bluuebunny/crossref_metadata_2025 huggingface dataset:
Reversible intracranial hypertension following treatment of an extracranial vascular malformation: case report
Authors: Pricola Fehnel Katie , Klein Jennifer , Warf Benjamin C. , Smith Edward R. , Orbach Darren B.
Published: February 2019

Pediatric hydrocephalus is a well-studied and still incompletely understood entity. One of the physiological means by which hydrocephalus and intracranial hypertension evolve is through perturbations to normal vascular dynamics. Here the authors report a unique case of an extracranial vascular anomaly resulting in persistently elevated intracranial pressures (ICPs) independent of CSF diversion in a patient with a Joubert syndrome–related disorder. The patient developed worsening intracranial hypertension after successful CSF diversion of Dandy-Walker malformation–associated hydrocephalus via endoscopic third ventriculostomy–choroid plexus cauterization (ETV/CPC). Vascular workup and imaging revealed an extracranial arteriovenous fistula of the superficial temporal artery at the site of a prior scalp intravenous catheter. Following microsurgical obliteration of the lesion, ICP normalized from > 30 cm H2O preoperatively to 11 cm H2O postoperatively. A repeat lumbar puncture at 4 months postoperatively again demonstrated normal pressure, and the patient remained asymptomatic for 9 months. Recurrent symptoms at 9 months were attributed to inadequate CSF diversion, and the patient underwent ventriculoperitoneal shunt placement. This is the first report of an extracranial-to-extracranial vascular anastomosis resulting in intracranial hypertension. This case report demonstrates the need to consider extracranial vascular anomalies as potential sources of persistently elevated ICP in the syndromic pediatric population.
Corpus callosotomy via laser interstitial thermal therapy: a case series
Authors: Palma Atilio E. , Wicks Robert T. , Popli Gautam , Couture Daniel E.
Published: February 2019

Corpus callosotomy has been used as a form of surgical palliation for patients suffering from medically refractory generalized seizures, including drop attacks. Callosotomy has traditionally been described as involving a craniotomy with microdissection. MR-guided laser interstitial thermal therapy (MRg-LITT) has recently been used as a minimally invasive method for performing surgical ablation of epileptogenic foci and corpus callosotomy. The authors present 3 cases in which MRg-LITT was used to perform a corpus callosotomy as part of a staged surgical procedure for a patient with multiple seizure types and in instances when further ablation of residual corpus callosum is necessary after a prior open surgical procedure. To the authors’ knowledge, this is the first case series of corpus callosotomy performed using the MRg-LITT system with a 3.3-year average follow-up. Although MRg-LITT is not expected to replace the traditional corpus callosotomy in all cases, it is a safe, effective, and durable alternative to the traditional open corpus callosotomy, particularly in the setting of a prior craniotomy.
Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative
Authors: Zakaria Hesham Mostafa , Bazydlo Michael , Schultz Lonni , Pahuta Markian A. , Schwalb Jason M. , Park Paul , Aleem Ilyas , Nerenz David R. , Chang Victor , _ _
Published: February 2019

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

METHODS

A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.
National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015
Authors: Sharma Mayur , Ugiliweneza Beatrice , Fortuny Enzo M. , Khattar Nicolas K. , Andaluz Noberto , James Robert F. , Williams Brian J. , Boakye Maxwell , Ding Dale
Published: February 2019

OBJECTIVE

The development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).

METHODS

The authors extracted data from the NIS database for the years 1998–2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.

RESULTS

A total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010–2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998–2011, bypass procedures for UIAs in 2012–2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.

CONCLUSIONS

Despite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors’ findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.
Effect of revascularization on cognitive outcomes in intracranial steno-occlusive disease: a systematic review
Authors: Kolb Bradley , Fadel Hassan , Rajah Gary , Saber Hamidreza , Luqman Ali , Rangel-Castilla Leonardo
Published: February 2019

OBJECTIVE

Steno-occlusive diseases of the cerebral vasculature have been associated with cognitive decline. The authors performed a systematic review of the existing literature on intracranial steno-occlusive disease, including intracranial atherosclerosis and moyamoya disease (MMD), to determine the extent and quality of evidence for the effect of revascularization on cognitive performance.

METHODS

A systematic search of PubMed/MEDLINE, the Thomson Reuters Web of Science Core Collection, and the KCI Korean Journal Database was performed to identify randomized controlled trials (RCTs) in the English-language literature and observational studies that compared cognitive outcomes before and after revascularization in patients with steno-occlusive disease of the intracranial vasculature, from which data were extracted and analyzed.

