Publications by authors named "Karl Schaller"

272 Publications

Longitudinal neuropsychological assessment after aneurysmal subarachnoid hemorrhage and its relationship with delayed cerebral ischemia: a prospective Swiss multicenter study.

J Neurosurg 2022 Apr 29:1-9. Epub 2022 Apr 29.

15Neuropsychology Unit, Department of Neurology, Cantonal Hospital St. Gallen.

Objective: While prior retrospective studies have suggested that delayed cerebral ischemia (DCI) is a predictor of neuropsychological deficits after aneurysmal subarachnoid hemorrhage (aSAH), all studies to date have shown a high risk of bias. This study was designed to determine the impact of DCI on the longitudinal neuropsychological outcome after aSAH, and importantly, it includes a baseline examination after aSAH but before DCI onset to reduce the risk of bias.

Methods: In a prospective, multicenter study (8 Swiss centers), 112 consecutive alert patients underwent serial neuropsychological assessments (Montreal Cognitive Assessment [MoCA]) before and after the DCI period (first assessment, < 72 hours after aSAH; second, 14 days after aSAH; third, 3 months after aSAH). The authors compared standardized MoCA scores and determined the likelihood for a clinically meaningful decline of ≥ 2 points from baseline in patients with DCI versus those without.

Results: The authors screened 519 patients, enrolled 128, and obtained complete data in 112 (87.5%; mean [± SD] age 53.9 ± 13.9 years; 66.1% female; 73% World Federation of Neurosurgical Societies [WFNS] grade I, 17% WFNS grade II, 10% WFNS grades III-V), of whom 30 (26.8%) developed DCI. MoCA z-scores were worse in the DCI group at baseline (-2.6 vs -1.4, p = 0.013) and 14 days (-3.4 vs -0.9, p < 0.001), and 3 months (-0.8 vs 0.0, p = 0.037) after aSAH. Patients with DCI were more likely to experience a decline of ≥ 2 points in MoCA score at 14 days after aSAH (adjusted OR [aOR] 3.02, 95% CI 1.07-8.54; p = 0.037), but the likelihood was similar to that in patients without DCI at 3 months after aSAH (aOR 1.58, 95% CI 0.28-8.89; p = 0.606).

Conclusions: Aneurysmal SAH patients experiencing DCI have worse neuropsychological function before and until 3 months after the DCI period. DCI itself is responsible for a temporary and clinically meaningful decline in neuropsychological function, but its effect on the MoCA score could not be measured at the time of the 3-month follow-up in patients with low-grade aSAH with little or no impairment of consciousness. Whether these findings can be extrapolated to patients with high-grade aSAH remains unclear. Clinical trial registration no.: NCT03032471 (ClinicalTrials.gov).
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http://dx.doi.org/10.3171/2022.2.JNS212595DOI Listing
April 2022

Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

Stroke 2022 Mar 23:STROKEAHA121036699. Epub 2022 Mar 23.

Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Germany (J.B., R.R., C.S., M.S., D.H.H., O.S., C.F.).

Background: Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort.

Methods: We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version-the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4-6).

Results: Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, <0.001) whereas the sensitivity decreased from 0.88 to 0.37 (<0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, <0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, <0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, <0.001).

Conclusions: The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification-presence of brain stem signs is required for grade V-should be added to the WFNS classification.

Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.
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http://dx.doi.org/10.1161/STROKEAHA.121.036699DOI Listing
March 2022

Degenerative Cervical Myelopathy: Development and Natural History [AO Spine RECODE-DCM Research Priority Number 2].

Global Spine J 2022 Feb;12(1_suppl):39S-54S

Division of Neurosurgery and Spine Program, University of Toronto, Ontario, Canada.

Study Design: Narrative review.

Objectives: To discuss the current understanding of the natural history of degenerative cervical myelopathy (DCM).

Methods: Literature review summarizing current evidence pertaining to the natural history and risk factors of DCM.

Results: DCM is a common condition in which progressive arthritic disease of the cervical spine leads to spinal cord compression resulting in a constellation of neurological symptoms, in particular upper extremity dysfunction and gait impairment. Anatomical factors including cord-canal mismatch, congenitally fused vertebrae and genetic factors may increase individuals' risk for DCM development. Non-myelopathic spinal cord compression (NMSCC) is a common phenomenon with a prevalence of 24.2% in the healthy population, and 35.3% among individuals >60 years of age. Clinical radiculopathy and/or electrophysiological signs of cervical cord dysfunction appear to be risk factors for myelopathy development. Radiological progression of incidental Ossification of the Posterior Longitudinal Ligament (OPLL) is estimated at 18.3% over 81-months and development of myelopathy ranges between 0-61.5% (follow-up ranging from 40 to 124 months between studies) among studies. In patients with symptomatic DCM undergoing non-operative treatment, 20-62% will experience neurological deterioration within 3-6 years.

Conclusion: Current estimates surrounding the natural history of DCM, particularly those individuals with mild or minimal impairment, lack precision. Clear predictors of clinical deterioration for those treated with non-operative care are yet to be identified. Future studies are needed on this topic to help improve treatment counseling and clinical prognostication.
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http://dx.doi.org/10.1177/21925682211036071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8859703PMC
February 2022

Current state of global neurosurgery activity amongst European neurosurgeons.

J Neurosurg Sci 2022 02 11. Epub 2022 Feb 11.

Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.

Background: The expanding field of global neurosurgery calls for a committed neurosurgical community to advocate for universal access to timely, safe, and affordable neurosurgical care for everyone, everywhere. This study aims to (i) assess the current state of global neurosurgery activity amongst European neurosurgeons and (ii) identify barriers to involvement in global neurosurgery initiatives.

Methods: Cross-sectional study through dissemination of a web-based survey, from September 2019 to January 2020, to collect data from European neurosurgeons at various career stages. Descriptive analysis was conducted on respondent data.

Results: Three hundred and ten neurosurgeons from 40 European countries responded. 53.5% regularly follow global neurosurgery developments. 29.4% had travelled abroad with a global neurosurgery collaborative, with 23.2% planning a future trip. Respondents from high income European countries predominantly travelled to Africa (41.6%) or Asia (34.4%), whereas, respondents from middle income European countries frequently traversed Europe (63.2%) and North America (47.4). Cost implications (66.5%) were the most common barrier to global neurosurgery activity, followed by interference with current practice (45.8%), family duties (35.2%), difficulties obtaining humanitarian leave (27.7%) and lack of international partners (27.4%). 86.8% would incorporate a global neurosurgery period within training programmes.

