bluuebunny/crossref_metadata_2025 huggingface dataset:
121 Development and Validation of a Predictive Score for Lumbar Synovial Cyst Recurrence
Authors: Page Paul , Greeneway Garret , Ammanuel Simon G. , Resnick Daniel K.
Published: March 2023

INTRODUCTION:

Lumbar Synovial Cysts represent a relatively rare clinical pathology that may result in radiculopathy or neurogenic claudication. Due to their potential for recurrence, some authors advocate for segmental fusion, as opposed to decompression alone, as a way to eliminate the risk for recurrence.

METHODS:

A retrospective review was conducted of all patients evaluated at a single center over 20 years who were found to have symptomatic lumbar synovial cysts requiring intervention. Only patients undergoing decompression without fusion were included in the analysis. Following this, baseline characteristics were obtained as well as radiographic information. A machine learning method (RiskSLIM) was then utilized to create a risk stratification score to identify patients at high risk for symptomatic cyst recurrence requiring repeat surgical intervention. Following this a 5-fold cross validation was completed.

RESULTS:

In total 89 patients were identified to have complete radiographic information. Of these, 11 patients developed cyst recurrence requiring reoperation. The Lumber Synovial Cyst Score (LSCS) was then created with an area under the curve of 0.83 with CAL error of 11.0%. Predicative factors were found to include facet inclination angle greater than 45 degrees, canal stenosis greater than 50%, T2 joint space hyperintensity, and presence of grade I spondylolisthesis. The probability of cyst recurrence ranged from < 5% for a score of 2 or less and > 88% for a score of 7.

CONCLUSIONS:

The LSCS model is a quick and accurate tool to assist in clinical decision making in treatment of lumbar synovial cysts.
136 Morphological Clusters of Chiari I Patients With Variable Response After Suboccipital Decompression
Authors: Nanda Pranav , Kons Zachary , Talati Pratik , Khanna Arjun , Shannon Elizabeth , Grannan Ben L. , Abulnaga Mazdak , Shnitzer Tal , Kahle Kristopher , Butler William
Published: March 2023

INTRODUCTION:

Chiari malformation type I (CM-I) can cause debilitating neurologic symptoms, most notably distinctive headaches, and the only existing definitive treatment is suboccipital decompression. While CM-I is typically defined as ≥5 mm downward displacement of cerebellar tonsils, overall CM-I cerebellar morphology is highly heterogeneous, and it is uncertain if this variability represents distinct patient populations or influences clinical response to suboccipital decompression.

METHODS:

186 adult CM-I patients with high-resolution T1-MRIs were retrospectively identified. Each patient’s cerebellum was non-linearly and diffeomorphically transformed to template brain, with this transformation’s inverse representing cerebellar deformation. A similarity matrix was generated between patients’ deformations using the Pearson correlation coefficient of their inverse transformations’ log Jacobian determinants within each cerebellar lobule. Spectral clustering was performed on this similarity matrix to identify patient clusters. Headache freedom after suboccipital decompression was compared between clusters by Kaplan-Meier analysis.

RESULTS:

Three morphological clusters of CM-I patients were identified. Cluster A is characterized by posteroinferior cerebellar fullness and platybasia; B by midline anterior-posterior compression; C solely by tonsillar descent. After suboccipital decompression, headaches were found to recur more frequently and sooner in Cluster B (p < 0.01).

CONCLUSIONS:

These analyses suggest that CM-I encapsulates morphologically distinct subtypes, here identified as Cluster A and Cluster B, with Cluster C representing an intermediate phenotype. These clusters vary significantly in clinical response to suboccipital decompression, which may have implications for surgical patient selection or operative technique. Future research should involve independent validation of this cluster scheme and optimization of treatment for patients in Cluster B, which is found here to have poorer surgical outcomes.
153 Utilizing a 32-Channel System for Treatment of Complex Movement Disorders: Initial Case Series
Authors: Sherman Benjamin , Ahmed Mahad , Tov Lior Lev , Verhein Jessica , Hornbeck Traci , Halpern Casey H. , Katz Maya , Henderson Jaimie M. , Buch Vivek
Published: March 2023

INTRODUCTION:

Complex, mixed movement disorders affecting multiple pathways (e.g., Holme’s Tremor (HT) or comorbid essential tremor (ET) with dystonia, among others) represent significant challenges for surgical treatment. These disease states are likely the result of combined or complex network pathologies, requiring multi-nodal targeting for DBS.

METHODS:

Multiple simultaneous deep targets were implanted using four 8-contact, directional leads placed through 2 burr-holes, which were connected to a 32-channel pulse generator. Targets were chosen based on disorders and comorbidities.

RESULTS:

Seven complex movement disorder patients were operated on at Stanford University using the approach described above. All seven patients in the series reported significant improvement in symptoms, and four patients also had objective metrics recorded demonstrating significant improvements. In these four patients, patient A presented with DBS-refractory Parkinsonian tremor and showed additional 17% reduction in UPDRS after addition of a third lead from an existing burr hole, utilizing the 32-channel system. Similarly patient C with HT and patients D and E with ET/dystonia all demonstrated significant improvement in TRS (p < 0.01) and dystonic symptoms after bilateral dual targeting of VIM and GPi through two burr-holes. Programming utilized tailored fractionation and stimulation parameters to achieve optimal results.

