A case report of an atypical severe case of skin picking disorder managed by a multidisciplinary team.

BACKGROUND: While skin picking disorder remains relatively common, it often does not present to psychiatry until significant morbidity or comorbidities are reached. It is described as recurrent picking of skin leading to skin lesions, with repeated attempts to decrease or stop skin picking. It is also often associated with significant distress or functional impairment. There has been limited research in this specific disorder and treatment efficacy has often been poor in severe cases. For various reasons, only a small amount of patients with this disorder present to care, and often to a multidisciplinary team prior to psychiatry. CASE PRESENTATION: This is a case presentation of a 44 year old male with a complex past psychiatric history, ultimately untreated for an underlying skin picking disorder. He presented for urgent medical care following a self-inflicted wound through the central frontal bone and dura over the course of 2 years. He was treated with current psychiatric evidence based medicine, including an SSRI, antipsychotic augmentation and NAC, along with habit reversal techniques during the admission. He was concurrently managed with the neurosurgery team, initially with a poor prognosis due to the severity of his presentation. He required debriding of the devitalized bone within the adjacent brain to cover the dural defect, IV antibiotics for 6 weeks, and an initial skin graft on his initial admission. CONCLUSIONS: This case in particular highlighted the importance of urgent treatment via a multidisciplinary approach to avoid mortality. It highlights the importance of increasing awareness about the disorder and that treatment with SSRI's, along with antipsychotic and NAC adjuncts remains the mainstay of acute treatment.

Quality of Life Following Surgical and Conservative Therapy of Pyogenic Spinal Infection: A Study of Long-term Outcome in 210 Patients.

OBJECT: The management and recommendations for treatment strategies of pyogenic spinal infection are still a highly controversial issue. The purpose of this study was to evaluate patient's quality of life (QoL) after surgical and conservative treatment of spinal infection. MATERIALS AND METHODS: We conducted a retrospective, single-center study. All patients treated between 2009 and 2016 were included in this study. For evaluation of QoL, we recorded each patient's satisfaction according to the 36-Item Short Form Health Survey (SF-36) questionnaire. Scores were compared with a U.S. standard population. RESULTS: Two hundred and ten adult patients with spondylodiskitis were identified. Of these, 155 (74%) underwent surgery and 55 (26%) were treated conservatively. The mean overall age was 68.6 (23-98) years. Seventy-two patients were females and 138 patients were males. The mean outcome values in the surgical group did not reach the level of the normative sample in one of eight items, whereas the conservative group revealed a reduced QoL in all items. Intergroup comparison revealed significant differences in all items (p < 0.05). CONCLUSION: In the patient population we investigated, QoL in surgically treated patients was better than that in conservatively managed patients.

Necessity of MRI-compatible deep brain stimulation systems - Hits and hints for decision making.

OBJECTIVES: Deep brain stimulation (DBS) is a safe and effective treatment option for patients with movement disorders as Parkinson's disease, essential tremor and dystonia[1]. For many of these patients the need for imaging may arise in the following years after implantation. The study's aim was to get an overview of the amount of patients with a DBS system who needed an MRI after successful implantation, and if they did, whether the imaging led to a surgical consequence. MATERIALS AND METHODS: In this retrospective descriptive work patients were included if they had their DBS implantation for at least 12 months at the time of analysis. Data were collected by retrospective analysis of the electronic patient files as well as a telephone interview. The reason of each imaging performed was assessed, if patients got MRI after the implantation, it was additionally recorded whether imaging led to a consequence (conservative treatment or surgery). An independent neurologist assessed if an MRI would have been better than a CT for the particular indication. RESULTS: From 54 included patients, 28 patients received imaging after implantation, either CT or MRI. 7 patients underwent MRIs, of whom 3 patients received cranial MRIs and 4 patients received lumbar spine MRIs. All cranial MRIs led to conservative therapy, in 2 lumbar MRIs the diagnosis led to surgery. Nearly 13 % of the imaging performed in our study population occurred because of fall events, 9 of the included patients developed or have had a tumor diagnosis. CONCLUSIONS: Safety of MRI for patients with implanted DBS-systems is and remains an important consideration. Since it can be assumed that patients at a younger age are more likely to get an MRI in the course of their disease, we suggest paying particular attention to the MRI's suitability of the DBS device by patients age. In the end it remains always an individual decision for the surgeon or the consulting physician, which system to use.