Conclusions: European neurosurgeons are interested in engaging in global neurosurgery partnerships, and several sustainable programmes focused on local capacity building, education and research have been established over the last decade. However, individual and system barriers to engagement persist. We provide insight into these to allow development of tailored mechanisms to overcome such barriers, enabling European neurosurgeons to advocate for the Global Surgery 2030 goals.
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http://dx.doi.org/10.23736/S0390-5616.21.05447-3DOI Listing
February 2022

Application of virtual reality in neurosurgery: Patient missing. A systematic review.

J Clin Neurosci 2022 Jan 5;95:55-62. Epub 2021 Dec 5.

Department of Neurosurgery, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland; Faculty of Medicine, Université de Genève (UNIGE), Geneva, Switzerland.

Virtual reality (VR) technology had its earliest developments in the 1970s in the U.S. Air Force and has since evolved into a budding area of scientific research with many practical medical purposes. VR shows a high potential to benefit to learners and trainees and improve surgery through enhanced preoperative planning and efficiency in the operating room. Neurosurgery is a field of medicine in which VR has been accepted early on as a useful and promising tool for neuro-navigation planning. Through recent technological developments, VR further increased its level of immersion, accessibility and intuitive use for surgeons and students and now reveals a therapeutic potential for patients. In this paper, we systematically reviewed the neurosurgery literature regarding the use of VR as an assistance for surgery or a tool centered on patients' care. A literature search conducted according to PRISMA guidelines resulted in the screening of 125 abstracts and final inclusion of 100 original publications reviewed. The review shows that neurosurgeons are now relatively familiar with VR technologies (N = 95 articles) for their training and practice. VR technologies are useful for education, pain management and rehabilitation in neurosurgical patients. Nevertheless, the current patient-oriented use of VR remains limited (N = 5 articles). Successful surgery does not only depend on the surgeon's skills and preparation, but also on patients' education, comfort, empowerment and care. Therefore further clinical research is needed to promote the direct use of VR technologies by patients in neurosurgery.
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http://dx.doi.org/10.1016/j.jocn.2021.11.031DOI Listing
January 2022

From Focused Ultrasound Tumor Ablation to Brain Blood Barrier Opening for High Grade Glioma: A Systematic Review.

Cancers (Basel) 2021 Nov 10;13(22). Epub 2021 Nov 10.

Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland.

Background: Focused Ultrasound (FUS) is gaining a therapeutic role in neuro-oncology considering its novelty and non-invasiveness. Multiple pre-clinical studies show the efficacy of FUS mediated ablation and Blood-Brain Barrier (BBB) opening in high-grade glioma (HGG), but there is still poor evidence in humans, mainly aimed towards assessing FUS safety.

Methods: With this systematic review our aim is, firstly, to summarize how FUS is proposed for human HGG treatment. Secondly, we focus on future perspectives and new therapeutic options. Using PRISMA 2020 guidelines, we reviewed case series and trials with description of patient characteristics, pre- and post-operative treatments and FUS outcomes. We considered nine case series (five about tumor ablation and four about BBB opening) with FUS-treated HGG patients between 1991 and 2021.

Results: Sixty-eight patients were considered in total, mostly males (67.6%), with a mean age of 50.5 ± 15.3 years old. Major complication rates were found in the tumor ablation group (26.1%). FUS has been rarely applied for direct tumoral ablation in human HGG patients with controversial results, but at the best of current studies, FUS-mediated BBB opening is showing good results with very low complication rates, paving the way for a new reliable technique to improve local chemotherapy delivery and antitumoral immune response.

Conclusions: FUS can become a complementary technique to surgical resection and standard radiochemotherapy in recurrent HGG. Ongoing trials could provide in the near future more data on FUS-mediated BBB opening impact on progression-free survival, overall survival and potential drug-delivery capacities.
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http://dx.doi.org/10.3390/cancers13225614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8615744PMC
November 2021

Do neurosurgeons follow the guidelines? A world-based survey on severe traumatic brain injury.

J Neurosurg Sci 2021 10;65(5):465-473

Department of Clinical Medicine, Faculty of Medicine, Human and Health Sciences, Macquarie University, Sydney, Australia.

Background: Traumatic brain injury (TBI) is going to be the third-leading cause of death worldwide, according to the WHO. Two European surveys suggested that adherence to brain trauma guidelines is poor. No study has compared compliance between low- (LMICs) and high-income (UHICs) countries. Hence, this study aimed to investigate differences in the management of severe TBI patients, comparing low- and high-income, and adherence to the BTF guidelines.

Methods: A web-based survey was spread through the Global Neuro Foundation, different neurosurgical societies, and social media.

Results: A total of 803 neurosurgeons participated: 70.4 from UHICs and 29.6% from LMICs. Hypertonic was administered as an early measure by the 73% and 65% of the responders in LMICs and UHICs, respectively (P=0.016). An invasive intracranial pressure monitoring was recommended by the 66% and 58% of the neurosurgeons in LMICs and UHICs, respectively (P<0.001). Antiseizure drugs (P<0.001) were given most frequently in LMICs as, against recommendations, steroids (87% vs. 61% and 86% vs. 81%, respectively). In the LMICs both the evacuation of the contusion and decompressive craniectomy were performed earlier than in UHICs (30% vs. 17% with P<0.001 and 44% vs. 28% with P=0.006, respectively). In the LMICs, the head CT control was performed mostly between 12 and 24 hours from the first imaging (38% vs. 23%, P<0.001).

Conclusions: The current Guidelines on TBI do not always fit to both the resources and circumstances in different countries. Future research and clinical practice guidelines should reflect the greater relevance of TBI in low resource settings.
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http://dx.doi.org/10.23736/S0390-5616.21.05475-8DOI Listing
October 2021

EEG Spatiotemporal Patterns Underlying Self-other Voice Discrimination.

Cereb Cortex 2022 04;32(9):1978-1992

Functional Brain Mapping Lab, Department of Fundamental Neurosciences, University of Geneva, 1202, Switzerland.

