A proposed stratification system to address the heterogeneity of Subdural Hematoma Outcome reporting in the literature

A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.

Arachnoid Cyst of the Cerebellopontine Angle: A Systematic Literature Review

OBJECTIVE

The role of surgical management of arachnoid cyst (AC) of the cerebellopontine angle (CPA) is uncertain. This topic has remained controversial with varying contradictory recommendations in the literature, which is limited to mostly case reports. We aimed to provide a comprehensive summary and analysis of symptoms, operative techniques, outcomes, and recurrence of all available surgical cases of AC of the CPA to date.

METHODS

A systematic literature search was performed in May 2022 querying several scientific databases. Inclusion criteria specified all studies and case reports of patients with AC located at the CPA for which any relevant surgical procedures were performed.

RESULTS

A total of 55 patients from the literature and 5 treated at our institution were included. Mean patient age was 29 years (range, 0.08-79 years), with nearly twice (1.7×) as many female as male patients (37 female, 22 male). Headaches (35%), hearing loss (30%), vertigo (22%), and ataxia (22%) were the most common presentations. Following surgery, 95% experienced symptom improvement, with complete resolution in 64%. Of patients with hearing loss, 44% reported a return to normal. The rate of mortality was 1.69%, and 10% of tumors recurred (mean follow-up 2.3 years [range, 0-15 years].

CONCLUSIONS

Symptomatic AC of the CPA is rare. It exhibits a proclivity for females and commonly manifests with headache, hearing loss, vertigo, and ataxia. While careful selection for surgical candidacy is needed and intervention should be reserved for patients with severe symptoms, surgical decompression is an effective tool for symptom alleviation and recovery.

Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study

Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.

Endoscopic endonasal transclival clipping of a cerebellar arteriovenous malformation feeding vessel and associated aneurysm; a 2D operative video

Positioned along the ventral surface of the pons, proximal superior cerebellar artery (SCA) aneurysms account for only 1.7% of all intracranial aneurysms [1]. Unlike more commonly encountered basilar artery aneurysms, patients often experience good outcomes when treated via endovascular coiling or surgical clipping [1,2]. These lesions frequently have a lateral projection and paucity of perforator arteries [2]. With further development of endoscopic endonasal techniques, access to this region is possible via a direct frontal exposure to the ventral brainstem, basilar artery and branching vessels. To date, there are only a limited number of reports describing an endoscopic endonasal transclival (EETC) approach for surgical clipping [3-5]. In this operative video, we detail the surgical clipping of a cerebellar arteriovenous malformation feeding vessel and an associated aneurysm using the EETC approach in a 59-year-old woman who presented with sudden onset of a severe headache. The feeding vessel and aneurysm's midline location, just below the take-off of the SCA made it a good candidate for this surgery. Major steps included in this video include 1) transsphenoidal exposure of and subsequent drilling of the clivus, 2) dural opening into the pre-pontine cistern and dissection of the aneurysm, 3) clipping of the aneurysm, and 4) multi-layered closure of the skull base defect. Overall, the patient tolerated the procedure well and was found to have no residual filling of the aneurysm or the AVM feeding vessel at 2-year follow-up. EETC is a viable surgical option for the treatment of aneurysm located along the midline of the pre-pontine cistern.

Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case

BACKGROUND

Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory.

OBSERVATIONS

A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula.

LESSONS

Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

Combined Transcranial and Endoscopic Endonasal Approach for Resection of a Complex Sinonasal Squamous Cell Carcinoma: Two-Dimensional Operative Video

