Non-invasive prehabilitation to foster widespread fMRI cortical reorganization before brain tumor surgery: lessons from a case series.

PURPOSE: The objective of this prospective, single-centre case series was to investigate feasibility, clinical outcomes, and neural correlates of non-invasive Neuromodulation-Induced Cortical Prehabilitation (NICP) before brain tumor surgery. Previous studies have shown that gross total resection is paramount to increase life expectancy but is counterbalanced by the need of preserving critical functional areas. NICP aims at expanding functional margins for extensive tumor resection without functional sequelae. Invasive NICP (intracranial neuromodulation) was effective but characterized by elevated costs and high rate of adverse events. Non-invasive NICP (transcranial neuromodulation) may represent a more feasible alternative. Nonetheless, up to this point, non-invasive NICP has been examined in only two case reports, yielding inconclusive findings. METHODS: Treatment sessions consisted of non-invasive neuromodulation, to transiently deactivate critical areas adjacent to the lesion, coupled with intensive functional training, to activate alternative nodes within the same functional network. Patients were evaluated pre-NICP, post-NICP, and at follow-up post-surgery. RESULTS: Ten patients performed the intervention. Feasibility criteria were met (retention, adherence, safety, and patient's satisfaction). Clinical outcomes showed overall stability and improvements in motor and executive function from pre- to post-NICP, and at follow-up. Relevant plasticity changes (increase in the distance between tumor and critical area) were observed when the neuromodulation target was guided by functional neuroimaging data. CONCLUSION: This is the first case series demonstrating feasibility of non-invasive NICP. Neural correlates indicate that neuroimaging-guided target selection may represent a valid strategy to leverage neuroplastic changes before neurosurgery. Further investigations are needed to confirm such preliminary findings.

Long-Term Results of Cortical Motor Stimulation for Neuropathic Peripheral and Central Pain: Real-World Evidence From Two Independent Centers.

BACKGROUND AND OBJECTIVES: Cortical motor stimulation (CMS) is used to modulate neuropathic pain. The literature supports its use; however, short follow-up studies might overestimate its real effect. This study brings real-world evidence from two independent centers about CMS methodology and its long-term outcomes. METHODS: Patients with chronic refractory neuropathic pain were implanted with CMS. The International Classification of Headache Disorders 3rd Edition was used to classify craniofacial pain and the Douleur Neuropathique en 4 Questions Scale score to explore its neuropathic nature. Demographics and clinical and surgical data were collected. Pain intensity at 6, 12, and 24 months and last follow-up was registered. Numeric rating scale reduction of ≥50% was considered a good response. The Clinical Global Impression of Change scale was used to report patient satisfaction. RESULTS: Twelve males (38.7%) and 19 females (61.3%) with a mean age of 55.8 years (±11.9) were analyzed. Nineteen (61.5%) were diagnosed from painful trigeminal neuropathy (PTN), and seven (22.5%) from central poststroke pain. The mean follow-up was 51 months (±23). At 6 months, 42% (13/31) of the patients were responders, all of them being PTN (13/19; 68.4%). At last follow-up, only 35% (11/31) remained responders (11/19 PTN; 58%). At last follow-up, the global Numeric rating scale reduction was 34% ( P = .0001). The Clinical Global Impression of Change scale punctuated 2.39 (±0.94) after 3 months from the surgery and 2.95 (±1.32) at last follow-up ( P = .0079). Signs of suspicious placebo effect were appreciated in around 40% of the nonresponders. CONCLUSION: CMS might show long-term efficacy for neuropathic pain syndromes, with the effect on PTN being more robust in the long term. Multicentric clinical trials are needed to confirm the efficacy of this therapy for this and other conditions.

Neuromodulation-induced prehabilitation to leverage neuroplasticity before brain tumor surgery: a single-cohort feasibility trial protocol.