CONCLUSIONS:

We present the largest initial case series demonstrating the feasibility of a 32-channel multi-target DBS strategy for treating complex movement disorders. This approach warrants further investigation for treating complex, multi-circuit neuropsychiatric disorders.
169 Exome Sequencing Implicates Endothelial Ras Signaling Network in Vein of Galen Aneurysmal Malformation
Authors: Mekbib Kedous Y. , Zhao Shujuan , Nelson-Williams Carol , Prendergast Andrew , Zeng Xue , Rolle Myron , Shohfi John , Smith Hannah , Ocken Jack , Moyer Quentin , Piwowarczyk Paulina , Allington Garrett , Dong Weilai , van der Ent Martijn A. , Chen Di , Li Boyang , Duran Daniel , Mane Shrikant M. , Walcott Brian Patrick , Stapleton Christopher J. , Aagaard-Kienitz Beverly , Rodesch Georges , Jackson Eric M. , Smith Edward R. , Orbach Darren , Berenstein Alejandro , Bilguvar Kaya , Zhao Hongyu , Erson-Omay Zeynep , King Philip D. , Huttner Anita , Lifton Richard , Boggon Titus , Nicoli Stefania , Jin Sheng Chih , Kahle Kristopher
Published: March 2023

INTRODUCTION:

Early neurovascular development is a complex and intricate process with devastating consequences when impaired. Vein of Galen Aneurysmal Malformations (VGAMs) are the most common and severe neonatal arteriovenous malformation and often present with high-output heart failure, hydrocephalus, neurodevelopmental delay, and brain hemorrhage. Despite their prevalence and severity, little is known regarding their genetic pathomechanism.

METHODS:

Genetic samples were collected from 114 VGAM probands, including 90 trios, from multiple sites. Collected specimens underwent whole exome sequencing, pathway analysis, and select ACVRL1 and EPHB4 mutations identified via sequencing were then studied in zebrafish models.

RESULTS:

Exome sequencing revealed a genome-wide significant burden of de novo mutations in Ras suppressor p120 Ras-GAP (RASA1) (enrichment = 324-fold; p = 4.8 x 10-7). Damaging transmitted variants were enriched in p120 Ras-GAP negative regulator Eph-B4 (EPHB4) (odds ratio = 27.4; p = 1.7 x 10-6). Eph-B4 missense variants caused loss of receptor tyrosine kinase activity constitutive Ras activation. Other probands had pathogenic variants in OMIM vascular disease genes PTNPN11, NOTCH1, and ACVRL1; the latter we found mutated in an ultra-rare multi-generational VGAM family. Pathway analysis identified enrichment of rare, damaging de novo and inherited variants in a network of interacting OMIM vascular disease genes involved in axon guidance (FDR = 2.3 x 10-5; enrichment = 3.65-fold). In zebrafish, the functional studies of ACVRL1 and EPHB4 confirmed severe vascular defects in mutant embryos.

CONCLUSIONS:

These results demonstrate that genetic regulation of a RASA1-centered Ras signaling hub is critical for cerebrovascular development and is impaired in VGAM pathogenesis. This finding has significant implications for the genetic counseling of patient families and the development of targeted therapeutics for VGAM neurovascular disorders.
172 Health Inequities in Access to Treatment for Unruptured Intracranial Aneurysms in the United States over 20 Years
Authors: Kandregula Sandeep , Savardekar Amey R. , Beyl Robbie , Caskey Joshua , Jee Elizabeth , Terrell Danielle , Adeeb Nimer , Whipple Garrett , Newman W. Christopher , Toms Jamie , Kosty Jennifer , Sharma Panjak , Cuellar Hugo , Guthikonda Bharat
Published: March 2023

INTRODUCTION:

Literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed across time.

METHODS:

The National Inpatient Sample (NIS) database was queried using diagnostic and procedural codes for adult patients who underwent open surgical or endovascular treatment for UIA. Aneurysmal SAH patients were used as a substitute control for patients with intracranial aneurysms that progressed to hemorrhage before intervention. A multivariable logistic regression model was constructed using patient factors and hospital factors to identify predictors of treatment.

RESULTS:

A total of 213,350 UIA patients and 173,375 aSAH patients from 2000-2019 were included in the final analysis. After adjusting for covariates, Black patients (0.715, 95% CI 0.699-0.730), Hispanic patients (0.734, 95% CI 0.717-0.751) and other racial/ethnic minority patients (0.633, 95% CI 0.617-0.651) had lower odds of intervention for UIA compared to White patients with UIA. Medicare patients had higher odds of treatment than private insurance patients while Medicaid and the uninsured patients had lower odds. Non-White/Hispanic females (0.697, 95% CI 0.646-0.752) and males (0.602, 95%CI 0.556-0.651) had lower treatment odds than their white counterparts, irrespective of insurance status. Multivariable regression analysis revealed that the treatment odds of Black patients improved over time, while other minority group patients had variable treatment odds over time.

CONCLUSIONS:

This analysis of NIS data from 2000 to 2019 demonstrates disparities in treatment for UIA across race, sex, insurance status, and hospital factors. The persistence of inequalities over time requires attention in order to target improvement.
175 Patient Safety Indicator 04 Does not Consistently Identify Failure to Rescue in the Neurosurgical Population
Authors: Azad Tej D. , Rodriguez Emily , Raj Divyaansh , Xia Yuanxuan , Materi Joshua , Rincon Torroella Jordina N. , Gonzalez L. Fernando , Suarez Jose , Tamargo Rafael Jesus , Brem Henry , Haut Elliot , Bettegowda Chetan
Published: March 2023

INTRODUCTION:

Patient safety indicator (PSI) 04 is a quality index designed by the Agency for Health Research and Quality to measure Failure to Rescue (FTR). PSI 04 has been scrutinized for inaccurately measuring FTR, a framework developed to capture a hospital’s ability to identify and manage preventable complications and post-operative mortality.

