13^th International Conference on Neurology and Neurosurgery June 19-21, 2017 Paris, France

Objective: Aim of this study is to determine whether providing education about the disease pathophysiology and drug mechanisms and side effects would be effective for reducing the use of pain medication while appropriately managing neurogenic pain in spinal cord injury (SCI) patients. Methods: In this prospective study, 109 patients with an SCI and neuropathic pain participated in an educational pain management program. This comprehensive program was specifically created for patients with an SCI and neuropathic pain. It consisted of six sessions, including educational training, over a six-week period. Results: Of 109 patients, 79 (72.5%) initially took more than two types of pain medication, and this decreased to 36 (33.0%) after the educational pain management program was completed. The mean pain scale score and the number of pain medications decreased compared to the baseline values. Compared to the non-response group, the response group had a shorter duration of pain onset (p=0.004), and a higher initial number of different medications (p<0.001) and certain types of medications. Conclusions: This study results imply that an educational pain management program can be a valuable complement to the treatment of spinal cord injured patients with neuropathic pain. Early intervention is important to prevent patients from developing chronic SCI-related pain.

Statement of the Problem: To investigate the relationship between dosimetric factors, tumor control rate, and occurrence of RION among 42 patients treated with hypofractionated radiosurgery. Methodology & Theoretical Orientation: From June 2011 to July 2015, 42 patients with perioptic tumor underwent hypofractionated radiosurgery (hSRS) at Asan Medical Center. Among 42 patients, 22 patients (52%) had a meningioma, 10 patients (24%) had a pituitary adenoma, four patients (10%) had a craniopharyngioma, four patients (10%) had a hemangioma, and two patients (5%) had a schwannoma. All tumors were located within 2 mm of the anterior visual pathway. 16 patients (38%) had undergone previous tumor resection, one patient (3%) had previously been treated with hSRS and no patient had previously treated with conventional fractionated radiotherapy. Hypofractionated radiosurgery was delivered in five sessions. Radiologic and ophthalmologic evaluations were performed preoperatively, and three and six months after hSRS and then annually. The average prescribed dose was 27.3 Gy. Findings: The mean follow-up was 22 months (range, 6-44 months). Tumor control was achieved in 40 patients (95%). Visual function improved in 13 patients (31%), showed no interval change in 25 patients (60%), whereas three patients (7%) experienced a worsening of visual function. Among three patients, two patients experienced deterioration of visual function due to tumor growth. One patient (2.4%) suffered a radiation-induced optic neuropathy. Conclusion & Significance: Hypofractionated radiosurgery is safe and effective treatment modality for treating benign perioptic tumors. We advocate hypofractionated radiosurgery can be a treatment alternative for patients who are not eligible for surgery.

Rosette forming glioneuronal tumor (RGNT) is a rare variant of glioneuronal tumor. It is described as an infratentorial form of dysembryoplastic neuroepithelial tumor (DNT). However, its clinicopathologic findings are distinct from that of DNT. RGNT, classified as WHO grade I tumor, usually shows indolent clinical course and rarely recurs even after subtotal resection. We report two cases of RGNT. One case had a recurrence at five years after the initial subtotal resection. Case I: A healthy middle-aged man presented with sudden onset dizziness. He didn’t show any neurological deficit at the time of diagnosis. We performed gross total resection and the patient recovered without any specific event. There has been no evidence of recurrence during four year follow-up. Case II: An eight-year old girl presented with GTC-type seizure and ill-defined temporal lesion was found on her MRI (figure 3-A). She showed no focal neurological deficit. Parents denied having surgical management at that time, however, her seizure became intractable two years after the initial diagnosis and she underwent subtotal resection (figure 3-B). Postoperative MRI showed cystic cavity along with residual solid component near to the medial temporal lobe (figure 3-C) and this cyst became slowly enlarged in size (figure 3-D). 4.5 years after the first operation, she came to ER complaining of severe headache and vomit. Tumor became significantly enlarge in both cystic and solid component (figure 3-E). We inserted an Ommaya catheter into the cystic cavity to relieve the pressure (figure 3-F). RGNT is a rare tumor which was first described as dysembryoplastic neuroepithelial tumor (DNT) of the cerebellum. Komori et al., defined RGNT as a specific disease in the characteristic location specifically in association with the fourth ventricle. RGNT arises in the fourth ventricle in 59% of the cases, and tend to have variable involvement of the CNS as shown in Table 1.3, 4. Supratentorial form of RGNT has not been reported yet. In our second case, we first report the supratentorial hemispheric RGNT. RGNT was assigned grade one by the World Health Organization, and given its benign clinical behavior, a complete resection of the tumor and cure may be possible. Among the previously reported cases, no evidence of recurrence in GTR or tumor growth in STR was seen in 34/37 (92%) of patient. However, a few cases of recurrence after subtotal resection has been reported and our second case showed a fatal recurrence four years after the first operation. In this matter, vigilant follow up is recommended after subtotal resection and adjuvant treatment might be beneficial in such cases. RGNT is known as a benign tumor and surgical resection has been advocated as a mainstay treatment. However, in many cases, gross total resection is not feasible and poses significant post-surgical complications. And because of its rarity, clinical course after surgical resection is not well demonstrated yet. In our second case, we experienced a fatal recurrence after subtotal resection, and are planning radiation therapy. Some reports reviewed recurrent cases of RGNT after gross total resection. We report a supratentorial hemispheric form of RGNT which recurred after surgical resection. Further studies are necessary to demonstrate the optimal treatment for this disease entity.

