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Giovanni Raffa, Maria Catena Quattropani, and Antonino Germanò

Maximal safe resection is the modern goal for surgery of intrinsic brain tumors located in or close to brain eloquent areas. Nowadays different neuroimaging techniques provide important anatomical and functional information regarding the brain functional organization that can be used to plan a customized surgical strategy to preserve functional networks, and to increase the extent of tumor resection. Among these techniques, navigated transcranial magnetic stimulation (nTMS) has recently gained great favor among the neurosurgical community for preoperative mapping and planning prior to brain tumor surgery. It represents an advanced neuroimaging technique based on the neurophysiological mapping of the functional cortical brain organization. Moreover, it can be combined with other neuroimaging techniques such as diffusion tensor imaging tractography, thus providing a reliable reconstruction of brain eloquent networks. Consequently, nTMS mapping may provide reliable noninvasive brain functional mapping, anticipating information that otherwise may be available to neurosurgeons only in the operating theater by using direct electrical stimulation. The authors describe the reliability and usefulness of the preoperative nTMS-based approach in neurosurgical practice, and briefly discuss their experience using nTMS as well as currently available evidence in the literature supporting its clinical use. In particular, special attention is reserved for the discussion of the role of nTMS as a novel tool for the preoperative neurophysiological mapping of motor and language networks prior to surgery of intrinsic brain tumors located in or close to eloquent networks, as well as for future and promising applications of nTMS in neurosurgical practice.

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Filippo F. Angileri, Salvatore Cardali, Alfredo Conti, Giovanni Raffa, and Francesco Tomasello

Object

Telemedicine provides a new approach to improve stroke care in community settings, delivering acute stroke expertise to hospitals in rural areas. Given the controversies in many aspects of the treatment of intracerebral hemorrhage (ICH) and the lack of guidelines, a prompt neurosurgical second opinion may facilitate the treatment of patients with ICH. Here, the authors' 8-year experience with the use of telemedicine in the management of ICH is reported.

Methods

The medical records of patients with ICH treated through a telemedicine system in the district of Messina, Italy, between June 2003 and June 2011 were retrospectively reviewed. Neuroradiological and clinical data for patients were transmitted through a high-technology “hub-and-spoke” telemedicine network. Neurosurgical teleconsulting (at the hub) was available for 7 peripheral hospitals (spokes) serving about 700,000 people. The authors analyzed 1) the time between peripheral hospital admission and the specialized second opinion consultation, 2) primary and secondary transfers to the authors' neurosurgery department, and 3) the treatments (surgical or medical) of patients transferred to the hub.

Results

The telemedicine network was used to treat more than 2800 patients, 733 with ICH. A neurosurgical consultation was provided in 38 minutes versus 160 minutes for a consultation without telemedicine. One hundred seventy-six (24%) of 733 patients were primarily transferred to the hub. Ninety-five patients (13%) underwent surgical treatment. The remaining 81 patients (11%) underwent neurointensive care. Eight (1.4%) of 557 patients treated at the spokes needed a secondary transfer for surgical treatment because of a worsening clinical condition and/or CT findings. Considering secondary and inappropriate transfers, the interpretation of data was correct in 96.5% of cases.

Conclusions

Telemedicine allowed rapid visualization of neuroradiological and clinical data, providing neurosurgical expertise to community hospitals on demand and within minutes. It allowed the treatment of patients at peripheral hospitals and optimized resources. A small percentage of patients treated at the peripheral hospitals had secondary deterioration. Telemedicine allowed fast patient transfer when necessary and provided improved accuracy in patient care.

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Ismail Zaed, Daniele Bongetta, Giuseppe Maria Della Pepa, Cesare Zoia, Teresa Somma, Matteo Zoli, Giovanni Raffa, and Grazia Menna

OBJECTIVE

Imposter syndrome (IS) occurs when high-achieving individuals have a pervasive sense of self-doubt combined with fear of being exposed as a fraud, despite objective measures of success. This is one of the main causes of burnout among professionals, threatening their mental health and general well-being. The prevalence and severity of IS among neurosurgery residents and young neurosurgeons has not been yet studied. The primary outcomes of this study were the prevalence and severity of IS.

METHODS

An anonymous cross-sectional survey including both a demographic questionnaire (Clance Imposter Phenomenon Survey) and compensatory mechanisms was distributed to young neurosurgeons and residents in neurosurgery in Italy.