Tissue expansion for challenging DBS hardware erosions in patients with Parkinson's disease.

•Consider tissue expanders for challenging DBS cases in PD patients with hardware erosion.•Placement of tissue expander is essential in planning the reconstruction.•MRI-compatibility of the tissue expander is paramount for shortening the total duration of anesthesia.•Role of routine skin biopsies to identify PD patients at additional risk for developing scalp defects should be investigated.

Motor evoked potentials versus Macrostimulation in predicting the postoperative motor threshold in STN Deep brain stimulation.

INTRODUCTION: Accuracy is crucial in Deep Brain Stimulation (DBS). Electrophysiological and image-based techniques are used to avoid suboptimal positioning. Macrostimulation is the gold standard to delineate the therapeutic window intraoperatively. Despite this, electrode revision rates due to malpositioning are as high as 17%. The goal was to compare motor evoked potentials (MEPs) with the gold standard of Macrostimulation. We assessed accuracy and precision as well as the correlation in predicting motor side effects at the initial mapping 4 weeks postoperatively. METHODS: In this prospective study intraoperative MEPs from 94 contacts in 16 patients undergoing STN DBS under local anesthesia were correlated to the postoperative threshold for stimulation-induced motor side effects and compared to intraoperative Macrostimulation. Analysis of accuracy, precision and correlation (Pearson) was performed. RESULTS: MEPs of the upper extremity had a mean percentage error of 25% (SD 38.8%) and correlated significantly with the motor threshold at postoperative mapping (R=0.235). Macrostimulation was less accurate and precise with a mean percentage error of - 68% (SD 78.8%) but had a higher correlation (R=0.388). MEPs rarely (3%) overestimated the threshold by maximally 1 mA. In contrast, Macrostimulation overestimated the threshold by over 1 mA in 69% leading to a false sense of security. CONCLUSION: MEPs are feasible in an awake setting during Deep Brain Stimulation in the STN for PD patients. MEPs of the upper extremity are more accurate and precise predicting the motor threshold and avoid a false sense of security in comparison to the gold standard of Macrostimulation.

From vision to action: Canadian leadership in ethics and neurotechnology.

This chapter explores the complex neuroethical aspects of neurosurgery and neuromodulation in the context of Canadian healthcare and innovation, as seen through the lens of the Pan Canadian Neurotechnology Ethics Consortium (PCNEC). Highlighted are key areas of ethical focus, each with its own unique challenges: technical advances, readiness and risk, vulnerable populations, medico-legal issues, training, and research. Through an exploration of Canadian neurotechnological practice from these various clusters, we provide a critical review of progress, describe opportunities to address areas of debate, and seek to foster ethical innovation. Underpinning this comprehensive review are the fundamental principles of solution-oriented, practical neuroethics, with beneficence and justice at the core. In our view, it is a moral imperative that neurotechnological advancements include a delineation of ethical priorities for future guidelines, oversight, and interactions.

Matching Quantitative MRI Parameters with Histological Features of Treatment-Naïve IDH Wild-Type Glioma.

Quantitative MRI allows to probe tissue properties by measuring relaxation times and may thus detect subtle changes in tissue composition. In this work we analyzed different relaxation times (T1, T2, T2* and T2') and histological features in 321 samples that were acquired from 25 patients with newly diagnosed IDH wild-type glioma. Quantitative relaxation times before intravenous application of gadolinium-based contrast agent (GBCA), T1 relaxation time after GBCA as well as the relative difference between T1 relaxation times pre-to-post GBCA (T1rel) were compared with histopathologic features such as the presence of tumor cells, cell and vessel density, endogenous markers for hypoxia and cell proliferation. Image-guided stereotactic biopsy allowed for the attribution of each tissue specimen to its corresponding position in the respective relaxation time map. Compared to normal tissue, T1 and T2 relaxation times and T1rel were prolonged in samples containing tumor cells. The presence of vascular proliferates was associated with higher T1rel values. Immunopositivity for lactate dehydrogenase A (LDHA) involved slightly longer T1 relaxation times. However, low T2' values, suggesting high amounts of deoxyhemoglobin, were found in samples with elevated vessel densities, but not in samples with increased immunopositivity for LDHA. Taken together, some of our observations were consistent with previous findings but the correlation of quantitative MRI and histologic parameters did not confirm all our pathophysiology-based assumptions.

