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BackgroundTo investigate whether patients with critical emergency conditions are seeking or receiving the medical care that they require, we characterized the reality of care for patients presenting with neuro-emergencies during the first phase of the COVID-19 pandemic.MethodsIn this observational, longitudinal cohort study, all neurosurgical admissions that presented to our department between February 1 and April 15 during the COVID-19 pandemic and during the same time period in 2019 were identified and categorized according to the presence of a neuro-emergency, the route of admission, management, and the category of disease. Further, the clinical course of patients with aneurysmal subarachnoid hemorrhage (aSAH) and chronic subdural hematoma (cSDH) was investigated representatively for severe vascular and semi-urgent traumatic conditions that present with a wide variety of symptoms.ResultsDuring the pandemic, the percentage of neuro-emergencies among all neurosurgical admissions remained similar but a larger proportion presented through the emergency department than through the outpatient clinic or by referral (*p = 0.009). The total number of neuro-emergencies was significantly reduced (*p = 0.0007) across all types of disease, particularly in vascular (*p = 0.036) but also in spinal (*p = 0.007) and hydrocephalus (*p = 0.048) emergencies. Patients with spinal emergencies presented 48 h later (*p = 0.001) despite comparable symptom severity. For aSAH, the number of cases, aSAH grade, aneurysm localization, and treatment modality did not change but strikingly, elderly patients with cSDH presented less frequently, with more severe symptoms (*p = 0.046), and were less likely to reach favorable outcome (*p = 0.003) at discharge compared with previous years.ConclusionsDespite pandemic-related restrictive measures and reallocation of resources, patients with neuro-emergencies should be encouraged to present regardless of the severity of symptoms because deferred presentation may result in adverse outcome. Thus, conservation of critical healthcare resources remains essential in spite of fighting COVID-19.

PurposePercutaneous paraspinal pedicle screw implantation (PPSI) reduces soft tissue trauma, blood loss, and postoperative pain but remains technically challenging and associated with radiation exposure and implant-related artefacts. Here, we determined the feasibility, screw accessibility, and the accuracy of navigated PPSI in the thoraco-lumbar sacral spine using intraoperative computed tomography (iCT) and robotic cone-beam CT (CBCT) imaging.MethodsBetween 2015 and 2018, 465 percutaneous paraspinal pedicle screws were implanted in 75 patients using iCT- or CBCT-based spinal navigation with 230 screws connected to rod reducers during screw assessment imaging (iCT 198; CBCT 32). Clinical and demographic data, intraoperative screw accessibility, and screw accuracy were analyzed and compared to a case-matched cohort of 75 patients undergoing navigated implantation of 481 pedicle screws through an open midline approach.ResultsBoth iCT and CBCT permitted reliable assessment of each implanted screw, regardless of artifacts caused by rod reducers. Although overall accuracy for correct placement was comparable between PPSI and open surgery (PPSI 96.6%; Open 94.2%), PPSI compared favorably to open surgery regarding complete placement within the pedicle (PPSI 90.1%; Open 75.1%; p  <  0.0001), regional placement accuracy in the lumbar (PPSI 97.8%; Open 91.5%; p  <  0.001), and lumbar-sacral spine (PPSI 100%; Open 81.2%; p  <  0.05), next to the duration of surgery and length of hospitalization.ConclusionsPPSI with iCT- and CBCT-based spinal navigation improves the accuracy, safety, and workflow of navigated spinal instrumentation. Next, a cost-effectiveness and outcome analysis should determine whether iCT and CBCT imaging are truly economically justified.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Abstract BACKGROUND Fragile, dilated moyamoya vessels are the main source of hemorrhagic stroke in moyamoya disease (MMD). However, the prevalence of hemorrhagic stroke largely differs between Asian and western countries, although the underlying pathophysiology has not been clarified. OBJECTIVE To systematically analyze the difference of collateral angioarchitectures between Japanese and European Caucasians with MMD. METHODS This study included 71 patients with MMD, including Japanese (n = 41) and European Caucasians (n = 30). Using preoperative cerebral angiography, the developments of lenticulostriate artery (LSA), anterior choroidal artery (AChoA), posterior communicating artery (PcomA), and posterior choroidal artery (PChoA) were precisely evaluated, and ethic difference was analyzed in terms of patients’ age and the onset type. RESULTS Cerebral angiography demonstrated that the marked dilatation of AChoA and PChoA were significantly more remarkable in Japanese than in European Caucasians (P = .004 and P = .002, respectively). Ageing advanced the dilatation and extension of PChoA and PcomA, and diminished the development of LSA in Japanese patients (P < .001, P = .03, and P = .03, respectively). European Caucasian patients did not have the specific dilated pattern like Japanese patients. CONCLUSION The marked dilatation of PChoA and PcomA is considered a powerful predictive marker of hemorrhage in MMD. Collateral channels spontaneously shift from the anterior to posterior circulation in Japanese patients during ageing but not in European Caucasian patients. These different dilation patterns of the collateral pathway may be associated with an ethnic difference of the clinical onset type in MMD.

