Background Intraventricular simple cysts, often termed intraventricular arachnoid cysts, are rare benign intracranial lesions in children and are usually asymptomatic. When they become symptomatic, the presentation is typically related to obstructive hydrocephalus or seizures. Clear clinical triggers for abrupt decompensation are not well defined. Observations A previously healthy 6.9-year-old boy presented in stupor with acute obstructive hydrocephalus. The only notable antecedent event was repetitive, forceful balloon inflation the night before, followed by early-morning headache and vomiting. Examination showed papilledema, nuchal rigidity, and positive Kernig and Brudzinski signs without focal deficits. CT revealed triventricular hydrocephalus with a normal fourth ventricle. Cerebrospinal fluid (CSF) and blood studies were unrevealing for infection. Worsening hydrocephalus prompted emergent frontal ventriculostomy. MRI confirmed supratentorial obstructive hydrocephalus with trans-ependymal CSF seepage. Endoscopic third ventriculostomy through the ventriculostomy tract exposed a thin, transparent, vascularized cyst bridging the right lateral ventricle and third ventricle near the foramen of Monro. Endoscopic cauterization and fenestration of the cyst wall restored CSF flow, and the child recovered fully without deficit. Lessons This case suggests that repetitive, forceful Valsalva-like maneuvers during excessive balloon inflation can acutely raise intracranial pressure and precipitate decompensation in children harboring an unrecognized intraventricular arachnoid cyst, resulting in acute obstructive hydrocephalus.

Headache after ventriculoperitoneal (VP) shunting is classically attributed to CSF over-drainage or shunt malfunction. We hypothesized that a subset of adults instead experience an occipital neuralgia-like pain syndrome (“Occipital Neuralgia”) from shunt hardware irritating the occipital nerves, and that these cases respond better to nerve-targeted treatments than to shunt revisions. We retrospectively reviewed 2,223 adults who underwent first-time VP shunt placement between 2000 and 2025 at a tertiary center. Patients with post-shunt headache were identified and classified as Occipital Neuralgia if they had occipital-predominant, lancinating pain with focal tenderness over the valve or tract, short-term relief from diagnostic occipital nerve block, and no evidence of over-drainage, malfunction, or infection on work-up. Clinical features, management, and outcomes (nerve blocks, neuromodulation, shunt adjustments or revisions) were compared between Occipital Neuralgia and other post-shunt headaches. Among 2,223 adults who underwent VP shunt placement, 32 patients (1.44

BACKGROUND:Recruitment to residency programs in hospitals located in other than major hubs ("remotely located") is a challenge in many countries. In 2011, the Israeli Ministry of Health launched a 10-year financial incentive to encourage physicians to enroll in residency programs in such hospitals. Nearly 1 billion New Israeli Shekels (260 million US$) were invested in that program which had only limited success. As a new physician association's collective agreement is impending, we aimed to measure the effectiveness of selected incentives in attracting medical school graduates to residencies in remotely located hospitals. METHODS:This study included Israeli medical students in their final year of medical school. We used an online questionnaire with multiple-choice demographic questions and a 5-point Likert scale to gauge the effect of various incentives on their preference for residency location. RESULTS:Between July and November 2022, 522 students responded (405 studied in Israeli medical schools [out of 705 students] and 117 in foreign medical schools [out of 1936 students]). Forty-two percent had at least one clerkship in a remotely located hospital, and 24% had included at least one remotely located hospital among their top five choices for internship. Only 13% reported that they prefer a residency program in those institutions. The incentive selected by students as most persuasive was government assistance in acceptance to and financial support for a fellowship abroad, followed by a financial grant and fewer on-call hours. Only 7% of the students indicated that no incentive would influence them to choose a remotely located hospital for their residency training. Medical education in a remotely located university and the choice of at least one remotely located hospital among the top five choices for internship were significantly associated with positive incentive receptivity, whereas male sex and older age were associated with negative receptivity. CONCLUSION:This study on the attitudes of Israeli medical school graduates toward incentives aimed at attracting them to residencies in remotely located institutions revealed that career development opportunities and assistance in obtaining fellowships might influence their choice.

