The surgical management of brain tumors is based on the principle that the extent of resection improves patient outcomes. Traditionally, neurosurgeons have considered that lesions in “non-eloquent” cerebrum can be more aggressively surgically managed compared to lesions in “eloquent” regions with more known functional relevance. Furthermore, advancements in multimodal imaging technologies have improved our ability to extend the rate of resection while minimizing the risk of inducing new neurologic deficits, together referred to as the “onco-functional balance.” However, despite the common utilization of invasive techniques such as cortical mapping to identify eloquent tissue responsible for language and motor functions, glioma patients continue to present post-operatively with poor cognitive morbidity in higher-order functions. Such observations are likely related to the difficulty in interpreting the highly-dimensional information these technologies present to us regarding cognition in addition to our classically poor understanding of the functional and structural neuroanatomy underlying complex higher-order cognitive functions. Furthermore, reduction of the brain into isolated cortical regions without consideration of the complex, interacting brain networks which these regions function within to subserve higher-order cognition inherently prevents our successful navigation of true eloquent and non-eloquent cerebrum. Fortunately, recent large-scale movements in the neuroscience community, such as the Human Connectome Project (HCP), have provided updated neural data detailing the many intricate macroscopic connections between cortical regions which integrate and process the information underlying complex human behavior within a brain “connectome.” Connectomic data can provide us better maps on how to understand convoluted cortical and subcortical relationships between tumor and human cerebrum such that neurosurgeons can begin to make more informed decisions during surgery to maximize the onco-functional balance. However, connectome-based neurosurgery and related applications for neurorehabilitation are relatively nascent and require further work moving forward to optimize our ability to add highly valuable connectomic data to our surgical armamentarium. In this manuscript, we review four concepts with detailed examples which will help us better understand post-operative cognitive outcomes and provide a guide for how to utilize connectomics to reduce cognitive morbidity following cerebral surgery.

OBJECTIVECervical spondylotic myelopathy (CSM) is a progressive degenerative pathology that frequently affects older individuals and causes spinal cord compression with symptoms of neck pain, radiculopathy, and weakness. Anterior decompression and fusion is the primary intervention to prevent neurological deterioration; however, in severe cases, circumferential decompression and fusion is necessary. Published data regarding perioperative morbidity associated with these complex operations are scarce. In this study, the authors sought to add to this important body of literature by documenting a large single-surgeon experience of single-session circumferential cervical decompression and fusion.METHODSA retrospective analysis was performed to identify intended single-stage anterior-posterior or posterior-anterior-posterior cervical spine decompression and fusion surgeries performed by the primary surgeon (V.C.T.) at Rush University Medical Center between 2009 and 2016. Cases in which true anterior-posterior cervical decompression and fusion was not performed (i.e., those involving anterior-only, posterior-only, or delayed circumferential fusion) were excluded from analysis. Data including standard patient demographic information, comorbidities, previous surgeries, and intraoperative course, along with postoperative outcomes and complications, were collected and analyzed. Perioperative morbidity was recorded during the 90 days following surgery.RESULTSSeventy-two patients (29 male and 43 female, mean age 57.6 years) were included in the study. Fourteen patients (19.4%) were active smokers, and 56.9% had hypertension, the most common comorbidity. The most common clinical presentation was neck pain in 57 patients (79.2%). Twenty-three patients (31.9%) had myelopathy, and 32 patients (44.4%) had undergone prior cervical spine surgery. Average blood loss was 613 ml. Injury to the vertebral artery was encountered in 1 patient (1.4%). Recurrent laryngeal nerve palsy was observed in 2 patients (2.8%). Two patients (2.8%) had transient unilateral hand grip weakness. There were no permanent neurological deficits. Dysphagia was encountered in 45 patients (62.5%) postoperatively, with 23 (32%) requiring nasogastric parenteral nutrition and 9 (12.5%) patients ultimately undergoing percutaneous endoscopic gastrostomy (PEG) placement. Nine of the 72 patients required a tracheostomy. The incidence of pneumonia was 6.9% (5 patients) overall, and 2 of these patients were in the tracheostomy group. Superficial wound infections occurred in 4 patients (5.6%). Perioperative death occurred in 1 patient. Reoperation was necessary in 10 patients (13.9%). Major perioperative complications (permanent neurological deficit, vascular injury, tracheostomy, PEG tube, stroke, or death) occurred in 30.6% of patients. The risk of minor perioperative complications (temporary deficit, dysphagia, deep vein thrombosis, pulmonary embolism, urinary tract infection, pneumonia, or wound infection) was 80.6%.CONCLUSIONSSingle-session anterior-posterior cervical decompression and fusion is an inherently morbid operation required in select patients with cervical spondylotic myelopathy. In this large single-surgeon series, there was a major perioperative complication risk of 30.6% and minor perioperative complication risk of 80.6%. This overall elevated risk for postoperative complications must be carefully considered and discussed with the patient preoperatively. In some situations, shared decision making may lead to the conclusion that a procedure of lesser magnitude may be more appropriate.

