INTRODUCTION/BACKGROUND:Testicular torsion (TT) represents an emergent pediatric condition that requires timely surgical intervention to minimize the likelihood of testicular loss. Numerous reasons may affect the survival rate of a torsed testis, including longer symptom duration, younger age, and higher degree of TT observed intraoperatively. "Door To Detorsion time" (DTD) has been described but not fully validated. OBJECTIVE:We sought to evaluate the DTD on outcomes of TT. STUDY DESIGN:We identified males 1-18 years old with TT over a 10-year period (January 1, 2015-December 31, 2024) in this retrospective and observational study. Univariate and multivariate analyses determined whether DTD, patient age, symptom duration, and degree of TT observed during surgery were predictors of testicular salvage. RESULTS:Of the 286 patients diagnosed with TT, the median age was 14 years, and the median symptom duration was 9 h. The median DTD was 146.5 min (ranging between 25 and 668 min): 133 min with a viable testes and 166 min with a nonviable testes. A total of 195 (68 %) patients underwent an orchiopexy compared to 91 (32 %) patients who had an orchiectomy. A multivariate analysis demonstrated that each 10-min increase in DTD was associated with a 6 % increase in odds of undergoing an orchiectomy. Each additional hour of DTD was associated with a 35 % increase in odds of an orchiectomy. For each additional hour of symptom duration, the odds of undergoing an orchiectomy versus an orchiopexy increased by 3 %. Patients with a degree of TT > 540 had a 4.85 times higher odds of orchiectomy compared to those treated with 0 degrees of TT. Patients with symptoms lasting 24 h or longer had an 8.9 times higher odds of requiring an orchiectomy compared to those treated within 24 h. For each additional year of age, the odds of an orchiectomy decreased by 14 %. DISCUSSION:Our study concurs with the literature with respect to a significantly increased risk of needing an orchiectomy with a longer DTD and extended symptom duration, with critical timepoints of greater than 6 h, greater than 12 h, and greater than 18 h. CONCLUSION:The DTD is a very significant but often ignored factor. Every 10 min delay in the Emergency Department reduces the survival of the testis. Recognizing the symptoms of TT especially in younger males and seeking timely medical attention, coupled with a hastened hospital course prior to surgery, decrease the need for testicular loss.

Background/Objectives: Ulnar nerve neuropathy at the elbow (UNE) is the second most common focal neuropathy of the upper extremity and often results from entrapment of the ulnar nerve as it traverses the elbow with insidious onset and gradual progression. This study describes the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in a cohort of patients presenting with acute UNE. Methods: This is a review of 103 patients with clinical features of UNE with acute onset who underwent EDX and US studies over a 25-year period (2010–2026) at our Neurodiagnostic Center. Results: Of the 103 patients with acute UNE, all experienced paresthesia in the ulnar nerve distribution. A total of 27 (26.2%) patients had elbow pain, and 99 (96.1%) had decreased pinprick sensation in the ulnar nerve distribution. Weakness of the following muscles was detected: abductor digiti minimi (ADM) (94 [91.3%]), FDI (first dorsal interosseous) (91 [88.3%]), and FDPu (flexor digitorum profundus—ulnar) (76 [73.8%]). Most patients had a clinical grade of 3 (severe: sensory and motor abnormalities as well as atrophy of the FDI and ADM muscles) (93 [90.3%]). Perioperative injuries were the most common etiology of acute UNE, consisting of 65 (63.1%) patients. The perioperative injury was noted after surgical procedures at varied locations, most frequently at the shoulder in 23 (35.4%) followed by coronary artery bypass in 9 (13.8%) and knee joint surgery in 8 (12.3%). Non-iatrogenic injuries affected 11 (10.7%) patients. The US study revealed cysts and tumors such as a Schwannoma in 14/76 (18.4%) patients. Focal demyelination was observed by EDX studies in 95 (92.2%) patients, and a conduction block was detected in 24 (23.3%). Motor and sensory axonal involvement was identified in 81 (78.6%) and 86 (83.5%) patients, respectively. Of the 76 patients who underwent an US study, 68 (90.6%) had an increase in the cross-sectional area of the ulnar nerve and 51 (68.0%) had a hypoechoic ulnar nerve at the elbow. Conclusions: In this study, the most common cause of acute UNE was periprocedural injury, most frequently following shoulder surgery. Acute UNE may also occur without a history of antecedent trauma or a surgical procedure. EDX and US studies provide complementary data to determine the severity and the etiology of acute UNE and guide further management.