METHODS:

We conducted a single-center retrospective cohort study. We identified patients from 1/12/2017-6/1/2021 who sustained a PSI 04-attributed complication (pneumonia, deep venous thrombosis/pulmonary embolism (DVT/PE), sepsis, shock/cardiac arrest, or gastrointestinal (GI) hemorrhage/acute ulcer), underwent a neurosurgical procedure, and had inpatient mortality. The primary outcome was whether the attributed PSI 04 designation was the primary driver of mortality.

RESULTS:

We identified 67 patients who met PSI 04 criteria (median age, 61; female sex, 43.4%). Nearly 20% of patients met the PSI complication criteria prior to admission. Patients who underwent emergent bedside procedures were more likely to present with poor GCS (P = 0.016), more likely to be intubated prior to admission (P = 0.016), and less likely to have mortality due to a PSI 04-related complication (P = 0.002). PSI 04-related complications were identified as the cause of death in only 43.2% of cases. Procedures occurring in the interventional radiology suite (OR, 23.2; 95% CI, 3.5-229.3; P = 0.003) or the operating room (OR, 6.2; 95% CI, 1.25-39.5; P = 0.03) were more likely to have mortality due to a PSI 04-related complication compared to bedside procedures.

CONCLUSIONS:

Most neurosurgical procedures meeting PSI 04 criteria took place outside of a traditional operating room and may capture a fundamentally different patient population. 65.7% of patients were inappropriately flagged as meeting PSI 04 criteria. PSI 04 currently identifies patients with complications unrelated to operating room procedures. Improvement in patient safety within neurosurgery necessitates the development of a subspecialty specific measure to capture FTR.
184 Clinical Outcomes of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicentre Study
Authors: Soliman Mohamed A. R. , Diaz-Aguilar Luis Daniel , Khan Asham , San Miguel Jose , Amaral Rodrigo Augusto , Lee Bryan S. , Abd-El-Barr Muhammad M. , Massey Gene , McMains Craig , Schwartz David Gary , Deol Gurvinder , Nguyen Andrew D. , Smith Tyler , Pimenta Luiz , Taylor William R. , Pollina John
Published: March 2023

INTRODUCTION:

The prone transpsoas lateral lumbar interbody fusion (PTP) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of the literature on the clinical outcomes of this procedure, with all the published being of a small sample size.

METHODS:

A retrospective electronic medical records review was conducted in ten centers for patients who underwent PTP. We collected the intraoperative data (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries), postoperative complications, the patient-reported outcome measures (PROMS) such as back pain visual analogue scale (VAS), and hospital stay.

RESULTS:

A total of 350 patients were included in the study. There was a significant improvement in the mean VAS by 4.4 ± 6.7 (p < 0.001). 2.8% had ALL rupture, 1.2% had cage subsidence, 0.4% had a vascular injury, and none had visceral injuries. The mean operative time was 229.9 ± 144 minutes, the mean EBL was 134.3±210.2 mL, and the mean hospital stay was 2.6 ± 2.2. In regard to postoperative complications, there was 8.9% new sensory symptoms, 6% transient hip flexor weakness, 1.4% wound infection, 1.4% cage subsidence, 0.6% psoas hematoma, 0.3% ureteric injury, 0.3% small bowel obstruction/ischemia, and 1.6% 90-days readmission.

CONCLUSIONS:

Multicenter consecutive case series show that PTP is well tolerated and has satisfactory clinical outcomes.
195 Aberrant Brain Biomechanics Initiates Ventricular Dilation in a Genetic Subtype of Congenital Hydrocephalus
Authors: Phan Duy , Dahl Peter , Koundal Sunil , Pedram Maysam , Deniz Engin , Benveniste Helene , Malvankar Nikhil , Kahle Kristopher
Published: March 2023

INTRODUCTION:

We have previously shown using human genetics and mouse models that TRIM71 is a bona fide disease gene causing human congenital hydrocephalus. Disease-associated mutations in TRIM71 disrupt neural stem cell proliferation, however how these developmental effects physiologically lead to ventricular dilation is not clear.

METHODS:

We developed a number of novel methods to characterize cerebrospinal fluid (CSF) circulation, including cilia-generated currents and bulk flow. We then used these methods to comprehensively characterize CSF dynamics and intracranial physiology in hydrocephalic Trim71R595H/+ mice that harbor the same point mutation found in human hydrocephalus patients.

RESULTS:

We found that in hydrocephalic Trim71R595H/+ mice, impaired neurogenesis results in a hypoplastic cerebrocortical wall that exhibits loss of stiffness and elasticity. This leads to a floppy hypercompliant state wherein the brain parenchyma is unable to hold the pressure exerted by CSF, thereby facilitating passive pooling of CSF and secondary distention of the ventricles. Ventriculomegaly occurs in the absence of altered cilia-generated CSF flow or congenital aqueductal obstruction. Neuroimaging studies in patients with TRIM71 mutations also suggest cortical hypoplasia as the primary physiological factor leading to secondary ventricular dilation and passive pooling of CSF.

CONCLUSIONS:

We highlight the importance of precisely regulated neural stem cell fate and neurogenesis for maintaining normal brain-CSF biomechanical interactions that limit ventricular expansion. We thus demonstrate that some or potentially many forms of CH are in fact a congenital brain malformation akin to microcephaly with secondarily enlarged ventricles rather than a primary disturbance in CSF circulation.
201 Descriptive Case Series of Oncologic Brachial Plexopathy at a Comprehensive Cancer Center
Authors: Lim Jaims , Moser Matthew , Popoola Daniel , Prasad Dheerendra , Fenstermaker Robert A. , Fabiano Andrew J. , Lipinski Lindsay
Published: March 2023

INTRODUCTION:

Primary compression or metastatic spread into the peripheral nervous system is an unfortunate sequela of solid-organ cancers and leads to serious pain and neurologic symptoms. Neoplastic brachial plexopathy is poorly understood and treatments vary based on systemic disease burden and symptoms.

METHODS:

After IRB approval, a systematic search of the medical record was conducted for patients with brachial plexopathy based on CPT from 2016 to 2020. Patients with direct neural infiltration and/or external compression by primary or metastatic tumor were included. Radiation-induced brachial plexopathy cases were excluded. Data were collected regarding demographics, primary cancer, symptoms, exam, pain management treatments, primary cancer management, and outcomes.

RESULTS:

A total of 15 patients were identified with either infiltrative or compressive brachial plexopathies. The most common primary cancer was breast. Other types included squamous cell carcinoma of the head and neck, renal cell carcinoma, cholangiocarcinoma, and prostate carcinoma. Patients presented with a diverse array of motor and sensory symptoms including proximal and distal upper extremity weakness, hand spasms, numbness and decreased sensation, paresthesia, and upper extremity swelling. The majority of included patients complained of pain of varying nature. Gabapentin, opioids, and pregabalin were the most common prescribed medications. Overall prognosis in patients with brachial plexus infiltration was poor and less than 1 year. There was little consensus on standardized treatment regimens and management for included patients with plexopathies.

CONCLUSIONS:

Neoplastic brachial plexopathy is a relatively uncommon, and perhaps underrecognized, pattern of metastatic disease or direct spread in solid organ malignancy and is often associated with severe symptoms and disability. This study highlights need for a multidisciplinary approach including medical oncology, neurosurgery, radiation medicine, pain management, and physical/occupational therapy.
202 Molecular Signature of Malignant Peripheral Nerve Sheath on Tumor Site
Authors: Smith Caitlyn , Rao Deepthi , Mesfin Fassil B.
Published: March 2023

INTRODUCTION:

Malignant peripheral nerve sheath tumors (MPNSTs) are rare, highly aggressive soft tissue sarcomas that may occur sporadically, in association with neurofibromatosis type I (NF1) or after radiotherapy (RT). High recurrence rates and distant metastases are common, with lung and bone being the most common sites, yet the anatomic distribution of molecular changes is largely unknown.

METHODS:

Using the cBioPortal platform and systematic bioinformatical-analysis of the Cancer Genome Atlas (MSKCC) Nature Genetics 2014 dataset, we screened the dataset for the ADAM3A gene in the completed gene panel and twelve MPNST patients [pulmonary (6), neck (1), chest-wall (2), calf (1), arm (2)] with were included in the study. Broadly, these twelve patients were categorized as primary-pulmonary MPNST (6) and non-pulmonary MPNST (6) subgroups.

RESULTS:

The putative copy-number alteration pattern involving the ADAM3A gene based on the primary site was distinct (p <0.0001). All six patients with primary-pulmonary MPNST showed ADAM3A amplification while all six patients with non-pulmonary MPNST demonstrated ADAM3A homodeletion. Remarkably, regardless of the underlying etiology and pathogenesis, ADAM3A amplification in primary-pulmonary MPNST was invariably noted across the board in sporadic (3), NF1-associated (2), and RT-associated (1) tumor samples (p <0.0001).

CONCLUSIONS:

The findings in this study highlight the site-specificity of the MPNST molecular landscape. Further studies are essential for understanding the underlying molecular implications, pathways, and the specific role of ADAM3A in pulmonary and non-pulmonary MPNSTs.
211 Subthalamic Nucleus Deep Brain Stimulation Engages Memory Networks in Patients With Parkinson’s Disease
Authors: Talati Pratik , Neudorfer Clemens , Kratter Ian , Jorge Ahmed , Henry Luke , Horn Andreas , Richardson Robert Mark
Published: March 2023

INTRODUCTION:

Parkinson’s disease (PD) patients with deep brain stimulation (DBS) implantation to the subthalamic nucleus (STN) often have neurocognitive side effects, but the modulated networks associated with their occurrence are largely unknown.

METHODS:

We localized electrodes and investigated brain connectivity seeding from stimulation volumes in patients that underwent subthalamic deep brain stimulation using a normative resting state functional connectome atlas composed of 1000 healthy subjects. Pre- and post-operative neuropsychological testing data was acquired before and after surgery using two similar memory paradigms (list recall and figure recall). The connectivity profiles associated with changes in these tests were calculated. Results were compared with automated meta-analysis maps calculated using neurosynth and neuroquery.

RESULTS:

41 patients were included in the analysis. Positive functional connections between stimulation sites and medial temporal lobe, medial prefrontal cortex, and parieto-occipital region were associated with improvement in list recall. This connectivity profile showed robustness in a leave-one-out cross-validation (R = 0.32, p = 0.027). A similar connectivity profile was associated with figure recall improvement, also robust to cross-validation (R = 0.30, p = 0.019). The profiles associated with the two tasks were able to cross-estimate performance on the respective other task (R = 0.45, p = 0.008; R = 0.26, p = 0.045). When comparing these connectivity profiles with meta-analytic maps in the neurosynth database, the cognitive terms involved with memory showed highest improvement. The neuroquery database areas of predicted activation overlapped with the connectivity maps in the midbody and posterior hippocampal region.

