Perez‐Vega, Carlos

BACKGROUND The authors aimed to evaluate the feasibility/safety of stereo-electroencephalography (SEEG) and SEEG-guided radiofrequency thermocoagulation (RFTC) in patients with drug-resistant epilepsy previously implanted with neuromodulation devices, using a retrospective cohort design evaluating patients treated at the Mayo Clinic Florida Epilepsy Center. OBSERVATIONS Nine patients (mean age 36.3 ± 10.9 years, 33% female) with prior implantation of neuromodulation devices were included. A vagus nerve stimulator was present in 8 of 9 patients, and 4 patients had undergone previous intracranial neuromodulation. Five patients underwent SEEG-RFTC. The mean SEEG monitoring duration was 6.5 ± 2.9 days. No intraoperative or procedural complications occurred, including hardware-related issues. No permanent or significant neurological/cognitive deficits occurred. One patient experienced transient postoperative neurological symptoms attributed to perilesional edema. Seizure reduction ranged from 50% to 75% following SEEG-RFTC. LESSONS SEEG and SEEG-RFTC are feasible in patients who have implanted neuromodulation devices, including intracranial implants. These procedures may be performed without interference with existing hardware and provide meaningful seizure reduction in highly refractory populations. Further studies with larger cohorts and longer follow-up are needed to better define efficacy and patient selection. https://thejns.org/doi/10.3171/CASE26376

Abstract Objective: Reading is a complex cognitive process requiring the integration of orthographic, phonological, and semantic information. The visual word form area, located in the ventral occipitotemporal cortex, is critically involved in orthographic decoding, and damage to this region is known to cause alexia. In contrast, the contributions of white matter pathways supporting reading are less well understood. Method: We present a unique neurosurgical case undergoing awake brain surgery for resection of a metastasis in the left occipitotemporal cortex. A tubular retractor was used to access the lesion and during the insertion of the retractor the patient underwent careful, continuous neuropsychological testing, including evaluation of reading. fMRI language mapping and diffusion MRI were performed preoperatively. Postoperative neuropsychological testing was completed two weeks after surgery to assess cognitive outcome. Results: The patient developed an alexia with letter-by-letter reading in real time during insertion of the tubular retractor. Stealth imaging enabled localization of the tubular retractor at the exact onset of the alexia and, by correlating this with tractography, showed that the tubular retractor was in the vertical occipital fasciculus (VOF). Conclusions: We present the first detailed case report linking the VOF to the acute onset of alexia observed intraoperatively during awake brain surgery. We discuss the connectomics of reading and possible contributions of the VOF in reading.

Introduction Infectious intracranial aneurysms (IIAs) are rare but serious complications of systemic infections, particularly infective endocarditis. These aneurysms are prone to rupture, leading to significant morbidity and mortality. Management strategies lack consensus due to the rarity of the condition and reliance on small case series. This study examines the clinical management of IIAs using data from a large multicenter cohort. Methods A retrospective registry-based cohort study was conducted across 11 tertiary care centers in the USA between 2018 and 2023. Patients with IIAs were identified based on clinical and radiographic criteria. The primary outcome was treatment failure defined as persistence, growth, or rupture of the aneurysm. Secondary outcomes were mortality and the modified Rankin Scale (mRS) score at 90 days and 1 year. Multivariate logistic regressions were used to identify outcome predictors. Results A total of 104 patients with 166 aneurysms were included, with a median age of 43 years. Medical management was successful in 56% of cases, with failure often within 18 days of initiation. Predictors of failure included younger age, larger aneurysm size, and rupture at presentation. Surgical and endovascular interventions achieved higher success rates with better outcomes. At 90 days, 57% of patients achieved functional independence (mRS 0–2), while the mortality rate was 24%. Conclusion This study highlights the limitations of medical management for IIAs and underscores the need for early surgical or endovascular intervention in high-risk patients. Outcome predictors aid clinical decision-making, optimizing patient management. Further research is needed to standardize management guidelines for IIAs.