BACKGROUND: A definitive diagnosis of brain lesions not amenable to surgery is mainly made by stereotactic needle biopsy. The diagnostic yield and safety of the frameless versus frame-based image-guided stereotactic techniques is unclear. Our objective was to evaluate the safety and accuracy of frameless versus frame-based stereotactic brain biopsy techniques. METHODS: A total of 278 patients (153 men; mean age: 65.5 years) with intra-axial brain lesions underwent frame-based (n = 148) or frameless image-guided stereotactic brain biopsy (n = 130) using a minimally invasive twist drill technique during 2010-2016 at Sheba Medical Center. Demographic, imaging, and clinical data were retrospectively analyzed. RESULTS: The diagnostic yield (>90%) did not differ significantly between groups. Overall morbidity (6.8% vs. 8.5%), incidence of permanent neurologic deficits (2.1% vs. 1.6%), mortality rate (0.7% vs. 0.8%), and postoperative computed tomography-detected asymptomatic (14.2% vs. 16.1%) and symptomatic (2.0% vs. 1.6%) bleeding also did not differ significantly between the frame-based and frameless cohorts, respectively. The diagnostic yield and complication rates related to the biopsy technique were not significantly associated with sex, age, entry angle to the skull and skull thickness, lesion location or depth, or radiologic characteristics. Diagnostic yield was significantly associated with the mean lesion volume. Smaller lesions were less diagnostic than larger lesions in both techniques (P = 0.043 frame-based and P = 0.048 frameless). CONCLUSIONS: The frameless biopsy technique is as efficient as the frame-based brain biopsy technique with a low complication rate. Lesion volume was the only predictive factor of diagnostic yield. The minimally invasive twist drill technique is safe and efficient.

Background. To determine the utility of an intraoperative magnetic resonance imaging (iMRI) system, the Polestar N30, for enhancing the resection control of non-enhancing intra-axial brain lesions. Materials and methods. Seventy-three patients (60 males [83.3%], mean age 37 years) with intra-axial brain lesions underwent resection at Sheba Medical Centre using the Polestar between February 2012 and the end of August 2018. Demographic and imaging data were retrospectively analysed. Thirty-five patients had a non-enhancing lesion (48%). Results. Complete resection was planned for 60/73 cases after preoperative imaging. Complete resection was achieved in 59/60 (98.3%) cases. After iMRI, additional resection was performed in 24/73 (32.8%) cases, and complete resection was performed in 17/60 (28.8%) cases in which a complete resection was intended. In 6/13 (46%) patients for whom incomplete resection was intended, further resection was performed. The extent of resection was extended mainly for non-enhancing lesions: 16/35 (46%) as opposed to only 8/38 (21%) for enhancing lesions. Further resection was not significantly associated with sex, age, intended resection, recurrence, or affected side. Univariate analysis revealed non-eloquent area, intended complete resection, and enhancing lesions to be predictive factors for complete resection, and non-enhancing lesions and scan time to be predictive factors for an extended resection. Non-enhancement was the only independent factor for extended resection. Conclusions. The Polestar N30 is useful for evaluating residual non-enhancing intra-axial brain lesions and achieving maximal resection.

The COVID-19 pandemic has resulted in a widespread shortage of personal protective equipment (PPE). Many healthcare workers, including neurosurgeons, have expressed concern about how to safely and adequately perform their medical responsibilities in these challenging circumstances. One of these concerns revolves around the pressing question: should providers continue to work in the absence of adequate PPE? Although the first peak of the COVID-19 crisis seems to have subsided and supply of PPE has increased, concerns about insufficient PPE availability remain. Inconsistent supply, limited efficacy, and continued high demand for PPE, combined with the continued threat of a second COVID-19 wave, mean that the issues surrounding PPE availability remain unresolved, including a duty to work. This paper offers an ethical investigation of whether neurosurgeons should perform their professional responsibilities with limited availability of PPE. We evaluate ethical considerations and conflicting duties and thereby hope to facilitate providers in making a well-considered personal and moral decision about this challenging issue.

BACKGROUND:Moyamoya disease refers to a progressive vasostenotic or vaso-occlusive disease that puts patients at risk for ischemic and/or hemorrhagic events. Surgical revascularization procedures aim to restore cerebral blood flow to mitigate stroke risk and functional decline. Direct and indirect bypass procedures have been proposed. Encephaloduroarteriosynangiosis (EDAS) with dural inversion is a well-accepted indirect procedure. METHODS:Patients with moyamoya disease undergoing EDAS with dural inversion between 2000 and 2019 were retrospectively reviewed. Clinical data including short-term and long-term outcome were measured using the modified Rankin Scale. Patient satisfaction was assessed in patients with a minimum of 3 years of clinical follow-up. RESULTS:Over a 20-year period, 54 patients underwent 88 EDAS with dural inversion procedures. Most patients underwent bilateral surgery (34/54 patients, 63.0%). Median age at surgery was 19 years (range, 1-63 years) with a median follow-up of 6 years (range, 1-20 years). Periprocedural complications occurred in 4 of 54 patients (7.4%). Periprocedural infarction occurred in 3 of 88 operations (3.4%). Functional outcome at 90 days was favorable (modified Rankin Scale score 0-2) in 92.6% of cases. On long-term follow-up, 3 patients experienced ischemic infarction (5.6%), and 1 patient (1.9%) experienced hemorrhagic infarction. Patients' overall satisfaction with the surgical procedure at last follow-up was determined in 36 of 45 patients with at least 3 years of follow-up (response rate 80.0%). Median satisfaction was very good (score 5; range, 3-5). CONCLUSIONS:EDAS with dural inversion is a safe and effective indirect revascularization procedure for pediatric and adult moyamoya disease that is associated with favorable long-term outcomes and high patient satisfaction.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. Methods We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. Results We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. Conclusion Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