Background/Objectives: Atrophy of the thenar muscles (abductor pollicis brevis [APB], opponens pollicis [OP], and flexor pollicis brevis [FPB]) is most commonly caused by carpal tunnel syndrome (CTS). It may also occur following injury to the recurrent motor branch of the median nerve, proximal median nerve neuropathy, medial cord/lower trunk plexopathy, T1 radiculopathy, ventral horn cell disorder at C8 or T1, disuse atrophy, or congenital aplasia. Clinical observation of flattening of the thenar eminence coupled with electrodiagnostic (EDX) and ultrasound (US) studies is valuable in determining the etiology of thenar atrophy. This study describes clinical, EDX, and US findings in a large cohort of patients with thenar muscle atrophy. Methods: This is a review of 197 patients (226 hands) with thenar atrophy who underwent EDX and US studies. Patients were divided into those with total thenar atrophy (all three thenar muscles were atrophic) or partial thenar atrophy (atrophy of one or two thenar muscles) based on clinical and US findings. Results: Of the 226 hands, 174 (77.0%) had partial thenar atrophy, 217 (96.0%) had sensory loss, and all hands demonstrated weakness of the APB and OP muscles on examination. A total of 220 (97.3%) hands had EDX evidence of severe median nerve entrapment at the carpal tunnel. The compound muscle action potentials (CMAPs) of the APB muscle and sensory nerve action potentials (SNAPs) were absent in 186 (82.3%) and 212 (93.8%) hands, respectively. US study showed hyperechoic APB and OP muscles in 225 (99.6%) hands. The Heckmatt grade, determined by US, was 3 in 152 (67.3%) hands, showing increased muscle echogenicity with loss of architecture and reduced bone reflection. Conclusions: In patients with thenar muscle atrophy, EDX studies were not always conclusive for confirming CTS due to an absence of SNAP and CMAP over the APB and second lumbrical muscles. In these cases, US is important to confirm the cause of thenar atrophy.

OBJECTIVE:Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to open resection for pediatric drug-resistant epilepsy (DRE). This systematic review and individual participant data meta-analysis aimed to identify independent predictors of seizure outcomes and operative and neurological complications following MRgLITT. METHODS:Uni- and multivariable mixed-effects Cox proportional-hazards regressions models were used to identify independent predictors of time to seizure recurrence following MRgLITT. Among patients with at least 12 months of follow-up, uni- and multivariable mixed-effects logistic regression analyses were conducted to ascertain the independent risk factors associated with seizure recurrence at last follow-up, operative complications, and postoperative neurological complications. RESULTS:A literature review identified 354 pediatric patients with a mean epilepsy duration of 7.5 (SD 5.3) years prior to MRgLITT. The mean age at seizure onset was 4.52 (SD 4.69) years, and focal seizures were more common (85.5%) than generalized seizures (14.5%). Lesions were detected on MRI in 82.1% of cases. The most common epilepsy etiologies were hypothalamic hamartoma (HH; 23.7%) and malformations of cortical development (23.7%). The mean follow-up duration after MRgLITT was 16.02 (SD 11.63) months. Engel class I outcomes were achieved in 57% of patients. In 205 cases where information was available regarding postoperative neurological complications, 35 patients (17.1%) experienced postoperative neurological complications, with hemiparesis as the most frequent complication (n = 16 patients). Of the 354 total patients who underwent MRgLITT, 8.2% underwent revision epilepsy surgery. No operative or clinical characteristics were associated with seizure recurrence. Seizure freedom probability was significantly higher among patients with HH compared to those with nonlesional MRI (p = 0.012). Patients with mesial temporal sclerosis experienced earlier seizure recurrence (p = 0.023), and an extratemporal surgical location was associated with longer seizure freedom probability (p = 0.034). Lesional MRI was associated with reduced odds of postoperative neurological complications (p = 0.031). CONCLUSIONS:MRgLITT may be a safe and effective alternative option for pediatric DRE. Further prospective studies are warranted to elucidate MRgLITT strategies in pediatric DRE.