Sinonasal squamous cell carcinoma (SCC) is a rare head-and-neck neoplasm that has a propensity to locally invade vital structures. Currently, the combination of surgical resection and radiation remains the optimal treatment.1 However, the extent of disease burden and involvement of surrounding anatomy may make these inoperable. Here, we demonstrate the successful application of multidisciplinary approach for surgical resection of a large, complex SCC lesion centered at the superior nasal cavity with extension into the eye orbits and brain. A two-step approach was performed; transcribiform, endoscopic piecemeal resection with reconstruction of the skull base, followed by a bifrontal craniotomy. Reconstruction was achieved using an inlay of DuraMatrix allograft (Stryker Inc., Kalamzoo, Michigan, United States) followed by an inlay of AlloDerm (Allergan Inc., Irvine, California, United States), anchored anteriorly and posteriorly with wide wings placed over the respective orbital roofs. Major steps include (1) a summary of the patient presentation and preoperative imaging, (2) resection of the tumor endonasally, (3) resection of the tumor intracranially from a bifrontal craniotomy, and (4) a review of the postoperative imaging. The patient tolerated the procedure (Fig. 1) well, returned to his baseline with no new neurologic deficits, and was placed on 6-week antibiotics regimen for osteomyelitis discovered during the operation. Approximately, 2 months after discharge, the patient unfortunately returned with altered mental status, was found to have sepsis, and expired shortly thereafter. This operative video illustrates the technical steps and capabilities of surgical treatment, achieving near-complete gross total resection of a complex SCC lesion using a multidisciplinary approach.

The link to the video can be found at: https://youtu.be/8ffckKIuBzM.

Spontaneous intracranial hypotension secondary to congenital spinal dural ectasia and genetic mosaicism for tetrasomy 10p: illustrative case

BACKGROUND

Spontaneous intracranial hypotension has historically been a poorly understood pathology that is often unrecognized and undertreated. Even more rarely has it been described in pediatric patients with an otherwise benign past medical history.

OBSERVATIONS

Herein the authors describe one of the youngest patients ever reported, a 2-year-old girl who developed severe headaches, nausea, and vomiting and experienced headache relief after lying down. Imaging revealed tonsillar herniation 14 mm below the foramen magnum, presumed to be a Chiari malformation, along with extensive dural cysts starting from thoracic level T2 down to the sacrum. She was found to have streaky skin pigmentary variation starting from the trunk down to her feet. Genetic analysis of skin biopsies revealed mosaicism for an isodicentric marker chromosome (10p15.3–10q11.2 tetrasomy) in 27%–50% of cells. After undergoing a suboccipital and cervical decompression at an outside institution, she continued to be symptomatic. She was referred to the authors’ hospital, where she was diagnosed with spontaneous intracranial hypotension.

LESSONS

After receiving a series of epidural blood patches, the patient experienced almost complete relief of her symptoms. To the authors’ knowledge, this is the first time this chromosomal anomaly has ever been reported in a living child, and this may represent a new genetic association with dural ectasia.

Occipitocervical fusion of traumatic atlanto-occipital dissociation in a patient with autofused cervical facet joints: illustrative case

BACKGROUND

Patients who survive traumatic atlanto-occipital dissociation (AOD) may present with normal neurological examinations and near-normal-appearing diagnostic images, such as cervical radiographs and computed tomography (CT) scans.

OBSERVATIONS

The authors described a neurologically intact 64-year-old female patient with a degenerative autofusion of her right C4–5 facet joints who presented to their center after a motor vehicle collision. Prevertebral soft tissue swelling and craniocervical subarachnoid hemorrhage prompted awareness and consideration for traumatic AOD. An abnormal occipital condyle–C1 interval (4.67 mm) on CT and craniocervical junction ligamentous injury on magnetic resonance imaging (MRI) confirmed the diagnosis of AOD. Her autofused right C4–5 facet joints were incorporated into the occipitocervical fusion construct.

LESSONS

Traumatic AOD can be easily overlooked in patients with a normal neurological examination and no associated upper cervical spine fractures. A high index of suspicion is needed when evaluating CT scans because normal values for craniocervical parameters are significantly different from the accepted ranges of normal on radiographs in the adult population. MRI of the cervical spine is helpful to evaluate for atlanto-occipital ligamentous injury and confirm the diagnosis. Occipitocervical fusion construct may need to be extended to incorporate spinal levels with degenerative autofusion to prevent adjacent level degeneration.