There is growing evidence showing that the representation of the human "self" recruits special systems across different functions and modalities. Compared to self-face and self-body representations, few studies have investigated neural underpinnings specific to self-voice. Moreover, self-voice stimuli in those studies were consistently presented through air and lacking bone conduction, rendering the sound of self-voice stimuli different to the self-voice heard during natural speech. Here, we combined psychophysics, voice-morphing technology, and high-density EEG in order to identify the spatiotemporal patterns underlying self-other voice discrimination (SOVD) in a population of 26 healthy participants, both with air- and bone-conducted stimuli. We identified a self-voice-specific EEG topographic map occurring around 345 ms post-stimulus and activating a network involving insula, cingulate cortex, and medial temporal lobe structures. Occurrence of this map was modulated both with SOVD task performance and bone conduction. Specifically, the better participants performed at SOVD task, the less frequently they activated this network. In addition, the same network was recruited less frequently with bone conduction, which, accordingly, increased the SOVD task performance. This work could have an important clinical impact. Indeed, it reveals neural correlates of SOVD impairments, believed to account for auditory-verbal hallucinations, a common and highly distressing psychiatric symptom.
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http://dx.doi.org/10.1093/cercor/bhab329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9070353PMC
April 2022

Syndrome of the trephined: clinical spectrum, risk factors, and impact of cranioplasty on neurologic recovery in a prospective cohort.

Neurosurg Rev 2022 Apr 7;45(2):1431-1443. Epub 2021 Oct 7.

Division of Neurorehabilitation, Department of Clinical Neurosciences, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland.

Syndrome of the trephined (SoT) is an underrecognized complication after decompressive craniectomy. We aimed to investigate SoT incidence, clinical spectrum, risk factors, and the impact of the cranioplasty on neurologic recovery. Patients undergoing a large craniectomy (> 80 cm) and cranioplasty were prospectively evaluated using modified Rankin score (mRS), cognitive (attention/processing speed, executive function, language, visuospatial), motor (Motricity Index, Jamar dynamometer, postural score, gait assessment), and radiologic evaluation within four days before and after a cranioplasty. The primary outcome was SoT, diagnosed when a neurologic improvement was observed after the cranioplasty. The secondary outcome was a good neurologic outcome (mRS 0-3) 4 days and 90 days after the cranioplasty. Logistic regression models were used to evaluate the risk factors for SoT and the impact of cranioplasty timing on neurologic recovery. We enrolled 40 patients with a large craniectomy; 26 (65%) developed SoT and improved after the cranioplasty. Brain trauma, hemorrhagic lesions, and shifting of brain structures were associated with SoT. After cranioplasty, a shift towards a good outcome was observed within 4 days (p = 0.025) and persisted at 90 days (p = 0.005). Increasing delay to cranioplasty was associated with decreased odds of improvement when adjusting for age and baseline disability (odds ratio 0.96; 95% CI, 0.93-0.99, p = 0.012). In conclusion, SoT is frequent after craniectomy and interferes with neurologic recovery. High suspicion of SoT should be exercised in patients who fail to progress or have a previous trauma, hemorrhage, or shifting of brain structures. Performing the cranioplasty earlier was associated with improved and quantifiable neurologic recovery. Graphical abstract.
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http://dx.doi.org/10.1007/s10143-021-01655-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8976790PMC
April 2022

Surgical treatment of brainstem cavernous malformations: an international Delphi consensus.

J Neurosurg 2021 Oct 1:1-11. Epub 2021 Oct 1.

1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany.

Objective: Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM.

Methods: A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM.

Results: Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery-, and BSCM-related aspects (22/37, 59%); and 4) clinical situation-based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios.

Conclusions: A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.
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http://dx.doi.org/10.3171/2021.3.JNS2156DOI Listing
October 2021

Comparison of the real-world effectiveness of vertical versus lateral functional hemispherotomy techniques for pediatric drug-resistant epilepsy: A post hoc analysis of the HOPS study.

Epilepsia 2021 11 12;62(11):2707-2718. Epub 2021 Sep 12.

Division of Neurosurgery, Department of Surgery, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.

Objective: This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri-insular/peri-Sylvian approach to hemispheric surgery is the superior technique in achieving long-term seizure freedom.

Methods: We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri-insular/peri-Sylvian, or lateral trans-Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time-to-event method and calculated using the Kaplan-Meier survival method.

Results: Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri-insular/peri-Sylvian or trans-Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%-70.2%) of the entire cohort at 10-year follow-up. Seizure freedom was 88.8% (95% CI = 78.9%-94.3%) at 1-year follow-up and persisted at 85.5% (95% CI = 74.7%-92.0%) across 5- and 10-year follow-up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%-91.5%) at 1-year to 72.1% (95% CI = 66.9%-76.7%) at 5-year to 57.2% (95% CI = 46.6%-66.4%) at 10-year follow-up for the lateral subgroup. Log-rank test found that vertical hemispherotomy was associated with durable seizure-free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time-to-seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08-6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05-12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique.

Significance: This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise-based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long-term seizure outcomes.
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http://dx.doi.org/10.1111/epi.17021DOI Listing
November 2021

Spinal Meningiomas: Influence of Cord Compression and Radiological Features on Preoperative Functional Status and Outcome.

Cancers (Basel) 2021 Aug 20;13(16). Epub 2021 Aug 20.

Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals and Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland.

Background: Radiological parameters predicting the postoperative neurological outcome after resection of a spinal meningioma (SM) are poorly studied, with controversial results.

Methods: Observational multicenter cohort (2011-2018) of adult patients undergoing surgery for resection of SM. Tumor-canal volume ratio (TCR), the areas related to the cord and tumor occupancy at maximum compression, the presence of dural tail, calcifications, signs of myelopathy, and postoperative cord expansion were compared with the modified McCormick scale (mMCS) preoperative and at follow-up.

Results: In the cohort ( = 90 patients), cord and tumor occupancy as well as cord compression and tumor volume showed a correlation with preoperative mMCS ( < 0.05, R -0.23; < 0.001, R 0.35; < 0.005, R -0.29; < 0.001, R 0.42). Cord occupancy had a strong correlation with cord compression ( < 0.001, R 0.72). Tumor occupancy and TCR were correlated with relative outcome at follow-up ( < 0.005 R 0.3; < 0.005 R 0.29). No correlation was found between cord re-expansion and clinical outcome at follow-up. Finally, a correlation was shown between preoperative signs of cord myelopathy and mMCS ( < 0.05 R 0.21) at follow-up.

Conclusions: Larger tumors showed lower preoperative functional status and a worse clinical outcome. Moreover, preoperative T2 cord signal changes are correlated with a poorer outcome.
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http://dx.doi.org/10.3390/cancers13164183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8393980PMC
August 2021

Microsurgical treatment of symptomatic vestibular schwannomas in patients under 40: different results before and after age of 30.