CONCLUSIONS:

This retrospective study relates modulation of brain networks associated with memory processing with improvements in two separate memory tasks.
212 Intra-Operative Near Real-Time Detection of Tumor Infiltration in IDH-Mutant Gliomas Using Desorption Electrospray Ionization-Mass Spectrometry (DESI-MS)
Authors: Garcia Diogo P. , Brown Hannah , Chen Rong , Jentoft Mark E. , Middlebrooks Erik , Chaichana Kaisorn L. , Cooks Graham , Quinones-Hinojosa Alfredo
Published: March 2023

INTRODUCTION:

Surgery remains the mainstay of treatment in gliomas. However, distinction between tumor infiltrated and non-infiltrated tissues remains a challenge with current surgical adjuncts, particularly at the margin. Isocitrate dehydrogenase (IDH) mutation is unique to IDH mutant glioma cells and can be used as a potential surrogate for tumor infiltration.

METHODS:

We conducted a prospective study, using intraoperative DESI-MS analysis on freshly obtained tissue samples to evaluate the presence of 2-hydroxyglutarate (2HG) by relative quantitation in comparison with an internal control (glutamate), with subsequent review of each smear by board-certified neuropathologist.

RESULTS:

Earlier iterations of our DESI-MS allowed for genotyping of the tumor with a total of 247 biopsies from a 49-patient study yielding sensitivity, specificity, and accuracy values of 89, 100, and 94% for core biopsies (n = 71). Subsequent improvement of DESI-MS, from absolute quantitation to relative measurement in comparison to glutamate (GLU) allowed for detection of IDH-mut infiltration at the margin. We have collected 183 biopsies (116 core and 67 margin) from 23 patients. Preliminary results of IDH mutation assessments of core biopsies indicate 93% sensitivity, 100% specificity, and 98% accuracy and margin biopsies indicate 88% sensitivity, 100% specificity, 94% accuracy, with turnover times averaging 3 minutes per patient. Tumor infiltration at the margin after surgical resection was detected in 88% of margin biopsies from IDH mutant tumors (30 of 34 biopsies).

CONCLUSIONS:

We present a novel system to allow intraoperative evaluation of tumor infiltration at the margin in IDH-mutant gliomas. Our method and its validation identified tumor infiltration beyond the surgical margins and serves as a foundation for future uses employing DESI-MS to allow for molecularly guided surgery in IDH-mut gliomas.
301 Natural History and Treatments of The Pediatrics’ Deep-Seated Brain Arteriovenous Malformations
Authors: Sattari Shahab Aldin , Yang Wuyang , Feghali James , Xu Risheng , Huang Judy
Published: March 2023

INTRODUCTION:

Literature is sparse about the hemorrhage risk associated with the pediatrics’ deep-seated brain AVMs (bAVMs) during the natural history and after treatment.

METHODS:

We retrospectively reviewed our institutional bAVM database from 1990 to 2019 and included pediatrics who had deep-seated bAVMs. We presented the annual hemorrhage risk; during the natural history and after treatments, and functional outcomes.

RESULTS:

After the screening of 914 patients, 31 pediatric cases; including 13 males and 18 females, with the mean (SD) age of 11.8 (4.4) were included. The most frequent presenting symptoms were headache (54.83%), weakness (38.7%), and seizure (22.5%). The mean (SD) of followed-up duration was 13.14 (12.5) years, during which 7(22.5%) AVMs were found obliterated, 10 (32.2%) individuals sustained hemorrhage, and the modified Rankin Score (mRS) worsened in 8 (25.8%) patients. The annual hemorrhage risk of natural history was 3.26% per patient, and the overall annual hemorrhage risk after treatment was 1.97% per patient. The annual hemorrhage risk in each treatment group was 0.64% per patient in radiosurgery, 6.3% per patient in surgery, and 6.29% per patient in embolization. Those with non-white race showed a trend of higher ruptured presentation (OR = 5 [0.84-41.68], p = 0.09). Female sex was associated with higher (OR = 13.076 [1.424-333.591], p = 0.048) and treatment radiosurgery was associated with lower (OR = 0.21 [0.03-1.02], p = 0.06) odds of follow-up hemorrhage. Headache presentation was associated with the lower odds of poor functional outcome (OR = 0.102 [0.011-0.670], p = 0.024).

CONCLUSIONS:

Given the substantial cumulative risk of lifelong hemorrhagic stroke in pediatric patients, timely definitive treatment is warranted. Radiosurgery treatment is beneficial when the risk-benefit profile is deemed favorable.
302 Super Mitochondria, the Next Super Therapy to Reverse Ischemic Damage in Stroke?
Authors: Monsour Molly , Gorsky Anna , Nguyen Hung , Castelli Vanessa , Lee Jea , Borlongan Cesario
Published: March 2023

INTRODUCTION:

Stroke represents a massive healthcare emergency, ranking in the top 5 causes of death and disability and impacting nearly 800,000 Americans annually. Current therapies are limited. A deeper analysis of the mechanisms of cell death after ischemic brain insult may usher novel safe and effective treatments. Mitochondrial damage serves as a key modulator of ischemic cell death, which may be reversible with transfer of healthy mitochondria from mesenchymal stem cells (MSCs) to ischemic neurons.

METHODS:

MSCs were grown under ambient condition (normal MSCs) (nMSCs) or metabolic switching paradigm involving exchanging galactose for glucose in the cell culture medium (switched MSCs) (sMSCs) then assayed for oxygen consumption rates using the Seahorse technology. Subsequently, primary neurons were subjected to OGD then co-cultured with either nMSCs or sMSCs, and assessed for cell viability, cell metabolism, mitochondrial reactive oxidative species mRNA, and mitochondrial ATP mRNA.

