Crucifixion and median neuropathy.

Crucifixion as a means of torture and execution was first developed in the 6th century B.C. and remained popular for over 1000 years. Details of the practice, which claimed hundreds of thousands of lives, have intrigued scholars as historical records and archaeological findings from the era are limited. As a result, various aspects of crucifixion, including the type of crosses used, methods of securing victims to crosses, the length of time victims survived on the cross, and the exact mechanisms of death, remain topics of debate. One aspect of crucifixion not previously explored in detail is the characteristic hand posture often depicted in artistic renditions of crucifixion. In this posture, the hand is clenched in a peculiar and characteristic fashion: there is complete failure of flexion of the thumb and index finger with partial failure of flexion of the middle finger. Such a "crucified clench" is depicted across different cultures and from different eras. A review of crucifixion history and techniques, median nerve anatomy and function, and the historical artistic depiction of crucifixion was performed to support the hypothesis that the "crucified clench" results from proximal median neuropathy due to positioning on the cross, rather than from direct trauma of impalement of the hand or wrist

Intraoperative Extracorporeal Irradiation for the Treatment of the Meningioma-Infiltrated Calvarium.

Objectives Complete removal of infiltrated bone is required to achieve a Simpson Grade 1 meningioma resection. Reconstruction of the resulting bone defect is typically achieved with a nonnative implant that can result in poor cosmesis, foreign body reaction, or infection. Extracorporeal irradiation and reimplantation of tumorous bone has been used for limb-sparing surgery with excellent results, but this treatment option is not routinely considered in meningioma surgery. We present a case of anterior fossa meningioma with tumorous overlying calvarium that was successfully managed with intraoperative extracorporeal irradiation and reimplantation. Design, Setting, and Participant A 37-year-old woman with persistent chronic headaches was found to have an anterior skull base meningioma with extension into the forehead frontal bone. Concurrently with mass resection, the bone flap was irradiated intraoperatively with 120 Gy. After resection of the tumor, the bone flap was replaced in its native position. Main Outcome Measures and Results Twenty-nine months postoperatively, the patient had an excellent cosmetic outcome with no radiographic evidence of tumor recurrence or significant bone flap resorption. Conclusion Intraoperative extracorporeal irradiation of tumorous calvaria during meningioma surgery is an effective, logistically feasible treatment option to achieve local tumor control and excellent cosmetic outcome

Making Waves in the Brain: What Are Oscillations, and Why Modulating Them Makes Sense for Brain Injury.

Traumatic brain injury (TBI) can result in persistent cognitive, behavioral and emotional deficits. However, the vast majority of patients are not chronically hospitalized; rather they have to manage their disabilities once they are discharged to home. Promoting recovery to pre-injury level is important from a patient care as well as a societal perspective. Electrical neuromodulation is one approach that has shown promise in alleviating symptoms associated with neurological disorders such as in Parkinson's disease (PD) and epilepsy. Consistent with this perspective, both animal and clinical studies have revealed that TBI alters physiological oscillatory rhythms. More recently several studies demonstrated that low frequency stimulation improves cognitive outcome in models of TBI. Specifically, stimulation of the septohippocampal circuit in the theta frequency entrained oscillations and improved spatial learning following TBI. In order to evaluate the potential of electrical deep brain stimulation for clinical translation we review the basic neurophysiology of oscillations, their role in cognition and how they are changed post-TBI. Furthermore, we highlight several factors for future pre-clinical and clinical studies to consider, with the hope that it will promote a hypothesis driven approach to subsequent experimental designs and ultimately successful translation to improve outcome in patients with TBI

Clinically indicated electrical stimulation strategies to treat patients with medically refractory epilepsy.