RESULTS

Nine papers were included, consisting of 2 RCTs and 7 observational cohort studies. Results from 2 randomized trials including 142 patients with symptomatic intracranial atherosclerotic steno-occlusion found no additional benefit to revascularization when added to maximal medical therapy. The certainty in the results of these trials was limited by concerns for bias and indirectness. Results from 7 observational trials including 282 patients found some cognitive benefit for revascularization for symptomatic atherosclerotic steno-occlusion and for steno-occlusion related to MMD in children. The certainty of these conclusions was low to very low, due to both inherent limitations in observational studies for inferring causality and concerns for added risk of bias and indirectness in some studies.

CONCLUSIONS

The effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.
Ideal sedation for stroke thrombectomy: a prospective pilot single-center observational study
Authors: Taqi M. Asif , Suriya Sajid S. , Sodhi Ajeet , Quadri Syed A. , Farooqui Mudassir , Zafar Atif , Mortazavi Martin M.
Published: February 2019

OBJECTIVE

Several retrospective studies have supported the use of conscious sedation (CS) over general anesthesia (GA) as the preferred methods of sedation for stroke thrombectomy, but a recent randomized controlled trial showed no difference in outcomes after CS or GA. The purpose of the Ideal Sedation for Stroke Thrombectomy (ISST) study was to evaluate the difference in time and outcomes in the reperfusion of anterior circulation in ischemic stroke using GA and monitored anesthesia care (MAC).

METHODS

The ISST study was a prospective, open-label registry. A total of 40 patients who underwent mechanical thrombectomy for anterior circulation ischemic stroke were enrolled. Informed consent was obtained from each patient before enrollment. The primary endpoint included the interval between the patient’s arrival to the interventional radiology room and reperfusion time. Secondary endpoints were evaluated to estimate the effects on the outcome of patients between the 2 sedation methods.

RESULTS

Of the 40 patients, 32 received thrombectomy under MAC and 8 patients under GA. The male-to-female ratio was 18:14 in the MAC group and 4:4 in the GA group. The mean time from interventional radiology room arrival to reperfusion in the GA group was 2 times higher than that in the MAC group. Complete reperfusion (TICI grade 3) was achieved in more than 50% of patients in both groups. The mean modified Rankin Scale score at 3 months was < 2 in the MAC group and > 3 in the GA group (p = 0.021).

CONCLUSIONS

The findings from the pilot study showed a significantly shorter time interval between IR arrival and reperfusion and better outcomes in patients undergoing reperfusion for ischemic stroke in the anterior circulation using MAC compared with GA.

Clinical trial registration no.: NCT03036631 (clinicaltrials.gov)
Extracranial-intracranial bypass approach to cerebral revascularization: a historical perspective
Authors: Soldozy Sauson , Costello John S. , Norat Pedro , Sokolowski Jennifer D. , Soldozy Kamron , Park Min S. , Tvrdik Petr , Kalani M. Yashar S.
Published: February 2019

While the majority of cerebral revascularization advancements were made in the last century, it is worth noting the humble beginnings of vascular surgery throughout history to appreciate its progression and application to neurovascular pathology in the modern era. Nearly 5000 years of basic human inquiry into the vasculature and its role in neurological disease has resulted in the complex neurosurgical procedures used today to save and improve lives. This paper explores the story of the extracranial-intracranial approach to cerebral revascularization.
National trends in cerebral bypass surgery in the United States, 2002–2014
Authors: Winkler Ethan A. , Yue John K. , Deng Hansen , Raygor Kunal P. , Phelps Ryan R. L. , Rutledge Caleb , Lu Alex Y. , Rodriguez Rubio Roberto , Burkhardt Jan-Karl , Abla Adib A.
Published: February 2019

OBJECTIVE

Cerebral bypass procedures are microsurgical techniques to augment or restore cerebral blood flow when treating a number of brain vascular diseases including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. With advances in endovascular therapy and evolving evidence-based guidelines, it has been suggested that cerebral bypass procedures are in a state of decline. Here, the authors characterize the national trends in cerebral bypass surgery in the United States from 2002 to 2014.

METHODS

Using the National (Nationwide) Inpatient Sample, the authors extracted for analysis the data on all adult patients who had undergone cerebral bypass as indicated by ICD-9-CM procedure code 34.28. Indications for bypass procedures, patient demographics, healthcare costs, and regional variations are described. Results were stratified by indication for cerebral bypass including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. Predictors of inpatient complications and death were evaluated using multivariable logistic regression analysis.