Neurosurg Rev 2022 Feb 17;45(1):873-882. Epub 2021 Aug 17.

Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, University of Geneva, Geneva, Switzerland.

In 10-15% of cases of vestibular schwannoma (VS), age at diagnosis is 40 years or less. Little is known about the differences in natural history, surgical findings, and postoperative outcomes of such younger patients as compared to those of greater age. To analyze clinical and surgical and imaging data of a consecutive series of n = 50 patients with unilateral sporadic VS, aged 40 years or younger - separated in a very young group (15-30 years) and a moderately young group (31-40 years). Retrospective case series. Fifty consecutive patients under 40 years of age underwent microsurgical resection of unilateral sporadic VS via the retrosigmoid approach. The study cohort was subdivided into two groups according to the age range: group A, age range 15-30 years (n = 23 patients), and group B, age range 31-40 years (n = 27 patients). The adherence of VS capsule to surrounding nervous structures and the tendency of the tumors to bleed were evaluated by reviewing video records; the course of the FN in relation to the tumor's surface was assessed in each case. Microsurgical removal of tumor was classified as total (T), near total (residual tumor volume < 5%), subtotal (residual tumor volume 5-10%), or partial (residual tumor volume > 10%). Mean tumor size of entire cohort was 2.53 (range: 0.6-5.8) cm: 2.84 cm in group A and 2.36 cm in group B (p = NS). Facial nerve course and position within the cerebellopontine angle did not differ significantly between the two groups. At 6-month follow-up, FN functional outcome was HBI-II in 69.5% in group A, versus 96.3% in group B (p < .001). Hearing preservation was achieved in 60.0% of patients of group A and in 58.3% of group B (p = NS). Total and near-total resection was feasible in 95.6% of cases of group A and in 88.9% of group B (p = NS). Tumor capsule was tightly adherent to nervous structures in 69.6% patients of group A and in 22.2% of group B (p < .05). Significant bleeding was encountered in 56.5% of group A tumors, and in 29.6% of group B tumors (p < .01). Microsurgery of VS in patients aged 40 or less is associated with good functional results, and with high rates of total and near total tumor removal. Patients < 30 years of age have more adherent tumor capsules. Furthermore, their tumors exhibit a tendency to larger sizes, to hypervascularization, to profuse intraoperative bleeding and they present worse long-term functional FN results when compared to patients in their fourth decade of life. Our limited experience seems to suggest that a near total resection in very young VS patients with large tumors should be preferred in adherent and hypervascularized cases, in order to maximize resection and preserve function.
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http://dx.doi.org/10.1007/s10143-021-01603-4DOI Listing
February 2022

Evaluation of the effect of standard neuronavigation and augmented reality on the integrity of the perifocal structures during a neurosurgical approach.

Neurosurg Focus 2021 08;51(2):E19

1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals; and.

Objective: Intracranial minimally invasive procedures imply working in a restricted surgical corridor surrounded by critical structures, such as vessels and cranial nerves. Any damage to them may affect patient outcome. Neuronavigation systems may reduce the risk of such complications. In this study, the authors sought to compare standard neuronavigation (NV) and augmented reality (AR)-guided navigation with respect to the integrity of the perifocal structures during a neurosurgical approach using a novel model imitating intracranial vessels.

Methods: A custom-made box, containing crisscrossing hard metal wires, a hidden nail at its bottom, and a wooden top, was scanned, fused, and referenced for the purpose of the study. The metal wires and an aneurysm clip applier were connected to a controller, which counted the number of contacts between them. Twenty-three naive participants were asked to 1) use NV to define an optimal entry point on the top, perform the smallest craniotomy possible on the wooden top, and to use a surgical microscope when placing a clip on the nail without touching the metal wires; and 2) use AR to preoperatively define an ideal trajectory, navigate the surgical microscope, and then perform the same task. The primary outcome was the number of contacts made between the metal wires and the clip applier. Secondary outcomes were craniotomy size, and trust in NV and AR to help avoid touching the metal wires, as assessed by a 9-level Likert scale.

Results: The median number of contacts tended to be lower with the use of AR than with NV (AR, median 1 [Q1: 1, Q3: 2]; NV, median 3 [Q1: 1, Q3: 6]; p = 0.074). The size of the target-oriented craniotomy was significantly lower with the use of AR compared with NV (AR, median 4.91 cm2 [Q1: 4.71 cm2, Q3: 7.55 cm2]; and NV, median 9.62 cm2 [Q1: 7.07 cm2; Q3: 13.85 cm2]). Participants had more trust in AR than in NV (the differences posttest minus pretest were mean 0.9 [SD 1.2] and mean -0.3 [SD 0.2], respectively; p < 0.05).

Conclusions: The results of this study show a trend favoring the use of AR over NV with respect to reducing contact between a clip applier and the perifocal structures during a simulated clipping of an intracranial aneurysm. Target-guided craniotomies were smaller with the use of AR. AR may be used not only to localize surgical targets but also to prevent complications associated with damage to structures encountered during the surgical approach.
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http://dx.doi.org/10.3171/2021.5.FOCUS21202DOI Listing
August 2021

Augmented reality-assisted roadmaps during periventricular brain surgery.

Neurosurg Focus 2021 08;51(2):E4

1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland.

Visualizing major periventricular anatomical landmarks intraoperatively during brain tumor removal is a decisive measure toward preserving such structures and thus the patient's postoperative quality of life. The aim of this study was to describe potential standardized preoperative planning using standard landmarks and procedures and to demonstrate the feasibility of using augmented reality (AR) to assist in performing surgery according to these "roadmaps." The authors have depicted stepwise AR surgical roadmaps applied to periventricular brain surgery with the aim of preserving major cognitive function. In addition to the technological aspects, this study highlights the importance of using emerging technologies as potential tools to integrate information and to identify and visualize landmarks to be used during tumor removal.
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http://dx.doi.org/10.3171/2021.5.FOCUS21220DOI Listing
August 2021

Current state of social media utilization in neurosurgery amongst European Association of Neurosurgical Societies (EANS) member countries.

Acta Neurochir (Wien) 2022 01 27;164(1):15-23. Epub 2021 Jul 27.

Department of Neurosurgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.

Background: Social Media (SoMe) is becoming increasingly used in the medical community, and its use has been related with academic productivity. However, utilization of SoMe in the European neurosurgical community has not been assessed systematically.

