Study Design.: Prospective quasi-experimental observational study. Objective.: The objective of this study was to evaluate whether duration of surgery is a modifiable risk factor for postoperative delirium (POD) after spine surgery and explore further modifiable risk factors. In addition, we sought to investigate the association between POD and postoperative cognitive dysfunction and persistent neurocognitive disorders. Summary of Background Data.: Advances in spine surgery enable technically safe interventions in elderly patients with disabling spine disease. The occurrence of POD and delayed neurocognitive complications (e.g. postoperative cognitive dysfunction/persistent neurocognitive disorder) remain a concern since these contribute to inferior functional outcomes and long-term care dependency after spine surgery. Materials and Methods.: This prospective single-center study recruited patients aged 60 years or above and scheduled for elective spine surgery between February 2018 and March 2020. Functional (Barthel Index, BI) and cognitive outcomes [Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) test battery; telephone Montréal Cognitive Assessment] were assessed at baseline, three (V3), and 12 months postoperatively. The primary hypothesis was that the duration of surgery predicts POD. Multivariable predictive models of POD included surgical and anesthesiological parameters. Results.: Twenty-two percent of patients developed POD (n=22/99). In a multivariable model, duration of surgery [OR_adj=1.61/h (95% CI, 1.20–2.30)], age [OR_adj=1.22/yr (95% CI, 1.10–1.36)], and baseline deviations of intraoperative systolic blood pressure [25th percentile: OR_adj=0.94/mm Hg (95% CI, 0.89–0.99); 90th percentile: OR_adj=1.07/mm Hg (95% CI, 1.01–1.14)] were significantly associated with POD. Postoperative cognitive scores generally improved (V3, ΔCERAD total z-score: 0.22±0.63). However, this positive group effect was counteracted by POD [beta: −0.87 (95% CI, −1.31 to 0.42)], older age [beta: −0.03/yr (95% CI, −0.05 to 0.01)], and lack of functional improvement [ΔBI; beta: −0.04/point (95% CI, −0.06 to 0.02)]. Cognitive scores at twelve months remained inferior in the POD group, adjusted for baseline cognition/age. Conclusions.: This study identified distinct neurocognitive effects after spine surgery, which are influenced by perioperative risk factors. Potential cognitive benefits are counteracted by POD, rendering its prevention critical in an aging population.

BACKGROUND AND OBJECTIVES: Despite a 90% success rate, microvascular decompression occasionally fails to resolve hemifacial spasm (HFS), necessitating revision surgery. We investigated recurrent cases to identify underlying causes. METHODS: We evaluated patients at our institution who underwent revision microvascular decompression because of recurrent or persistent HFS, assessing recurrence causes, decompression techniques, complications, and outcomes. Data considered included demographics, preoperative symptoms, disease duration, offending vessel, and magnetic resonance findings. Surgical notes and intraoperative videos were reviewed, and telephone interviews were conducted for recent outcomes. RESULTS: Out of our ongoing series of 493 patients, 43 patients (8.7%) required revision surgery with a patient cohort of 33 females and 10 males. The average symptom duration was 10 years. The median time between primary and revision surgery was 14 months. Thirteen patients (30.2%) underwent initial surgery elsewhere. Adhesions of Teflon pledgets to the facial nerve were the primary cause of nonresolution in 23 patients (53.5%), while in 13 (30.2%), a missed vascular compression was identified. Sixteen patients (37.2%) had sufficient decompression by removing the conflicting pledgets. During 10 revisions (23.3%), additional Teflon pledgets were necessary. After a median follow-up of 67 months after revision surgery, 27 patients (62.8%) reported complete spasm resolution. Six patients (14.0%) had a good outcome with over 90% reduction of their spasms, 3 patients (7.0%) stated a fair outcome (50% improvement), while 7 patients (16.3%) had no improvement. CONCLUSION: According to our results, adhesions of Teflon to the facial nerve may cause HFS recurrence. Therefore, whenever possible, Teflon should be placed without nerve contact between the brainstem and the offending vessel. Using a sling or bridge technique seems to be beneficial because it leaves the facial nerve completely free. Persistent symptoms often result from missed offending vessels in the pontomedullary sulcus indicating the benefit of endoscopic inspection of this area with an endoscope.

Background: Glioblastoma is the most aggressive primary brain tumor in adults. The prognosis is still very poor with a median survival time less than a year. A growing body of data supports the role for fatty acid oxidation (FAO) in the aggressive behavior of glioblastoma. We have previously shown that meldonium, an orally active compound that impairs FAO, caused significant growth reduction of glioblastoma in mice. Here, we report three cases of experimental meldonium-containing therapy in end-stage recurrent glioblastoma patients. Methods: Three end-stage glioblastoma patients, who had second relapse tumor progression after standard of care therapy, received 500 mg meldonium twice a day on the top of the existing therapy regimen. Tolerability and treatment outcomes were monitored. Results: Meldonium was well tolerated by all three patients. One patient experienced long-term growth arrest and maintained clinically stable disease status, currently 24 months into treatment with meldonium. In contrast, the other two patients passed away. Conclusions: The case reports presented here suggest good tolerability and the potential for meldonium to improve outcome in glioblastoma patients. Controlled clinical trials need to follow to evaluate systematically possible benefits from the integration of meldonium into standard glioblastoma treatment protocols.

BACKGROUND: Eosinophilic granuloma (EG) belongs to the family of Langerhans cell histiocytosis (LCH) and is considered to be a benign disease typically found in children younger than 15 years of age. Here, the authors describe an EG of unusual localization and clinical presentation. OBSERVATIONS: The authors report a 9-year-old girl with an EG presenting as an osteolytic lesion of the clivus. After transsphenoidal resection and histological confirmation, adjuvant chemotherapy was initiated. Presenting signs and symptoms were weight loss, episodic grimacing, and moderate ballism-like movements. After a follow-up-period of 32 months, the patient presented with a total resolution of initial symptoms and no further tumor growth. LESSONS: Although these lesions are rare, one should consider EG as a differential diagnosis when confronted with osteolytic lesions of the clivus.

BACKGROUND: Colloid cysts (CCs) are benign lesions commonly located in the third ventricle, near the foramen of Monro. They constitute about 0.5%–1% of all intracranial tumors. As benign lesions, CCs can be found incidentally, but they can also present with neurological deterioration and are even associated with sudden death, which might be explained as a result of obstructive hydrocephalus. Thus, larger and symptomatic CCs are often considered for surgery. OBSERVATIONS: The following case presents a rare and curious instance of a spontaneously regressing CC. This represents the 11th case ever reported about an extremely rare occurrence: the spontaneous regression of a previously diagnosed CC in the third ventricle. LESSONS: Carefully selected asymptomatic CCs can be monitored through regular imaging studies and neurological examinations. If regression of the cyst is observed, physicians should not be surprised, as this event, although rare, has been documented and published in 11 cases, including this one. https://thejns.org/doi/10.3171/CASE24498