Traumatic brain injury (TBI) is a major health concern in children and adults as it has been proposed as a risk factor for the development of subsequent neurologic diseases that often lead to irreversible brain damage or death. A meta-analysis of TBI identified several key associations, notably etiological pathology and complications from the nature of the injury, and various clinical presentations. The exact mechanism of cellular injury is not well understood. This novel device allows for varied shockwave propagation to simulate cellular injury and independently study the role of shockwave pressure change and shear force damage. The purpose of this device is to determine the overall consequences of traumatic exposure to brain tissue, and to provide a system in which tissue could be directly observed during and immediately after exposure to shockwave propagation. The pneumatic air-gun based device delivers a blast via a quick release valve directly to the 96-well culture plate positioned on top of a microscope. Modulating the volume of fluid in the well allows for independent control over shear forces generated by the blast shockwaves. The device is used in a laboratory controlled system with high temporal and spatial resolution. Novelties include real-time cellular imaging and analysis of explosive shockwaves, screening for pharmacological compounds that may ameliorate the effects of a brain trauma, testing materials capable of protecting cells from trauma, and identifying the best treatment and diagnostic path based on injury from head trauma. Future applications will be used to study pharmacological effects of calcium signaling in response to trauma, search for additional signaling pathways in response to varying intensities, and expand the system to allow for study of entire organs.

Lan Hoang-Minh completed her doctoral studies in the Department of Biomedical Engineering at the University of Florida in Gainesville, Florida, USA. She is now a postdoctoral fellow in the laboratory of Dr. Matthew Sarkisian, studying the molecular and cellular mechanisms governing the proliferation of glioblastoma cells. Particularly, her postdoctoral work has focused on examining the role and characteristics of primary cilia, small cellular organelles recently frequently observed in human patients’ glioblastoma biopsies and derived cell lines. In collaboration with a strong team of brain tumor investigators at the University of Florida, she has been investigating how these organelles and associated proteins may be involved in tumor pathogenesis and possibly resistance to standard-of-care therapy. She has also been collaborating with Dr. Loic Deleyrolle in examining the metabolic characteristics of fast and slow-cycling glioblastoma cells and various metabolic strategies to target those cell populations. She recently received a two-year American Brain Tumor Association Basic Research Fellowship Grant.

Malignancies often exhibit rewired metabolism in order to satisfy the major energy and biosynthesis requirements of rapidly growing tumors. Despite the presence of sufficient oxygen in their environment, tumors frequently exhibit elevated glycolysis. This metabolic reprogramming to glycolysis, known as the Warburg phenomenon, has commonly been associated with an impairment of mitochondrial function, thus restricting the metabolism of alternative substrates and limiting tumor cells’ metabolic diversity and adaptation. Here, we demonstrate that glioblastoma (GBM) tumor cells display metabolic heterogeneity, with fast-cycling cells harnessing anaerobic glycolysis and slow- cycling cells oxidative metabolism to support their growth and survival. We report the existence of SCCs in GBM, cells that display migration, invasion, and chemoresistance characteristics that might underlie tumor recurrence. SCCs consistently demonstrate heightened mitochondrial respiration activity as well as increased fatty acid metabolism. In addition, SCCs are more sensitive to inhibition of oxidative phosphorylation than to glucose deprivation, in vitro and in a murine xenograft model of GBM, and targeting both oxidative phosphorylation and the glycolytic pathway has a combinatorial inhibitory effect on GBM cell viability. These results demonstrate the presence of cellular subpopulations that exhibit distinct metabolic activities in GBM and highlight the importance of comprehensive metabolic inhibition in the novel GBM treatment strategies.

Patricia Dreier completed her Bachelor Degree in Biology and Chemistry before studying Medicine at State University of Guayaquil in Ecuador. As part of medical school, she did Clinical Rotations in Neurology and Neurosurgery at Jackson Memorials Hospital in Miami. After working in Pediatric department in public hospitals in her hometown, she completed three years of Neurosurgical training at University of New Mexico in USA followed by a Research fellowship at Peter Jannetta Center for Cranial Nerve Disorders in Pittsburgh. After one year of functional neurosurgery in Buenos Aires Argentina, she enrolled in the Neurology and Neurorehabilitation Center at Luzerner Kantonsspital where she contributes to clinical and research activities in Stroke and Cognitive Neurosciences. She has also participated in various research projects in Epilepsy Surgery in children with cortical dysplasia. Her profes-sional interests include Pain, Epilepsy and Pediatric Neurosurgery.