Introduction: Neurosurgery for brain tumors needs to find a complex balance between the effective removal of targeted tissue and the preservation of surrounding brain areas. Neuromodulation-induced cortical prehabilitation (NICP) is a promising strategy that combines temporary inhibition of critical areas (virtual lesion) with intensive behavioral training to foster the activation of alternative brain resources. By progressively reducing the functional relevance of targeted areas, the goal is to facilitate resection with reduced risks of neurological sequelae. However, it is still unclear which modality (invasive vs. non-invasive neuromodulation) and volume of therapy (behavioral training) may be optimal in terms of feasibility and efficacy. Methods and analysis: Patients undertake between 10 and 20 daily sessions consisting of neuromodulation coupled with intensive task training, individualized based on the target site and neurological functions at risk of being compromised. The primary outcome of the proposed pilot, single-cohort trial is to investigate the feasibility and potential effectiveness of a non-invasive NICP protocol on neuroplasticity and post-surgical outcomes. Secondary outcomes investigating longitudinal changes (neuroimaging, neurophysiology, and clinical) are measured pre-NICP, post-NICP, and post-surgery. Ethics and dissemination: Ethics approval was obtained from the Research Ethical Committee of Fundació Unió Catalana d'Hospitals (approval number: CEI 21/65, version 1, 13/07/2021). The results of the study will be submitted to a peer-reviewed journal and presented at scientific congresses. Clinical trial registration: ClinicalTrials.gov, identifier NCT05844605.

Cognitive and quality-of-life related factors of body mass index (BMI) improvement after deep brain stimulation in the subcallosal cingulate and nucleus accumbens in treatment-refractory chronic anorexia nervosa.

BACKGROUND: Up to 20% of the cases of anorexia nervosa (AN) are chronic and treatment-resistant. Recently, the efficacy of deep brain stimulation (DBS) for severe cases of AN has been explored, with studies showing an improvement in body mass index and other psychiatric outcomes. While the effects of DBS on cognitive domains have been studied in patients with other neurological and psychiatric conditions so far, no evidence has been gathered in AN. METHODS: Eight patients with severe, chronic, treatment-resistant AN received DBS either to the nucleus accumbens (NAcc) or subcallosal cingulate (SCC; four subjects on each target). A comprehensive battery of neuropsychological and clinical outcomes was used before and 6-month after surgery. FINDINGS: Although Body Mass Index (BMI) did not normalise, statistically significant improvements in BMI, quality of life, and performance on cognitive flexibility were observed after 6 months of DBS. Changes in BMI were related to a decrease in depressive symptoms and an improvement in memory functioning. INTERPRETATION: These findings, although preliminary, support the use of DBS in AN, pointing to its safety, even for cognitive functioning; improvements of cognitive flexibility are reported. DBS seems to exert changes on cognition and mood that accompany BMI increments. Further studies are needed better to determine the impact of DBS on cognitive functions.

Short- and long-term outcome of patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To describe short-term and 5-year rates of mortality and poor outcome in patients with spontaneous aneurysmal subarachnoid hemorrhage (aSAH) who received repair treatment. METHODS: In this prospective observational study, mortality and poor outcome (modified Rankin Scale score 3-6) were analyzed in 311 patients with aSAH at 3 months, 1 year, and 5 years follow-up. Sensitivity analysis was performed according to treatment modality. In-hospital and 5-year complications were analyzed. RESULTS: Of 476 consecutive patients with spontaneous subarachnoid hemorrhage, 347 patients (72.9%) had aSAH. Of these, 311 (89.6%) were treated (242 endovascular, 69 neurosurgical), with a mean follow-up of 43.4 months (range, 1 to 145). Three-month, 1-year, and 5-year mortality was 18.4%, 22.9%, and 29.0%, and poor outcome was observed in 42.3%, 36.0%, and 36.0%, respectively. Adjusted poor outcome was lower in endovascular than in neurosurgical treatment at 3 months (odds ratio [OR] 0.36 [95% confidence interval [CI] 0.18-0.74]), with an absolute difference of 15.8% (number needed to treat = 6.3), and at 1 year (OR = 0.40 [95% CI 0.20-0.81]), with an absolute difference of 15.9% (number needed to treat = 6.3). Complications did not differ between the 2 procedures. However, mechanical ventilation was less frequent with the endovascular technique (OR 0.67 [95% CI 0.54-0.84]). CONCLUSIONS: Patients with aSAH treated according to current guidelines had a short-term mortality of 18.4% and 5-year mortality of 29%. The majority (64.0%) of patients remained alive without disabilities at 5-year follow-up. Patients prioritized to endovascular treatment had better outcomes than those referred to neurosurgery because endovascular coiling was not feasible.