Methods: An online search was undertaken to discover SoMe accounts of (1) national and related neurosurgical societies listed on the EANS website, (2) neurosurgical journals present on EANS website, (3) neurosurgery centers within EANS member countries, as listed on their website. SoMe accounts of Facebook, Twitter, YouTube, and Instagram were searched for journals and societies, and Twitter, Instagram, and Facebook for neurosurgery departments. The number of likes/followers/subscribers was recorded.

Results: Five (31%) neurosurgery journals had a SoMe presence. The highest number of followers, likes, and tweets was found for JNNP, and Journal of Neurological Surgery Part B had the most subscribers and video views. SoMe usage was identified for 11 national (28.2%) and 2 multi-national neurosurgical societies. From these, the French Society of Neurosurgery had the largest number of Facebook followers (> 2800) and Likes (> 2700), the Society of British Neurological Surgeons had the largest number of Twitter followers (> 2850), whereas EANS overall had the most followers on Twitter > 5100 and Facebook > 5450. A total of 87 SoMe neurosurgery center accounts were found on either Facebook, Instagram or Twitter, for 64 of 1000 centers (6.4%) in 22 of 40 different countries (55%). Of these 67% (n = 43/64) arose from 6 countries (England, Germany, Italy, Romania, Turkey, Ukraine). There were more Facebook accounts (n = 42) than Instagram accounts (n = 23) or Twitter accounts (n = 22).

Conclusion: SoMe use amongst neurosurgical societies and departments in Europe is very limited. From our perspective, explanations are lacking for the correlated numbers to the market shares of SoMe in the respective countries. Further research, including a survey, to follow up on this important topic should be undertaken among EANS members.
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http://dx.doi.org/10.1007/s00701-021-04939-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313658PMC
January 2022

Clinical Outcomes between Stand-Alone Zero-Profile Spacers and Cervical Plate with Cage Fixation for Anterior Cervical Discectomy and Fusion: A Retrospective Analysis of 166 Patients.

J Clin Med 2021 Jul 12;10(14). Epub 2021 Jul 12.

Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06519, USA.

Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy and/or radiculopathy who had ACDF with SA or CP from Jan 2013-Dec 2016. We measured surgical outcomes including Bazaz dysphagia score at 3 months, Nurick grade at last follow-up, and length of hospital stay. 166 patients (92F/74M) were reviewed. 92 presented with radiculopathy (55%), 37 with myelopathy (22%), and 37 with myeloradiculopathy (22%). The average operative time with CP was longer than SA (194 ± 69 vs. 126 ± 46 min) ( 0.001), as was the average length of hospital stay (2.1 ± 2 vs. 1.5 ± 1 days) ( = 0.006). At 3 months, 82 patients (49.4%) had a follow-up for dysphagia, with 3 patients reporting mild dysphagia and none reporting moderate or severe dysphagia. Nurick grade at last follow-up for the myelopathy and myeloradiculopathy cohorts improved in 63 patients (85%). Prolonged length of stay was associated with reduced odds of having an optimal outcome by 0.50 (CI = 0.35-0.85, = 0.003). Overall, we demonstrate that there is no significant difference in neurological outcome or rates of dysphagia between SA and CP, and that both lead to overall improvement of symptoms based on Nurick grading. However, we also show that the SA group has shorter length of hospital stay and operative time compared to CP.
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http://dx.doi.org/10.3390/jcm10143076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8305235PMC
July 2021

Neuropsychological Outcomes after Surgery for Olfactory Groove Meningiomas.

Cancers (Basel) 2021 May 21;13(11). Epub 2021 May 21.

Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, 1205 Geneva, Switzerland.

Background: In recent years, several studies have reported abnormal pre- and postoperative neuropsychological functioning in patients with meningiomas located in the prefrontal cortex (notably the ventromedial region). In the case of olfactory groove meningiomas, the tumor is in direct contact with the inferior aspect of the prefrontal cortex, a cortical region with crucial roles in decision-making, cognition and memory functions, potentially negatively impacting neuropsychological functions.

Materials And Methods: We retrospectively compared pre- and post-operative neuropsychological testing of 17 patients undergoing surgical removal of olfactory groove meningiomas in our institution between January 2013 and December 2018. Neuropsychological results were obtained from the patients' medical history and normalized as z-scores of their respective cognitive functions.

Results: Assessment of cognitive follow-up showed an important heterogeneity among patients. Pre-operative cognitive impairment was observed in most patients, particularly in cognitive flexibility (mean z-score: -1.35). Immediate post-operative cognitive status showed an overall impairment in all domains of cognition, significant for the domains of attention ( = 0.0273) and flexibility ( = 0.0234) and almost significant for the domain of language ( = 0.0547). The late follow-up at one year showed a trend towards general improvement, although attention and flexibility remained impaired.

Discussion: Olfactory groove meningiomas impact pre-frontal cortex cognitive functions, particularly in the domain of cognitive flexibility. After an initial postoperative worsening, patients tended to improve in most aspects after one year, aside from cognitive flexibility and attention.
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http://dx.doi.org/10.3390/cancers13112520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8196649PMC
May 2021

Intraoperative subcortico-cortical evoked potentials of the visual pathway under general anesthesia.

Clin Neurophysiol 2021 07 9;132(7):1381-1388. Epub 2021 Apr 9.

Faculty of Medicine, University of Geneva, Geneva, Switzerland; Departement of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland.

Objective: To assess whether intraoperative subcortical mapping of the visual pathways during brain surgeries was feasible.

Methods: Subcortico-cortical evoked potentials (SCEPs: 30 stimulations/site, biphasic single pulse, 1.3 Hz, 0.2 ms/phase, maximum 10 mA; bipolar probe) were measured in 12 patients for stimulation of the optic radiation, Meyer's loop or optic nerve. Recorded sites were bilateral central, parietal, parieto-occipital, occipital (subdermal scalp electrodes, 5-4000 Hz). The minimum distances from the stimulation locations, i.e. the closest border of the resection cavity to the diffusion tensor imaging based visual pathways, were evaluated postoperatively (smallest distance across coronal, sagittal and axial planes).

Results: Stimulation elicited SCEPs when the visual tracts were close (≤4.5 mm). The responses consisted of a short (P1, 3.0-5.6 ms; 8/8 patients) and of a middle (P2, 15-21.6 ms; 3/8 patients) latency waveforms. In agreement with the neuroanatomy, ipsilateral occipital responses were obtained for temporal or parietal stimulations, and bi-occipital responses for optic nerve stimulations.

Conclusions: For the first time to our knowledge, intraoperative SCEPs were observed for stimulations of the optic radiation and of Meyer's loop. Short latency responses were found in agreement with fast conduction of the visual pathway's connecting myelinated fibers.