Background Cerebral radiation necrosis (RN) is a chronic inflammatory process that may develop following radiotherapy for a primary or metastatic brain tumor or arteriovenous malformation (AVM). A single infusion dose of intra-arterial (IA) bevacizumab (BV) is a viable option. The aim of this study was to assess the safety and efficacy of IA BV infusion in patients with steroid-refractory cerebral RN.  Materials and methods A total of 33 patients with imaging-confirmed brain RN underwent at least one IA BV infusion over a 9-year duration. BV was administered as a single 2.5 mg/kg (n=24) or 5.0 mg/kg (n=9) infusion dose.  Results Diagnoses included brain metastasis (17 (51.5%)), AVM (10 (30.3%)), and primary brain tumors (six (18%)). All patients experienced either complete relief or significant symptom improvement after the IA IV infusion. The initial brain MRIs performed following the IA BV infusion revealed a decreased size of the RN in all patients. Two patients had minimal side effects. Of the 16 (48.5%) patients who experienced an RN recurrence, 10 underwent a repeat IA BV infusion. The mean duration between the first IA BV infusion and last follow-up was 23.2 months (range: 0.1-85.2 months). Age (p = 0.00587), tumor pathology (p = 0.03509), and BV dosage (p = 0.02420) were significant predictors of RN recurrence. Conclusions IA infusion of BV was well-tolerated by all patients, with substantial clinical and radiological improvement. Further research is needed to explore additional factors that may impact the effectiveness of BV treatment in RN patients.

Background/Objectives: The Wartenberg sign is a diagnostic feature of ulnar nerve neuropathy. It results from unbalanced activity of the abductor digiti minimi (ADM) and extensor digiti minimi (EDM) muscles secondary to weakness of the third palmar interosseous muscle. Rarely, this sign may occur in the absence of an underlying ulnar neuropathy, which we refer to as the “pseudo Wartenberg sign” (PWS). Methods: This is a retrospective review of 10 patients manifesting an inability to adduct the little finger towards the ring finger with no evidence of an ulnar neuropathy. We describe the clinical and electrodiagnostic (EDX) findings in these patients and discuss the pathophysiologic basis of PWS. Results: The most common cause was an injury in five (50.0%) patients: avulsion of the third volar interosseous muscle in two (20.0%), contracture of the ADM muscle in one (10.0%), and trauma-related dystonia in two (20.0%). The most frequent mechanism of PWS was focal dystonia of specific hand muscles in seven (70.0%) patients. Needle electromyography (EMG) demonstrated no denervation changes in ulnar nerve-innervated hand muscles; the motor and sensory conduction was normal in the ulnar nerve in all patients. Four (40.0%) patients underwent ultrasound studies, with a hyperechoic, avulsed third volar interosseous muscle in one, a hyperechoic and atrophic ADM muscle in one, normal hypothenar and extensor muscles in one, and a normal hypothenar muscle in one. Conclusions: Neurologists, neurosurgeons, and hand and orthopedic surgeons should be aware of the rare cases in which the inability to adduct the little finger may occur in the absence of ulnar neuropathy and look for other causes like avulsion of the third palmar interosseus muscle or focal hand dystonia.

Background/Objectives: This is a retrospective review of 36 patients with electrodiagnostic (EDX) confirmation of carpal tunnel syndrome (CTS) and ultrasound (US) detection of marked median nerve enlargement (defined as a cross-sectional area [CSA] of 40 mm2 or greater) at the wrist. Methods: We describe the clinical, electrodiagnostic (EDX), and US findings in these patients and discuss the pathophysiologic basis of a markedly enlarged median nerve. Results: The markedly enlarged median nerve was detected by US in a total of 39 hands (36 patients, with 3 bilateral). Of the 39 hands, thenar atrophy was observed in 15 (38.5%) hands, and pinprick loss in the median nerve distribution was noted in all hands. Moderately severe or severe median nerve entrapment at the carpal tunnel (CT) was confirmed by EDX studies in 21 (53.8%) and 16 (41.0%) hands, respectively. A total of 12 (30.8%) hands had no compound muscle action potentials (CMAPs) over the abductor pollicis brevis muscle, and sensory nerve action potentials (SNAPs) were not detected in 31 (79.5%) hands. The wrist CSA was between 40 and 44 mm2 in 20 (51.3%) hands, between 45 and 49 mm2 in 13 (33.3%) hands, and 50 mm2 or greater in 6 (15.4%) hands. Conclusions: The implications of the markedly enlarged median nerve for surgical management of CTS are unknown, and future prospective studies are needed.