Interleukin-6 Inhibition Reduces Neuronal Injury In A Murine Model of Ventilator-Induced Lung Injury

Mechanical ventilation is a known risk factor for delirium, a cognitive impairment characterized by frontal cortex and hippocampal dysfunction. Although interleukin-6 (IL-6) is upregulated in mechanical ventilation-induced lung injury (VILI) and may contribute to delirium, it is not known whether inhibition of systemic IL-6 mitigates delirium-relevant neuropathology. To histologically define neuropathological effects of IL-6 inhibition in an experimental VILI model. VILI was simulated in anesthetized adult mice using a 35cc/kg tidal volume mechanical ventilation model. There were two controls groups: 1) spontaneously breathing, or 2) anesthetized and mechanically ventilated with 10cc/kg tidal volume to distinguish effects of anesthesia from VILI. Two hours prior to inducing VILI, mice were treated with either anti-IL-6 antibody, anti-IL-6 receptor antibody, or saline. Neuronal injury, stress, and inflammation were assessed using immunohistochemistry. Cleaved caspase-3 (CC3), a neuronal apoptosis marker, was significantly increased in the frontal (p<0.001) and hippocampal (p<0.0001) brain regions and accompanied by significant increases in c-Fos and heat shock protein-90 in the frontal cortices of VILI mice compared to controls (p<0.001). These findings were not related to cerebral hypoxia and there was no evidence of irreversible neuronal death. Frontal and hippocampal neuronal CC3 were significantly reduced with anti-IL-6 antibody (p<0.01 and p<0.0001, respectively), anti-IL-6 receptor antibody (p<0.05 and p<0.0001, respectively) compared to saline VILI mice. VILI induces potentially reversible neuronal injury and inflammation in the frontal cortex and hippocampus, which is mitigated with IL-6 inhibition. These data suggest a potentially novel neuroprotective role of systemic IL-6 inhibition that justifies further investigation.

Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites

BACKGROUND

Revascularization of the posterior inferior cerebellar artery (PICA) is typically performed with the occipital artery (OA) as an extracranial donor. The p3 segment is the most accessible recipient site for OA-PICA bypass at its caudal loop inferior to the cerebellar tonsil, but this site may be absent or hidden due to a high-riding location.

OBJECTIVE

To test our hypothesis that freeing p1 PICA from its origin, transposing the recipient into a shallower position, and performing OA-p1 PICA bypass with an end-to-end anastomosis would facilitate this bypass.

METHODS

The OA was harvested, and a far lateral craniotomy was performed in 16 cadaveric specimens. PICA caliber and number of perforators were measured at p1 and p3 segments. OA-p3 PICA end-to-side and OA-p1 PICA end-to-end bypasses were compared.

RESULTS

OA-p1 PICA bypass with end-to-end anastomosis was performed in 16 specimens; whereas, OA-p3 PICA bypass with end-to-side anastomosis was performed in 11. Mean distance from OA at the occipital groove to the anastomosis site was shorter for p1 than p3 segments (30.2 vs 48.5 mm; P < .001). Median number of perforators on p1 was 1, and on p3, it was 4 (P < .001).

CONCLUSION

Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops or aberrant anatomy is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.

Occipital artery to p3 segment of posterior inferior cerebellar artery bypass in treating a complex fusiform aneurysm

We provide a case report of a 58-year-old man who presented with a ruptured fusiform dissecting aneurysm located at the junction of the vertebral artery and posterior inferior cerebellar artery (PICA). Due to the lesion's complexity, a two-step approach was planned for revascularisation of PICA using the occipital artery (OA) prior to coiling embolisation. An end-to-side OA-PICA bypass was performed with implantation at the caudal loop of the p3 PICA segment. Fifteen days after the procedure, the aneurysm underwent stent-assisted coiling for successful obliteration of the aneurysm. The patient tolerated this procedure well and now at 1.5 years of follow-up remains free from any neurological deficits (modified Rankin Score 0). This case report illustrates one of the unique scenarios where both the vascular territory involved and morphological features of the aneurysm prohibited the use of more conventional means, necessitating the use of an arterial bypass graft for successful treatment of this lesion. As open vascular surgery is becoming less common in the age of endovascular coiling, our article uniquely reports on the combined use of both endovascular and microsurgical techniques to treat a complex aneurysm of the posterior circulation.