RESULTS

From 2002 to 2014, there was an increase in the annual number of cerebral bypass surgeries performed in the United States. This increase reflected a growth in the number of cerebral bypass procedures performed for adult moyamoya disease, whereas cases performed for occlusive vascular disease or cerebral aneurysms declined. Inpatient complication rates for cerebral bypass performed for moyamoya disease, vascular occlusive disease, and cerebral aneurysm were 13.2%, 25.1%, and 56.3%, respectively. Rates of iatrogenic stroke ranged from 3.8% to 20.4%, and mortality rates were 0.3%, 1.4%, and 7.8% for moyamoya disease, occlusive vascular disease, and cerebral aneurysms, respectively. Multivariate logistic regression confirmed that cerebral bypass for vascular occlusive disease or cerebral aneurysm is a statistically significant predictor of inpatient complications and death. Mean healthcare costs of cerebral bypass remained unchanged from 2002 to 20014 and varied with treatment indication: moyamoya disease $38,406 ± $483, vascular occlusive disease $46,618 ± $774, and aneurysm $111,753 ± $2381.

CONCLUSIONS

The number of cerebral bypass surgeries performed for adult revascularization has increased in the United States from 2002 to 2014. Rising rates of surgical bypass reflect a greater proportion of surgeries performed for moyamoya disease, whereas bypasses performed for vascular occlusive disease and aneurysms are decreasing. Despite evolving indications, cerebral bypass remains an important surgical tool in the modern endovascular era and may be increasing in use. Stagnant complication rates highlight the need for continued interest in advancing available bypass techniques or technologies to improve patient outcomes.
Novel rodent model for simulation of sylvian fissure dissection and cerebrovascular bypass under subarachnoid hemorrhage conditions: technical note and timing study
Authors: Perry Avital , Graffeo Christopher S. , Carlstrom Lucas P. , Anding William J. , Link Michael J. , Rangel-Castilla Leonardo
Published: February 2019

OBJECTIVE

Sylvian fissure dissection following subarachnoid hemorrhage (SAH) is a challenging but fundamental skill in microneurosurgery, and one that has become increasingly difficult to develop during residency, given the overarching management trends. The authors describe a novel rodent model for simulation of sylvian fissure dissection and cerebrovascular bypass under SAH conditions.

METHODS

A standardized microvascular anastomosis model comprising rat femoral arteries and veins was used for the experimental framework. In the experimental protocol, following exposure and skeletonization of the vessels, extensive, superficial (1- to 2-mm) soft-tissue debridement was conducted and followed by wound closure and delayed reexploration at intervals of 7, 14, and 28 days. Two residents dissected 1 rat each per time point (n = 6 rats), completing vessel skeletonization followed by end-to-end artery/vein anastomoses. Videos were reviewed postprocedure to assess scar score and relative difficulty of dissection by blinded raters using 4-point Likert scales.

RESULTS

At all time points, vessels were markedly invested in friable scar, and exposure was subjectively assessed as a reasonable surrogate for sylvian fissure dissection under SAH conditions. Scar score and relative difficulty of dissection both indicated 14 days as the most challenging time point.

CONCLUSIONS

The authors’ experimental model of femoral vessel skeletonization, circumferential superficial soft-tissue injury, and delayed reexploration provides a novel approximation of sylvian fissure dissection and cerebrovascular bypass under SAH conditions. The optimal reexploration interval appears to be 7–14 days. To the authors’ knowledge, this is the first model of SAH simulation for microsurgical training, particularly in a live animal system.
Cerebral revascularization after the Carotid Occlusion Surgery Study: what candidates remain, and can we do better?
Authors: White Timothy G. , Abou-Al-Shaar Hussam , Park Jung , Katz Jeffrey , Langer David J. , Dehdashti Amir R.
Published: February 2019

OBJECTIVE

Cerebral revascularization for carotid occlusion was previously a mainstay procedure for the cerebrovascular neurosurgeon. However, the 1985 extracranial-intracranial bypass trial and subsequently the Carotid Occlusion Surgery Study (COSS) provided level 1 evidence via randomized controlled trials against bypass for symptomatic atherosclerotic carotid occlusion disease. However, in a small number of patients optimal medical therapy fails, and some patients with flow-limiting stenosis develop a perfusion-dependent neurological examination. Therefore it is necessary to further stratify patients by risk to determine who may most benefit from this intervention as well as to determine perioperative morbidity in this high-risk patient population.

METHODS

A retrospective review was performed of all revascularization procedures done for symptomatic atherosclerotic cerebrovascular steno-occlusive disease. All patients undergoing revascularization after the publication of the COSS in 2011 were included. Perioperative morbidity and mortality were assessed as the primary outcome to determine safety of revascularization in this high-risk population. All patients had documented hypoperfusion on hemodynamic imaging.