Validation of 3D fluoroscopy for image-guidance registration in depth electrode implantation for medically refractory epilepsy.

BACKGROUND: Frame registration is a critical step to ensure accurate electrode placement in stereotactic procedures such as stereoelectroencephalography (SEEG) and is routinely done by merging a computed tomography (CT) scan with the preoperative magnetic resonance (MR) examination. Three-dimensional fluoroscopy (XT) has emerged as a method for intraoperative electrode verification following electrode implantation and more recently has been proposed as a registration method with several advantages. METHODS: We compared the accuracy of SEEG electrode placement by frame registration with CT and XT imaging by analyzing the Euclidean distance between planned and post-implantation trajectories of the SEEG electrodes to calculate the error in both the entry (EP) and target (TP) points. Other variables included radiation dose, efficiency, and complications. RESULTS: Twenty-seven patients (13 CT and 14 XT) underwent placement of SEEG electrodes (319 in total). The mean EP and TP errors for the CT group were 2.3 mm and 3.3 mm, respectively, and 1.9 mm and 2.9 mm for the XT group, with no statistical difference (p = 0.75 and p = 0.246). The time to first electrode placement was similar (XT, 82 ± 10 min; CT, 84 ± 22 min; p = 0.858) and the average radiation exposure with XT (234 ± 55 mGy*cm) was significantly lower than CT (1245 ± 123 mGy*cm) (p < 0.0001). Four complications were documented with equal incidence in both groups. CONCLUSIONS: The use of XT as a method for registration resulted in similar implantation accuracy compared with CT. Advantages of XT are the substantial reduction in radiation dose and the elimination of the need to transfer the patient out of the room which may have an impact on patient safety and OR efficiency.

Comparing Programming Sessions of Vim-DBS.

Background: Essential Tremor (ET) is a progressive neurological disorder characterized by postural and kinetic tremor most commonly affecting the hands and arms. Medically intractable ET can be treated by deep brain stimulation (DBS) of the ventral intermediate nucleus of thalamus (VIM). We investigated whether the location of the effective contact (most tremor suppression with at least side effects) in VIM-DBS for ET changes over time, indicating a distinct mechanism of loss of efficacy that goes beyond progression of tremor severity, or a mere reduction of DBS efficacy. Methods: We performed programming sessions in 10 patients who underwent bilateral vim-DBS surgery between 2009 and 2017 at our department. In addition to the intraoperative (T1) and first clinical programming session (T2) a third programming session (T3) was performed to assess the effect- and side effect threshold (minimum voltage at which a tremor suppression or side effects occurred). Additionally, we compared the choice of the effective contact between T1 and T2 which might be affected by a surgical induced "brain shift." Discussion: Over a time span of about 4 years VIM-DBS in ET showed continuous efficacy in tremor suppression during stim-ON compared to stim-OFF. Compared to immediate postoperative programming sessions in ET-patients with DBS, long-term evaluation showed no relevant change in the choice of contact with respect to side effects and efficacy. In the majority of the cases the active contact at T2 did not correspond to the most effective intraoperative stimulation site T1, which might be explained by a brain-shift due to cerebral spinal fluid loss after neurosurgical procedure.

Early versus Delayed Surgery for Spinal Epidural Abscess : Clinical Outcome and Health-Related Quality of Life.