Background The COVID-19 pandemic confronts healthcare workers, including neurosurgeons, with difficult choices regarding which patients to treat. Methods In order to assist ethical triage, this article gives an overview of the main considerations and ethical principles relevant when allocating resources in times of scarcity. Results We discuss a framework employing four principles: prioritizing the worst off, maximizing benefits, treating patients equally, and promoting instrumental value. We furthermore discuss the role of age and comorbidity in triage and highlight some principles that may seem intuitive but should not form a basis for triage. Conclusions This overview is presented on behalf of the European Association of Neurosurgical Societies and can be used as a toolkit for neurosurgeons faced with ethical dilemmas when triaging patients in times of scarcity.

Purpose: The AspireSR (R) is a vagal nerve stimulation (VNS) device that operates as a closed-loop system, delivering an automatic stimulation in response to an ictal heart rate increase that serves as a predictor for an imminent seizure. Our purpose is to assess the outcome of the AspireSR (R) in a patient population managed in a pediatric neurology unit. Methods: The records of patients who underwent transplantation during 2015-2017 and are continuously followed in one pediatric-epilepsy clinic, were retrospectively analyzed. Collected information included demo-graphics, use of antiepileptic drugs and seizure type, frequency and duration before and after VNS implantation. Results: 46 patients ages 5-31 years (mean 15.7 +/- 5.8), mean age at implantation 14 5.8 years, were included. 29 patients (63%) were new insertions and 17 of the patients (37%) underwent a VNS replacement to the AspireSR (R) model. Mean follow-up was 13 +/- 7.5 months (range 2-29 months). The total cohort responder rate (patients with >= 50% reduction in seizure frequency compared to the pre-implantation period) was 60.9%. (62% in the new insertion group; while 59% in the replacement group had additional benefit over their former VNS model, p = 0.981). Epilepsy etiology, age, age at implantation and type of seizures pre-implantation showed no correlation to response-rate. Five patients (10.9%) experienced complete seizure-freedom following implantation (4/5 in the "new insertion" group). Responses were reported at median follow up of 5 +/- 1.3 months post-implantation. 67.4% experienced shorter seizure duration post-implantation. Conclusion: Our results suggest that the AspireSR (R) device provides an early and meaningful benefit to drug-resistant epilepsy patients, which is relevant for both patients with new insertions and those with replacements of former VNS devices.

BACKGROUNDGlobal trends, such as the population aging, the increase of chronic morbidity, soaring costs of healthcare services, and work overload in hospitals raise the need to find innovative solutions for providing quality medical services. One solution adopted by healthcare systems around the world is "home hospitalization," that is, providing an array of necessary health services in the patient's home, instead of in the hospital department. The aim of this focus article is to explore the spread of home hospitalization worldwide and examine the challenges and pathways for its adoption and implementation. Many countries, including the United States, Canada, the United Kingdom, and Australia, operate home-based hospitalization programs. In Israel, the service is in its infancy, but in view of the extreme workload and the high mortality rate from infections in acute care hospitals, home hospitalization has recently gained public interest and political support, which may encourage its further development.

Neonatal cervical osteomyelitis is extremely rare, with only a few cases having been reported. We report a neonate with cervical osteomyelitis and extensive inflammation of the surrounded tissues that caused nerve root compression and upper limb paresis.

Endoscopic resection is becoming a well-established treatment option for patients with colloid cysts of the third ventricle. A disadvantage of this approach is the decreased ability to resect cysts in their entirety. Correlations between magnetic resonance imaging (MRI) features and cyst content could potentially help surgeons decide on the extent of resection and approach. We attempted to identify a correlation between patients’ MRI imaging patterns and difficult cyst removal, post-operative adverse outcomes and the need for cerebrospinal fluid (CSF) diversion, in order to detect markers that may affect pre-surgical planning.

A 6 months old infant, diagnosed with a rare mutation causing severe hemophilia A, presented with spinal epidural hematoma. Parents later admitted the infant had glass cupping therapy performed within 2 weeks of the onset of symptoms. The rare mutation, rare bleeding complication, and the eventual course of therapy applied in this case will be discussed in our case report.

