Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature

OBJECTIVES

Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective.

MATERIALS AND METHODS

This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded.

RESULTS

Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective.

CONCLUSIONS

Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.

Placement of Left Subclavian Origin Stent for Subclavian Steal Syndrome

Subclavian steal syndrome is characterized by the vertebral artery flow inversion as a result of a stenotic lesion in the origin of the subclavian artery. Subclavian origin stenting is an important armamentarium of neurointerventional surgeons. A 79-year-old patient presented with left arm claudication and dizziness while exercising, alongside upper extremity coolness at rest. Examination revealed blood pressure difference of 15 mm Hg in the left arm when compared with the right, with Doppler ultrasonography demonstrating reversal of flow in the left vertebral artery. Aortic arch run with pigtail catheter demonstrated the extent of stenosis and served as a roadmap for stent deployment. Placement of a long sheath across the subclavian stenosis into the aortic arch allowed atraumatic delivery and precise deployment of the covered stent (Video 1). No neurologic deficits were reported postoperatively, with Doppler ultrasonography revealing anterograde flow in the left vertebral artery demonstrating resolution of subclavian steal syndrome.

Rapid temporary coiling of the parent artery for the management of intraprocedural aneurysm rupture

Intraprocedural rupture (IPR) of an intracranial aneurysm is the most feared complication of primary and stent-assisted coiling because it carries a high risk of morbidity and mortality. The endovascular strategy applied to control IPR depends on the cause of the rupture and stage of the procedure. Rupture during primary or stent-assisted coiling is traditionally managed with the use of continued packing, balloon microcatheter placement, or in rare cases, with parent artery sacrifice. In this technical note, we describe the use of temporary coiling of the parent artery to control IPR in three cases. Temporary parent artery coiling creates a subocclusive state, resulting in aneurysmal blood flow reduction without interruption of blood flow to the distal territory. Flow reduction combined with the thrombogenicity of the previously deployed coils results in hemostasis. In the cases presented here, IPR occurred during the late stage of coiling. In each case, parent artery coiling was performed along with heparin reversal. After confirmation of hemostasis, the coils were retrieved to restore normal blood flow. We demonstrate that the technique of temporary parent artery coiling may be a safe and effective option for the management of IPR during primary or stent-assisted coiling.

Endovascular management of radial artery loop for neuroangiography: Case series

Background

Radial loops are rare congenital radial artery anomalies that may pose a significant challenge to successful transradial neuroangiography. In this case series, we describe the anatomy and frequency of radial artery loops and provide a technique for successful navigation of this anatomic anomaly.

Methods

We reviewed our database of radial diagnostic or interventional neuroangiographic procedures to identify cases in which a radial loop was encountered during the procedure. The loop pattern, the presence of an associated recurrent radial artery branch, navigation technique, and procedure-related complications were recorded. A descriptive analysis was performed.

Results

A total of 997 transradial approach procedures were performed over a 9-month period. A radial loop was identified in 10 (1.0%) patients. The average age was 68.6 ± 14.3 years. A microcatheter advanced over a microwire was used to navigate the loop and avoid entry into the recurrent branch. A diagnostic neuroangiographic procedure was performed successfully in 8 cases and an intervention was performed successfully in 1 case. A 360° loop was present in 2 of these cases. In each case, transradial access was performed successfully. In 1 other diagnostic case, transradial access was aborted, and the femoral artery was accessed to perform the procedure.

Conclusions

A radial loop was present in 1% of the cases in this series. Our technical results suggest that this anomaly should not be considered a contraindication to transradial neuroangiography because the procedure was successfully performed in most (9 of 10) cases using a microcatheter system to navigate the loop.

Use of expandable stent retriever for mechanical thrombectomy of the right internal carotid artery terminus occlusion

Background:

Tigertriever (Rapid Medical, Sunrise, FL) is an adjustable-diameter stent retriever that is being tested in an investigational device exemption clinical trial, Treatment with Intent to Generate Reperfusion (TIGER). The retriever is available in three lengths with corresponding adjustable diameters; however, a single device cannot be used for multiple thrombectomy attempts. A clicker-based expansion mechanism allows incremental expansion of the retriever and step-wise increase in radial force to the parent vessel diameter. The clicker mechanism is used to expand the stent retriever until it is apposed with the vessel walls. Rest of the procedure is similar to a mechanical thrombectomy performed with a conventional stent retriever and is demonstrated in the video.