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BACKGROUND Responsive neuromodulation (RNS) is a treatment option for patients with medically refractory bilateral mesial temporal lobe epilepsy (MTLE). A paucity of data exists on the feasibility and clinical outcome of hippocampal-sparing bilateral RNS depth lead placements within the parahippocampal white matter or temporal stem. OBJECTIVE To evaluate seizure reduction outcomes with at least a 1-yr follow-up in individuals with bilateral MTLE undergoing hippocampus-sparing implantation of RNS depth leads. METHODS A retrospective analysis of prospectively collected data was performed on patients at our institution with bilateral MTLE who were implanted with RNS depth leads along the longitudinal extent of bitemporal parahippocampal white matter or temporal stem. Baseline and postoperative seizure frequency, previous surgical interventions, and postimplantation electrocorticography and stimulation data were analyzed. RESULTS Ten patients were included in the study (7 male, 3 female). Overall seizure frequency declined by a median 44.25% at 3.13 yr (standard deviation 3.31) postimplantation. Four patients (40%) achieved 50% responder rate at latest follow-up. Two of four patients with focal onset bilateral tonic-clonic seizures became completely seizure-free. Forty percent of patients were previously implanted with a vagus nerve stimulator, and 20% underwent a prior temporal lobectomy. All depth lead placements were confirmed as radiographically located in the parahippocampal white matter or temporal stem without hippocampus violation. There were no cases of lead malposition. CONCLUSION Extrahippocampal or temporal stem white matter targeting during RNS surgery for bitemporal MTLE is feasible and allows for electrographic seizure detection. Larger controlled studies with longer follow-up are needed to validate these preliminary findings.

Introduction Dural venous sinus thrombosis (DVST) is a relatively understudied complication of vestibular schwannoma (VS) surgery. Several studies have examined this topic; however, there is limited data on the incidence, clinical progression, and proper management of this patient population. Methods A retrospective review was performed for patients undergoing surgery for VS at a single institution. All postoperative imaging was reviewed for incidence of DVST. Demographic data were collected including tumor and surgical characteristics along with postoperative course. Results A total of 63 patients underwent resection of their VS. The incidence of DVST was 34.9%. The operative time was greater in the dural venous sinus thrombosis (DSVT) group, at an average of 6.69 hours versus 4.87 in the no DSVT cohort (p = 0.04). Tumor size was correlationally significant (p = 0.051) at 2.75 versus 2.12 cm greatest diameter. The translabyrinthine approach was most prevalent (68.2%). The side of the thrombosis was ipsilateral to the tumor and surgery in all patients. The sigmoid sinus was most commonly involved (95.5%). Of them, 85% patients had a codominant or thrombus contralateral to the dominant sinus. All patients were asymptomatic. No patients were treated with anticoagulation. Resolution of thrombus was seen in five (22.7%) of the patients on last follow-up imaging. There were no hemorrhagic complications. Conclusion The overall incidence of DVST was (34.9%) of 63 patients who underwent VS surgery. All patients were asymptomatic and none were treated with anticoagulation. In our study, continuing to observe asymptomatic patients did not lead to any adverse events.

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Objective Endovascular treatment of carotid-cavernous fistulas (CCFs) has been consistently shown to give excellent results and is currently the mainstay of treatment of these complex vascular pathologies. Onyx is currently the most widely used agent, but there has been concern over high rates of cranial nerve (CN) deficits seen in patients with CCF treated with Onyx and paucity of data on long-term outcomes. Methods This is a retrospective analysis of patients who underwent transvenous Onyx embolization between 2011 and 2018. The data collected included demographics, comorbidities, presenting symptoms, CCF morphology, degree of obliteration, procedure-related complications, clinical outcomes, and follow-up. Results A total of seven patients (five females) were included. The median age was 66 years (range: 15–79 years). Median duration of symptoms before treatment was 4 weeks (range: 1–24 weeks). There were three direct and four indirect CCFs. Barrow classification is as follows: A-3; B-3; C-0; and D-1. Immediate complete occlusion was achieved in all cases. There was also one case of immediate postoperative change in CN function (new partial CN VI deficit) that resolved completely at 1-month follow-up. The mean length of stay was 3 days (±2). The preoperative extraocular movement CN deficits had the following outcomes: three resolved; two improved; and one persisted. Proptosis, chemosis, conjunctival injection, and tinnitus were resolved in all patients. The median follow-up was 34 months (range: 10–91 months). Conclusion Transvenous Onyx embolization is a safe and effective treatment of CCFs when technical aspects to reduce complications are performed diligently. Our technique demonstrates safety of the Onyx as a stand-alone embolization for the treatment of CCF.