Remote cerebellar hemorrhage (RCS) is a rare complication after supratentorial neurosurgical procedures (0.2-4.9%) and even less common following spinal surgery, related to acute CSF hypovolemia. The cerebellar cognitive affective syndrome (CCAS) also called as Schmahmann's syndrome, characterized by deficits in language, visual spatial and executive functions, and affective dysregulation, is an under recognized manifestation of cerebellar damage. We present the case of a 66 year old male who was presented with an acute cerebellar motor syndrome after a postoperative incidental acute drainage of CSF after a cervical wound revision of a posterior C1-C2 fusion for an unstable D'Alonzo type III odontoid fracture. The head CT showed an acute remote cerebellar hemorrhage. In further neuropsychological test, the patient was found to have a cognitive affective cerebellar syndrome.

Sniedze Murniece is working as a Neuroanesthesiologist at Riga East University Hospital, Latvia. Currently, she is pursuing her PhD in Medicine and doing her research in Spinal Neurosurgery and Cerebral Oxygen Saturation Monitoring.

Introduction: Cerebral hypoxia is a leading cause of adverse cerebral outcomes. Regional cerebral oxygenation intraoperative monitoring can prevent from complications like cognitive dysfunction, organ failure reducing hospitalization time. Aim: The aim of the study was to determine whether prone position impacts cerebral oxygenation in spinal neurosurgical patients using near infrared spectroscopy device intraoperatively. Materials & Methods: 25 patients (mean age 56 years) undergoing transpedicular fixation, microdiscectomy, removal of spinal tumors in prone position were included. Cerebral oxygen saturation (rScO2) was continuously monitored using INVOS 4100 NIRS device. We assessed cognitive dysfunction, blood loss, postoperative complications (stroke, organ dysfunction, days spent in ICU). Anesthesia induction: fentanyl 0.1-0.2 mg, propofol 1-2 mg/kg, cisatracurium 0.2 mg/kg; maintenance-fentanyl 0.03-0.06 μg/kg/min, cisatracurium 0.06-0.1 mg/kg/h, sevoflurane to MAC 0.7-1.0, FiO2 0.5. Results: Mean rScO2 during induction was 72% for left side (L), 73% right side (R). In prone position L74%, R74%, was returning back to spinal position L74%, R73% during the whole surgery L73%, and R73%. Significant difference in calculated mean rScO2 values between supine and prone position was not observed. Despite the calculated mean rScO2 values 11/25 patients showed a slight up to significant decrease in rScO2 in prone position. The minimum rScO2 value observed was 55%. One patient with adipositas rScO2 values decreased for 26% from baseline values when turned to prone position (from 85% supine to 58% in prone position). No incidence of cognitive dysfunction, stroke, organ dysfunction was observed, no patients were admitted to ICU. Conclusions: Although our first experience revealed that the mean intraoperative cerebral oxygen saturation changes during spinal neurosurgery in prone position from baseline values is not significant, almost half of the patients experienced mild to moderate decrease in cerebral oxygen saturation. Near infrared spectroscopy devices can be served as a supplementary tool in spinal neurosurgery to maintain adequate cerebral oxygen saturation.

Objectives: Botulinum neurotoxin type A (BoNT/A) has been widely used to decrease spasticity and enhance function in stroke patients with upper limb spasticity. In the current study, we investigated a new botulinum neurotoxin type A, termed as letibotulinumtoxinA (Botulax®) and compared its efficacy and safety for post-stroke upper limb spasticity with that of onabotulinumtoxinA (Botox®). Methods: Two kinds of botulinum neurotoxin type A (Botulax® and Botox®) were used. One set of injection were performed and total injected doses were 309.21±62.48U (Botulax group) and 312.64±49.99U (Botox group) (p>0.05). Main measures: Primary outcome was measured using the modified Ashworth scale for wrist flexors at week four and secondary outcome was measured using modified Ashworth scale for wrist flexors, elbow flexors, finger flexors, and thumb flexors as well as global assessment in spasticity, disability assessment scale, and caregiver burden scale at baseline, 4, 8, and 12 weeks. Safety measures including adverse events, vital signs and physical examination, and laboratory tests were also monitored. Results: The mean ages for the Botulax group were 56.81±9.49 and which for the Botox group were 56.93±11.93. In primary outcome, the change in modified Ashworth scale for wrist flexors was -1.45±0.61 in the Botulax group and -1.40±0.57 in the Botox group, and the difference between the two groups was -0.06 (95% CI: -0.23–0.12, p>0.05; p=0.5253). In secondary outcome, both groups also demonstrated significant improvements with respect to modified Ashworth scale, global assessment in spasticity, disability assessment scale, and caregiver burden scale during the study periods (p<0.05), and no significant difference was observed between the two groups (p>0.05). In addition, safety measures showed no significant differences between the two groups (p>0.05). Conclusions: The efficacy and safety of Botulax were comparable with those of Botox in treatment of post-stoke upper limb spasticity.