Case Description:

We present a case of a 59-year-old woman who presented with left-upper extremity weakness, facial droop, and hemineglect. Perfusion imaging demonstrated increased time-to-peak. Angiography showed right internal carotid artery terminus occlusion. The patient underwent successful mechanical thrombectomy (Thrombolysis in Cerebral Infarction 2b reperfusion) using the Tigertriever and was discharged home without any perioperative complications.

Conclusion:

An adjustable, expandable stent retriever allows operator to size the stent retriever to match the target artery diameter. The expandable design of stent retriever has potential implications for distal vessel occlusion mechanical thrombectomy.

Sovereign immunity and its implications for neurosurgery

The proportion of neurosurgeons facing a malpractice suit each year is highest among all medical and surgical specialties. It is critical for neurosurgeons to understand local malpractice laws because they vary among states. Sovereign immunity, as described in the 11th constitutional amendment, provides absolute immunity to states from being sued by their residents and by other states. A state may waive its sovereign immunity, however, and substitute itself as the defendant in place of a state-employed physician in the court of law. This means that a physician working for a state-funded hospital may not be liable to a malpractice suit. Further provisions of the law allow the state not to pay indemnity beyond a certain limit, which discourages plaintiff attorneys from pursuing indemnity charges against physicians working for state-funded institutions. In this review, the authors describe the concept of sovereign immunity and its implications for the practice of neurosurgery.

Treatment of Carotid Ophthalmic Aneurysm With Woven EndoBridge (WEB SL): 2-Dimensional Operative Video

Wide-necked cerebral aneurysms often require complex treatment strategies for optimal treatment. As the surgeon's arsenal continues to expand, consideration of all potential applications of available devices is important. The Woven EndoBridge (WEB) device (MicroVention-Terumo, Aliso Viejo, California) capitalizes on flow disruption to promote thrombosis and is Food and Drug Administration (FDA) approved for saccular wide-necked bifurcation aneurysms located at the middle cerebral artery bifurcation, internal carotid artery (ICA) terminus, anterior communicating artery complex, and basilar apex. In this video, we demonstrate an off-label use of the WEB to treat a wide-necked type II1 ophthalmic artery aneurysm, highlighting the importance of correct device sizing. The patient is a 74-yr-old woman with a family history of aneurysms. Her aneurysm was found incidentally after a minor trauma. Observation and various treatment options were considered. The patient preferred to avoid open surgical intervention and dual antiplatelet therapy. Endoluminal flow diversion for types II and III ophthalmic artery aneurysms has relatively low occlusion rates and a higher incidence of visual field deficits.1 A WEB device can be an excellent alternative to treat these aneurysms. A biaxial system was used to selectively catheterize the supraclinoid internal carotid artery and then the aneurysm, and optimal flow diversion was achieved. The patient did well and was discharged home the next day on aspirin alone. Six-month angiography showed near-occlusion of the aneurysm and ophthalmic artery patency. The neck remnant will be followed up with repeat angiography in 6 mo. The patient gave informed consent for the procedure and video recording. Institutional review board approval was deemed unnecessary. Video ©University at Buffalo Neurosurgery, 2019. With permission.

Measurement of instant flow reserve to quantify functional flow limitation across stenosis in intracranial atherosclerotic disease

Angiographic stenosis may not be an accurate reflection of physiological flow limitation. Measurement of instant flow reserve (IFR) to quantify functional flow limitation across stenosis may be valuable in identifying lesions causing significant flow limitation. A case of left middle cerebral artery atherosclerotic disease is presented. Because medical therapy had failed, endovascular revascularization was chosen. In this video 1, IFR measurement to guide submaximal balloon angioplasty with a 1.5×9 mm non-compliant Mini-Trek balloon (Abbott) is demonstrated. Pressure gradient across the middle cerebral artery-M1 stenosis was measured with a Volcano pressure wire (Philips) before and after submaximal balloon angioplasty. An excellent radiographic result and flow improvement into the severely stenosed segment were achieved, with an IFR increase from 0.23 to 0.89. The degree of corresponding stenosis changed from 85% to 30%. No periprocedural complication was observed. IFR can help to identify lesions requiring treatment in select patients and prevent the tendency to overtreat a lesion that is not physiologically significant.

