Clinical outcomes after MRI connectivity-guided radiofrequency thalamotomy for tremor

OBJECTIVE: Radiofrequency thalamotomy (RF-T) is an established treatment for refractory tremor. It is unclear whether connectivity-guided targeting strategies could further augment outcomes. The aim of this study was to evaluate the efficacy and safety of MRI connectivity-guided RF-T in severe tremor. METHODS: Twenty-one consecutive patients with severe tremor (14 with essential tremor [ET], 7 with Parkinson's disease [PD]) underwent unilateral RF-T at a single institution between 2017 and 2020. Connectivity-derived thalamic segmentation was used to guide targeting. Changes in the Fahn-Tolosa-Marin Rating Scale (FTMRS) were recorded in treated and nontreated hands as well as procedure-related side effects. RESULTS: Twenty-three thalamotomies were performed (with 2 patients receiving a repeated intervention). The mean postoperative assessment time point was 14.1 months. Treated-hand tremor scores improved by 63.8%, whereas nontreated-hand scores deteriorated by 10.1% (p < 0.01). Total FTMRS scores were significantly better at follow-up compared with baseline (mean 34.7 vs 51.7, p = 0.016). Baseline treated-hand tremor severity (rho = 0.786, p < 0.01) and total FTMRS score (rho = 0.64, p < 0.01) best correlated with tremor improvement. The most reported side effect was mild gait ataxia (n = 11 patients). CONCLUSIONS: RF-T guided by connectivity-derived segmentation is a safe and effective option for severe tremor in both PD and ET

Can early cranioplasty reduce the incidence of hydrocephalus after decompressive craniectomy? A meta-analysis.

Background: Do alterations of cerebrospinal fluid dynamics secondary to decompressive craniectomy (DC) lead to hydrocephalus, and can this effect be mitigated by early cranioplasty (CP)? In this meta-analysis, we evaluated whether the timing of CP decreased the incidence of postoperative hydrocephalus. Methods: We performed a systematic search of PubMed/MEDLINE, Scopus, and the Cochrane databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for English language articles (1990-2020). We included case series, case-control, and cohort studies, and clinical trials assessing the incidence of hydrocephalus in adult patients undergoing early CP (within 3 months) versus late CP (after 3 months) after DC. Results: Eleven studies matched the inclusion criteria. The rate of postoperative hydrocephalus was not significantly different between the early (=96/1063; 9.03%) and late CP (=65/966; 6.72%) group (P = 0.09). Only in the three studies specifically reporting on the rate of hydrocephalus after DC performed to address traumatic brain injury (TBI) alone was there a significantly lower incidence of hydrocephalus with early CP (P = 0.01). Conclusion: Early CP (within 90 days) after DC performed in TBI patients alone was associated with a lower incidence of hydrocephalus. However, this finding was not corroborated in the remaining eight studies involving CP for pathology exclusive of TBI

Neurological update: consult the neurosurgical oracle for a standard operating procedure

Standard operating procedures (SOPs) contain general instructions and principles to standardize care, to improve effective and safe healthcare. Developing new, or updating current, SOPs is, however, challenging in fields where high-level evidence is limited. Still, SOPs alone have been shown to result in less complications. In this narrative review, we describe the process of creating a consensus-based SOP that is pragmatic for clinical practice since it can be created regardless of the current level of evidence. Through live audience engagement platforms, a group of experts will be able to both anonymously respond to a created questionnaire, and (subsequently) discuss the results within the same meeting. This modified Digital Delphi method as described here can be used as a tool toward consensus-based healthcare

Decompressive craniectomy in aneurysmal subarachnoid haemorrhage for hematoma or oedema versus secondary infarction

PURPOSE: Decompressive craniectomy (DC) has been proposed as lifesaving treatment in aneurysmal subarachnoid haemorrhage (aSAH) patients with elevated intracranial pressure (ICP). However, data is sparse and controversy exists whether the underlying cause of elevated ICP influences neurological outcome. The purpose of this study is to clarify the role of the underlying cause of elevated ICP on outcome after DC. MATERIALS AND METHODS: We retrospectively studied the one-year neurological outcome in a single-centre cohort to identify predictors of favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3) outcome. Additionally, available individual patient data in the literature was reviewed with a special emphasis on the underlying reason for DC. RESULTS: From 2006-2015, 53 consecutive aSAH patients underwent DC. Nine (17%) achieved favourable, 44 (83%) unfavourable outcome (31 patients died). One fourth of the patients undergoing DC for hematoma or (hematoma-related) oedema survived favourably (increasing to 46% for patients aged <51 years), versus none of the patients undergoing DC for secondary infarction. Analysis of individual data of 105 literature patients showed a similar trend, although overall outcome was much better: half of the patients undergoing DC for hematoma/oedema regained independence, versus less than one-fourth of patients undergoing DC for secondary infarction. CONCLUSIONS: DC in aSAH patients is associated with high rates of unfavourable outcome and mortality, but hematoma or oedema as underlying reason for DC is associated with better outcome profiles compared to secondary infarction. Future observational cohort studies are needed to further explore the different outcome profiles among subpopulations of aSAH patients requiring DC