Anterior Cerebral Artery Bypass for Complex Aneurysms: Advances in Intracranial-Intracranial Bypass Techniques

BACKGROUND

Anterior cerebral artery (ACA) bypasses for complex aneurysms are infrequently performed, yet previous experience demonstrates the importance of intracranial-intracranial bypasses. Here we describe technical advances in intracranial-intracranial bypass techniques and their clinical results.

METHODS

Twenty-three patients with complex aneurysms requiring ACA bypasses were retrospectively studied. Ten patients were treated in period 1 (1997-2013) and 13 in period 2 (2014-2018).

RESULTS

There were 3 precommunicating, 8 communicating, and 8 postcommunicating ACA aneurysms, plus 4 middle cerebral artery aneurysms. ACA in situ bypass was the most commonly performed (9 patients; 39%). The classic left A3 ACA-right A3 ACA in situ bypass was performed in 5 patients, but 3 new in situ variations emerged in period 2: left pericallosal artery (PcaA)-right PcaA (n = 1), left callosomarginal artery (CmaA)-right CmaA (n = 2), and left CmaA-right A3 ACA (n = 1). The sole reimplantation in period 1 was the ipsilateral and vertical PcaA-CmaA reimplantation, whereas reimplantations in period 2 were contralateral and horizontal (left PcaA-right PcaA and right A3 ACA-left anterior internal frontal artery). The A1 ACA was used as a donor only in period 2 in 4 patients with middle cerebral artery bifurcation aneurysms. Bypass patency was 91%, and 21 patients (91%) improved or remained at neurologic baseline (mean [standard deviation] follow-up duration, 26 [8.2] months).

CONCLUSIONS

ACA bypass techniques continue to evolve with the addition of several variations. These variations push bypass techniques beyond the standard constructs and add important alternatives to our bypass arsenal.

Intradural Extramedullary Surgical Lysis of an Arachnoid Web of the Spine: 2-Dimensional Operative Video

Arachnoid web of the spine (AWS) is a rare and subtle lesion that can have severe neurological consequences. Patients typically present with progressive myelopathic symptoms and have no more than a slight indentation of spinal cord on imaging, commonly referred to as the "scalpel sign." A unique feature associated with this lesion is the extent of (and sometimes the rapidity of) the recovery that occurs following treatment. In this operative video, we highlight the treatment of a 32-yr-old male with a history of lumbar spondylosis, who, over a 2 wk period, developed progressive spasticity and weakness of the entire left lower extremity and left foot numbness. Magnetic resonance imaging revealed a T4-T5 "scalpel sign" and spinal cord compression on computed topography myelogram, which was subsequently taken to the operating theater. The major steps in this video include the following: A) a summary of the patient's presentation and preoperative imaging, B) the technical steps in the surgical lysis of the AWS, and C) his postoperative course. The patient tolerated the procedure well, demonstrating a rapid improvement in symptoms postoperative day 1. At the time of most recent follow-up (4 mo), the patient remains neurologically intact with a full return to his neurologic baseline. Surgical lysis of AWS demonstrated to be a curative procedure with rapid neurological recovery, showing no signs of recurrence or regression. Consent was given by the patient for the use of deidentified images and the intraoperative video for educational purposes at the time consent was obtained for the surgical procedure, in accordance with our institution's policy.