Safety and feasibility of ulnar artery access for neuroangiography and neurointervention: a case series

BACKGROUND

Radial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a reason to convert to femoral access, but ulnar artery access may prevent complications associated with transfemoral procedures.

OBJECTIVE

To evaluate the safety and feasibility of ulnar access for neurointerventions and diagnostic neuroangiographic procedures.

METHODS

Consecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data recorded were demographics, procedure indication, devices, technique, and complications. Descriptive analysis was performed.

RESULTS

Ulnar artery access was obtained for 21 procedures in 18 patients (mean age 70.3±7.8 years; nine men). Procedures included 13 diagnostic angiograms and eight neurointerventions (3 left middle meningeal artery embolization, 1 of which was aborted; 2 carotid artery stenting; 2 angioplasty; 1 mechanical thrombectomy for in-stent thrombosis). A right-sided approach with ultrasound guidance was used for all cases except one. Indications included small caliber radial artery (n=9), radial artery occlusion (n=10), and radial artery preservation for potential bypass (n=2). A 5-French slender sheath was used for diagnostic angiography; a 6-French slender sheath was used for neurointerventions. No case required conversion to femoral access. Two patients had minor hematomas after the procedure; one other had ulnar artery occlusion on 30-day ultrasonography.

CONCLUSION

Ulnar access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to radial access, potentially avoiding complications associated with femoral access.

Transradial access for flow diversion of intracranial aneurysms: Case series

BACKGROUND

Transradial access for neurointerventions offers advantages of fewer access-site complications, reduced procedure time, and greater patient comfort over transfemoral access. Data about transradial access for flow diversion are limited. We share our early experience with transradial access for flow diversion in a relatively large case series.

METHODS

Consecutive patients who underwent Pipeline embolization device (Medtronic) deployment via transradial access were included in the study, irrespective of location and laterality of the intracranial aneurysm. The cases were performed between July 2016 and October 2019. Demographics, aneurysm characteristics, and procedure-related details (including catheter systems used) were recorded and statistically evaluated.

RESULTS

Thirty-five transradial flow diversion procedures were attempted in 32 patients, of which 33 procedures were successful. In two cases involving left common carotid artery and internal carotid artery access, guide catheter herniation into the aortic arch led to abandonment of transradial access in favor of transfemoral access. The most common aneurysm locations in the transradial access procedures were the posterior communicating artery (n = 7), ophthalmic artery (n = 7), and superior hypophyseal artery (n = 7). Most transradial access procedures (66.7%) were performed using a biaxial catheter system. 6-French Benchmark (Penumbra) and Phenom 27 (Medtronic) were the most commonly utilized guide- and microcatheters, respectively. One patient had intraprocedural subarachnoid hemorrhage. No access-site complications occurred.

CONCLUSION

This study demonstrates safety and feasibility of transradial access for Pipeline embolization device deployment and shows the versatility of this approach for different catheter systems. Tortuosity and acute angulation of the left common carotid artery and internal carotid artery were associated with approach failure.

Septal dysembryoplastic neuroepithelial tumor: a comprehensive clinical, imaging, histopathologic, and molecular analysis

BACKGROUND

Dysembryoplastic neuroepithelial tumors (DNETs) are uncommon neural tumors presenting most often in children and young adults and associated with intractable seizures. Rare midline neoplasms with similar histological features to those found in DNETs have been described near the septum pellucidum and termed "DNET-like neoplasms of the septum pellucidum." Due to their rarity, these tumors have been described in just a few reports and their genetic alterations sought only in small series.

METHODS

We collected 20 of these tumors for a comprehensive study of their clinical, radiological, and pathological features. RNA sequencing or targeted DNA sequencing was undertaken on 18 tumors, and genome-wide DNA methylation profiling was possible with 11 tumors. Published cases (n = 22) were also reviewed for comparative purposes.