A Randomized Trial of Deep Brain Stimulation to the Subcallosal Cingulate and Nucleus Accumbens in Patients with Treatment-Refractory, Chronic, and Severe Anorexia Nervosa: Initial Results at 6 Months of Follow Up.

BACKGROUND: The main objective of this study was to assess the safety and efficacy of deep brain stimulation (DBS) in patients with severe anorexia nervosa (AN). METHODS: Eight participants received active DBS to the subcallosal cingulate (SCC) or nucleus accumbens (NAcc) depending on comorbidities (affective or anxiety disorders, respectively) and type of AN. The primary outcome measure was body mass index (BMI). RESULTS: Overall, we found no significant difference (p = 0.84) between mean preoperative and postoperative (month 6) BMI. A BMI reference value (BMI-RV) was calculated. In patients that received preoperative inpatient care to raise the BMI, the BMI-RV was defined as the mean BMI value in the 12 months prior to surgery. In patients that did not require inpatient care, the BMI-RV was defined as the mean BMI in the 3-month period before surgery. This value was compared to the postoperative BMI (month 6), revealing a significant increase (p = 0.02). After 6 months of DBS, five participants showed an increase of ≥10% in the BMI-RV. Quality of life was improved (p = 0.03). Three cases presented cutaneous complications. CONCLUSION: DBS may be effective for some patients with severe AN. Cutaneous complications were observed. Longer term data are needed.

Focal status epilepticus as a manifestation of idiopathic hypertrophic cranial pachymeningitis.

BACKGROUND: Idiopathic hypertrophic cranial pachymeningitis (IHCP) is an uncommon disease of unknown etiology characterized by thickening of the cerebral dura mater with possible associated inflammation. The most frequently described clinical symptoms include headache, cranial nerve palsy, and cerebellar dysfunction. Epilepsy and/or status epilepticus as main presentation is very uncommon. CASE PRESENTATION: Two consecutive cases are presented of patients manifesting focal status epilepticus secondary to IHCP, with clinical, laboratory [blood test and cerebrospinal fluid (CSF) analysis], neuroradiologic [magnetic resonance imaging (MRI) at 3 Tesla and digital subtraction angiography (DSA)], and therapeutic data. One patient underwent meningeal biopsy; pathology findings are also included. Corticosteroid therapy resulted in clinical improvement in both cases, and neuroimaging showed decreased abnormal morphology, compared to initial findings. CONCLUSION: In the diagnostic approach to focal status epilepticus or epilepsy, IHCP must be considered a potential, although extremely infrequent, cause. Anti-inflammatory treatment is an effective addition to antiepileptic drug therapy in patients with IHCP.

Surgical Position, Cause of Extracranial Internal Carotid Artery Dissection, Presenting as Pourfour Du Petit Syndrome: Case Report and Literature Review.

Dissection of the internal carotid artery is a rare cause of stroke overall, but causes 22% of strokes in younger patients. A common clinical presentation is as Claude Bernard Horner syndrome. We report a craniotomy with 30 degrees rotation of the neck (standard position) in a patient with no major risk factors for carotid dissection, who showed a Pourfour du Petit syndrome due to a dissection of the internal carotid artery. To the best of our knowledge, this is the first reported case in which a common surgical position causes an internal carotid artery dissection in a patient without relevant risk factors. The presentation with Pourfour du Petit syndrome is extremely unusual.