Focal epilepsies represent approximately half of all diagnoses, and more than one-third of these patients are refractory to pharmacologic treatment. Although resection can result in seizure freedom, many patients do not meet surgical criteria, as seizures may be multifocal in origin or have a focus in an eloquent region of the brain. For these individuals, several U.S. Food and Drug Administration (FDA)-approved electrical stimulation paradigms serve as alternative options, including vagus nerve stimulation, responsive neurostimulation, and stimulation of the anterior nucleus of the thalamus. All of these are safe, flexible, and lead to progressive seizure control over time when used as an adjunctive therapy to antiepileptic drugs. Focal epilepsies frequently involve significant comorbidities such as cognitive decline. Similar to antiepilepsy medications and surgical resection, current stimulation targets and parameters have yet to address cognitive impairments directly, with patients reporting persistent comorbidities associated with focal epilepsy despite a significant reduction in the number of their seizures. Although low-frequency theta oscillations of the septohippocampal network are critical for modulating cellular activity and, in turn, cognitive processing, the coordination of neural excitability is also imperative for preventing seizures. In this review, we summarize current FDA-approved electrical stimulation paradigms and propose that theta oscillations of the medial septal nucleus represent a novel neuromodulation target for concurrent seizure reduction and cognitive improvement in epilepsy. Ultimately, further advancements in clinical neurostimulation strategies will allow for the efficient treatment of both seizures and comorbidities, thereby improving overall quality of life for patients with epilepsy

Chondroblastoma of the Clivus: Case Report and Review.

Background and Importance Chondroblastoma is a benign primary bone tumor that typically develops in the epiphyses of long bones. Chondroblastoma of the craniofacial skeleton is extremely rare, with most cases occurring in the squamosal portion of the temporal bone. In this report, we describe the first case of chondroblastoma of the clivus presenting with cranial neuropathy that was treated with endoscopic endonasal resection. We review the literature on craniofacial chondroblastomas with particular emphasis on extratemporal lesions. Case Presentation A 27-year-old woman presented with severe headache, left facial dysesthesias, and diplopia. Physical examination revealed hypesthesia in the left maxillary nerve dermatome, and complete left abducens nerve palsy. Imaging demonstrated an expansile intraosseous mass originating in the upper clivus with extension superiorly into the sella turcica and laterally to involve the medial wall of the left cavernous sinus. The tumor was completely resected via an endoscopic endonasal approach, with postoperative improvement in lateral gaze palsy. Histopathology was consistent with chondroblastoma. Conclusion Chondroblastoma is a rare tumor of the craniofacial skeleton that should be included in the differential diagnosis of an osteolytic lesion of the clivus. Complete surgical resection remains the mainstay of treatment

Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma.

Petrous apex cholesterol granulomas (PACG) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. A 19-year-old woman presented with a recurrent right abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom- and recurrence-free. Endoscopic endonasal surgery must be adapted to manage recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences

A Multilayered Technique for Repair of the Suboccipital Retrosigmoid Craniotomy

Objective  Our primary objective was to retrospectively review our single institution experience using an anatomic multilayered repair of the retrosigmoid suboccipital craniotomy. Our secondary objective was to review the existing body of literature on the repair of this craniotomy and compare our outcomes to previous results. Design  Retrospective review of 25 consecutive patients undergoing repair for the retrosigmoid craniotomy. Setting  University of California Davis Medical Center (2010-2016). Participants  A total of 25 consecutive patients who underwent retrosigmoid craniotomy and repair. Exclusion criteria included patients who were under the age of 18 years. Main Outcome Measures  Main outcomes included incidence of postoperative headache, cerebrospinal fluid leak, and wound infections. Results  Postoperative headache was reported in two patients in this series (8%). None of the patients in the series developed cerebrospinal fluid leak or wound infections. Mean follow-up period was 16 months. Conclusion  Our multilayered anatomic repair after retrosigmoid suboccipital craniotomy results in favorable clinical results and may help reduce the risks associated with this operation

A Multilayered Technique for Repair of the Suboccipital Retrosigmoid Craniotomy

Objective  Our primary objective was to retrospectively review our single institution experience using an anatomic multilayered repair of the retrosigmoid suboccipital craniotomy. Our secondary objective was to review the existing body of literature on the repair of this craniotomy and compare our outcomes to previous results. Design  Retrospective review of 25 consecutive patients undergoing repair for the retrosigmoid craniotomy. Setting  University of California Davis Medical Center (2010-2016). Participants  A total of 25 consecutive patients who underwent retrosigmoid craniotomy and repair. Exclusion criteria included patients who were under the age of 18 years. Main Outcome Measures  Main outcomes included incidence of postoperative headache, cerebrospinal fluid leak, and wound infections. Results  Postoperative headache was reported in two patients in this series (8%). None of the patients in the series developed cerebrospinal fluid leak or wound infections. Mean follow-up period was 16 months. Conclusion  Our multilayered anatomic repair after retrosigmoid suboccipital craniotomy results in favorable clinical results and may help reduce the risks associated with this operation