RESULTS

The commonest presenting symptoms and signs were related to raised intracranial pressure; 40% of cases required cerebrospinal fluid diversion. Epilepsy was seen in approximately one third of cases. All patients had an indolent disease course, despite metastasis within the neuraxis in a few cases. Radiologically, the septum verum/septal nuclei were involved in all cases and are the proposed site of origin for septal DNET (sDNET). Septal DNET showed a high frequency (~80%) of mutations of platelet derived growth factor receptor A (PDGFRA), and alterations in fibroblast growth factor receptor 1 (FGFR1) and neurofibromatosis type 1 (NF1) were also identified. In a genomic DNA methylation analysis alongside other neural tumors, sDNETs formed a separate molecular group.

CONCLUSIONS

Genetic alterations that are different from those of cerebral DNETs and a distinct methylome profile support the proposal that sDNET is a distinct disease entity.

Transradial middle meningeal artery embolization for chronic subdural hematoma using Onyx: case series

Background

Middle meningeal artery (MMA) embolization is an emerging therapy for the resolution of subacute or chronic subdural hematoma (CSDH). CSDH patients are often elderly and have several comorbidities. We evaluated our experience with transradial access (TRA) for MMA embolization using predominantly Onyx under conscious sedation.

Methods

Data for consecutive patients who underwent transradial MMA embolization for CSDH during a 2-year period (2018–2019) were analyzed from a single-center, prospectively-maintained database. Patient demographics, comorbidities, ambulatory times, subdural hematoma resorption status, and guide catheter type were recorded. Conversion to femoral access and complication rates were also recorded. Univariate and multivariate analyses were performed.

Results

Forty-six patients (mean age, 71.7±14.4 years) were included in this study. Mean CSDH size was 14±5.5 mm. Most (91.3%) TRA embolizations were performed with 6-French 0.071-inch Benchmark guide catheters (Penumbra). MMA embolization was successful in 44 patients (95.7%) (including two cases of TRA conversion). Twenty-one (48%) patients had a severe Charlson Comorbidity Index (>5). Symptomatic improvement was noted in 39 of 44 patients (88.6%). Mean length of stay was 4±3 days. Patients were ambulated immediately postprocedure. At mean follow-up (8±4 weeks), 86.4% of patients had complete or partial CSDH resolution. Persistent use of antiplatelet agents after the procedure was associated with failed or minimal CSDH resorption (5 of 6, 83.3% vs 9 of 38 23.7% with complete or near-complete resolution; P=0.009).

Conclusion

Transradial Onyx MMA embolization under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities.

The Reproducibility of Cerebrovascular Randomized Controlled Trials

BACKGROUND

Numerous randomized controlled trials (RCTs) relevant to the cerebrovascular field have been performed. The fragility index was recently developed to complement the P value and measure the robustness and reproducibility of clinical findings of RCTs.

OBJECTIVE

In this study, we evaluate the fragility index for key surgical and endovascular cerebrovascular RCTs and propose a novel RCT classification system based on the fragility index.

METHODS

Cerebrovascular RCTs reported between 2000 and 2018 were reviewed. Six key areas were specifically targeted in relation to stroke, carotid stenosis, cerebral aneurysms, and subarachnoid hemorrhage. The correlation between fragility index, number of patients lost to follow-up, and fragility quotient were evaluated to propose a classification system for the robustness of the studies.

RESULTS

A total of 20 RCTs that reported significant differences between both study groups in terms of the primary outcome were included. The median fragility index for the trials was 5.5. An additional 30 randomly selected RCTs were added to propose a classification system with high reliability. The difference between the number of patients lost to follow-up and fragility index inversely correlated with the fragility quotient and was used to divide the robustness of the RCTs into 3 classes reflecting the reproducibility of the trial.

CONCLUSIONS

Neurosurgeons and neurointerventionalists should exercise caution with interpreting the results of cerebrovascular RCTs, especially when the sample size and events numbers are small and there is a high number of patients who were lost to follow-up, as quantitatively identified using the proposed classification system.

Impact of endovascular reperfusion on low National Institutes of Health Stroke Scale score large-vessel occlusion stroke

INTRODUCTION

Effectiveness of mechanical thrombectomy for mild-deficit stroke due to large-vessel occlusion is controversial. We present a single-center consecutive case series on thrombectomy for large-vessel occlusion mild stroke. We evaluated various thrombectomy parameters to better understand disagreement in the literature.