Intraoperative Neurophysiological Evidence of Hydrogen Peroxide-Induced Stroke in Insular Tumor Surgery.

Hydrogen peroxide (H2O2) is commonly used as a haemostatic agent in all type of surgeries. Some adverse effects have been described related to its use. However, only very few cases are published in the literature of a stroke associated with the application of this agent directly to the brain. We present the case of a patient operated on for a right insular tumor with the assistance of intraoperative neurophysiological monitoring who developed a postoperative severe hemiparesis caused by a stroke in left middle cerebral artery territory due to the irrigation with H2O2. Based on this case, we recommend avoiding the H2O2 irrigation for hemostasis in surgery for brain tumors when vascular structures are exposed.

Recomendaciones sobre el uso de ácido 5-aminolevulínico en la cirugía de los gliomas malignos. Documento de consenso / Recommendations on the use of 5-amino-levulinic acid in surgery of malignant gliomas. Consensus document. The Neuro-oncology Working Group of the Spanish Neurosurgical Society (SENEC)

Cuando hablamos de pacientes con gliomas de alto grado se encuentra, entre otros factores con interés pronóstico, la radicalidad de la cirugía efectuada. Las limitaciones para su ejecución se deben bien a la extensión del tumor o bien a su localización, en un área elocuente. En un intento de conseguir este objetivo hemos desarrollado en los últimos tiempos diversos métodos que nos permiten maximizar la resección del tumor, intentando siempre causar la menor morbilidad posible. Uno de estos es el empleo del ácido 5-aminolevulínico (5-ALA) y el desarrollo de la cirugía guiada con fluorescencia a partir de su uso. No obstante, para su correcta utilización requiere conocer ante qué producto estamos, la forma de administración, las precauciones a que estamos obligados y cómo poder sacarle el máximo rendimiento. Miembros del Grupo de Trabajo de Neurooncología (GTNO) de la Sociedad Española de Neurocirugía (SENEC) han elaborado esta guía o documento de consenso con el objetivo de homogeneizar y facilitar la toma de decisiones en la utilización del 5-ALA para la cirugía tumoral encefálica guiada con fluorescencia, y en particular en la resección de los gliomas de alto grado (AU)

Among the prognostic factors when it comes to patients with high-grade gliomas, we find the radicality of the surgery performed. The limitations of this factor are caused by either the extension of the tumour or its location in an eloquent area. To achieve this goal, in the last few years we have developed several methods that allow us to maximise tumour resection, while always trying to cause the least possible co-morbidity. One of these methods includes the use of 5-amino-levulinic acid (5-ALA) and the development of fluorescence guided surgery. However, optimal performance requires knowledge of the product employed, the mode of administration and precautions to consider. Members of the neuro-oncology work group of the Spanish Neurosurgical Society (SENEC) have prepared this guideline or consensus document for anyone who wishes to become familiar with the use of 5-ALA fluorescence-guided surgery in the management of high-grade gliomas. For those who already utilise this technique, this document can be useful for consultation purposes (AU)

[Recommendations on the use of 5-amino-levulinic acid in surgery of malignant gliomas. Consensus document. The Neuro-oncology Working Group of the Spanish Neurosurgical Society (SENEC)]. / Recomendaciones sobre el uso de ácido 5-aminolevulínico en la cirugía de los gliomas malignos. Documento de consenso.