OBJECTIVE:Advances in the analysis and collation of radiographic datasets have enhanced presurgical planning for various neurosurgical procedures, including clipping of cerebral aneurysms, surgical resection of tumors, and arteriovenous malformation management. The surgical theater (ST) system converts radiographic datasets, traditionally interpreted as a series of two-dimensional images, into three-dimensional interactive models better allowing understanding of anatomy as well as the complex anatomic relationships between different diagnostic phase I datasets. METHODS:We reviewed the capabilities and impact of the ST system on patients treated by our pediatric epilepsy service at our institution. RESULTS:The ST system was used in the treatment of 85 patients in our pediatric epilepsy service. Multiple layers of phase I data were converted into a single, multi-layered 3D model which added precision to points of collaboration on creating Phase II plans, allowed for the collaborative creation of detailed surgical plans and facilitated VR practice of complex surigcal plans with intraoperative augmented reality navigation. We highlight both current and future applications and present 4 cases to illustrate how ST is applied in our clinical setting. SIGNIFICANCE:The multi-layered and 3D model of the ST system facilitates epilepsy decision-making for both diagnosis and treatment, enhances surgical navigation, and even allows, in a robust virtual reality (VR) environment, the practice of complex surgical procedures. PLAIN LANGUAGE SUMMARY:The surgical theater (ST) system converts two-dimensional imaging tests (eg MRI, MEG, CT and PET) into three-dimensional interactive models. This helps physicians understand complex Phase I datasets and make decisions for the diagnosis and treatment of pediatric epilepsy. These models also facilitate patient and family education, which may reduce their anxiety. In this article, we discuss the current and future applications of the ST system and how it is used to treat pediatric patients with epilepsy at our Institution. We also describe four of our patients to show how the ST system works in a clinical setting.

Background Diffuse midline gliomas (DMG) are a subset of malignant gliomas that could be linked to an H3K27M mutation. Hydrocephalus may be the initial presenting condition because of its frequent pontine location. This study evaluated the outcomes of tumor resection, endoscopic third ventriculostomy (ETV), and ventriculoperitoneal shunt (VPS) placement in DMG patients compared to wild-type (WT) tumors in treating hydrocephalus. Materials and methods We identified newly diagnosed pediatric and adult patients with midline tumors over an eight-year period (September 14, 2016-July 1, 2024). Results Out of a total of 74 patients, 20 (27.0%) patients were diagnosed with an H3K27M mutation, and 24 (32.4%) presented with hydrocephalus. Patients with a DMG H3K27M mutant (15 patients) were statistically more likely to be diagnosed with hydrocephalus compared to those with a WT midline glioma (9 patients) (p<0.001). Of the 24 patients with hydrocephalus, 8 (34.8%) underwent a VPS placement, 5 (22.7%) had tumor resection, 5 (21.7%) underwent an ETV, and 4 (17.4%) had both a VPS and ETV. A significant difference in hydrocephalus-free survival was observed among the treatment groups (p=0.0013). ETV failure was significantly higher in H3K27M patients while VPS was more successful in managing hydrocephalus.  Conclusions As H3K27M mutation analysis is not available rapidly when patients initially present with midline gliomas, neurosurgeons use their best clinical judgment regarding the management of hydrocephalus. VPS demonstrated superior outcomes compared to ETV in controlling hydrocephalus among patients with a DMG H3K27M mutation in the present study; therefore, neurosurgical teams should have increased vigilance following ETV in this population.

Background/Objectives: Elderly patients with carpal tunnel syndrome (CTS) have more severe clinical, ultrasonic, and electrodiagnostic (EDX) findings compared to younger patients. Thenar weakness and atrophy are more common at initial presentation in the elderly population with CTS. Methods: This is a retrospective review of 187 very elderly patients (aged 80 years and older) with EDX confirmation of CTS. We describe the clinical, EDX, and US features in these patients and compare the severity of the median nerve entrapment at the carpal tunnel (CT) by EDX findings to a middle-aged cohort (ages 40–50 years). Results: The total number of very elderly hands with CTS was 289 (187 patients total, with bilateral symptoms in 102 patients). Of the 289 hands, thenar atrophy was observed in 75 (26.0%) hands, weakness of the abductor pollicis brevis (APB) muscle was detected in 178 (61.6%) hands, and pinprick decrease/loss was noted in 265 (91.7%) hands. Of the total 289 hands, 57 (66.3%) hands’ median nerve stimulation did not evoke compound muscle action potentials over the APB and second lumbrical muscles. Sensory nerve action potentials were not detected in 211 (76.2%) hands. Comparing the sensitivities of various US measurements in diagnosing CTS, the cross-sectional area at the CT inlet had the highest sensitivity among the various measurements. As the CSA at the CT inlet increases, the odds of a greater CTS severity by EDX studies also increase (OR = 1.109, p-value = 0.001). The very elderly patients with CTS more frequently had more severe CTS compared to the middle-aged patients with CTS (chi-squared = 102.653, p-value < 0.001). Conclusions: The very elderly patients appear to seek medical care only when the CTS has become severe. The primary care physicians should look for signs and symptoms of CTS in the very elderly and encourage prompt treatment. Surgeons should be cognizant of the differences in the clinical, EDX, and US studies in the very elderly patient cohort with CTS. US is highly useful in evaluating CTS when the EDX studies become non-localizing in severe CTS, as often seen in the very elderly patients.