METHODS

Data from a retrospective cohort of large-vessel occlusion mild stroke patients (National Institutes of Health Stroke Scale <6) treated with mechanical thrombectomy over 6 years and 2 months were analyzed. Patients were divided into 2 groups: successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b or 3) and failed reperfusion (modified Thrombolysis in Cerebral Infarction 0,1, or 2a). Ninety-day modified Rankin Scale in-hospital mortality, and symptomatic hemorrhage rates were compared between groups. Multivariate logistic regression was performed to evaluate reperfusion status as a predictor of 90-day favorable (modified Rankin Scale 0-2) and excellent (modified Rankin Scale 0-1) outcomes.

RESULTS

We identified 61 patients with large-vessel occlusion mild stroke who underwent thrombectomy. Reperfusion was successful in 49 patients and a failure in 12. The successful group exhibited significantly higher rates of favorable outcome (83.7% vs. 25.0%; p < 0.001) and excellent outcome (69.4% vs.16.7%; p = 0.002) at 90 days. In-hospital mortality was significantly higher in the failure group (41.7% vs.10.2%; p = 0.019). Multivariate logistic regression identified successful reperfusion as a significant predictor (p = 0.001) of 90-day favorable outcome.

CONCLUSION

Reperfusion success was significantly associated with improved functional outcomes in large-vessel occlusion mild stroke mechanical thrombectomy. Future studies should consider reperfusion rates when evaluating the effectiveness of thrombectomy against that of medical management in these patients.

Cerebral Revascularization for Moyamoya Syndrome Associated with Sickle Cell Disease: A Systematic Review of the Literature on the Role of Extracranial-Intracranial Bypass in Treating Neurologic Manifestations of Pediatric Patients with Sickle Cell Disease

Moyamoya syndrome (MMS) in patients with sickle cell disease (SCD) accentuates the risk of recurrent strokes. Chronic transfusion therapy (CTT) is an excellent option for preventing recurrent strokes in most patients with SCD. In SCD with MMS, CTT may fail as a long-term solution. Cerebral revascularization, in the form of extracranial-intracranial bypass, has been shown to prevent recurrent strokes in this cohort. We review the evolution of this paradigm shift in the management of SCD-associated MMS. A systematic review, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, was conducted. Our primary objectives were 1) to study the evolution of cerebral revascularization techniques in management of MMS in SCD and 2) to analyze the impact of neurosurgical intervention in this high-risk population. Four patients with SCD-associated MMS, who underwent indirect cerebral revascularization at our institute were retrospectively reviewed. A summary of 13 articles chronicling the advent and subsequent evolution of cerebral revascularization as a viable treatment strategy for stroke prevention in SCD-associated MMS is presented. The literature review suggests that early detection and surgical intervention (in addition to CTT) could significantly reduce stroke recurrence and improve neurocognitive outcome. Our short series of 4 patients also had a good outcome and no recurrence of strokes postoperatively. The literature emphasizes the use of a traditional standardized protocol for early identification (transcranial Dopplers, selective magnetic resonance angiography, and CTT). Early treatment and screening that involves early magnetic resonance angiography and referral to neurosurgery for revascularization may be considered for this high-risk population.

Gender disparities in academic rank achievement in neurosurgery: a critical assessment

OBJECTIVE

The objective of this study was to evaluate whether there are disparities in academic rank and promotion between men and women neurosurgeons.

METHODS

The profiles of faculty members from 50 academic neurosurgery programs were reviewed to identify years in practice, number of PubMed-indexed publications, Doctor of Philosophy (PhD) attainment, and academic rank. The number of publications at each academic rank was compared between men and women after controlling for years in practice by using a negative binomial regression model. The relationship between gender and each academic rank was also determined after controlling for clustering at the institutional level, years in practice, and number of publications.

RESULTS

Of 841 faculty members identified, 761 (90%) were men (p = 0.0001). Women represented 12% of the assistant and associate professors but only 4% of the full professors. Men and women did not differ in terms of the percentage holding a PhD, years in practice, or number of publications at any academic rank. After controlling for years in practice and clustering at the facility level, the authors found that men were twice as likely as women to be named full professor (OR 2.2, 95% CI 1.09-4.44, p = 0.03). However, when institution, years in practice, PhD attainment, h-index, and number of publications were considered, men and women were equally likely to attain full professorship (OR 0.9, 95% CI 0.42-1.93).