Background: Dysphagia is a frequent finding on intensive care units (ICUs) and is associated with increased reintubation rates, pneumonia, and prolonged ICU-stay. Only a limited numbers of ICUs have access to a Speech and Language Pathologist (SLP). Hence, it falls upon the critical care team to estimate dysphagia risk and define the safest feeding route. Therefore, the aim of this study was to evaluate if the feeding route established by the ICU-team is changed after a standardized dysphagia assessment (DA) by an SLP. Furthermore, we tried to identify predictors for the need of a SLP assessment looking at the change in feeding route (CIFR) after DA. Methods: We performed a retrospective analysis of patients consecutively admitted for at least 48 h in 2018, to the ICU of the Department of Neurology and Neurosurgery. Following variables were assessed: Referral to an SLP, feeding route before and after DA by an SLP, main diagnosis, and ventilation parameters. Results: From 497 included patients (65 years, IQR 51–77), 148 received a DA, confirming dysphagia in 125 subjects. DA by the SLP resulted in a significant CIFR, with 32 (21.6%) subjects receiving stricter diets, and in 29 (19.6%) cases a reduction of dietary recommendations. 50 patients lacked readiness for oral intake due to severely affected oral phase or reduced consciousness. Conclusion: Dysphagia is a frequent finding in the Neuro-ICU. Assessment of dysphagia-risk and safest feeding route differ significantly between the SLP and the critical care team. Besides implementation of standardized operating procedures for DA, the presence of ICU-specific trained SLP should be mandatory.

Purpose Radiolucent carbon fiber-reinforced PEEK (CFRP) pedicle screws have improved imaging and radiation planning in spine oncology. However, these benefits are often limited by titanium cages used in combination. This study reports our initial experience using novel CFRP cages in oncologic spine surgeries, comparing their surgical feasibility, complications, and imaging performance to titanium cages. Methods We retrospectively analyzed 13 patients who received CFRP cages between July 2021 and May 2023. Clinical, surgical, follow-up, and imaging data were evaluated. A matched cohort with titanium cages was used to assess postoperative MRI visibility of anatomical landmarks, rated by independent reviewers. Results Thirteen CFRP cages were implanted (mean age 61 ± 11 years; 54% female). Indications included spinal metastases (54%) and primary bone tumors. Most procedures involved the thoracic spine (62%), followed by lumbar (23%) and cervical (15%). Median instrumentation spanned 4 segments; 62% had two-staged surgeries. Three complications occurred: 1 cage dislocation (requiring revision), 1 wound infection, and 1 post-incisional hernia. Median radiologic follow-up was 74 days, with no further dislocations. Postoperative MRI showed significantly better visibility of key spinal landmarks with CFRP cages versus titanium ( p  < .05, Wilcoxon signed-rank test). Conclusion CFRP cages are a viable alternative to titanium in oncologic spine surgery, offering comparable usability and improved postoperative imaging. These advantages may support better radiotherapy planning and complication detection, warranting further investigation.

Spinal tuberculosis is due to globalization no longer a disease limited to developing nations. It remains in Germany a rarity and still a difficult diagnosis. Here we analyzed patients with spinal tuberculosis treated at our neurosurgical department. According to the infected anatomic segment, patients were assigned in one of three groups. Surgery was performed when neurological deficit due to mechanical compression, deformity, instability, severe pain, necrotic bone or failure to respond to anti-tuberculous treatment were observed. We identified 34 patients with spinal tuberculosis who underwent surgical treatment. In the cervical spinal tuberculosis group, there were 15 cases (46.9%) In most cases treatment consisted of spinal instrumentation. In the thoracic group, 10 cases (29.4%) were observed. The treatment was performed by dorsolateral spinal instrumentation. For the thoracolumbar group, 9 cases (26.4%) were observed. In most cases dorsolateral spinal instrumentation was performed. One patient in the first group and one patient in the third group relapsed after operation. A second surgery was necessary. Patients with chronic back pain, immigration background and/or neurological deficit spinal TB should be considered as a differential diagnosis. Combined surgical intervention and medical treatment is associated with a favorable outcome.