Dr Roy Glenwood Spurling (1894-1968) is a foundational figure in modern neurosurgery whose leadership and ingenuity transformed the discipline. A graduate of Harvard Medical School and deeply influenced by Harvey Cushing, Spurling pioneered the first dedicated neurosurgical service at the University of Louisville in 1926. The establishment of the university's neurosurgical residency program in 1946 became a model for training neurosurgeons and set benchmarks for surgical education. His vision extended nationally as a co-founder of the Harvey Cushing Society in 1932 (later called the American Association of Neurological Surgeons) and served as inaugural secretary and later president. During World War II, Spurling's tenure as Assistant Chief of Surgery at Walter Reed Hospital revolutionized military neurosurgery. He introduced new standards of care for disk surgery and peripheral nerve injuries in the Military and Veterans Affairs Hospital. In 1945, his management of General George Patton's cervical spine injury and quadriplegia highlighted neurosurgery's growing role in trauma care. Spurling served as neurosurgical consultant for the Veterans' Administration (1946-1953) and remained in charge of the neurosurgical services at the University of Louisville until his retirement in 1960. He collaborated with Michael E. DeBakey to disseminate knowledge through the American Lecture Series. Colleagues worldwide celebrated his leadership in neurosurgical education. Spurling's legacy continues to define neurosurgical excellence today.

Gorham-Stout disease (GSD), also known as vanishing bone disease or massive osteolysis, is a rare entity characterized by destruction of the osseous matrix and proliferation of vascular structures resulting in bone resorption. While neurological complications such as cerebrospinal rhinorrhea secondary to cranial involvement and paraplegia from spinal involvement have been reported, peripheral nerve complications are not known. We describe a case of radial nerve palsy that was an iatrogenic complication of shoulder replacement surgery with bone loss of the humerus resembling GSD. A 71-year-old male with a history of left total shoulder arthroplasty followed by a revision reverse total shoulder arthroplasty noted a "bone protruding" and pain in the left upper arm 12 years later. X-rays showed that the proximal portion of the humerus was not detectable. CT scan of the left upper extremity revealed loosening of the humeral component with prominent osteolysis most pronounced around the distal stem. The patient underwent a revision of the reverse total shoulder arthroplasty with replacement of the humeral head and shaft. He experienced numbness, pain, and weakness of the left shoulder and arm with wrist drop postoperatively. Physical exam revealed marked weakness of the dorsiflexors of the wrist and digits, wasting and weakness of the brachioradialis muscle, and loss of pinprick sensation of the superficial radial nerve distribution. Needle EMG showed denervation changes in the extensor digitorum communis, brachioradialis, and extensor carpi radialis longus muscles. An ultrasound (US) study showed enlargement of the left radial nerve at the spiral groove. The EDX and US findings suggested a left radial nerve palsy at the spiral groove. There were minimal EMG abnormalities in the deltoid and triceps muscles suggesting additional involvement of the posterior cord of the brachial plexus. This case illustrates the potential for iatrogenic radial nerve palsy following shoulder replacement surgery with significant bone loss of the humerus resembling GSD.

Intraoperative malignant cerebral edema is a rare but life-threatening complication that can arise during a traumatic decompressive craniectomy. The swelling may be significant enough to preclude skin closure. The current standard of care is to resect sufficient edematous brain tissue to close the scalp to establish an immune-competent barrier to the intracranial space. We report two pediatric patients who developed malignant edema during craniectomy that prevented skin closure. Both patients underwent placement of a temporary vacuum-assisted closure (VAC) device, facilitating resolution of the edema without sacrifice of brain tissue before scalp closure. Case #1 sustained a fall; head computed topography (CT) revealed a left subdural hematoma (SDH) and hemispheric infarct with midline shift. A craniotomy was performed during which malignant cerebral edema developed, preventing dural closure or scalp approximation. A VAC was placed which remained for 17 days, followed by successful primary closure of the scalp. Case #2 suffered multiple injuries from inflicted trauma; head CT demonstrated a large acute SDH over the left frontal and parietal region with a midline shift to the right. Emergent craniotomy was performed, and significant cranial edema was encountered to a degree for which medical intervention was not effective enough to allow skin closure. A VAC device was placed which was removed 8 days later with primary scalp closure. No infectious complications arose in either case, and no complications were attributable to the VAC devices. A temporizing VAC to protect the intracranial space when severe malignant cerebral edema occurs during a craniectomy may be preferable to tissue resection.