OBJECTIVE: Spinal epidural abscess (SEA) is a severe and life-threatening disease. Although commonly performed, the effect of timing in surgical treatment on patient outcome is still unclear. With this study, we aim to provide evidence for early surgical treatment in patients with SEA. METHODS: Patients treated for SEA in the authors' department between 2007 and 2016 were included for analysis and retrospectively analyzed for basic clinical parameters and outcome. Pre- and postoperative neurological status were assessed using the American Spinal Injury Association Impairment Scale (AIS). The self-reported quality of life (QOL) based on the Short-Form Health Survey 36 (SF-36) was assessed prospectively. Surgery was defined as "early", when performed within 12 hours after admission and "late" when performed thereafter. Conservative therapy was preferred and recommend in patients without neurological deficits and in patients denying surgical intervention. RESULTS: One hundred and twenty-three patients were included in this study. Forty-nine patients (39.8%) underwent early, 47 patients (38.2%) delayed surgery and 27 (21.9%) conservative therapy. No significant differences were observed regarding mean age, sex, diabetes, prior history of spinal infection, and bony destruction. Patients undergoing early surgery revealed a significant better clinical outcome before discharge than patients undergoing late surgery (p=0.001) and conservative therapy. QOL based on SF-36 were significantly better in the early surgery cohort in two of four physical items (physical functioning and bodily pain) and in one of four psychological items (role limitation) after a mean follow-up period of 58 months. Readmission to the hospital and failure of conservative therapy were observed more often in patients undergoing conservative therapy. CONCLUSION: Our data on both clinical outcome and QOL provide evidence for early surgery within 12 hours after admission in patients with SEA.

The accuracy of 3D fluoroscopy (XT) vs computed tomography (CT) registration in deep brain stimulation (DBS) surgery.

BACKGROUND: Stereotactic registration is the most critical step ensuring accuracy in deep brain stimulation (DBS) surgery. 3D fluoroscopy (XT) is emerging as an alternative to CT. XT has been shown to be safe and effective for intraoperative confirmation of lead position following implantation. However, there is a lack of studies evaluating the suitability of XT to be used for the more crucial step of registration and its capability of being merged to a preoperative MRI. This is the first study comparing accuracy, efficiency, and radiation exposure of XT- vs CT-based stereotactic registration and XT/MRI merging in deep brain stimulation. METHODS: Mean absolute differences and Euclidean distance between planned (adjusted for intraoperative testing) and actual lead trajectories were calculated for accuracy of implantation. The radiation dose from each scan was recorded as the dose length product (DLP). Efficiency was measured as the time between the patient entering the operating room and the initial skin incision. A one-way ANOVA compared these parameters between patients that had either CT- or XT-based registration. RESULTS: Forty-one patients underwent DBS surgery-25 in the CT group and 16 in the XT group. The mean absolute difference between CT and XT was not statistically significant in the x (p = 0.331), y (p = 0.951), or z (p = 0.807) directions. The Euclidean distance between patient groups did not differ significantly (p = 0.874). The average radiation exposure with XT (220.0 ± 0.1 mGy*cm) was significantly lower than CT (1269.3 ± 112.9 mGy*cm) (p < 0.001). There was no significant difference in registration time between CT (107.8 ± 23.1 min) and XT (106.0 ± 18.2 min) (p = 0.518). CONCLUSION: XT-based frame registration was shown to result in similar implantation accuracy and significantly less radiation exposure compared with CT. Our results surprisingly showed no significant difference in registration time, but this may be due to a learning curve effect.

Resection of central nervous system lymphoma: a paradigm shift?

Central nervous system lymphomas (CNSL) are traditionally regarded as non-surgically treated tumors with a poor prognosis. Usually, only stereotactic biopsy is performed to establish the diagnosis, and most patients show disease progression within half a year. A recent study questioned this view, since patients who had surgical resection of CNSL manifestations prior to adjuvant therapy reportedly had a better outcome than patients who had biopsy only. We performed a retrospective analysis of our patient database to identify patients with CNSL who had undergone "accidental" tumor removal in our department between 2002 and 2013. Four patients had CNSL specific therapy following surgery. One patient received no further therapy because of his bad clinical status. Five patients with CNSL were treated surgically. Three patients were in complete remission at nine, thirteen and 45 months postoperatively, while two others had disease progression at 45 months, respectively. The median survival was 22.6 months. Gross total removal of CNSL may improve outcome. We present a series of five patients who had surgical resection of CNSL. While the importance of chemotherapy is beyond doubt, more data on the effect of surgery on the prognosis of patients with CNSL are needed. However, the paradigm of medical treatment only for CNSL is being challenged.

Upright MRI after decompression of spinal stenosis and concurrent spondylolisthesis.