Patients Taking Antithrombotic Medications Present Less Frequently with Ruptured Aneurysms

BACKGROUND

Conflicting findings exist on the protective role of aspirin against aneurysmal subarachnoid hemorrhage (SAH). In this retrospective analysis, we compare the risk of SAH at presentation between patients treated microsurgically who were regularly taking an antithrombotic medication versus those who were not.

METHODS

Consecutive patients with solitary aneurysms treated by the senior author using a microsurgical approach were included from a database of patients treated between January 2010 and April 2013 at a tertiary academic medical center. χ² and logistic regression analysis were performed, comparing the risk of SAH with antithrombotic use.

RESULTS

A total of 347 patients were included in the study, 156 (45%) of whom presented with SAH. A total of 63 patients (18%) were taking an antithrombotic medication (aspirin, 53; clopidogrel, 6; both, 4) and 12 (4%) were on anticoagulation medication. Multivariate analysis was conducted using SAH as the primary outcome and included patient age (odds ratio [OR], 0.99), gender (male, OR, 0.65), tobacco use (OR, 1.43), alcohol use (OR, 1.02), coronary artery disease (OR, 1.84), diabetes (OR, 1.03), hypertension (OR 0.91), and posterior circulation location (OR, 1.47). This analysis found that only antithrombotic use (OR, 0.20) was associated with a significantly lower rate of rupture at the time of presentation (P < 0.001).

CONCLUSIONS

Patients taking an antithrombotic were less likely to present with ruptured aneurysms. No difference was found for those taking anticoagulants. Patient outcomes did not differ between those on an antithrombotic versus those without. A randomized controlled trial is needed to further investigate the application of antithrombotics for preventing SAH.

Primary Aneurysmal Bone Cyst of the Thoracic Spine: A Pediatric Case Report

BACKGROUND

To date, only a few documented cases exist of complete or near-complete paraplegia of the lower extremities following collapse of a vertebral body secondary to an aneurysmal bone cyst. We describe the preceding symptoms associated with this catastrophic event along with surgical management and recovery.

CASE DESCRIPTION

A previously healthy, 13-year-old girl had experienced months of ongoing back pain with associated posture change. After collapsing at home in the bathroom, she was brought in by emergency medical services and presented to the neurosurgery service with an American Spinal Injury Association A spinal cord injury. Imaging revealed a collapsed T4 vertebral body including expanded and fluid-filled posterior elements and severe kyphotic spine angulation resulting in cord compression corresponding to her sensory and motor deficits. She underwent emergent surgery for spinal cord decompression with a T2-T4 laminectomy, transpedicular tumor resection, and T1-7 instrumented fusion. The patient tolerated the procedure well postoperatively. At 9 months after the event, she is ambulating independently without the use of crutches or a cane and has regained full strength for all muscle groups of her lower extremities.

CONCLUSIONS

The unique combination of back pain and posture change symptoms in an otherwise healthy pediatric patient should heighten clinical suspicion for a possible aneurysmal bone cyst of the spine when formulating a differential diagnosis. Additionally, despite the clinical severity at presentation, patients may still experience significant recovery following expeditious surgical intervention.

Peripheral white blood cell count as a screening tool for ventriculostomy-related infections

One of the most common complications following external ventricular drain (EVD) placement is infection. Routine cultures of cerebrospinal fluid (CSF) are often used to screen for infection, however several days may pass before infection is discovered. In this study, we compared the predictive value of daily recorded vital sign parameters and peripheral white blood count (WBC) in identifying ventriculostomy-related infections. Patients with EVDs who had CSF cultures for microorganisms performed between January 2011 and July 2017 were assigned to either an infected and/or uninfected study group. Clinical parameters were then compared using t-test, chi squared and multiple logistic regression analyses. Patients of any age and gender were included. One hundred seventy uninfected and 10 infected subjects were included in the study. Nine of the 10 infected patients had an elevated WBC (>10.4 × 10³/μL), with a significantly greater WBC (15.9 × 10³/μL) than the uninfected group (10.4 × 10³/μL) (p-value ≤ 0.0001). Using logistic regression, we found no association between patient vital signs and CSF infection except for WBC (p = .003). As a diagnostic marker for CSF infection, the sensitivity and specificity of WBC elevation greater than 15 × 10³/μL was 70% (7/10) and 90.2% (147/163), respectively. This study serves as a 'proof of concept' that WBC could be useful as potential screening tool for early detection of CSF infection post-EVD placement. Future investigation using a large, multicenter prospective study is needed to further assess the applicability of this parameter.