Cranioplasty is a relatively straightforward and common procedure, yet it carries a substantial rate of infection that causes major morbidity and mortality. The authors' objective was to assess the effect of various variables on the risk of developing post-cranioplasty infections, and to enable the prediction and reduction of its incidence, contributing to an improved patient-selection. The medical records, microbiologic cultures, imaging studies and operative reports of patients who have undergone cranioplasty between the years 2008-2014 at Sheba Medical Center, a tertiary care teaching hospital in Tel-Hashomer, Israel, were reviewed and evaluated for potential predictive factors of infection. Cox regression was applied for uni- as well as multi-variate analyses, and a Kaplan-Meier curve and Log-Rank test were used to describe the association between neurological deficit prior to operation and occurrence of infection. Eighty-eight patients who had undergone cranioplasties using autologous as well as various artificial materials were included in the study. The overall rate of infection was 13.6%; median time to infection was 30.5 days (interquartile range: 17.35-43.5). Pre-operative degree of neurological disability was the strongest predictor for infection in both uni- and multi-variate analyses (Hazard ratio [HR]=18.9, 95% confidence interval [CI]: 1.9-187 p=0.014). Patients admitted due to trauma (HR=7.04 CI: 0.9-54.6, p=0.062) and autologous graft material (HR=2.88, 95% CI: 0.92-9.09, p=0.07) were associated with a trend toward a higher risk for infection. In conclusion, careful patient selection is a key concept in avoiding harmful post-cranioplasty infections. Modified Rankin Score yields a well-established tool that predicts the risk of infection.

OBJECTIVE:The aim of this study was to determine the utility of an intraoperative magnetic resonance imaging (i-MRI) system (Polestar N-10, 20, 30) in achieving maximal resection of intra-axial brain lesions.METHODS:The subjects comprised 163 patients with intra-axial brain lesions who underwent resection at Sheba Medical Center using the Polestar from February 2000 through February 2012. Demographic and imaging data were obtained and analyzed retrospectively. The patients included 83 men (50.9%) and had a mean age of 43 years. High-grade gliomas were diagnosed in 72 patients, low-grade gliomas in 35, metastases in 22, and various pathologies (e.g., cavernous angiomas, juvenile pilocytic astrocytoma, pleomorphic xanthoastrocytoma, etc.) were diagnosed in 34. The majority of the lesions (84, 51.5%) were located in or near eloquent areas. Fifty-one patients had nonenhancing lesions.RESULTS:We intended to achieve complete resection in 110 of 163 cases, based on preoperative imaging. Complete resection was achieved in 90 of these 110 (81.8%) cases. Intraoperative MRI led to additional resection in 42.3% of the total cases and to complete resection in 43.3% of all the cases in which a complete resection was achieved. In 76.8% of these cases, 2 intraoperative scans were sufficient to achieve complete resection. Sex, age, intent of resection, recurrence, affected side, and radiologic characteristics did not differ significantly between cases in which intraoperative MRI led to further resection and cases in which it did not. Nonenhancing lesions of all types were 3 times more likely to require additional resection after obtaining intraoperative MRIs (P = .02).CONCLUSIONS:The Polestar (N-10, 20, 30) proved useful for evaluating residual intra-axial brain lesions and achieving the maximal extent of resection in 42.3% of the total cases and in 43.3% of cases in which complete resection was achieved. Intraoperative MRI led to extended resection in 46.9% of patients for whom the initial intent was to perform an incomplete resection. Nonenhancement was the only independent variable predicting the usefulness of intraoperative MRI for additional lesion resection.

Posterior meningocele is an uncommon form of spina bifida. We present a case of unique posterior meningocele diagnosed at the early second trimester anatomical scan using 2D and 3D ultrasound. The sonographic appearance resembled "lasso". The prenatal follow-up was uneventful, with no demonstration of tethered cord. Clinical, neurological and radiological examinations following delivery and at the age of four months were unremarkable.

We describe a newborn infant with multiple congenital skull fractures and intracranial hemorrhage. He also had multiple skin folds suggesting a connective tissue abnormality. Electron microscopy of the skin biopsy showed collagen abnormalities with a “hieroglyphic appearance.” The analysis of the synthesis of collagen in the cultured dermal fibroblasts demonstrated an accumulation of procollagen I. Molecular analysis found a nonsense mutation Q225X in ADAMTS2 gene, which encodes procollagen I N‐terminal proteinase. All these findings confirmed the diagnosis of Ehlers–Danlos syndrome type VIIC (MIM 225410). Family studies suggested a founder effect in Ashkenazi Jews originating from Belarus. Prenatal diagnosis in the subsequent pregnancy reassured the parents that the fetus was an unaffected carrier. © 2008 Wiley‐Liss, Inc.