RESULTS:

Compared to nMSCs, sMSCs displayed robust mitochondrial respiration as evidenced by higher basal energy production, larger spare respiratory capacity, greater ATP production, and decreased proton (H+) leak. Co-culture of OGD-exposed neurons with sMSCs conferred increased cell viability and enhanced cell metabolism, coupled with reduced mitochondrial reactive oxidative species mRNA and elevated mitochondrial ATP mRNA, which were significantly better than those afforded by nMSCs.

CONCLUSIONS:

These findings suggest sMSCs generated “super” mitochondria. Metabolic switching produces healthy mitochondria that may enhance the mitochondrial transfer between MSCs and ischemic cells warranting consideration as a stroke therapeutic.
309 Mechanical Thrombectomy for Acute Basilar Artery Occlusion, Where Do We Stand? A Safety and Efficacy Analysis
Authors: Abbas Rawad , Chen Ching-Jen , Atallah Elias , El Naamani Kareem , Herial Nabeel , Gooch Michael , Jabbour Pascal , Rosenwasser Robert H. , Tjoumakaris Stavropoula I.
Published: March 2023

INTRODUCTION:

Acute basilar artery occlusion accounts for 1% of all ischemic strokes, but more often than not, leads to devastating neurological injury and mortality. Many institutions still opt for best medical therapy for this type of ischemic stroke, however there is increasing evidence that mechanical thrombectomy for these patients leads to better outcomes.

METHODS:

This study was a retrospective chart review of a prospectively maintained database for patients with acute basilar artery occlusion treated with mechanical thrombectomy from January 2014 through March 2022.

RESULTS:

Our study included a total of 74 patients. The mean age was 62.7 years and 55.4% were male. The most common comorbidity was hypertension (73%). The mean door to puncture time was 75 minutes and the mean procedure time was 54 minutes. 86.5% of patients had a good mTICI score (≥ 2b). There were 4 patients who had procedural complications, and symptomatic intracerebral hemorrhage occurred in 3 patients. At 90 days, 62.5% of patients had a favorable functional outcome (mRS, 0 – 3). The mortality rate was 32.4% and 2% during the hospital admission and at 90 days respectively. Finally, on univariate analysis, the need for adjunct treatment and higher presenting NIHSS score was associated with poor functional outcome at 90 days (p-value, 0.03 and <0.001 respectively). Shorter procedure time was associated with better revascularization (mTICI score ≥ 2b) (p-value, 0.0015).

CONCLUSIONS:

Our findings showed that MT is safe and effective for patients presenting with acute basilar artery conclusion and is in conjunction with previous literature. Final results from upcoming trials should hopefully establish MT as gold standard for these patients.
325 Evaluating the Utility of Repeat CT Scans in Patients With Isolated Traumatic Subarachnoid Hemorrhage
Authors: McNulty Jack , Nawabi Noah , Kilgallon John , Stopa Brittany M. , Smith Timothy R.
Published: March 2023

INTRODUCTION:

Subarachnoid hemorrhage (SAH) is a relatively common consequence of head trauma. Treatment of traumatic SAH (tSAH) patients often involves serial CT imaging to assess for expansile hemorrhage. However, evidence suggests that tSAH rarely leads to neurologic deterioration or necessitates neurosurgical intervention, particularly in patients who present neurologically intact. Thus, the current standard of care may be overly extensive.

METHODS:

Patients presenting to Mass General Brigham Hospitals with tSAH between 2000 and 2021 were eligible for inclusion. Patients were excluded if: (a) their SAH was non-traumatic, (b) they experienced another form of intracerebral hemorrhage, or (c) they had a documented GCS of 12 or lower. Univariate and multivariate regression models were used to analyze the retrospectively collected data.

RESULTS:

Overall, 293 patients were included, 130 of which were male. The most common mechanism of trauma was fall from standing (n = 171). 131 patients presented with other significant traumatic injuries in addition to their tSAH. The mean number of total CTs for all patients was 2.3, with 230 patients (78.50%) receiving at least two CT scans and 92 patients (31.40%) receiving three or more scans. Of the 230 patients receiving multiple scans, only 12 (5.22%) had any degree of documented hemorrhagic expansion. No patients developed acute neurologic deterioration or required neurosurgical intervention related to their bleed.

CONCLUSIONS:

The standard of care for tSAH patients centers on close observation and repeat CT imaging. However, these repeat CTs rarely demonstrate any degree of hemorrhagic expansion for patients who present neurologically intact. Excessive CT imaging is thus unlikely to affect patient management and potentially presents an unnecessary burden to both the patient and the hospital staff.
328 Incidence and Number of Missed Chemical Venous Thromboembolic Event Prophylactic Doses Predict the Development of Venous Thromboembolic Events in Traumatic Brain Injury Patients
Authors: Cole Kyril , Nguyen Sarah Elizabeth , Gelhard Savannah , Menacho Sarah Tamara , Grandhi Ramesh
Published: March 2023

INTRODUCTION:

Venous thromboembolic events (VTE) are a major concern in trauma and intensive care, with traumatic brain injury (TBI) patients at an elevated risk. Chemical VTE prophylaxis is used to prevent VTE development. Concerning TBI patients, achieving a fine balance between the risk of worsening hemorrhage and clot development is important. To date, there has been no correlation between the number of missed doses and VTE development in this population.

METHODS:

Data were retrospectively collected among 818 TBI patients admitted to a level I trauma center between 2015-2020.