Insular cavernous malformation resection through a minipterional, transsylvian approach

Cavernous malformations of the brain are low-flow vascular lesions that have a propensity to hemorrhage. Extensive surgical approaches are often required for operative cure of deep-seated lesions. A 23-year-old female presented with a cavernous malformation of the left posterior insula with surrounding hematoma measuring up to 3 cm. A minimally invasive (mini-)pterional craniotomy with a transsylvian approach was selected. Endoscopic assistance was utilized to confirm complete resection of the lesion. The minipterional craniotomy is a minimally invasive approach that provides optimal exposure for sylvian fissure dissection and resection of many temporal and insular lesions.

The video can be found here: https://youtu.be/9z6_EhU6lxs.

Arachnoid web of the spine: a systematic literature review

OBJECTIVEAn arachnoid web of the spine (AWS) is a rare and oftentimes challenging lesion to diagnose, given its subtle radiographic findings. However, when left untreated, this lesion can have devastating effects on a patient's neurological function. To date, only limited case reports and series have been published on this topic. In this study, the authors sought to better describe this lesion, performing a systematic literature review and including 2 cases from their institution's experience.METHODSA systematic literature search was performed in September 2018 that queried Ovid MEDLINE (1946-2018), PubMed (1946-2018), Wiley Cochrane Library: Central Register of Controlled Trials (1898-2018), and Thompson Reuters Web of Science: Citation Index (1900-2018), per PRISMA guidelines. Inclusion criteria specified all studies and case reports of patients with an AWS in which any relevant surgery types were considered and applied. Studies on arachnoid cysts and nonhuman populations, and those that did not report patient treatments or outcomes were excluded from the focus review.RESULTSA total of 19 records and 2 patients treated by the senior authors were included in the systematic review, providing a total of 43 patients with AWS. The mean age was 52 years (range 28-77 years), and the majority of patients were male (72%, 31/43). A syrinx was present in 67% (29/43) of the cases. All AWSs were located in the thoracic spine, and all but 2 (95%) were located dorsally (1 ventrally and 1 circumferentially). Weakness was the most frequently reported symptom (67%, 29/43), followed by numbness and/or sensory loss (65%, 28/43). Symptoms predominated in the lower extremities (81%, 35/43). It was found that nearly half (47%, 20/43) of patients had been experiencing symptoms for 1 year or longer before surgical intervention was performed, and 35% (15/43) of reports stated that symptoms were progressive in nature. The most commonly used surgical technique was a laminectomy with intradural excision of the arachnoid web (86%, 36/42). Following surgery, 91% (39/43) of patients had reported improvement in their neurological symptoms. The mean follow-up was 9.2 months (range 0-51 months).CONCLUSIONSAWS of the spine can be a debilitating disease of the spine with no more than an indentation of the spinal cord found on advanced imaging studies. The authors found this lesion to be reported in twice as many males than females, to be associated with a syrinx more than two-thirds of the time, and to only have been reported in the thoracic spine; over 90% of patients experienced improvement in their neurological function following surgery.

A novel proposed grading system for cerebellar arteriovenous malformations

OBJECTIVE

The objective of this study was to evaluate the existing Spetzler-Martin (SM), Spetzler-Ponce (SP), and Lawton-Young (LY) grading systems for cerebellar arteriovenous malformations (AVMs) and to propose a new grading system to estimate the risks associated with these lesions.

