Editor Choice: Presurgical nTMS Language Mapping

Background: Navigated transcranial magnetic stimulation (nTMS) is increasingly used in presurgical brain mapping. Preoperative nTMS results correlate well with direct cortical stimulation (DCS) data in the identification of the primary motor cortex. Repetitive nTMS can also be used for mapping of speech-sensitive cortical areas.

Objective: The current cohort study compares the safety and effectiveness of preoperative nTMS with DCS mapping during awake surgery for the identification of language areas in patients with left-sided cerebral lesions.

Methods: Twenty patients with tumors in or close to left-sided language eloquent regions were examined by repetitive nTMS before surgery. During awake surgery, language-eloquent cortex was identified by DCS. nTMS results were compared for accuracy and reliability with regard to DCS by projecting both results into the cortical parcellation system.

Free Editor Choice with CME: Single or Double Nerve Transfer

Background: The recovery of elbow flexion in upper brachial plexus injury can be achieved by the reinnervation of the biceps muscle (single reinnervation), but concomitant restoration of brachialis and biceps function (double reinnervation) has been recommended to improve elbow flexion strength.

Objective: To prospectively compare morbidity and outcomes of single or double muscle reinnervation in restoring elbow flexion following incomplete injury to the brachial plexus.

Methods: Forty consecutive patients were prospectively submitted to single or double muscle reinnervation. Elbow flexion strength was evaluated with a push-and-pull dynamometer 12 months after surgery. Hand morbidity related to the procedures was evaluated by the Semmes-Weinstein monofilaments test, quantification of static 2-point discrimination, and measurements of handgrip and lateral pinch strength in serial evaluations up to the final follow-up.

Editor Choice: Delayed Infarctions and Vasospasm Following SAH

Background: Delayed cerebral ischemia is common after aneurysmal subarachnoid hemorrhage (aSAH) and is a major contributor to poor outcome. Yet, although generally attributed to arterial vasospasm, neurological deterioration may also occur in the absence of vasospasm.

Objective: To determine the relationship between delayed infarction and angiographic vasospasm and compare the characteristics of infarcts related to vasospasm vs those unrelated.

Methods: A retrospective review of patients with aSAH admitted from July 2007 through June 2011. Patients were included if they were admitted within 48 hours of SAH, had a computed tomography scan both 24 to 48 hours following aneurysm treatment and ≥7 days after SAH, and had a catheter angiogram to evaluate for vasospasm. Delayed infarcts seen on late computed tomography but not postprocedurally were attributed to vasospasm if there was moderate or severe vasospasm in the corresponding vascular territory on angiography. Infarct volume was measured by perimeter tracing.

Free Editor Choice with CME: Subarachnoid Hemorrhage With Negative Initial Catheter Angiography

Background: Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial.

Objective: To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging.

Methods: Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram.

Free Editor Choice: Results of Universal Protocol Implementation

Background: Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals.

Objective: To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute.

Methods: The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation.