Exoscopic versus Microscopic Surgery in 5-ALA-Guided Resection of High-Grade Gliomas.

Background: Glioma surgery has been remarkably enhanced in the past 2 decades, with improved safety and limited but improved life expectations. The fluorescence-guided resection of high-grade gliomas (HGGs) plays a central role in this sense, allowing a greater extent of resection (EOR). The introduction of exoscopic-guided surgery may be considered in implementing fluorescence techniques over traditional microscopes. We present the application and the advantages of exoscopic-guided surgery compared to microscopic surgery in tumor resection guided by 5-ALA fluorescence in patients with HGGs. Methods: Ten consecutive patients underwent surgery for HGG resection. The surgery was performed via an exoscopic-guided procedure (Olympus ORBEYE) and after the oral administration of Gliolan 5 h before the procedure. During surgery, the procedure shifted to using a microscopic (Kinevo 900, Zeiss) view. The intensity of the fluorescence under the two different procedures was subjectively measured in different picture samples during the surgery on a 1 to 5 (from minimum to maximum) scale. The brightness of the surgical field and the detailing of the anatomy were also analyzed comparatively. Results: Among the ten patients, the histopathological diagnosis was an high-grade glioma in all cases. In nine cases, it was possible to achieve gross total resection. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1-5, was 4.5 in the exoscope group and 3.5 in the microscope group (p < 0.01). Conclusions: The exoscopic-guided surgery adds advantages to traditional fluorescence-guided surgery with 5-aminolevulinic acid. Beyond the important advantage of low cost and the possibility to perform collaborative surgeries, it adds a plain and continuous visualization of the tumor and offers advantages in the surgical field of fluorescence-guided glioma surgery compared to the microscopic-guided one.

Transorbital penetrating intracranial injury involving bilateral frontal lobes with evisceration of right eye: A case report.

Key Clinical Message: Timely diagnosis, multidisciplinary surgical intervention, and appropriate imaging are crucial in managing transorbital-penetrating intracranial injuries (TOPIs), minimizing morbidity, and optimizing patient outcomes. Abstract: Transorbital-penetrating intracranial injuries (TOPIs) are rare occurrences with potential for severe neurological complications and high mortality rates. Prompt diagnosis and management are essential to mitigate adverse outcomes. Understanding injury patterns and employing appropriate imaging modalities are crucial for effective surgical planning and patient care. We present a case of a 22-year-old male mechanic who sustained a TOPI involving bilateral frontal lobes with evisceration of the right eye following a workplace accident with a metal cutter. Upon arrival at the emergency department, the patient exhibited vision loss in the right eye, proptosis, and a dilated pupil. Imaging studies revealed the trajectory of a metal arrow through the right orbital roof, necessitating surgical intervention. A multidisciplinary team performed bifrontal craniectomy with duroplasty to remove the foreign body and address associated injuries. Postoperatively, the patient received broad-spectrum antibiotics and anticonvulsants, leading to full recovery and discharge on postoperative day 10. TOPIs present unique challenges due to their rarity and potential for devastating consequences. Our case highlights the importance of timely diagnosis, meticulous surgical planning, and multidisciplinary collaboration in achieving favorable outcomes. Radiological imaging plays a crucial role in guiding treatment decisions and optimizing patient care. This report underscores the significance of early surgical intervention, antimicrobial therapy, and prophylactic measures in reducing morbidity and mortality associated with TOPIs.

Facial nerve electrical motor evoked potential in cerebellopontine angle tumors for its anatomical and functional preservation.

Background: Among the technical measures to preserve facial nerve (FN) function, intraoperative neuromonitoring has become mandatory and is constantly being scrutinized. Hence, to determine the efficacy of FN motor evoked potentials (FNMEPs) in predicting long-term motor FN function following cerebellopontine angle (CPA) tumor surgery, an analysis of cases was done. Methods: In 37 patients who underwent CPA surgery, FNMEPs through corkscrew electrodes positioned at C5-C6 and C6-C5 (C is the central line of the brain as per 10-20 EEG electrode placement) were used to deliver short train stimuli and recorded from the orbicularis oculi, oris, and mentalis muscles. Results: In 58 patients, triggered electromyography (EMG) was able to identify the FN during resection of tumor, but 8 out of these (4.64%) patients developed new facial weakness, whereas 3 out of 38 (1.11%) patients who had intact FN function MEP (decrement of FN target muscles - CMAPs amplitude peak to peak >50-60%), developed new facial weakness (House and Brackmann grade II to III). Conclusion: The FNMEP has significant superiority over triggered EMG when tumor is giant and envelops the FN.