METHODS

Data for patients with cerebellar AVMs treated microsurgically in two tertiary medical centers were retrospectively reviewed. Data from patients at institution 1 were collected from September 1999 to February 2013, and at institution 2 from October 2008 to October 2015. Patient outcomes were classified as favorable (modified Rankin Scale [mRS] score 0-2) or poor (mRS score 3-6) at the time of discharge. Using chi-square and logistic regression analysis, variables associated with poor outcomes were assigned risk points to design the proposed grading system. The proposed system included neurological status prior to treatment (poor, +2 points), emergency surgery (+1 point), age > 60 years (+1 point), and deep venous drainage (deep, +1 point). Risk point totals of 0-1 comprised grade 1, 2-3 grade 2, and 4-5 grade 3.

RESULTS

A total of 125 cerebellar AVMs of 1328 brain AVMs were reviewed in 125 patients, 120 of which were treated microsurgically and included in the study. With our proposed grading system, we found poor outcomes differed significantly between each grade (p < 0.001), while with the SM, SP, and LY grading systems they did not (p = 0.22, p = 0.25, and p = 1, respectively). Logistic regression revealed grade 2 had 3.3 times the risk of experiencing a poor outcome (p = 0.008), while grade 3 had 9.9 times the risk (p < 0.001). The proposed grading system demonstrated a superior level of predictive accuracy (area under the receiver operating characteristic curve [AUROC] of 0.72) compared with the SM, SP, and LY grading systems (AUROC of 0.61, 0.57, and 0.51, respectively).

CONCLUSIONS

The authors propose a novel grading system for cerebellar AVMs based on emergency surgery, venous drainage, preoperative neurological status, and age that provides a superior prognostication power than the formerly proposed SM, SP, and LY grading systems. This grading system is clinically predictive of patient outcomes and can be used to better guide vascular neurosurgeons in clinical decision-making.

Outcomes in different age groups with primary Ewing sarcoma of the spine: a systematic review of the literature

OBJECTIVEEwing sarcoma (ES) is among the most prevalent of bone sarcomas in young people. Less often, it presents as a primary lesion of the spine (5%-15% of patients with ES).METHODSA systematic literature search was performed, querying several scientific databases per PRISMA guidelines. Inclusion criteria specified all studies of patients with surgically treated ES located in the spine. Patient age was categorized into three groups: 0-13 years (age group 1), 14-20 years (age group 2), and > 21 (age group 3).RESULTSEighteen studies were included, yielding 28 patients with ES of the spine. Sixty-seven percent of patients experienced a favorable outcome, with laminectomies representing the most common (46%) of surgical interventions. One-, 2-, and 5-year survival rates were 82% (n = 23), 75% (n = 21), and 57% (n = 16), respectively. Patients in age group 2 experienced the greatest mortality rate (75%) compared to age group 1 (9%) and age group 3 (22%). The calculated relative risk score indicated patients in age group 2 were 7.5 times more likely to die than other age groups combined (p = 0.02).CONCLUSIONSPrimary ES of the spine is a rare, debilitating disease in which the role of surgery and its impact on one's quality of life and independence status has not been well described. This study found the majority of patients experienced a favorable outcome with respect to independence status following surgery and adjunctive treatment. An increased risk of recurrence and death was also present among the adolescent age group (14-20 years).

Cerebral Aneurysms Differ in Patients with Hysterectomies

OBJECTIVE

Female sex is a well-known risk factor for aneurysm formation. Although the role of the ovaries and estrogen in aneurysm development has been supported, other organ-hormone pairs unique between sexes also may be implicated. In this study, we aimed to determine whether intracranial aneurysms microsurgically clipped in patients with previous hysterectomies exhibit any unique aneurysm characteristics from those without hysterectomies.

METHODS

Solitary aneurysms microsurgically treated by the senior author (M.T.L.) were included from a database of patients treated between January 2010 and April 2013 at a tertiary academic medical center. Only female patients and patients equal or older in age to the youngest patient in the hysterectomy group were included in the control group. Patient and aneurysm characteristics were compared using the χ² test for categorical variables and the independent t test analysis for continuous variables.