OBJECTIVE CSF leaks are a significant source of patient morbidity following intradural spine surgeries. Watertight dural closure is crucial during these procedures to minimize the risk of a CSF leak. This study reports postoperative outcomes and changes in patient management after switching to penetrating titanium clips for dural closure in a large cohort of pediatric patients receiving a tethered cord release (TCR) or a selective dorsal rhizotomy (SDR). METHODS An IRB-approved retrospective review was conducted of the medical charts of all patients who underwent thoracolumbar dorsal midline dural closure with the AnastoClip GC Closure System during the 7 years between May 22, 2017, and May 21, 2024. Selected data such as evidence of a CSF leak and postoperative length of stay were collected. RESULTS A total of 290 patients were treated with AnastoClips GC for dural closure. Of these patients, 232 (80.0%) underwent a TCR only, 52 (17.9%) received an SDR, and 6 (2.1%) underwent a complex TCR. The mean duration between surgery and last follow-up was 7.96 months (range 0.27–54.57 months). One patient, who received a simple TCR, experienced a transient pseudomeningocele without headache, emesis, or visible leak that resolved without surgical intervention within 8 weeks. Three (1%) patients had positional headaches without other evidence of a CSF leak, all limited to the initial 2 weeks of postoperative care. Six (2%) patients had delayed wound healing, 2 of whom underwent operative wound revisions. As of January 1, 2021, patients no longer had to lie flat postoperatively. While 60.6% of TCR patients were discharged from the hospital on POD 1 (none on POD 0) prior to this date, 87.5% of patients were discharged from the hospital on either POD 0 (3.1%) or POD 1 (84.4%) afterward. Similarly, 50% of SDR patients were discharged on POD 2 or 3 after the need for lying flat postoperatively was removed versus 21% before the protocol change. CONCLUSIONS AnastoClip GC Closure System titanium clips are safe and effective for dural closure in both TCR and SDR, with rare complications. Their efficacy has prompted us to remove flat bed rest requirements for postoperative patients, significantly reducing the length of stay, and has opened the door to making simple TCRs a same-day surgery.

BACKGROUND:Patients with brain metastases and concurrent hydrocephalus warrant expedited treatment. This study evaluated survival outcomes of patients with brain metastases and hydrocephalus treated with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) placement.  Materials and methods: Twenty patients with brain metastases and hydrocephalus were treated with ETV or VPS over 10 years (July 18, 2013-November 20, 2023). Our findings were juxtaposed against data from 77 published controls to assess whether ETV and VPS management correlated with enhanced survival.  Results: The most common primary cancer diagnoses were breast (9 [45%]) and non-small cell lung cancer (5 [25%]). Seven (35%) patients had leptomeningeal carcinomatosis. The initial procedure to treat hydrocephalus was a VPS in 13 (65%) patients; seven (35%) had an ETV first. Patients with a single brain metastatic lesion had a longer median overall survival (OS) than those with more than one metastatic site (154.5 versus 67.0 days). Our cohort had a similar median OS following the ETV/VPS procedure compared to published data (92.5 versus 91 days). In both ETV and VPS subsets, our cohort had a longer median OS than published data: 106 versus 56 days for ETV and 79 versus 56 days for VPS.  Conclusions: Patients with brain metastases and hydrocephalus who underwent an ETV or VPS placement had improved survival compared to historical controls and if they had only one metastatic lesion. Interdisciplinary evaluation of patients with brain metastases by neurosurgeons as well as medical and radiation oncologists is warranted to facilitate systemic therapy after hydrocephalus relief.