Significance: The mapping of the visual pathways was found feasible for neurosurgeries under general anesthesia.
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http://dx.doi.org/10.1016/j.clinph.2021.02.399DOI Listing
July 2021

MRI-Compatible and Conformal Electrocorticography Grids for Translational Research.

Adv Sci (Weinh) 2021 05 8;8(9):2003761. Epub 2021 Mar 8.

Bertarelli Foundation Chair in Neuroprosthetic Technology Laboratory for Soft Bioelectronic Interfaces Institute of Microengineering Institute of Bioengineering Center for Neuroprosthetics Ecole Polytechnique Fédérale de Lausanne (EPFL) Geneva 1202 Switzerland.

Intraoperative electrocorticography (ECoG) captures neural information from the surface of the cerebral cortex during surgeries such as resections for intractable epilepsy and tumors. Current clinical ECoG grids come in evenly spaced, millimeter-sized electrodes embedded in silicone rubber. Their mechanical rigidity and fixed electrode spatial resolution are common shortcomings reported by the surgical teams. Here, advances in soft neurotechnology are leveraged to manufacture conformable subdural, thin-film ECoG grids, and evaluate their suitability for translational research. Soft grids with 0.2 to 10 mm electrode pitch and diameter are embedded in 150 µm silicone membranes. The soft grids are compatible with surgical handling and can be folded to safely interface hidden cerebral surface such as the Sylvian fold in human cadaveric models. It is found that the thin-film conductor grids do not generate diagnostic-impeding imaging artefacts (<1 mm) nor adverse local heating within a standard 3T clinical magnetic resonance imaging scanner. Next, the ability of the soft grids to record subdural neural activity in minipigs acutely and two weeks postimplantation is validated. Taken together, these results suggest a promising future alternative to current stiff electrodes and may enable the future adoption of soft ECoG grids in translational research and ultimately in clinical settings.
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http://dx.doi.org/10.1002/advs.202003761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097365PMC
May 2021

Single-hole, ruptured parenchymal arteriovenous fistula of the mesencephalon: not known vascular malformation of the brain or a posthemorrhagic entity?

Ideggyogy Sz 2021 Mar;74(3-4):126-128

Neuroradiology Division, Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland.

The subtypes of brain arteriovenous malformations, with direct, single-hole fistulas without co-existing nidus are not described as existing entities inside the brain parenchyma but on the pial surface. True parenchymal arteriovenous malformations present with nidal structure, even if they are small, whereas surface lesions may present a direct fistulous configuration. In this case of midbrain haemorrhage a direct arteriovenous fistula was detected at the level of the red nucleus between a paramedian midbrain perforator artery and a paramedian parenchymal vein, with pseudo-aneurysm formation at the fistulous connection, without signs of adjacent nidus structure. The hypothesis whether a pre-existing arteriovenous fistula ruptured or a spontaneous haemorrhage has caused the fistulous connection is discussed.
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http://dx.doi.org/10.18071/isz.74.0126DOI Listing
March 2021

Surgical management of spinal metastases involving the cervicothoracic junction: results of a multicenter, European observational study.

Neurosurg Focus 2021 05;50(5):E7

2Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich.

Objective: Surgical management of spinal metastases at the cervicothoracic junction (CTJ) is highly complex and relies on case-based decision-making. The aim of this multicentric study was to describe surgical procedures for metastases at the CTJ and provide guidance for clinical and surgical management.

Methods: Patients eligible for this study were those with metastases at the CTJ (C7-T2) who had been consecutively treated in 2005-2019 at 7 academic institutions across Europe. The Spine Instability Neoplastic Score, neurological function, clinical status, medical history, and surgical data for each patient were retrospectively assessed. Patients were divided into four surgical groups: 1) posterior decompression only, 2) posterior decompression and fusion, 3) anterior corpectomy and fusion, and 4) anterior corpectomy and 360° fusion. Endpoints were complications, surgical revision rate, and survival.

Results: Among the 238 patients eligible for inclusion this study, 37 were included in group 1 (15%), 127 in group 2 (53%), 18 in group 3 (8%), and 56 in group 4 (24%). Mechanical pain was the predominant symptom (79%, 189 patients). Surgical complications occurred in 16% (group 1), 20% (group 2), 11% (group 3), and 18% (group 4). Of these, hardware failure (HwF) occurred in 18% and led to surgical revision in 7 of 8 cases. The overall complication rate was 34%. In-hospital mortality was 5%.

Conclusions: Posterior fusion and decompression was the most frequently used technique. Care should be taken to choose instrumentation techniques that offer the highest possible biomechanical load-bearing capacity to avoid HwF. Since the overall complication rate is high, the prevention of in-hospital complications seems crucial to reduce in-hospital mortality.
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http://dx.doi.org/10.3171/2021.2.FOCUS201067DOI Listing
May 2021

Meningiomas and Cognitive Impairment after Treatment: A Systematic and Narrative Review.

Cancers (Basel) 2021 Apr 13;13(8). Epub 2021 Apr 13.

Neurosurgical Division, Department of Neurosciences, Geneva University Hospitals, 1206 Geneva, Switzerland.

Clinical outcomes after surgery for intracranial meningiomas might be overvalued as cognitive dimensions and quality of life are probably underreported. This review aims to summarize the current state of cognitive screening and treatment-related outcomes after meningioma surgery. We present a systematic review (Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA-P) 2015-based) of cognitive outcomes after intracranial meningioma surgery. A total of 1572 patients (range 9-261) with a mean age of 58.4 years (range 23-87), and predominantly female ( = 1084, 68.9%) were identified. Mean follow-up time after treatment was 0.86 ± 0.3 years. Neuropsychological assessment was very heterogeneous, but five dimensions of cognition were described: memory (19/22); attention (18/22); executive functions (17/22); language (11/22); flexibility (11/22 studies). Cognitive abilities were impaired in 18 studies (81.8%), but only 1 showed deterioration in all dimensions simultaneously. Memory was the most affected. with significant post-therapy impairment in 9 studies (40.9%). Postoperatively, only 4 studies (18.2%) showed improvement in at least one dimension. Meningioma patients had significantly lower cognitive scores when compared to healthy subjects. Surgery and radiotherapy for meningiomas were associated with cognitive impairment, probably followed by a partial recovery. Cognition is poorly defined, and the assessment tools employed lack standardization. Cognitive impairment is probably underreported in meningioma patients.
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http://dx.doi.org/10.3390/cancers13081846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070481PMC
April 2021

Safety of Nitrous Oxide Anesthesia in a Selected Group of Patients Undergoing Neurosurgery: An Exploratory Subgroup Analysis of the ENIGMA Trials.