RESULTS

At total of 35 revascularization procedures were included in this review. The most common indication was for patients with recurrent strokes, who were receiving optimal medical therapy and who suffered from cerebrovascular steno-occlusion. At 30 days only 3 perioperative ischemic events were observed, 2 of which led to no long-term neurological deficit. Immediate graft patency was good, at 94%. Long term, no further strokes or ischemic events were observed, and graft patency remained high at 95%. There were no factors associated with perioperative ischemic events in the variables that were recorded.

CONCLUSIONS

Cerebral revascularization may be done safely at high-volume cerebrovascular centers in high-risk patients in whom optimal medical therapy has failed. Further research must be done to develop an improved methodology of risk stratification for patients with symptomatic atherosclerotic cerebrovascular steno-occlusive disease to determine which patients may benefit from intervention. Given the high risk of recurrent stroke in certain patients, and the fact that patients fail medical therapy, surgical revascularization may provide the best method to ensure good long-term outcomes with manageable up-front risks.
Allogeneic adipose-derived mesenchymal stem cell sheet that produces neurological improvement with angiogenesis and neurogenesis in a rat stroke model
Authors: Ryu Bikei , Sekine Hidekazu , Homma Jun , Kobayashi Tomonori , Kobayashi Eiji , Kawamata Takakazu , Shimizu Tatsuya
Published: February 2019

OBJECTIVE

Stem cell therapy is a promising strategy for the treatment of severe cerebral ischemia. However, targeting sufficient grafted cells to the affected area remains challenging. Choosing an adequate transplantation method for the CNS appears crucial for this therapy to become a clinical reality. The authors used a scaffold-free cell sheet as a translational intervention. This method involves the use of cell sheet layers and allows the transplantation of a large number of cells, locally and noninvasively. The authors evaluated the effectiveness of allogeneic adipose tissue–derived mesenchymal stem cell sheets in a rat model of stroke.

METHODS

The animals, subjected to middle cerebral artery occlusion, were randomly divided in two groups: one in which a cell sheet was transplanted and the other in which a vehicle was used (n = 10/group). Over a period of 14 days after transplantation, the animals’ behavior was evaluated, after which brain tissue samples were removed and fixed, and the extent of angiogenesis and infarct areas was evaluated histologically.

RESULTS

Compared to the vehicle group, in the cell sheet group functional angiogenesis and neurogenesis were significantly increased, which resulted in behavioral improvement. Transplanted cells were identified within newly formed perivascular walls as pericytes, a proportion of which were functional. Newly formed blood vessels were found within the cell sheet that had anastomosed to the cerebral blood vessels in the host.

CONCLUSIONS

The transplantation approach described here is expected to provide not only a paracrine effect but also a direct cell effect resulting in cell replacement that protects the damaged neurovascular unit. The behavioral improvement seen with this transplantation approach provides the basis for further research on cell sheet–based regenerative treatment as a translational treatment for patients with stroke.
Incidence, classification, and treatment of angiographically occult intracranial aneurysms found during microsurgical aneurysm clipping of known aneurysms
Authors: Burkhardt Jan-Karl , Chua Michelle H. , Winkler Ethan A. , Rutledge W. Caleb , Lawton Michael T.
Published: February 2019

OBJECTIVE

During the microsurgical clipping of known aneurysms, angiographically occult (AO) aneurysms are sometimes found and treated simultaneously to prevent their growth and protect the patient from future rupture or reoperation. The authors analyzed the incidence, treatment, and outcomes associated with AO aneurysms to determine whether limited surgical exploration around the known aneurysm was safe and justified given the known limitations of diagnostic angiography.

METHODS

An AO aneurysm was defined as a saccular aneurysm detected using the operative microscope during dissection of a known aneurysm, and not detected on preoperative catheter angiography. A prospective database was retrospectively reviewed to identify patients with AO aneurysms treated microsurgically over a 20-year period.

RESULTS

One hundred fifteen AO aneurysms (4.0%) were identified during 2867 distinct craniotomies for aneurysm clipping. The most common locations for AO aneurysms were the middle cerebral artery (60 aneurysms, 54.1%) and the anterior cerebral artery (20 aneurysms, 18.0%). Fifty-six AO aneurysms (50.5%) were located on the same artery as the known saccular aneurysm. Most AO aneurysms (95.5%) were clipped and there was no attributed morbidity. The most common causes of failed angiographic detection were superimposition of a large aneurysm (type 1, 30.6%), a small aneurysm (type 2, 18.9%), or an adjacent normal artery (type 3, 36.9%). Multivariate analysis identified multiple known aneurysms (odds ratio [OR] 3.45, 95% confidence interval [CI] 2.16–5.49, p < 0.0001) and young age (OR 0.981, 95% CI 0.965–0.997, p = 0.0226) as independent predictors of AO aneurysms.