BackgroundMinimally invasive surgery (MIS) for evacuation of spontaneous intracerebral hemorrhage (ICH) has shown promise but there remains a need for intraoperative performance assessment considering the wide range of evacuation effectiveness. In this feasibility study, we analyzed the benefit of intraoperative 3-dimensional imaging during navigated endoscopy-assisted ICH evacuation by mechanical clot fragmentation and aspiration.Methods18 patients with superficial or deep supratentorial ICH underwent MIS for clot evacuation followed by intraoperative computerized tomography (iCT) or cone-beam CT (CBCT) imaging. Eligibility for MIS required (a) availability of intraoperative iCT or CBCT, (b) spontaneous lobar or deep ICH without vascular pathology, (c) a stable ICH volume (20–90 ml), (d) a reduced level of consciousness (GCS 5–14), and (e) a premorbid mRS ≤ 1. Demographic, clinical, and radiographic patient data were analyzed by two independent observers.ResultsNine female and 9 male patients with a median age of 76 years (42–85) presented with an ICH score of 3 (1–4), GCS of 10 (5–14) and ICH volume of 54 ± 26 ml. Clot fragmentation and aspiration was feasible in all cases and intraoperative imaging determined an overall evacuation rate of 80 ± 19% (residual hematoma volume: 13 ± 17 ml; p < 0.0001 vs. Pre-OP). Based on the intraoperative imaging results, 1/3rd of all patients underwent an immediate re-aspiration attempt. No patient experienced hemorrhagic complications or required conversion to open craniotomy. However, routine postoperative CT imaging revealed early hematoma re-expansion with an adjusted evacuation rate of 59 ± 30% (residual hematoma volume: 26 ± 37 ml; p < 0.001 vs. Pre-OP).ConclusionsRoutine utilization of iCT or CBCT imaging in MIS for ICH permits direct surgical performance assessment and the chance for immediate re-aspiration, which may optimize targeting of an ideal residual hematoma volume and reduce secondary revision rates.

Metastases account for the majority of cancer deaths. Bone represents one of the most common sites of distant metastases, and spinal bone metastasis is the most common source of neurological morbidity in cancer patients. During metastatic seeding of cancer cells, endothelial–tumor cell interactions govern extravasation to the bone and potentially represent one of the first points of action for antimetastatic treatment. The ephrin-B2–EphB4 pathway controls cellular interactions by inducing repulsive or adhesive properties, depending on forward or reverse signaling. Here, we report that in an in vivo metastatic melanoma model, ephrin-B2-mediated activation of EphB4 induces tumor cell repulsion from bone endothelium, translating in reduced spinal bone metastatic loci and improved neurological function. Selective ephrin-B2 depletion in endothelial cells or EphB4 inhibition increases bone metastasis and shortens the time window to hind-limb locomotion deficit from spinal cord compression. EphB4 overexpression in melanoma cells ameliorates the metastatic phenotype and improves neurological outcome. Timely harvesting of bone tissue after tumor cell injection and intravital bone microscopy revealed less tumor cells attached to ephrin-B2-positive endothelial cells. These results suggest that ephrin-B2–EphB4 communication influences bone metastasis formation by altering melanoma cell repulsion/adhesion to bone endothelial cells, and represents a molecular target for therapeutic intervention.

Abstract BACKGROUND The grading system for moyamoya disease is not established. OBJECTIVE To assess the usefulness of a recently proposed grading system for stratifying the clinical severity and predicting postoperative morbidity in adult moyamoya disease. METHODS We investigated 176 hemispheres from 89 adult patients who were diagnosed with moyamoya disease in Japan. Their data were analyzed using the Berlin grading system with minor modifications. After summarizing the numerical values for digital subtraction angiography (1-3 points), magnetic resonance imaging (0-1 points), and single-photon emission computed tomography (0-2 points), 3 grades of moyamoya disease were defined: mild (grade I) = 1 to 2 points, moderate (grade II) = 3 to 4 points, and severe (grade III) = 5 to 6 points. In total, 82 of 161 hemispheres underwent superficial temporal artery to middle cerebral artery anastomosis and indirect synangiosis. Postoperative neurological morbidity was included within 30 d after surgery. RESULTS Preoperative examinations categorized 87 hemispheres as grade I, 39 as grade II, and 50 as grade III. There was a significant correlation between the Berlin grading system and clinical severity (P < .001). Perioperative complications occurred in 12 of 82 (14.6%) hemispheres, including transient ischemic attack in 3 hemispheres, ischemic stroke in 4 hemispheres, symptomatic hyperperfusion in 4 hemispheres, and intracerebral hemorrhage in 1 hemisphere. The Berlin grading system was related to their occurrence (P < .001). CONCLUSION The Berlin grading system facilitates the stratification of clinical severity and predicting postoperative neurological morbidity in adult moyamoya disease, thereby suggesting its general usage in clinical practice.

Cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) are critical complications following aneurysmal subarachnoid hemorrhage (aSAH), contributing to substantial morbidity and mortality. This retrospective cohort study investigated thrombocyte count (TC) dynamics as a potential marker for predicting CVS and DCI in 233 adult patients with aSAH. Parameters including TC, C-reactive protein, hematocrit, CVS, and DCI were analyzed using logistic regression, Spearman correlation, and time-to-event analysis. CVS and DCI occurred in 71.1% and 41.2% of patients, respectively. A relative thrombocyte count decrease greater than 12.6% within the early post-aSAH period was significantly associated with increased risks of CVS ( p  < 0.001; 95% CI 4.74–25.3) and DCI ( p  = 0.003; 95% CI 1.39–5.43). Temporal analysis revealed that greater TC decrease correlated with earlier CVS onset ( p  = 0.00016; R =-0.28), with a median of three days from the minimum TC to CVS onset. This association suggests a potential diagnostic window for early detection and intervention if validated in prospective studies.