J Neurosurg Anesthesiol 2022 Jul 23;34(3):306-312. Epub 2021 Apr 23.

Departments of Neurosurgery.

Background: The Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia (ENIGMA)-I and ENIGMA-II were randomized clinical trials that assessed the safety of nitrous oxide anesthesia in patients undergoing noncardiac surgery. In this study, we performed an exploratory pooled analysis of both ENIGMA trials to assess the safety of nitrous oxide in a selected group of patients undergoing neurosurgery.

Methods: Data from each ENIGMA trial were collated into a single database. Information regarding patient demographics, comorbidities, medication use, anesthesia, surgical procedure, and postoperative complications was extracted. Multivariate logistic regression was conducted for postoperative complications to assess the risk associated with nitrous oxide.

Results: A total of 830 patients were included in our analysis: 417 received nitrous oxide anesthesia, and 413 received nitrous oxide-free anesthesia. Baseline patient and perioperative characteristics were comparable. Procedural data were available for 535 patients (64%); of these, 507 (95%) underwent spinal neurosurgery and 28 (5%) underwent cranial neurosurgery. Patients in the nitrous oxide group had lower inspired oxygen concentration (30% vs. 38%; P<0.001) and end-tidal volatile agent concentration (0.56 vs. 0.89 minimal alveolar concentration equivalents; P<0.001) compared with the nitrous oxide-free group. Use of nitrous oxide was not associated with increased risk of postoperative complications (myocardial infarction, cardiac arrest, stroke, infection, severe vomiting, fever, pneumonia, pneumothorax, blood transfusion, venous thromboembolism, or death) (odds ratio: 1.22; 95% confidence interval: 0.89-1.65; P=0.22) or prolonged length of hospital stay (median 5.0 vs. 4.2 d for nitrous oxide and nitrous oxide-free groups; P=0.28).

Conclusion: Nitrous oxide did not increase the risk of postoperative complications or prolonged length of hospital stay in the neurosurgical cohort enrolled in the ENIGMA-I and ENIGMA-II trials.
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http://dx.doi.org/10.1097/ANA.0000000000000771DOI Listing
July 2022

Clonal Evolution of a High-Grade Pediatric Glioma With Distant Metastatic Spread.

Neurol Genet 2021 Apr 15;7(2):e561. Epub 2021 Feb 15.

Center for Translational Research in Onco-Hematology (E.M., V.D., P.-Y.D., P.T., D.M.), University of Geneva, Department of Oncology, Geneva University Hospital, Geneva and Swiss Cancer Center Léman (SCCL); Genetic Core Facility (S.N.), Geneva University Hospital; Diagnostic Department, Neuroradiology Division, (M.-I.V.), Neurosurgery Service (K.S.), and Department of Pathology (J.A.L.), Geneva University Hospital, Geneva, Switzerland.

Objective: High-grade glioma (HGG) rarely spreads outside the CNS. To test the hypothesis that the lesions were metastases originating from an HGG, we sequenced the relapsing HGG and distant extraneural lesions.

Methods: We performed whole-exome sequencing of an HGG lesion, its local relapse, and distant lesions in bone and lymph nodes.

Results: Phylogenetic reconstruction and histopathologic analysis confirmed the common glioma origin of the secondary lesions. The mutational profile revealed an IDH1/2 wild-type HGG with an activating mutation in and biallelic focal loss of (9p21). In the metastatic samples and the local relapse, we found an activating mutation, further copy number gains in chromosome 7 (), and a putative pathogenic driver mutation in a canonical splice site of

Conclusions: Our findings demonstrate tumor spread outside the CNS and identify potential genetic drivers of metastatic dissemination outside the CNS, which could be leveraged as therapeutic targets or potential biomarkers.
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http://dx.doi.org/10.1212/NXG.0000000000000561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063622PMC
April 2021

Occult Disco-Ligamentous Lesions of the Subaxial c-Spine-A Comparison of Preoperative Imaging Findings and Intraoperative Site Inspection.

Diagnostics (Basel) 2021 Mar 5;11(3). Epub 2021 Mar 5.

Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany.

Despite the general acceptance of magnetic resonance imaging (MRI) as the gold standard for diagnostics of traumatic disco-ligamentous injuries in the subaxial cervical spine, clinical experience shows cases where no lesion is detected in MRI exams but obtained during surgery. The aim of this study was to compare intraoperative site inspection to preoperative imaging findings and to identify radiological features of patients having a risk for under- or over-estimating disco-ligamentous lesions. We performed a retrospective analysis of our clinical database, considering all patients who underwent surgical treatment of the cervical spine via an anterior approach after trauma between June 2008 and April 2018. Only patients with availability of immediate preoperative computed tomography (CT), 3-Tesla MRI scans, and information about intraoperative findings were considered. Results of preoperative imaging were set in context to intraoperative findings, and receiver operator characteristics (ROC) were calculated. Out of 144 patients receiving anterior cervical surgery after trauma, 83 patients (mean age: 59.4 ± 20.5 years, age range: 12-94 years, 63.9% males) were included in this study. Included patients underwent surgical treatment via anterior cervical discectomy and fusion (ACDF; 79 patients) or anterior cervical corpectomy and fusion (4 patients) with ventral plating. Comparing preoperative imaging findings to intraoperative site inspection, a discrepancy between imaging and surgical findings was revealed in 14 patients, leading to an overall specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of the cervical spine of 100%/77.4%. Yet, adding the existence of prevertebral hematoma and/or vertebral fractures according to preoperative imaging improved the sensitivity to 95.2%. Lack of sensitivity was most likely related to severe cervical spondylosis, rendering correct radiological reporting difficult. Thus, the risk of missing a traumatic disco-ligamentous injury of the cervical spine in imaging seems to be a particular threat in patients with preexisting degenerative cervical spondylosis. In conclusion, incorporating the existence of prevertebral hematoma and/or vertebral fractures can significantly improve diagnostic yield.
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http://dx.doi.org/10.3390/diagnostics11030447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998602PMC
March 2021

Trends and outcomes for non-elective neurosurgical procedures in Central Europe during the COVID-19 pandemic.

Sci Rep 2021 03 17;11(1):6171. Epub 2021 Mar 17.