CONCLUSIONS

Meticulous inspection of common aneurysm sites within the surgical field will identify AO aneurysms during microsurgical dissection of another known aneurysm. Simultaneous identification and treatment of these additional undiagnosed aneurysms can spare patients later rupture or reoperation, particularly in those with multiple known aneurysms and a history of subarachnoid hemorrhage. Limited microsurgical exploration around a known aneurysm can be performed safely without additional morbidity.
The temporoinsular projection system: an anatomical study
Authors: Nachtergaele Pieter , Radwan Ahmed , Swinnen Stijn , Decramer Thomas , Uytterhoeven Mats , Sunaert Stefan , van Loon Johannes , Theys Tom
Published: February 2019

OBJECTIVE

Connections between the insular cortex and the amygdaloid complex have been demonstrated using various techniques. Although functionally well connected, the precise anatomical substrate through which the amygdaloid complex and the insula are wired remains unknown. In 1960, Klingler briefly described the “fasciculus amygdaloinsularis,” a white matter tract connecting the posterior insula with the amygdala. The existence of such a fasciculus seems likely but has not been firmly established, and the reported literature does not include a thorough description and documentation of its anatomy. In this fiber dissection study the authors sought to elucidate the pathway connecting the insular cortex and the mesial temporal lobe.

METHODS

Fourteen brain specimens obtained at routine autopsy were dissected according to Klingler’s fiber dissection technique. After fixation and freezing, anatomical dissections were performed in a stepwise progressive fashion.

RESULTS

The insula is connected with the opercula of the frontal, parietal, and temporal lobes through the extreme capsule, which represents a network of short association fibers. At the limen insulae, white matter fibers from the extreme capsule converge and loop around the uncinate fasciculus toward the temporal pole and the mesial temporal lobe, including the amygdaloid complex.

CONCLUSIONS

The insula and the mesial temporal lobe are directly connected through white matter fibers in the extreme capsule, resulting in the appearance of a single amygdaloinsular fasciculus. This apparent fasciculus is part of the broader network of short association fibers of the extreme capsule, which connects the entire insular cortex with the temporal pole and the amygdaloid complex. The authors propose the term “temporoinsular projection system” (TIPS) for this complex.
Gastrostomy tube placement increases the risk of ventriculoperitoneal shunt infection: a multiinstitutional study
Authors: Al-Holou Wajd N. , Wilson Thomas J. , Ali Zarina S. , Brennan Ryan P. , Bridges Kelly J. , Guivatchian Tannaz , Habboub Ghaith , Krishnaney Ajit A. , Lanzino Giuseppe , Snyder Kendall A. , Flanders Tracy M. , Than Khoi D. , Pandey Aditya S.
Published: February 2019

OBJECTIVE

Gastrostomy tube placement can temporarily seed the peritoneal cavity with bacteria and thus theoretically increases the risk of shunt infection when the two procedures are performed contemporaneously. The authors hypothesized that gastrostomy tube placement would not increase the risk of ventriculoperitoneal shunt infection. The object of this study was to test this hypothesis by utilizing a large patient cohort combined from multiple institutions.

METHODS

A retrospective study of all adult patients admitted to five institutions with a diagnosis of aneurysmal subarachnoid hemorrhage between January 2005 and January 2015 was performed. The primary outcome of interest was ventriculoperitoneal shunt infection. Variables, including gastrostomy tube placement, were tested for their association with this outcome. Standard statistical methods were utilized.

RESULTS

The overall cohort consisted of 432 patients, 47% of whom had undergone placement of a gastrostomy tube. The overall shunt infection rate was 9%. The only variable that predicted shunt infection was gastrostomy tube placement (p = 0.03, OR 2.09, 95% CI 1.07–4.08), which remained significant in the multivariate analysis (p = 0.04, OR 2.03, 95% CI 1.04–3.97). The greatest proportion of shunts that became infected had been placed more than 2 weeks (25%) and 1–2 weeks (18%) prior to gastrostomy tube placement, but the temporal relationship between shunt and gastrostomy was not a significant predictor of shunt infection.