OBJECTIVEThe treatment of patients with spinal stenosis and concurrent degenerative spondylolisthesis is controversial. Two large randomized controlled clinical trials reported contradictory results. The authors hypothesized that a substantial number of patients will show evidence of micro-instability after a sole decompression procedure.METHODSThis study was a retrospective analysis of all cases of lumbar spinal stenosis treated at the Frankfurt University Clinic (Universitätsklinik Frankfurt) from 2010 through 2013. Patients who had associated spondylolisthesis underwent upright MRI studies in flexion and extension for identification of subtle signs of micro-instability. Clinical outcome was assessed by means of SF-36 bodily pain (BP) and physical functioning (PF) scales.RESULTSA total of 21 patients were recruited to undergo upright MRI studies. The mean duration of follow-up was 65 months (SD 16 months). Of these 21 patients, 10 (47%) showed signs of micro-instability as defined by movement of > 4 mm on flexion/extension MRI. Comparison of mean SF-36 BP and PF scores in the group of patients who showed micro-instability versus those who did not showed no statistically significant difference on either scale.CONCLUSIONSThere seems to be a substantial subset of patients who develop morphological micro-instability after sole decompression procedures but do not experience any clinically significant effect of the instability.

Infective endocarditis in patients with pyogenic spondylodiscitis: implications for diagnosis and therapy.

OBJECTIVEThe incidence of patients with pyogenic spinal infection is increasing. In addition to treatment of the spinal infection, early diagnosis of and therapy for coexisting infections, especially infective endocarditis (IE), is an important issue. The aim of this study was to evaluate the proportion of coexisting IE and the value of routine transesophageal echocardiography (TEE) in the management of these patients.METHODSThe medical history, laboratory data, radiographic findings, treatment modalities, and results of TEE of patients admitted between 2007 and 2017 were analyzed.RESULTSDuring the abovementioned period, 110 of 255 total patients underwent TEE for detection of IE. The detection rate of IE between those patients undergoing and not undergoing TEE was 33% and 3%, respectively (p < 0.0001). Thirty-six percent of patients with IE needed cardiac surgical intervention because of severe valve destruction. Chronic renal failure, heart failure, septic condition at admission, and preexisting heart condition were significantly associated with coexisting IE. The mortality rate in patients with IE was significantly higher than in patients without IE (22% vs 3%, p = 0.002).CONCLUSIONSTEE should be performed routinely in all patients with spondylodiscitis.

The Impact of Early Corticosteroid Pretreatment Before Initiation of Chemotherapy in Patients With Primary Central Nervous System Lymphoma.

BACKGROUND: The optimal timing of corticosteroid (CS) treatment in patients with primary central nervous system (CNS) lymphoma (PCNSL) remains controversial. While poor clinical presentation may justify early treatment with CS, this may ultimately result in reduced concentrations of chemotherapeutic agents via perturbations in the permeability of the blood-brain barrier. OBJECTIVE: To investigate whether early CS exposure is associated with beneficial outcomes and/or reduced occurrence of adverse events as opposed to delayed/concomitant administration. METHODS: Herein we performed a retrospective observational analysis using patients that were prospectively entered into a database. All patients whom were admitted to the University Hospital between 2009 and 2015 with newly diagnosed PCNSL were included within our study. RESULTS: Our cohort included 50 consecutive patients diagnosed with PCNSL; of these, in 30 patients CS administration was initiated prior to chemotherapy (early), whilst in the remaining 20 patients CS administration was initiated concomitantly with their chemotherapeutic regimen (concomitant). Within the early vs concomitant CS administration groups, no significant differences were observed with regard to progression-free survival (PFS) (P = .81), overall survival (OS) (P = .75), or remission (P = .68; odds ratio 0.76 and confidence interval [95%] 0.22-2.71). Critically, the timing of CS initiation was not associated with either PFS (P = .81) or PFS (P = .75). CONCLUSION: Early CS administration was not associated with a deterioration in response to chemotherapy, PFS, or OS. As such, administration of CS prior to initiation of chemotherapy is both reasonable and safe for patients with newly diagnosed PCNSL.

Stereotactic biopsy of cerebellar lesions: straight versus oblique frame positioning.