BACKGROUND AND OBJECTIVES: Rising US healthcare costs and the COVID-19 pandemic put increased pressure on hospitals to reduce patient length of stay (LOS) while maintaining high-quality care. We aimed to determine if implementing a pathway for same-day discharge after elective neuroendovascular procedures to a monitored hotel setting is safe, feasible, and cost-effective. METHODS: We evaluated patient outcomes after elective neuroendovascular procedures and same-day discharge to an on-campus Care Hotel. The study enrolled patients aged ≥18 years from October 1, 2020, to February 28, 2023. Exclusion criteria comprised major comorbidities, additional care necessitating hospitalization, absence of a caregiver, insurer-mandated hospitalization, or patient refusal of the Care Hotel model. Primary outcomes were readmission rate or prolonged LOS, new ischemic or hemorrhagic complications rate, and death rate from vascular causes within 6 months. Secondary outcomes included adverse events and deaths related to causes other than vascular complications within 6 months and changes in modified Rankin Scale score by 1 or more points at last follow-up. Healthcare cost savings associated with same-day discharge were analyzed using a control group. RESULTS: The study included 42 patients discharged to the Care Hotel and 84 controls. The average age was 61 years in the Care Hotel group and 64 years in the control group, and aneurysm treatment was the most frequent neuroendovascular procedure (83.3% and 79.8%, respectively). The readmission and extended LOS rates were 4.8% for the Care Hotel group. The rate of new ischemic or hemorrhagic complications was 4.8%. Cost analysis estimated savings of $7730.12 per procedure. CONCLUSION: This study suggests that the Care Hotel model is a safe, feasible, and cost-effective option for carefully selected patients undergoing elective neuroendovascular interventions. Adherence to discharge readiness criteria and meticulous patient selection are critical to minimizing complications and readmissions.

Abstract Confounding results of engineered mesenchymal stem cells (MSCs) used as cellular vehicles has plagued technologies whereby success or failure of novel approaches may be dismissed or inaccurately ascribed solely to the biotechnology platform rather than suitability of the human donor. Polymeric materials were screened for non‐viral engineering of MSCs from multiple human donors to deliver bone morphogenic protein‐4 (BMP4), a protein previously investigated in clinical trials for glioblastoma (GBM) to combat a subpopulation of highly invasive and tumorigenic clones. A “smart technology” that target the migratory and stem‐like nature of GBM will require: (1) a cellular vehicle (MSC) which can scavenge and target residual cells left behind after surgical debulking and deliver; (2) anti‐glioma cargo (BMP4). Multiple MSC donors are safely engineered, though varied in susceptibility to accept BMP4 due to intrinsic characteristics revealed by their molecular signatures. Efficiency is compared via secretion, downstream signaling, differentiation, and anti‐proliferative properties across all donors. In a clinically relevant resection and recurrence model of patient‐derived human GBM, we demonstrate that nanoengineered MSCs are not “donor agnostic” and efficacy is influenced by the inherent suitability of the MSC to the cargo. Therefore, donor profiles hold greater influence in determining downstream outcomes than the technical capabilities of the engineering technology.

OBJECTIVE Chordomas are rare tumors of the skull base and spine believed to arise from the vestiges of the embryonic notochord. These tumors are locally aggressive and frequently recur following resection and adjuvant radiotherapy. Proton therapy has been introduced as a tissue-sparing option because of the higher level of precision that proton-beam techniques offer compared with traditional photon radiotherapy. This study aimed to compare recurrence in patients with chordomas receiving proton versus photon radiotherapy following resection by applying tree-based machine learning models. METHODS The clinical records of all patients treated with resection followed by adjuvant proton or photon radiotherapy for chordoma at Mayo Clinic were reviewed. Patient demographics, type of surgery and radiotherapy, tumor recurrence, and other variables were extracted. Decision tree classifiers were trained and tested to predict long-term recurrence based on unseen data using an 80/20 split. RESULTS Fifty-three patients with a mean ± SD age of 55.2 ± 13.4 years receiving surgery and adjuvant proton or photon therapy to treat chordoma were identified; most patients were male. Gross-total resection was achieved in 54.7% of cases. Proton therapy was the most common adjuvant radiotherapy (84.9%), followed by conventional or external-beam radiation therapy (9.4%) and stereotactic radiosurgery (5.7%). Patients receiving proton therapy exhibited a 40% likelihood of having recurrence, significantly lower than the 88% likelihood observed in those treated with nonproton therapy. This was confirmed on logistic regression analysis adjusted for extent of tumor resection and tumor location, which revealed that proton adjuvant radiotherapy was associated with a decreased risk of recurrence (OR 0.1, 95% CI 0.01–0.71; p = 0.047) compared with photon therapy. The decision tree algorithm predicted recurrence with an accuracy of 90% (95% CI 55.5%–99.8%), with the lowest risk of recurrence observed in patients receiving gross-total resection with adjuvant proton therapy (23%). CONCLUSIONS Following resection, adjuvant proton therapy was associated with a lower risk of chordoma recurrence compared with photon therapy. The described machine learning models were able to predict tumor progression based on the extent of tumor resection and adjuvant radiotherapy modality used.