RESULTS:

Overall VTE incidence was 9% (7.6% DVT; 3.2% PE; 1.7% both). Median time to DVT and PE was 7 (IQR: 4-11) and 5 days (IQR: 3-12), respectively. VTE occurred in 37.8% of patients who missed prophylactic doses and 28.4% who did not (p = 0.089). In patients who experienced a VTE, compared to non-VTE patients, missed chemical prophylaxis dosing was primarily due to a pending invasive procedure (44.8% vs. 25.2%, p = 0.02) and the presence of additional bleeding (13.8% vs. 2.8%, p = 0.005). Non-VTE patients missed prophylactic dosing primarily from patient or family refusal (42.1% vs. 3.4%, p < 0.001). VTE incidence was higher in patients receiving invasive neurosurgery (45.9% vs. 30.5%, p = 0.007). Univariate analysis demonstrated 4-6 total missed doses as predicting the highest VTE risk (OR 4.08, 95% CI: 1.53-10.86, p = 0.005). No VTE were seen in >7 missed doses, presumably due to an overall high mortality rate of 13.5%.

CONCLUSIONS:

This study is novel in showing the incidence and number of missed chemical VTE prophylaxis to predict an increased VTE risk in TBI patients. Our study suggests a threshold of 4 missed doses to be particularly important in this critical patient population.
336 Prognostic Significance of Plasma Insulin Level for Deep Venous Thrombosis in Patients with Severe Traumatic Brain Injury in Critical Care
Authors: Du Min , Tang Rui , Zhang Qing-Hong , Liu Haiyan , Ji Zongsu , Zhou Min
Published: March 2023

INTRODUCTION:

Whether insulin resistance is underlying the deep venous thrombosis (DVT) development in patients with traumatic brain injury (TBI) is elusive.

METHODS:

A prospective observational study of 73 severe TBI patients who had measurements of plasma insulin, glucose, glucagon-like peptide 1 (GLP-1), inflammatory factors, and hematological profile within 4 preset time periods during 2 weeks after TBI. Ultrasonic surveillance of DVT was tracked weekly. Two-way ANOVA analysis was applied to determine whether the factors could discriminate between patients with and without DVT. Partial correlations of insulin level with other variables were carried out in patients with or without DVT. Factors associated with DVT were analyzed by multivariable logistic regression. Neurological outcome 6 months after TBI was assessed for Glasgow Outcome Scale (GOS).

RESULTS:

Among patients with an average (SD) age of 53 ± 16 years, DVT developed in 20 patients (27%). The 14-day plasma insulin levels were higher in patients with DVT (P = 0.01). Platelet profile discriminated significantly between patients with and without DVT. None of other factors differed between the two groups. Patients with insulin therapy had significant higher insulin (P = 0.006), glucose (P < 0.001) and GLP-1 (P = 0.01) levels, and were more likely to develop DVT (60% vs. 15%, P < 0.001) with concomitant platelet depletion. Insulin levels correlated with glucose, GLP-1 levels, and platelet exclusively in patients without DVT. Conversely, in patients with DVT, insulin correlated negatively with GLP-1 level (r = -0.297, P = 0.016). Age (P = 0.01) and elevated insulin level at day 4-7 (P = 0.04) were independently associated with DVT. Patients with insulin therapy also showed worse GOS (P = 0.001).

CONCLUSIONS:

Elevated insulin level in the first 14 days after TBI may present insulin resistance in TBI, which was associated with consistent platelet activation, thus increasing risk of DVT.
343 Influence of Duraplasty on Clinical, Radiological, and Surgical Factors Associated with Syrinx Location in Children Treated for Chiari Malformation Type I and Syringomyelia: A Park-Reeves Syringomyelia Research Consortium Study
Authors: Emmert A. Scott , Yahanda Alexander T. , Limbrick David Delmar , Mangano Francesco T.
Published: March 2023

INTRODUCTION:

Analyses of factors associated with syrinx location in Chiari malformation type I (CM-I) and syringomyelia (SM) are limited by the low individual incidences of syringes in certain spinal cord segments but could have important clinical implications on surgical planning, interpretation of postoperative imaging, and outcomes.

METHODS:

The Park-Reeves Syringomyelia Research Consortium database of pediatric patients with CM-I with SM was queried for patients who underwent first-time operation for posterior fossa decompression with (PFDD) or without (PFD) duraplasty. Clinical, radiological, and surgical data were compared among patients with cervical, thoracic, cervicothoracic, and holocord syringes.

RESULTS:

390 patients (90 cervical, 41 thoracic, 149 cervicothoracic, and 110 holocord) were analyzed. PFDD enhanced the magnitude of change on postoperative imaging in patients with cervical syringes. Patients with cervical or cervicothoracic syringes who underwent PFDD were less likely to develop postsurgical headaches, nausea and vomiting, or infections. However, PFDD was associated with more complications less than 6 months after surgery in patients with thoracic syringes and more complications overall in patients with cervicothoracic and holocord syringes.

CONCLUSIONS:

In the largest multi-institutional analysis of the effects of syrinx location in CM-I with SM, patients with cervicothoracic and holocord syringes experienced the greatest magnitude of change on postoperative imaging parameters while those with thoracic syringes experienced the fewest and smallest magnitude of postoperative radiological changes. PFDD-associated enhancement of postoperative radiological changes in cervical, thoracic, and holocord syringes did not necessarily translate into improvements in clinical symptoms or complication rates following surgery. PFDD is associated with greater clinical benefit for patients with cervical or cervicothoracic syringes but is less appropriate for patients with thoracic syringes based on outcomes and complication profiles.
357 Image-Guided Farlateral Lumbar Foraminotomy and Microdiscectomy: Operative Technique and Outcomes
Authors: De Biase Gaetano , Garcia Diogo P. , Pirris Stephen M. , Nottmeier Eric W.
Published: March 2023

INTRODUCTION:

Three dimensional image-guidance is frequently used to improve the safety of complex spine surgeries. Its adoption remains mostly limited as and aid with instrumentation placement.