ObjectivesProximal median nerve (PMN) neuropathies are caused by lesions proximal to the carpal tunnel, which include the forearm, elbow, upper arm, and brachial plexus. Differentiating between carpal tunnel syndrome and PMN neuropathies is important to guide management and is based on clinical, electrodiagnostic (EDX), and ultrasound (US) findings. This study describes the clinical, EDX, and US features in 62 patients with PMNs.MethodsAll patients underwent EDX studies, and 52 (83.9%) had a US study. The patients were assigned to one of the following four localization zones of PMN neuropathies based on clinical and EDX criteria: Zone 1: extends from the fascicles in the brachial plexus contributing to the median nerve to the innervation of the pronator teres (PT); Zone 2: distal to the branch to the PT and proximal to the origin of the anterior interosseous nerve (AIN); Zone 3: involves the origin of the AIN; and Zone 4: distal to the origin of the AIN and proximal to the carpal tunnel. The localization was based on the pattern of muscle weakness, topography of EMG abnormalities, and US study findings.ResultsThe anatomical locations of the PMN neuropathies based on clinical, EDX, and US findings were as follows: Zone 1 in 38 patients (61.3%), Zone 2 in 6 patients (9.7%), Zone 3 in 7 patients (11.3%), and Zone 4 in 11 patients (17.7%). The most common etiology among all 62 patients was iatrogenic injury (30 [48.4%]), followed by non-iatrogenic trauma (20 [32.2%]). The following EDX findings were noted: prolonged distal motor latency (29 [46.8%]), decreased motor nerve conduction velocity in the forearm (22 [35.5%]), low amplitude or absent compound muscle action potentials (50 [80.6%]), and abnormal or absent sensory nerve action potentials (50 [80.6%]). Of the 52 (83.9%) patients who underwent US studies, a total of 22 (42.3%) patients showed an increased cross-sectional area of the median nerve. A neuroma was observed in 9 patients (17.4%).ConclusionIt is often possible to localize the site of the median nerve involvement and gain insight into the underlying cause based on clinical and EMG findings, but in certain cases, a US study may be necessary to confirm the location.

Background:Frameless image-guided radiosurgery (IGRS) is an effective and non-invasive method of treating patients who are unresponsive to medical management for trigeminal neuralgia (TN). This study evaluated the use of frameless IGRS to treat patients with medically refractory TN.Methods:We performed a retrospective review of records of 116 patients diagnosed with TN who underwent frameless IGRS using a linear accelerator (LINAC) over 10 years (March 2012-February 2023). All patients had failed medical management for TN. Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. Each patient received a BNI score before frameless IGRS and following treatment. Failure was defined as a BNI score IV-V at the last follow-up and/or undergoing a salvage procedure following IGRS.Results:All patients had a BNI score of either IV or V before the frameless IGRS. The mean follow-up duration for all 116 patients following IGRS was 44.1 months. Most patients (81 [69.8%]) had not undergone surgery (microvascular decompression [MVD] or rhizotomy) or stereotactic radiosurgery (SRS) for TN before frameless IGRS. A total of 41 (35.3%) patients underwent a salvage procedure (MVD, rhizotomy, or an additional IGRS) following frameless IGRS. The mean duration between the initial frameless IGRS and salvage procedure was 20.1 months. At the last follow-up, a total of 110 (94.8%) patients had a BNI score of I-III. No complications were reported after the frameless IGRS. The BNI score at the last follow-up was lower compared to the initial BNI for patients regardless of prior intervention (P < 0.001). Patients who failed IGRS had a higher BNI score at the last follow-up compared to those who did not fail IGRS (2.8 vs. 2.5, P = 0.05). Patients with pain relief had a shorter follow-up compared to those with pain refractory to SRS (38.0 vs. 55.1, P = 0.005).Conclusion:In this large cohort of patients with medically refractory TN, frameless IGRS resulted in durable pain control in the majority of patients without any toxicity.

ObjectivesGunshot wounds of the upper extremities may cause permanent neurovascular injuries, leading to significant morbidity, chronic pain, functional loss, and disability. While there are many reports on the incidence and intraoperative findings in gunshot-related nerve injuries (GSNI) sustained during wars, there is a paucity of details pertaining to GSNI of the upper extremities in civilians. The goal of this paper is to provide the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in 22 patients with GSNI of the upper extremities.MethodsThis is a retrospective study of patients referred for EDX studies to evaluate the presence of nerve injury after sustaining GSWs to the upper extremities. All patients underwent EDX studies, and 16 patients had US evaluations. Numerous metrics were documented including presenting symptoms, neurological abnormalities, EDX findings, and US features.ResultsThe forearm was the most frequent location of injury (8 [36%] patients). The ulnar nerve was the most common injured nerve (10 [45%] patients), followed by the brachial plexus (7 [32%] patients). All patients complained of muscle weakness; the most frequently affected muscles were the first dorsal interosseous (FDI) (14 [64%] patients) and abductor pollicis brevis (APB) (11 [50%] patients). Muscle atrophy was noted in 19 (86%) patients, 15 of whom had atrophy of the FDI. Axonotmesis was the type of nerve injury in all patients based on EDX studies. Of the 16 patients who underwent US studies, a neuroma in continuity was noted in 4 (25%) patients and neurotmesis in 1 (6.2%) patient. Eleven (69%) patients had enlarged and/or hypoechoic nerves.ConclusionsAxonotmesis of the ulnar nerve was the most common finding among patients sustaining gunshot injuries to the upper extremities. EDX and US studies provide valuable insight into the underlying pathophysiology and guidance for management of patients with GSNI of the upper extremities.