CONCLUSIONS

Data analysis of the top neurosurgery programs suggests that although there are fewer women than men holding positions in academic neurosurgery, faculty rank attainment does not seem to be influenced by gender.

Posterior Interhemispheric Precuneal Approach: Fundamental Principles and Case Illustration: 3-Dimensional Operative Video

Peritrigonal lesions are deeply seated and are surrounded by critical neurovascular structures. Traditional transcortical approaches carry the risk of damage to important surrounding white matter tracts. In this regard, a posterior interhemispheric approach gives a more direct and less invasive route and therefore is a reasonable alternative to transcortical approaches. The 3-dimensional video includes illustrations and animations showing the anatomy of the white matter tracts around the trigone and explains the physiological basis of posterior interhemispheric precuneal approach to this complex region. This also includes a 3-dimensional operative video of the same approach in a 50-yr-old male patient with left periatrial lesion describing surgical techniques and nuances.

An informed written consent has been obtained from the patient.

One-piece Orbitozygomatic Craniotomy for Resection of Rathke's Cleft Cyst: Operative Video

Objective  The video stars orbitozygomatic resection of Rathke's cleft cyst with suprasellar extension in a 37-year-old male patient presenting with severe headaches and bitemporal hemianopia. Clinical and radiological characteristics along with surgical technique (positioning, bony opening, surgical dissection and debulking, closure), histopathology, and postoperative course are described.

Methods  Preoperative MRI demonstrated a noncontrast-enhancing cystic lesion in the sella with suprasellar extension causing compression of both optic nerves. A one-piece orbitozygomatic craniotomy was performed. The tumor was encountered in the interoptic space. First, the cyst was decompressed and fluid appearing like motor oil was aspirated. Both optic nerves were decompressed and dissected free from the cyst wall. Intraoperatively, the most challenging aspect was separating the tumor from surrounding vascular structures, including bilateral A1 arteries and the left carotid bifurcation. A combination of sharp and blunt dissection was utilized to free the tumor from adhesions to critical neurovascular structures. Once freed, the suprasellar aspect of the tumor was mobilized into the operative cavity and debulked. Finally, the sellar component of the tumor was removed all the way down to the sellar floor. Postoperative MRI demonstrated decompressed bilateral optic nerves with an intact pituitary stalk with preservation of normal pituitary gland. Histopathology identified pathognomonic features consistent with diagnosis of Rathke's cleft cyst, including flattened ciliated epithelium and presence of Rathke's cleft remnants.

Results  Postoperatively, bilateral improvement in vision was noted with transient diabetes insipidus. Patient was discharged home on postoperative day 4.

Conclusion  A one-piece orbitozygomatic craniotomy is an effective and safe strategy for resection of Rathke's cleft cysts with suprasellar extension.

The link to the video can be found at: https://youtu.be/-Yqtcd2gLSs .

Delayed Spinal Arachnoiditis Following Aneurysmal Subarachnoid Hemorrhage: A Case Report

Spinal arachnoiditis (SA) is a rare and delayed complication of aneurysmal subarachnoid hemorrhage (aSAH). We present a case of delayed SA associated with thoracic and lumbar arachnoid cysts in a patient with aSAH secondary to a ruptured vertebral artery aneurysm. The patient underwent a thoracic laminectomy for decompression of the spinal cord, lysis of arachnoid adhesions, and fenestration of an arachnoid cyst. We present the pathogenesis, diagnosis, treatment, and management of spinal arachnoiditis as a rare complication of aSAH. 

Role of Stereotactic Radiosurgery in the Management of Multiple Metastases in the Region of the Motor Cortex: Long-term Survival in Three Cases

The management of patients with multiple brain metastases, in contrast to those with solitary metastases, continues to evolve. Recent evidence suggests that aggressive microsurgical and radiosurgical management of patients with multiple brain metastases may lead to improved survival and quality of life. The three cases discussed in this report are examples of patients with multiple brain metastases who had excellent outcomes following treatment with microsurgical and radiosurgical approaches. A common feature of each patient is the presence of multiple metastases in the region of the motor cortex. The rationale for this selection is to demonstrate that aggressive management can have a favorable outcome despite the presence of multiple metastases in eloquent regions of the brain.