Among the prognostic factors when it comes to patients with high-grade gliomas, we find the radicality of the surgery performed. The limitations of this factor are caused by either the extension of the tumour or its location in an eloquent area. To achieve this goal, in the last few years we have developed several methods that allow us to maximise tumour resection, while always trying to cause the least possible co-morbidity. One of these methods includes the use of 5-amino-levulinic acid (5-ALA) and the development of fluorescence guided surgery. However, optimal performance requires knowledge of the product employed, the mode of administration and precautions to consider. Members of the neuro-oncology work group of the Spanish Neurosurgical Society (SENEC) have prepared this guideline or consensus document for anyone who wishes to become familiar with the use of 5-ALA fluorescence-guided surgery in the management of high-grade gliomas. For those who already utilise this technique, this document can be useful for consultation purposes.

Abordaje endoscópico de los quistes gliales pineales sintomáticos / Endoscopics approach in sintomatics pineal cysts

Objetivo. Los quistes gliales pineales (QGP) son infrecuentes. El manejo quirúrgico de estos quistes no está consensuado. En la literatura se recogen 18 casos tratados por vía endoscópica. El objetivo de este trabajo es contribuir con nuestra experiencia en el tratamiento endoscópico de los QGP. Material y método. Entre 1999 y 2004, cinco pacientes con QGP sintomáticos, con o sin hidrocefalia, se trataron mediante vintriculostomía premamilar endoscópica (VPE) y fenestración del quiste. Se utilizó un endoscopio rígido, con sistema de neuronavegación en los casos sin hidrocefalia. Resultados. En el período de seguimiento (de 6 meses a 4 años) se recoge una resolución clínica en 4 casos y una disminución del tamaño del quiste en todos los casos. Todas las VPE fueron permeables en el seguimiento. No hubo déficits clínicos permanentes en ningún caso. Discusión. No existe en la literatura un acuerdo en el mejor tratamiento quirúrgico de los QGP. A pesar de la gran aceptación de lavía endoscópica, un gran número de autores abogan por una cirugía abierta o por una cirugía extereotáxica como la mejor opción. Además, existen algunas diferencias en el manejo quirúrgico endoscópico según ofrece la literatura.Conclusión. La VPE con la fenestración del quiste es un tratamiento eficiente debido a la baja morbilidad y a la eficacia en la resolución clínica y radiológica de los QGP con o sin hidrocefalia. La cirugía abierta, especialmente con la ayuda endoscópica, podría ser un tratamiento de segunda elección, y la cirugía estereotáxica debería abandonarse en estos casos.

Abordaje endoscópico de los quistes gliales pineales sintomáticos / Endoscopics approach in sintomatics pineal cysts

Objetivo. Los quistes gliales pineales (QGP) son infrecuentes. El manejo quirúrgico de estos quistes no está consensuado. En la literatura se recogen 18 casos tratados por vía endoscópica. El objetivo de este trabajo es contribuir con nuestra experiencia en el tratamiento endoscópico de los QGP. Material y método. Entre 1999 y 2004, cinco pacientes con QGP sintomáticos, con o sin hidrocefalia, se trataron mediante vintriculostomía premamilar endoscópica (VPE) y fenestración del quiste. Se utilizó un endoscopio rígido, con sistema de neuronavegación en los casos sin hidrocefalia. Resultados. En el período de seguimiento (de 6 meses a 4 años) se recoge una resolución clínica en 4 casos y una disminución del tamaño del quiste en todos los casos. Todas las VPE fueron permeables en el seguimiento. No hubo déficits clínicos permanentes en ningún caso. Discusión. No existe en la literatura un acuerdo en el mejor tratamiento quirúrgico de los QGP. A pesar de la gran aceptación de lavía endoscópica, un gran número de autores abogan por una cirugía abierta o por una cirugía extereotáxica como la mejor opción. Además, existen algunas diferencias en el manejo quirúrgico endoscópico según ofrece la literatura.Conclusión. La VPE con la fenestración del quiste es un tratamiento eficiente debido a la baja morbilidad y a la eficacia en la resolución clínica y radiológica de los QGP con o sin hidrocefalia. La cirugía abierta, especialmente con la ayuda endoscópica, podría ser un tratamiento de segunda elección, y la cirugía estereotáxica debería abandonarse en estos casos.(AU)