Bechtle, Perry S.

Objective: Study perioperative strategies for optimizing neuroprotection in complex spine deformity correction surgery. Methods: We report the case of a patient with severe lumbar dextroscoliosis, thoracolumbar junction hyperkyphosis with a 40-degree Cobb angle levoconvex scoliosis who underwent spinal deformity correction with loss of neuromonitoring during surgery. We performed a literature review on perioperative management of complex spine deformity. Results: A 50-year-old man presented with lumbar pain and right L4 radiculopathy. Surgical intervention for deformity correction and decompression was indicated with T4−L4 posterior instrumentation L2/L3 and L3/L4 transforaminal lumbar interbody fusion. Surgery was aborted due to the loss of neuromonitoring. Postsurgery, the patient had left sensory deficit and the neurocritical care team clinically suspected and deduced the anatomic location of the spinal cord compression. Magnetic resonance imaging confirmed a T10−T11 hyperintensity suggestive of cord ischemia due to osteophyte compressing the spinal cord. The patient underwent a second corrective surgery with no intraoperative events and has no long-term neurological sequela. Conclusions: This case illustrates that a comprehensive perioperative approach and individualized risk factor assessment is useful in complex spine deformity surgery. Further research is needed to determine how this individualized comprehensive approach can lead to intraoperative and postoperative countermeasures that improved spine surgery outcomes. Level of Evidence: Level V.

Abstract BACKGROUND AND IMPORTANCE Data supporting the use of electrocorticography (ECoG) monitoring during electrical stimulation in awake craniotomies for resection of supratentorial neoplasms is robust, but its applicability during active resection is often limited by the inability to keep the array in place. Given the known survival benefit of gross total resection in glioma surgery, novel approaches to surgical monitoring are warranted to maximize safe resection and optimize surgical outcomes in patients with glioblastoma. CLINICAL PRESENTATION A 68-yr-old right-handed woman presented to the emergency department with confusion. Imaging studies revealed a bifrontal intra-axial brain lesion. She underwent a left-sided awake craniotomy procedure with cortical and subcortical mapping. During surgical resection, multiple electrographic seizures were detected on continuous ECoG monitoring with a customized 22-channel high-density hollow circular array. She remained without clinical evidence of seizures at 3 mo after surgery. CONCLUSION We report a unique case of serial electrographic seizures detected during continuous intraoperative ECoG monitoring during active surgical resection of a glioblastoma using a novel circular hollow array during an awake craniotomy. The use of continuous ECoG monitoring during active resection may provide additional data, with potential influence in outcomes for patients undergoing resection of high-grade glial neoplasms.

Background and Study Aims/Objective Metastatic brain tumors are the most common type of adult brain tumors. Treatment involves surgery and/or radiation therapy. Surgery is typically reserved for patients with good neurologic function, solitary and accessible lesions, symptomatic lesions, and/or those with good systemic control of their primary cancer. Deep-seated lesions, however, are typically treated with palliative options including radiation and medical therapies. We summarize our personal experience with minimally invasive surgical approaches for these deep-seated metastatic brain tumors using tubular retractors with exoscopic visualization. Material and Methods Patients with deep-seated metastatic brain tumors who were operated on from January 2016 to December 2017 by the senior author were collected prospectively. “Deep seated” was defined as any subcortical location below the deepest adjacent sulcus in close proximity to the basal ganglia and/or thalamus. “Minimally invasive” was defined as the use of tubular retractors with exoscopic visualization. Results A total of 15 consecutive patients with an average ± standard deviation age of 63 ± 12 years underwent surgical resection of a deep-seated metastasis. The tumor was located in the centrum semiovale in seven (47%) (3 corticospinal tract, 2 superior longitudinal fasciculus, 1 visual tract, 1 inferior frontal occipital fasciculus), basal ganglia in three (20%), thalamus in two (13%), and cerebellum in three (20%). Median percentage resection was 100% (interquartile range:100–100%), and, following surgery, seven (47%), seven (47%), and one (7%) had an improved, stable, and worse Karnofsky Performance Score, respectively. No patients had notable local complications including stroke, infection, hemorrhage, and/or seizure. All patients underwent postoperative stereotactic radiosurgery. Conclusion This minimally invasive approach can be used to achieve extensive resection with minimal morbidity for arguably the highest risk metastatic brain tumors.

ABSTRACT OBJECTIVE Remote cerebellar hemorrhage (RCH) is an infrequent and poorly understood complication of supratentorial neurosurgical procedures. We retrospectively compared 42 patients who experienced RCH with a case-matched control cohort, to delineate risk factors associated with the occurrence of this complication. METHODS Between 1988 and 2000, 42 patients experienced RCH after supratentorial neurosurgical procedures at our institution. Diagnoses were made on the basis of postoperative computed tomographic or magnetic resonance imaging findings in all cases. The medical records for these patients were reviewed and compared with those for a control cohort of 43 patients, matched for age, sex, surgical lesion, and type of craniotomy, who were treated during the same period. RESULTS RCH most commonly occurred after frontotemporal craniotomies for unruptured aneurysm repair or temporal lobectomy and was frequently an incidental finding on postoperative computed tomographic scans. However, some cases of RCH were associated with significant morbidity, and two patients died. Preoperative aspirin use and elevated intraoperative systolic blood pressure were significantly associated with RCH (P = 0.026 and P = 0.036, respectively). Pathological findings for two cases demonstrated hemorrhagic infarctions in both. CONCLUSION RCH most commonly follows supratentorial neurosurgical procedures, performed with the patient in the supine position, that involve opening of cerebrospinal fluid cisterns or the ventricular system (such as unruptured aneurysm repair or temporal lobectomy). Preoperative aspirin use and moderately elevated intraoperative systolic blood pressure are potentially modifiable risk factors associated with the development of RCH. Although RCH can cause death or major morbidity, most cases are asymptomatic or exhibit a benign course. Cerebellar “sag” as a result of cerebrospinal fluid hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, is the most likely pathophysiological cause of RCH.