moreover, EB's accuracy and speed in both reading and writing words and non-words were within the normal range, whereas difficulties emerged in reading loan words and in tasks with homophones. EB's functional magnetic resonance imaging (fMRI) patterns for several linguistic and metalinguistic tasks were similar to those observed in the dominant hemisphere of controls, suggesting that his language network conforms to a left-like linguistic neural blueprint. However, a stronger frontal recruitment suggests that linguistic tasks are more demanding for him. Finally, no specific reading activation was found in EB's occipitotemporal region, a finding consistent with the surface dyslexia-like behavioral pattern of the patient. While a lone right hemisphere may not be sufficient to guarantee full blown linguistic competences after early hemispherectomy, EB's behavioral and fMRI patterns suggest that his lone right hemisphere followed a left-like blueprint of the linguistic network.

Operative and nonoperative linguistic outcomes in brain injury patients.

OBJECTIVE AND BACKGROUND: Linguistic function is one of vulnerable aspects of traumatic brain injury (TBI) which may have destructive effects on patients' communicative activities and daily life, years following trauma. This paper attempts to answer the controversy whether surgery affects increase and decrease of linguistic impairment or not. MATERIALS AND METHODS: Two hundred forty-one TBI patients aged 18-65 with abnormal CT findings and at least 20 minute post-trauma amnesia (PTA), who were conscious at discharge, participated in this study. Based on operative intervention, the samples were divided into two groups: operative and nonoperative. Cognitive and aphasic deficits were inspected formally and pragmatic disorder was informally appraised at discharge. RESULTS: The groups had no significant differences in aphasia incidence and language pragmatic impairment, though they were significantly distinctive in aphasia subcategories and cognitive deficit after trauma. Fluent aphasia was more common in both groups alike. In aphasia subcategories, however, transcortical sensory aphasia (TSA) in operative and anomia in nonoperative group were the most prevalent. Several variables appeared strikingly related to higher aphasia in operative groups as follows: moderate to severe injury, 18-35 and over 50 years of age, more than 1 week PTA, intracranial surgery of multiple lesions in left or bilateral hemisphere fronto-temporal cortex plus post-trauma cognitive and pragmatic impairments, and diffuse axonal injuries. DISCUSSION: Almost certainly, meaningful drop of cognitive function post surgery roots back in significant loss of initial consciousness level. Related factors to postoperative aphasia suggest taking policies through surgery intervention. Discerning the indispensable contributions of neurosurgeons, neurolinguists, and neuroscientists, results inspire more clinical future studies.

All strictures are not alike: laparoscopic removal of nonadjustable Silastic bands after banded Roux-en-Y gastric bypass.

BACKGROUND: The concept of a nonadjustable Silastic band (NASB) has been used to promote surgically induced weight loss for >30 years. Vertical banded Roux-en-Y gastric bypass is an example. Some patients develop serious, band-related complications requiring treatment. Narrowing at the NASB will lead to refractory nausea, vomiting, regurgitation, and, even, malnutrition, requiring revision of their bariatric operation. We report on the evaluation, diagnosis, and laparoscopic treatment of proximal obstructive symptoms secondary to a NASB. METHODS: From February 2005 to January 2009, we retrospectively reviewed the preoperative and perioperative data for 6 patients who had presented with proximal obstructive symptoms after undergoing banded Roux-en-Y gastric bypass. RESULTS: The mean interval from primary NASB placement to surgery was 58 months (range 25-110). The mean duration of symptoms was 29 months (range 8-70). All patients presented with multiple symptoms, but all had nausea, vomiting, regurgitation, and dysphagia to liquids and solids. The patients had undergone multiple upper endoscopies (mean 4, range 3-6) and dilations (mean 1.3, range 1-2) without relief of their symptoms. All patients underwent successful laparoscopic removal of the NASB. Their mean hospital stay was 1 day (range 0-2). No operative or postoperative complications occurred. The reflux and obstructive symptoms had resolved immediately postoperatively in all patients. CONCLUSION: Patients with a NASB in place can experience proximal obstructive symptoms. Endoscopy is deceptive in judging the stomal size, because the endoscope can be pushed through the band area. Moreover, endoscopic dilation will offer no benefit in most patients with symptomatic banded Roux-en-Y gastric bypass. Laparoscopic removal of the NASB is safe, relieves the symptoms immediately, and can be applied to patients who have undergone both open and laparoscopic Silastic banded bariatric procedures.

Life-saving hemicraniectomy for fulminant acute disseminated encephalomyelitis.

Fulminant acute disseminated encephalomyelitis (ADEM) is a rare demyelinating disorder, which most often occurs after an infection or vaccination. It frequently presents with focal neurologic signs and an altered sensorium. Patients often require critical care for airway management but are typically treated with medical therapy alone, including intravenous steroids and other immunotherapies. We present a case of dominant hemisphere fulminant ADEM in a patient who required neurosurgical intervention and a life-saving hemicraniectomy despite maximum medical therapy.