CONCLUSIONS

Gastrostomy tube placement significantly increases the risk of ventriculoperitoneal shunt infection.
Chordoma of the corpus callosum: case report
Authors: Rinaldo Lorenzo , Priemer David S. , Vortmeyer Alexander O. , Cohen-Gadol Aaron A. , Brat Daniel J. , Mahajan Anita , Giannini Caterina , Burns Terry C.
Published: February 2019

Chordomas are neoplasms that typically arise from midline skeletal structures and rarely originate within the intradural compartment of the CNS. A chordoma arising from the corpus callosum has not been previously described. The authors report the surgical management of a chordoma originating within the splenium of the corpus callosum. To determine the incidence and distribution of intracranial intradural chordoma, a literature search for additional cases was performed. MEDLINE was searched using the MeSH keyword “chordoma,” yielding 2010 articles. These articles were screened for cases of primary intradural chordoma rostral to the craniocervical junction, which led to the identification of 46 relevant articles. The authors report the case of a 69-year-old man who initially presented with nonspecific neurological symptoms including spatial disorientation and cognitive decline. These symptoms eventually prompted intracranial imaging, including MRI, which revealed a ring-enhancing, heterogeneous, cystic mass localized within the splenium of the corpus callosum and extending into the bilateral ventricles. The lesion was believed to represent a high-grade glioma and the patient underwent a left interhemispheric approach and subtotal resection. After pathologic evaluation confirmed a diagnosis of an anaplastic chordoma, the patient underwent further resection. A gross-total resection (GTR) was achieved with a transfalcine approach to the contralateral portion of the tumor. Postoperatively, the patient had a partial left homonymous quadrantanopsia, but was otherwise at his neurological baseline. Proton beam radiotherapy was performed to the resection cavity but diffuse intraventricular disease ensued. The results of a literature search suggest that a chordoma arising in the corpus callosum has not been previously described. The present case demonstrates that chordomas can occur in the corpus callosum, and illustrates the utility of a transfalcine approach for GTR of lesions in this location, as well as the need for improved strategies to prevent intraventricular dissemination.
Contralateral progression after unilateral evacuation of bilateral chronic subdural hematomas: the volume relation ratio as prognostic factor?
Authors: Scheichel Florian , Popadic Branko , Ungersboeck Karl , Marhold Franz
Published: February 2019

OBJECTIVE

Unilateral evacuation of bilateral chronic subdural hematomas (bcSDHs) is associated with higher retreatment rates than an initial bilateral intervention. One reason for that is a possible progression in the size of the contralateral side after unilateral treatment. Thus, the authors focused their study on finding predictors of the need for contralateral retreatment.

METHODS

All patients who had undergone unilateral or bilateral evacuation of bcSDHs in the Department of Neurosurgery at the University Hospital of St. Poelten during a 5-year period (7/2012 to 6/2017) were retrospectively identified. The preoperative hematoma volume was calculated using the XYZ/2 method.

RESULTS

Of a total of 103 patients with bcSDHs, 61 patients underwent bilateral evacuation and 42 patients underwent unilateral evacuation. The retreatment rate after bilateral evacuation was significantly lower than that after unilateral evacuation (14.8% vs 31%, respectively; p = 0.049). Contralateral retreatment after unilateral evacuation was necessary in 9 patients (21.4%). The preoperative contralateral hematoma volume was significantly higher in those patients who needed contralateral retreatment after initial unilateral evacuation (68.4 cm3 vs 27.4 cm3, respectively; p < 0.001). Furthermore, the so-called volume relation ratio created by dividing the smaller by the larger hematoma volume was significantly higher when contralateral retreatment became necessary (0.56 vs 0.21, respectively; p < 0.001).

CONCLUSIONS

Patients needing evacuation of bcSDHs should be considered for primary bilateral evacuation if the hematoma volume on the smaller side is greater than 40 cm3 and the subsequent volume relation ratio is greater than 0.4.
Emergency endoscopic third ventriculostomy for blocked shunts? Univariate and multivariate analysis of independent predictors for failure
Authors: Chan David Y. C. , Tsang Anderson C. O. , Ho Wilson W. S. , Cheng Kevin K. F. , Li Lai F. , Tsang Frederick C. P. , Taw Benedict B. T. , Pu Jenny K. S. , Leung Gilberto K. K. , Lui Matthew W. M.
Published: February 2019

OBJECTIVE

Hydrocephalus with a blocked ventriculoperitoneal (VP) shunt is a life-threatening condition. Emergency endoscopic third ventriculostomy (ETV) is a potential treatment option. The aim of the study was to identify independent risk factors associated with failure of ETV in treating patients with blocked shunts.