OBJECTIVE: Biospies of brain lesions with unknown entity are an everyday procedure among many neurosurgical departments. Biopsies can be performed frame-guided or frameless. However, cerebellar lesions are a special entity with a more complex approach. All biopsies in this study were performed stereotactically frame guided. Therefore, only biopsies of cerebellar lesions were included in this study. We compared whether the frame was attached straight versus oblique and we focused on diagnostic yield and complication rate. METHODS: We evaluated 20 patients who underwent the procedure between 2009 and 2017. Median age was 56.5 years. 12 (60%) Patients showed a left sided lesion, 6 (30%) showed a lesion in the right cerebellum and 2 (10%) patients showed a midline lesion. RESULTS: The stereotactic frame was mounted oblique in 12 (60%) patients and straight in 8 (40%) patients. Postoperative CT scan showed small, clinically silent blood collection in two (10%) of the patients, one (5%) patient showed haemorrhage, which caused a hydrocephalus. He received an external ventricular drain. In both patients with small haemorrhage the frame was positioned straight, while in the patient who showed a larger haemorrhage the frame was mounted oblique. In all patients a final histopathological diagnosis was established. CONCLUSION: Cerebellar lesions of unknown entity can be accessed transcerebellar either with the stereotactic frame mounted straight or oblique. Also for cerebellar lesions the procedure shows a high diagnostic yield with a low rate of severe complications, which need further treatment.

"Two is not enough" - Impact of the number of tissue samples obtained from stereotactic brain biopsies in suspected glioblastoma.

OBJECTIVE: Stereotactic procedures are performed in many neurosurgical departments in order to obtain tumor tissue from brain lesions for histopathological evaluation. Biopsies can be performed frame-guided and frame less. Some departments use a biopsy needle (cylinder probe), others a forceps for repetitive smaller tissue samples. Although the applied techniques are somehow different, it is still unclear how many tissue samples have to be taken to establish reliably a final diagnosis based on histopathological and genetic examinations. Only precise histopathological diagnosis results in adequate therapy. METHODS: We included 43 consecutive patients who underwent stereotactic biopsy of a suspected glioblastoma between 02/2013 and 07/2015. All patients showed contrast enhancing tumors in the MRI. The patients underwent stereotactic biopsy with the Leksell frame attached to their head. All stereotactic procedures were performed in the presence of a neuropathologist. Target and Entry Points were calculated with BrainLab iplan software (BrainLab iplan 1.0, Munich, Germany). First the two samples 5mm before the Target (pre-target) and the "Targetpoint" itself were analyzed (group 1), then a histopathological evaluation of all samples was performed (group 2). RESULTS: Mean number of extracted samples was 14. Using classical hematoxylin-eosin stainings, in group 1 histopathological diagnosis was correct in only 30 cases accounting for 73%. Contrariwise a final diagnosis was made in 100% in group 2. CONCLUSION: If only two tissue samples were evaluated in this group of patients with suspected glioblastoma, a correct diagnosis was possible in only 73% of the cases. We conclude that two samples are not enough to establish a final diagnosis even in a subgroup of suspected glioblastoma.

Biopsies of pediatric brainstem lesions display low morbidity but strong impact on further treatment decisions.

OBJECTIVE: The course of malignant brain stem gliomas in childhood is rarely positive. Because of limited therapeutic options and potentially hazardous biopsies oncologist often relay on MRI diagnoses only for further therapy decisions. In this study we show that brain stem biopsies display a low morbidity rate and neuropathological assessment has a considerable impact on further treatment decision. METHODS: Within 18-months five children with brainstem symptoms and the radiological diagnosis of a malignant brainstem glioma, were identified. From this time point it was possible to analyze all samples with the 450K methylome analysis. Other neuropathological techniques included classical histology with immunohistochemistry. Surgery was performed as biopsy, either microsurgical, frame-guided (Leksell), robot-assisted (ROSA) or navigated (BrainLab, two children). RESULTS: Mean age of the children was 7.5years (range: newborn to 12years). There was no biopsy-related morbidity or mortality. The mean number of taken samples was 12 (range: 1-25). Histologic diagnosis could be established in all children, however, 450K methylome diagnosis was positive in only two out of five patients. CONCLUSION: Despite the technically difficult biopsies, all specimens were sufficient for immunohistochemical diagnosis, however, 450K methylome analysis could only be better established where multiple small samples were taken, instead of few larger ones. Based on the preoperative radiological diagnosis suggesting malignant brainstem glioma, all children would have been treated with combined radiation and temozolomid chemotherapy. Nevertheless, due to the availability of histology and molecular diagnostics, individualized therapy could be performed, preventing in two out of five children from unnecessary radiation and chemotherapy.