Do we really apply evidence-based-recommendations to spine surgery? Results of an international survey.

OBJECTIVE: This international survey investigated Evidence-Based Medicine (EBM) in spine surgery by measuring its acceptance among spine surgeons. It assessed their understanding of EBM and how they apply it in practice by analyzing responses to various clinical scenarios.. MATERIALS AND METHODS: Following the CHERRIES guidelines, an e-survey was distributed to multiple social media forums for neurosurgeons and orthopedic surgeons on Facebook, LinkedIn, and Telegram and circulated further through email via the authors' network. Three hundred participants from Africa, Asia, Europe, North America, and Oceania completed the survey. RESULTS: Our study revealed that 67.7% (n = 203) of respondents used EBM in their practice, and 97.3% (n = 292) believed training in research methodology and EBM was necessary for the practice of spine surgery. Despite this endorsement of using EBM in spine surgery, we observed varied responses to how EBM is applied in practice based on example scenarios. The responders who had additional training tended to obey EBM guidelines more than those who had no additional training. Most surgeons responded as always or sometimes prescribing methylprednisolone to patients with acute spinal cord injury. Other significant differences were identified between geographical regions, training, practice settings, and other factors. CONCLUSIONS: Most respondents used EBM in practice and believed training in research methodology and EBM is necessary for spine surgery; however, there were significant variations on how to use them per case. Thus, the appropriate application of EBM in clinical settings for spinal surgery must be further studied.

Retraction notice to "Decency in neurosurgery" [Brain Spine 4 (2024), 102744].

[This retracts the article DOI: 10.1016/j.bas.2023.102744.].

Recurrent artery of Heubner aneurysms in focus: insights into occurrence and current treatment paradigms.

INTRODUCTION: The recurrent artery of Heubner (RAH), also known as the medial striate artery, is the most clinically important perforator of the anterior cerebral artery. RAH aneurysm is relatively rare, with 11 cases found in the present literature review, but poses significant clinical challenges due to potential impact on cognitive and motor functions. This systematic review explored available case reports to comprehensively understand clinical presentation, diagnosis, management and outcome in RAH aneurysm. MATERIALS AND METHODS: Following PRISMA guidelines, this systematic review extensively explored RAH aneurysms, covering demographics, symptoms, diagnosis, treatments and outcomes. Comprehensive searches on PubMed, Scopus, Google Scholar, and Science Direct employed keywords such as "recurrent artery of Heubner aneurysm" and "Heubner's artery." RESULTS: After extensive screening, 9 qualifying studies were identified, with 11 patients diagnosed with rare RAH aneurysm. Median age was 55 years (standard deviation, 15.3 years), with 54.5% males. 45.5% of patients presented risk factors, including Moyamoya disease in 2 patients. The majority were classified as grade I/II on the Hunt and Hess (H&H) and World Federation of Neurological Societies (WFNS) systems. Aneurysms were predominantly located in the A1 segment, with a mean size of 4.7 mm. Treatments varied, with clipping being the most frequent (63.6%). The mortality rate was 18.2%. Clipping was associated with favorable outcomes but higher rates of infarction. CONCLUSION: This analysis highlighted the various symptoms, therapy methods and outcomes of RAH aneurysm, with A1 being the predominant origin. Future research should explore potential genetic predisposition factors and novel therapeutic interventions to address gaps in our knowledge.

Global Neurosurgical Challenges: A Focus on Central Asia.