METHODS

The authors retrospectively reviewed data from consecutive patients admitted for blocked shunt treated by ETV during the study period from 2000 to 2016. Univariate and multivariate analyses were performed to identify independent factors associated with failed ETV for blocked shunts, such as age, sex, history of CNS infection, number of previous shunt revisions, operations performed as an emergency or elective, number of specialists, and other factors.

RESULTS

In total, 121 patients underwent ETV during the study period. Of these, 31 patients (25.6%) had ETV for treatment of a blocked shunt. In 25 (80.6%) of 31 ETV was performed as an emergency procedure. There was no significant difference in the success rate of ETV depending on whether it was performed as an emergency procedure (64% [16/25]) or an elective procedure (66.7% [4/6]; OR 0.062, 95% CI 0.001–2.708; p = 0.149). Univariate and multivariate analyses identified that history of a CNS infection was an independent risk factor for failure of ETV in treating patients with a blocked shunt (OR 0.030, 95% CI 0.001–0.888; p = 0.043).

CONCLUSIONS

Emergency ETV had a comparable success rate as elective ETV. A history of CNS infection is an independent predictor of ETV failure in treating patients with blocked shunts.
Modulation of neural oscillations by vagus nerve stimulation in posttraumatic multifocal epilepsy: case report
Authors: Ilyas Adeel , Toth Emilia , Pizarro Diana , Riley Kristen O. , Pati Sandipan
Published: February 2019

The putative mechanism of vagus nerve stimulation (VNS) for medically refractory epilepsy is desynchronization of hippocampal and thalamocortical circuitry; however, the nature of the dose-response relationship and temporal dynamics is poorly understood. For greater elucidation, a study in a nonepileptic rat model was previously conducted and showed that rapid-cycle (RC) VNS achieved superior desynchrony compared to standard-cycle (SC) VNS. Here, the authors report on the first in-human analysis of the neuromodulatory dose-response effects of VNS in a patient with posttraumatic, independent, bilateral mesial temporal lobe epilepsy refractory to medications and SC-VNS who was referred as a potential candidate for a responsive neurostimulation device. During stereotactic electroencephalography (SEEG) recordings, the VNS device was initially turned off, then changed to SC-VNS and then RC-VNS settings. Spectral analysis revealed a global reduction of power in the theta (4–8 Hz) and alpha (8–15 Hz) bands with both SC- and RC-VNS compared to the stimulation off setting (p < 0.001). Furthermore, in the alpha band, both SC- and RC-VNS were associated with greater global desynchrony compared to the off setting (p < 0.001); and, specifically, in the bilateral epileptogenic hippocampi, RC-VNS further reduced spectral power compared to SC-VNS (p < 0.001). The dose-response and temporal effects suggest that VNS modulates regional and global dynamics differently.
Neuroendoscopic fenestration of glioependymal cysts to the ventricle: report of 3 cases
Authors: Alvarado Anthony M. , Smith Kyle A. , Chamoun Roukoz B.
Published: February 2019

Glioependymal cysts are rare congenital lesions of the central nervous system. Reported surgical treatments of these lesions have varied and yielded mixed results, and the optimal surgical strategy is still controversial. The authors here report the clinical and surgical outcomes for three adult patients successfully treated with neuroendoscopic fenestration into the ventricular system. The patients had presented with symptomatic glioependymal cysts in the period from 2013 to 2016 at the authors’ institution. All underwent minimally invasive neuroendoscopic fenestration of the glioependymal cyst into the lateral ventricle via a stereotactically guided burr hole. Presenting clinical and radiological findings, operative courses, and postintervention outcomes were evaluated.

All three patients initially presented with symptoms related to regional mass effect of the underlying glioependymal cyst, including headaches, visual disturbances, and hemiparesis. All patients were successfully treated with endoscopic fenestration of the cyst wall into the lateral ventricle, where the wall was thinnest. Postoperatively, all patients reported improvement in their presenting symptoms, and neuroimaging demonstrated decompression of the cyst. Clinical follow-up ranged from 4 months to 5 years without evidence of reexpansion of the cyst or shunt requirement.