RESULTS

A total of 103 responses were collected. The prevalence rate was 81.6%. Among the respondents with IS, 42.7% showed moderate signs, 27.2% frequent, and only 11.7% had an intense symptomatology. Level of education, female sex, and academic achievements were all identified as predictive factors of IS.

CONCLUSIONS

A total of 81.6% of respondents reported potentially significant levels. The implications of IS on both the outcomes in patients and the well-being of neurosurgeons should be evaluated in future studies.

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Giovanni Raffa, Thomas Picht, Antonino Scibilia, Judith Rösler, Johannes Rein, Alfredo Conti, Giuseppe Ricciardo, Salvatore Massimiliano Cardali, Peter Vajkoczy, and Antonino Germanò

OBJECTIVE

Surgical treatment of convexity meningiomas is usually considered a low-risk procedure. Nevertheless, the risk of postoperative motor deficits is higher (7.1%–24.7% of all cases) for lesions located in the rolandic region, especially when an arachnoidal cleavage plane with the motor pathway is not identifiable. The authors analyzed the possible role of navigated transcranial magnetic stimulation (nTMS) for planning resection of rolandic meningiomas and predicting the presence or lack of an intraoperative arachnoidal cleavage plane as well as the postoperative motor outcome.

METHODS

Clinical data were retrospectively collected from surgical cases involving patients affected by convexity, parasagittal, or falx meningiomas involving the rolandic region, who received preoperative nTMS mapping of the motor cortex (M1) and nTMS-based diffusion tensor imaging (DTI) fiber tracking of the corticospinal tract before surgery at 2 different neurosurgical centers. Surgeons’ self-reported evaluation of the impact of nTMS-based mapping on surgical strategy was analyzed. Moreover, the nTMS mapping accuracy was evaluated in comparison with intraoperative neurophysiological mapping (IONM). Lastly, we assessed the role of nTMS as well as other pre- and intraoperative parameters for predicting the patients’ motor outcome and the presence or absence of an intraoperative arachnoidal cleavage plane.

RESULTS

Forty-seven patients were included in this study. The nTMS-based planning was considered useful in 89.3% of cases, and a change of the surgical strategy was observed in 42.5% of cases. The agreement of nTMS-based planning and IONM-based strategy in 35 patients was 94.2%. A new permanent motor deficit occurred in 8.5% of cases (4 of 47). A higher resting motor threshold (RMT) and the lack of an intraoperative arachnoidal cleavage plane were the only independent predictors of a poor motor outcome (p = 0.04 and p = 0.02, respectively). Moreover, a higher RMT and perilesional edema also predicted the lack of an arachnoidal cleavage plane (p = 0.01 and p = 0.03, respectively). Preoperative motor status, T2 cleft sign, contrast-enhancement pattern, and tumor volume had no predictive value.

CONCLUSIONS

nTMS-based motor mapping is a useful tool for presurgical assessment of rolandic meningiomas, especially when a clear cleavage plane with M1 is not present. Moreover, the RMT can indicate the presence or absence of an intraoperative cleavage plane and predict the motor outcome, thereby helping to identify high-risk patients before surgery.

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Antonino Scibilia, Carmen Terranova, Vincenzo Rizzo, Giovanni Raffa, Adolfo Morelli, Felice Esposito, Raffaella Mallamace, Gaetano Buda, Alfredo Conti, Angelo Quartarone, and Antonino Germanò

Spinal tumor (ST) surgery carries the risk of new neurological deficits in the postoperative period. Intraoperative neurophysiological monitoring and mapping (IONM) represents an effective method of identifying and monitoring in real time the functional integrity of both the spinal cord (SC) and the nerve roots (NRs). Despite consensus favoring the use of IONM in ST surgery, in this era of evidence-based medicine, there is still a need to demonstrate the effective role of IONM in ST surgery in achieving an oncological cure, optimizing patient safety, and considering medicolegal aspects. Thus, neurosurgeons are asked to establish which techniques are considered indispensable. In the present study, the authors focused on the rationale for and the accuracy (sensitivity, specificity, and positive and negative predictive values) of IONM in ST surgery in light of more recent evidence in the literature, with specific emphasis on the role of IONM in reducing the incidence of postoperative neurological deficits. This review confirms the role of IONM as a useful tool in the workup for ST surgery. Individual monitoring and mapping techniques are clearly not sufficient to account for the complex function of the SC and NRs. Conversely, multimodal IONM is highly sensitive and specific for anticipating neurological injury during ST surgery and represents an important tool for preserving neuronal structures and achieving an optimal postoperative functional outcome.