Department of Neurosurgery, Ceske Budejovice Hospital, Ceske Budejovice, Czech Republic.

The world currently faces the novel severe acute respiratory syndrome coronavirus 2 pandemic. Little is known about the effects of a pandemic on non-elective neurosurgical practices, which have continued under modified conditions to reduce the spread of COVID-19. This knowledge might be critical for the ongoing second coronavirus wave and potential restrictions on health care. We aimed to determine the incidence and 30-day mortality rate of various non-elective neurosurgical procedures during the COVID-19 pandemic. A retrospective, multi-centre observational cohort study among neurosurgical centres within Austria, the Czech Republic, and Switzerland was performed. Incidence of neurosurgical emergencies and related 30-day mortality rates were determined for a period reflecting the peak pandemic of the first wave in all participating countries (i.e. March 16th-April 15th, 2020), and compared to the same period in prior years (2017, 2018, and 2019). A total of 4,752 emergency neurosurgical cases were reviewed over a 4-year period. In 2020, during the COVID-19 pandemic, there was a general decline in the incidence of non-elective neurosurgical cases, which was driven by a reduced number of traumatic brain injuries, spine conditions, and chronic subdural hematomas. Thirty-day mortality did not significantly increase overall or for any of the conditions examined during the peak of the pandemic. The neurosurgical community in these three European countries observed a decrease in the incidence of some neurosurgical emergencies with 30-day mortality rates comparable to previous years (2017-2019). Lower incidence of neurosurgical cases is likely related to restrictions placed on mobility within countries, but may also involve delayed patient presentation.
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http://dx.doi.org/10.1038/s41598-021-85526-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969942PMC
March 2021

Hemispherectomy Outcome Prediction Scale: Development and validation of a seizure freedom prediction tool.

Epilepsia 2021 05 13;62(5):1064-1073. Epub 2021 Mar 13.

Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.

Objective: To develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug-resistant epilepsy.

Methods: We analyzed 1267 hemispheric surgeries performed in pediatric participants across 32 centers and 12 countries to identify predictors of seizure freedom at 3 months after surgery. A multivariate logistic regression model was developed based on 70% of the dataset (training set) and validated on 30% of the dataset (validation set). Missing data were handled using multiple imputation techniques.

Results: Overall, 817 of 1237 (66%) hemispheric surgeries led to seizure freedom (median follow-up = 24 months), and 1050 of 1237 (85%) were seizure-free at 12 months after surgery. A simple regression model containing age at seizure onset, presence of generalized seizure semiology, presence of contralateral 18-fluoro-2-deoxyglucose-positron emission tomography hypometabolism, etiologic substrate, and previous nonhemispheric resective surgery is predictive of seizure freedom (area under the curve = .72). A Hemispheric Surgery Outcome Prediction Scale (HOPS) score was devised that can be used to predict seizure freedom.

Significance: Children most likely to benefit from hemispheric surgery can be selected and counseled through the implementation of a scale derived from a multiple regression model. Importantly, children who are unlikely to experience seizure control can be spared from the complications and deficits associated with this surgery. The HOPS score is likely to help physicians in clinical decision-making.
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http://dx.doi.org/10.1111/epi.16861DOI Listing
May 2021

The perspectives of mapping and monitoring of the sense of self in neurosurgical patients.

Acta Neurochir (Wien) 2021 05 8;163(5):1213-1226. Epub 2021 Mar 8.

Laboratory of Neurocognitive Science, Center for Neuroprosthetics and Brain Mind Institute, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland.

Surgical treatment of tumors, epileptic foci or of vascular origin, requires a detailed individual pre-surgical workup and intra-operative surveillance of brain functions to minimize the risk of post-surgical neurological deficits and decline of quality of life. Most attention is attributed to language, motor functions, and perception. However, higher cognitive functions such as social cognition, personality, and the sense of self may be affected by brain surgery. To date, the precise localization and the network patterns of brain regions involved in such functions are not yet fully understood, making the assessment of risks of related post-surgical deficits difficult. It is in the interest of neurosurgeons to understand with which neural systems related to selfhood and personality they are interfering during surgery. Recent neuroscience research using virtual reality and clinical observations suggest that the insular cortex, medial prefrontal cortex, and temporo-parietal junction are important components of a neural system dedicated to self-consciousness based on multisensory bodily processing, including exteroceptive and interoceptive cues (bodily self-consciousness (BSC)). Here, we argue that combined extra- and intra-operative approaches using targeted cognitive testing, functional imaging and EEG, virtual reality, combined with multisensory stimulations, may contribute to the assessment of the BSC and related cognitive aspects. Although the usefulness of particular biomarkers, such as cardiac and respiratory signals linked to virtual reality, and of heartbeat evoked potentials as a surrogate marker for intactness of multisensory integration for intra-operative monitoring has to be proved, systemic and automatized testing of BSC in neurosurgical patients will improve future surgical outcome.
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http://dx.doi.org/10.1007/s00701-021-04778-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053654PMC
May 2021

Isolated subarachnoid hemorrhage in mild traumatic brain injury: is a repeat CT scan necessary? A single-institution retrospective study.

Acta Neurochir (Wien) 2021 11 1;163(11):3209-3216. Epub 2021 Mar 1.

Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland.

Background: Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common finding in the emergency department. In many centers, a repeat CT scan is routinely performed 24 to72 h following the trauma to rule out further radiological progression. The aim of this study is to assess the clinical utility of the repeat CT scan in clinical practice.

Methods: We reviewed the medical charts of all patients who presented to our institution with mild TBI (mTBI) and isolated SAH between January 2015 and October 2017. CT scan at admission and control after 24 to 72 h were examined for each patient in order to detect any possible change. Neurological deterioration, antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries, and length of stay in hospital were analyzed.

Results: Of the 649 TBI patients, 106 patients met the inclusion criteria. Fifty-four patients were females and 52 were males with a mean age of 68.2 years. Radiological iSAH progression was found in 2 of 106 (1.89) patients, and one of them was under antiplatelet therapy. No neurological deterioration was observed. Ten of 106 (9.4%) patients were under anticoagulation therapy, and 28 of 106 (26.4%) were under antiplatelet therapy.

Conclusion: ISAH in mTBI seems to be a radiological stable entity over 72 h with no neurological deterioration. The clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost. Regardless of anticoagulation/antiplatelet therapy, neurologic observation and symptomatic treatment solely could be a reasonable alternative.
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http://dx.doi.org/10.1007/s00701-020-04622-0DOI Listing
November 2021
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