Compared to open resection and shunting of the cyst contents, minimally invasive endoscopic fenestration of a glioependymal cyst into the ventricular system is a safe and effective surgical option. This approach is practical, is less invasive than open resection, and appears to provide a long-term solution.
Neurochemical effects of motor cortex stimulation in the periaqueductal gray during neuropathic pain
Authors: de Andrade Emerson Magno , Martinez Raquel C. R. , Pagano Rosana L. , Lopes Patricia S. S. , Auada Aline V. V. , Gouveia Flavia V. , Antunes Geiza F. , Assis Danielle V. , Lebrun Ivo , Fonoff Erich T.
Published: February 2019

OBJECTIVE

Motor cortex stimulation (MCS) is a neurosurgical technique used to treat patients with refractory neuropathic pain syndromes. MCS activates the periaqueductal gray (PAG) matter, which is one of the major centers of the descending pain inhibitory system. However, the neurochemical mechanisms in the PAG that underlie the analgesic effect of MCS have not yet been described. The main goal of this study was to investigate the neurochemical mechanisms involved in the analgesic effect induced by MCS in neuropathic pain. Specifically, we investigated the release of γ-aminobutyric acid (GABA), glycine, and glutamate in the PAG and performed pharmacological antagonism experiments to validate of our findings.

METHODS

Male Wistar rats with surgically induced chronic constriction of the sciatic nerve, along with sham-operated rats and naive rats, were implanted with both unilateral transdural electrodes in the motor cortex and a microdialysis guide cannula in the PAG and subjected to MCS. The MCS was delivered in single 15-minute sessions. Neurotransmitter release was evaluated in the PAG before, during, and after MCS. Quantification of the neurotransmitters GABA, glycine, and glutamate was performed using a high-performance liquid chromatography system. The mechanical nociceptive threshold was evaluated initially, on the 14th day following the surgery, and during the MCS. In another group of neuropathic rats, once the analgesic effect after MCS was confirmed by the mechanical nociceptive test, rats were microinjected with saline or a glycine antagonist (strychnine), a GABA antagonist (bicuculline), or a combination of glycine and GABA antagonists (strychnine+bicuculline) and reevaluated for the mechanical nociceptive threshold during MCS.

RESULTS

MCS reversed the hyperalgesia induced by peripheral neuropathy in the rats with chronic sciatic nerve constriction and induced a significant increase in the glycine and GABA levels in the PAG in comparison with the naive and sham-treated rats. The glutamate levels remained stable under all conditions. The antagonism of glycine, GABA, and the combination of glycine and GABA reversed the MCS-induced analgesia.

CONCLUSIONS

These results suggest that the neurotransmitters glycine and GABA released in the PAG may be involved in the analgesia induced by cortical stimulation in animals with neuropathic pain. Further investigation of the mechanisms involved in MCS-induced analgesia may contribute to clinical improvements for the treatment of persistent neuropathic pain syndromes.
Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures
Authors: Linzey Joseph R. , Burke James F. , Nadel Jeffrey L. , Williamson Craig A. , Savastano Luis E. , Wilkinson D. Andrew , Pandey Aditya S.
Published: February 2019

OBJECTIVE

It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery.

METHODS

This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively.

RESULTS

Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70–79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00.

CONCLUSIONS

Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.
The effect of ICP monitoring in severe traumatic brain injury: a propensity score–weighted and adjusted regression approach
Authors: Rønning Pål , Helseth Eirik , Skaga Nils-Oddvar , Stavem Knut , Langmoen Iver A.
Published: February 2019

OBJECTIVE

The use of intracranial pressure (ICP) monitoring has been postulated to be beneficial in patients with severe traumatic brain injury (TBI), although studies investigating this hypothesis have reported conflicting results. The objective of this study was to evaluate the effect of inserting an ICP monitor on survival in patients with severe TBI.

METHODS

The Oslo University Hospital trauma registry was searched for the records of all patients admitted between January 1, 2002, and December 31, 2013, who fulfilled the Brain Trauma Foundation criteria for intracranial hypertension and who survived at least 24 hours after admission. The impact of ICP monitoring was investigated using both a logistic regression model and a multiple imputed, propensity score–weighted logistic regression analysis.

RESULTS

The study involved 1327 patients, in which 757 patients had an ICP monitor implanted. The use of ICP monitors significantly increased in the study period (p < 0.01). The 30-day overall mortality was 24.3% (322 patients), divided into 35.1% (200 patients, 95% confidence interval [CI] 31.3%–39.1%) in the group without an ICP monitor and 16.1% (122 patients, 95% CI 13.6%–18.9%) in the group with an ICP monitor. The impact of ICP monitors on 30-day mortality was found to be beneficial both in the complete case analysis logistic regression model (odds ratio [OR] 0.23, 95% CI 0.16–0.33) and in the adjusted, aggregated, propensity score–weighted imputed data sets (OR 0.22, 95% CI 0.15–0.35; both p < 0.001). The sensitivity analysis indicated that the findings are robust to unmeasured confounders.

CONCLUSIONS

The authors found that the use of an ICP monitor is significantly associated with improved survival in patients with severe head injury.