Background: Patients with recurrent glioblastoma (GBM) have limited treatment options. This study determined whether patients with recurrent GBM treated with initial radiation/temozolomide (TMZ) and reirradiation using fractionated stereotactic radiotherapy (FSRT) had improved outcomes. Materials and methods: We identified 95 patients with recurrent GBM, 50 of whom underwent FSRT at recurrence and 45 who had systemic treatment only (control). The median total FSRT dose at the time of GBM recurrence was 30 Gy in five fractions of the gadolinium-enhanced tumor only. Results: With a median follow-up of 18 months, the progression-free survival (PFS) and overall survival (OS) following initial GBM diagnosis were longer in the reirradiation group compared to the control group (13.5 vs. 7.5 months [p=0.001] and 24.6 vs. 12.6 months [p<0.001], respectively). For patients who underwent reirradiation, the median time interval between the end of the initial radiation and reirradiation was 15.2 months. The median OS after GBM recurrence was longer in the reirradiation group versus the control group (9.9 vs. 3.5 months [p<0.001]), with a one-year OS survival rate of 22%. The hazard ratio for death of patients in the reirradiation group was 0.31 [0.19-0.50]. The reirradiation group had a higher percentage of patients who received bevacizumab (BEV, 62.0% vs. 28.9%, p=0.002) and a lower percentage of patients whose TMZ was discontinued due to toxicity (8.0% vs. 28.9%, p=0.017) compared to the control group. Conclusions: Reirradiation utilizing FSRT was associated with improved PFS and OS after GBM recurrence compared to the control group who did not receive additional irradiation.

Hirayama disease (HD) is a rare disorder characterized by insidious asymmetric neurogenic atrophy primarily involving the upper extremities. HD most commonly affects adolescent males and has a favorable prognosis for arrest of progression. Electrodiagnostic (EDX) studies show chronic denervation changes in the distal upper extremity muscles. A cervical spine MRI in neck flexion may reveal compression of the cervical ventral spinal cord. We report clinical, EDX, and MRI findings in two cases of HD. The first case involved a 15-year-old male with a six-month history of progressive weakness, wasting, and tremulous movements of the left hand without pain or paresthesia. A physical exam revealed marked wasting of the left intrinsic hand muscles with polyminimyoclonus. Needle electromyography (EMG) revealed fasciculations (simultaneous with the polyminimyoclonus) while at rest and recruitment of 1-2 large polyphasic units in the left C8, T1, and, to a lesser extent, the C7 distribution. A T2-weighted flexion cervical spine MRI revealed narrowing and anterior displacement of the posterior dura of the cervical cord, leading to cord compression at C5-6 and C6-7. At last contact 11 years following symptom initiation, the patient continued to complain of profound weakness of the left hand without pain or numbness. The second case involved a 17-year-old male who was found to have wasting of the intrinsic muscles of the non-dominant left hand on a routine physical examination. The left first dorsal interosseus, abductor digiti minimi, abductor pollicis brevis, and extensor pollicis longus muscles were found to be clinically weak. Polyminimyoclonus involving all fingers of the left hand was also observed. A needle EMG demonstrated fasciculations with large amplitudes and wide duration motor unit potentials in the left C8, T1, and, to a lesser extent, C7 distribution. An ultrasound study showed frequent fasciculations in the left intrinsic hand muscles and the distal forearm muscles simultaneously with the polyminimyoclonus. A T2-weighted cervical spine MRI scan in the flexed sagittal position revealed anterior displacement of the dura and an enlarged epidural space from C4-C7. At last follow-up 11 months later, the findings were unchanged. The EDX studies and cervical MRI findings were consistent with HD in both cases. The role of EDX studies and cervical spine flexion MRI in diagnosing HD and the correlation between polyminimyoclonus and fasciculations are highlighted.