OBJECTIVE: To evaluate the current state of neurosurgical care in Central Asia, identify the challenges and advancements, and propose recommendations to improve neurosurgical capabilities and access in Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. METHODS: A comprehensive review of the neurosurgical infrastructure, availability of neurosurgeons, technological advancements, and healthcare policies in the five Central Asian countries. Analysis included published literature, healthcare reports, and expert opinions to assess the state of neurosurgical care and identify areas for improvement. RESULTS: Significant variation in neurosurgical care was observed across the region. Kazakhstan showed notable advancements, including an increased number of neurosurgeons and progress in specialized fields such as vascular neurosurgery and brain tumor management. Other countries, like Uzbekistan, Tajikistan, and Kyrgyzstan, made strides in improving neurosurgical care but still faced substantial challenges. Common issues included a shortage of neurosurgeons, limited facilities, and inadequate access to modern technology. The lack of research data further highlighted the need for urgent intervention. CONCLUSIONS: To enhance neurosurgical care in Central Asia, a multipronged approach involving targeted investments, policy reforms, international collaborations, and knowledge sharing is recommended. This includes establishing specialized neurosurgical training programs and fellowships, investing in infrastructure and technology, fostering international collaborations for training and research, introducing early neurosurgery education in medical schools, improving access to online education resources, and promoting telemedicine for consultations and follow-up care. These measures are necessary to expand access to essential neurosurgical care and improve outcomes in the regions.

Assessing bacterial prevalence and resistance in paediatric meningitis: safeguarding the central nervous system.

Introduction: Paediatric bacterial meningitis (PBM) represents a major contributor to childhood morbidity and mortality globally, with heightened susceptibility in low- and middle-income nations where antimicrobial resistance (AMR) is highly prevalent. Pakistan exemplifies this setting, with widespread antibiotic overuse driving AMR expansion. Thus, expediting PBM diagnosis and targeted antibiotic therapy is imperative yet challenged by the dynamic local epidemiology. This study aimed to delineate the recent bacterial etiologies and AMR profiles of PBM from a major Pakistani diagnostics laboratory to inform empirical treatment. Materials and methods: This prospective observational investigation evaluated PBM epidemiology in patients under 18 years old admitted to the study hospital. Standard cerebrospinal fluid analysis identified bacterial pathogens and antibiotic susceptibility patterns. Results: Among 171 PBM cases, 152 (88.9%) had bacterial isolates confirmed via culture. The cohort was 42.7% male with a mean age of 3 months. The most prevalent pathogens among infants younger than 3 months were Escherichia coli, Enterococcus faecium, and Staphylococcus epidermidis, contrasting with S. epidermidis, Streptococcus pneumoniae, and Staphylococcus hominis predominating in older children. Staphylococcal isolates exhibited considerable penicillin and erythromycin resistance but maintained vancomycin and linezolid susceptibility. Other resistance patterns varied. Conclusion: These findings highlight the pressing threat of paediatric AMR in Pakistan, underscoring the need for vigilant AMR surveillance and judicious antimicrobial use. This study provides a reference to current PBM epidemiology to guide context-specific empirical therapy.

Carving a Path to the Brain: A Study on Neurosurgery Career Choices.

BACKGROUND: Medical students often face challenges in choosing a career path due to limited exposure to specialized fields like neurosurgery. Understanding their perceptions and experiences is crucial in addressing the gaps in neurosurgical education and inspiring future neurosurgeons. METHODS: A cross-sectional study was conducted involving 461 medical students, utilizing convenience sampling. Data collection employed a validated, self-administered tool. Statistical analysis in SPSS Version 25 included t-tests and chi-square tests, comparing scores based on age, gender, year of study, and exposure to the formal neurosurgical rotations in their institute. Significance value was set at P < 0.05. RESULTS: In the study of 461 medical students, 79.8% identified with the 19-23 age group, and 63.8% affirmed neurosurgery exposure. Medical students' perceptions included: 167 (36.3%) students found neurosurgery teaching sufficient; 164 (35.6%) disagreed that obtaining neurosurgical history is difficult; 224 (48.6%) agreed on neurosurgical disease complexity; and 250 (54.2%) found these diseases challenging and interesting. A majority of 183 (39.7%) respondents agreed that neurosurgical diseases had poor outcomes. Regarding training for neurosurgical surgery, 205 (44.5%) participants strongly agreed on its length, and 215 (46.7%) consented to extensive operating hours. However, 167 (36.3%) strongly disagreed about the ample job prospects in Pakistan. CONCLUSIONS: Enhancing neurosurgery education with quality, consistency, and adaptability is essential to bridge gaps and inspire future neurosurgeons. These findings guide improvements in educational programs, preparing a skilled workforce to meet evolving health-care demands.