METHODS:

We performed a retrospective chart review of image-guided farlateral foraminotomies and microdiscectomies performed by a single surgeon from January 2018 to July 2021. Demographics, operative times and outcomes were collected. The stealth reference arc is fixated on the patient's skin using the Ioband. The O-arm is used to perform an intraoperative CT-scan automatically registered to the image-guided system. The location of the paraspinal incision is ascertained using the image-guided dilator to allow adequate trajectory to the neural foramen that minimizes the amount of facet joint that needs to be removed. The foraminotomy and/or discectomy is accomplished using microsurgical technique. Image guidance can be used to help guide the foraminotomy.

RESULTS:

20 patients were included in our study; 14 (70%) underwent image-guided farlateral microdiscectomy and 6 (30%) foraminotomy. The most common microdiscectomy level was L5-S1 (50%). Mean age was 66 ± 10.2 (SD) years; 16(80%) were male; BMI 27.5 ± 3 kg/m2;. Total procedure time was 117.4 ± 24.6 minutes; OR time 172.5 ± 22.5 minutes; EBL 21.5 ± 16.6 ml. Average length of stay 0.85 ± 0.6 days, with 5 (25%) discharge on the same day; all patients were discharged home. We did not observe intraoperative complications; all patients reported significant improvement of their presenting symptoms. Mean follow-up was 19.4 ± 28.7 months.

CONCLUSIONS:

FDA-approved use of spinal image-guidance requires a reference arc to be attached to the bony spine. Our technique of attaching the reference arc to the skin is an off-label use, we do not recommend it for instrumentation placement as there is mild navigation inaccuracy (2-3 mm). This technique allows for general accuracy to ascertain the location of the incision and trajectory and can help guide the foraminotomy.
363 Treatment of Spinal Metastasis in the 21th Century
Authors: Bonk Maximilian-Niklas , Wolfert Christina , Shiban Ehab
Published: March 2023

INTRODUCTION:

Spinal metastases may present with different degrees of mechanical instability. The Spinal Instability Neoplastic Score (SINS) was developed to assess spinal neoplastic-related instability. Few have validated it clinically

METHODS:

A retrospective analysis of patients with a pathologic fracture due to a spinal metastasis between 01/2018-12/2020 was performed. We selected patients with a minimum follow-up of 12 months and analyzed them according to the SINS criteria. In the conservative-group group no spinal surgery was perfomed, in contrast the patients in the surgical-group underwent one or more surgeries, respectively. For both groups were the primary endpoint the progression of vertebral-body fracture following radiotherapy.

RESULTS:

In the conservative-group 332 Patients were identified. 30/283/19 Patients presented with low/moderate/high SINS, respectively. Fracture progression following radiotherapy was seen in 30%/30%/42% in cases with low/moderate/high SINS (P = 0.522), respectively. 17% of the progression cases in the moderate-group developed neurological deficits. In the interventional-group 35 patient were identified. 6/48/16 Patient presented with low/moderate/high SINS, respectively. Fracture-progression following radiotherapy was not seen in any case. In all cases we did not see any secondary alignment disorder or hints for an instability like loosening-hem. The overall survival was 59% in the conservative-group and 75% in the interventional-group. Analyzing the quality of life, we choose the walking-ability as a main-feature. 92% in the interventional-group are still able to walk, in contrast 86% in the conservative-group.

CONCLUSIONS:

SINS is an especially useful tool for assess stability of a pathologic fractures. Moderate or high SINS are associated with a remarkably high risk of fracture progression as well as risk for neurological deterioration. Furthermore, there are hints, that a corpectomy is not always necessary due to the secondary strengthening of the vertebral body by radio oncology.
369 Successful Image-Guided Stereotactic Radiosurgery for Treatment of Spasticity
Authors: Romanelli Pantaleo , Thomas Evan M.
Published: March 2023

INTRODUCTION:

Close to 100 million people worldwide suffer the sequelae of severe trauma to the brain or spinal cord. Spasticity and related pain are a common and debilitating long-term complication in survivors. Conventional surgical treatments such as baclofen pumps & cordotomy are effective but offered to a very limited number of patients.

METHODS:

Four patients with refractory spasticity and related pain due to traumatic brain and/or spinal cord injury, brain and/or spinal cord surgery, and stroke underwent stereotactic irradiation of selected cervical or lumbar roots. The treatment was delivered to the post-ganglionic sensory segment of cervical roots or to the dorsolateral sensory region of lumbar roots. Selection of the irradiated roots was based on somatotopic distribution of spasticity and related pain as well as EMG findings. Modified Ashworth Scale (MAS) and Visual Analogue Score (VAS) have been used to assess spasticity and related pain levels before and after the procedure.

RESULTS:

The treatment was well tolerated. Marked symptomatic relief on spasticity and pain was found in all the patients. After 2 years, the median reduction of MAS score was 50%. The mean reduction of MAS and VAS was, respectively, 43,7% and 64.3%.

CONCLUSIONS:

SRS of spinal nerve roots appears to be a safe and effective noninvasive treatment for patients with spasticity and pain caused by brain or spinal cord injury. This technique provides a useful option for the treatment of a wide variety of patients suffering from the long-term sequelae of neurological injury and can broadly expand the ability to treat patients currently orphan of treatment. A randomized, sham-controlled prospective study is underway to provide further insight.