RESULTS

A total 233 patients were included in the study. Forty-three patients (19%) had undergone a previous hysterectomy; none had oophorectomies recorded. No difference in mean age (P = 0.89), hypertension (P = 0.38), alcohol use (P = 0.87), tobacco use (P = 0.22), or aneurysm location (P = 1) existed. However, patients in the hysterectomy group more often presented in a good neurologic condition before surgery (88% vs. 74%, P = 0.04) and had fewer large aneurysms (8% vs. 24%, P = 0.03). Also, fewer presented with a ruptured aneurysm (28%) then the nonhysterectomy group (51%) (P = 0.004).

CONCLUSIONS

Female patients with a surgical history of a hysterectomy have a lower rate of large aneurysms, present in better neurologic condition, and are less likely to present with a ruptured aneurysm than females without a hysterectomy.

Surgical Clipping of Previously Ruptured, Coiled Aneurysms: Outcome Assessment in 53 Patients

BACKGROUND

Occasionally, previously coiled aneurysms will require secondary treatment with surgical clipping, representing a more complicated aneurysm to treat than the naïve aneurysm. Patients who initially presented with a ruptured aneurysm may pose an even riskier group to treat than those with unruptured previously coiled aneurysms, given their potentially higher risk for rerupture. The objective of this study was to assess the clinical outcomes of patients who undergo microsurgical clipping of ruptured previously coiled cerebral aneurysms. In addition, we present a thorough review of the literature.

METHODS

A total of 53 patients from a single institution who initially presented with a subarachnoid hemorrhage and underwent surgical clipping of a previously coiled aneurysm between December 1997 and December 2014 were studied. Clinical features, hospital course, and preoperative and most recent functional status (Glasgow Outcome Scale score) were reviewed retrospectively.

RESULTS

The mean time interval from coiling to clipping was 2.6 years, and mean follow-up was 5.5 years (range, 0.1-14.7 years). Five patients (9.8%) presented with rebleed prior to clipping. Most patients (79.3%, 42/53) experienced good neurologic outcomes. Most showed no change (81%, 43/53) or improvement (13%, 7/53) in functional status after microsurgical clipping. One patient (2%) deteriorated clinically, and there were 2 mortalities (4%).

CONCLUSIONS

Microsurgical clipping of previously ruptured, coiled aneurysms is a promising treatment method with favorable clinical outcomes.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine

BACKGROUND

Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment.

METHODS

A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision.

RESULTS

In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001).

CONCLUSIONS

CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

Caregiving on the Hopi Reservation: Findings from the 2012 Hopi Survey of Cancer and Chronic Disease

A family caregiver provides unpaid assistance to a family member/friend with a chronic disease, illness or disability. The caregiving process can affect a caregiver's quality of life by reducing time for themselves, for other family members and for work. The 2000 Behavioral Risk Factor Surveillance Survey estimates that 16 % of adult American Indians (AIs) are caregivers. A 2012 survey collected knowledge and personal experience data from a random sample of Hopi men and women (248 men and 252 women). Self-identified caregivers answered questions on time spent caregiving, caregiver difficulties and services requested. Approximately 20 % of the 500 Hopi participants self-identified as caregivers (N = 98), with 56 % female. Caregivers in contrast to non-caregivers had a lower percentage of ever having a mammogram (86, 89 %), a higher percentage of ever having had a Pap smear test (89.1, 85.6 %), a prostate specific antigen test (35, 30.6 %) and ever having had a colonoscopy (51.2, 44 %). Almost 21 % of caregivers reported difficulty with stress and 49 % reported it as their greatest caregiver difficulty. More males (28.6 %) identified financial burden as the greatest difficulty than females (p = 0.01). Training on patient care was the service that caregivers would like to receive most (18.2 %). The percentage of Hopi's providing caregiving was similar to national averages, although among men, was somewhat higher than national data (44 vs. 34 %). Stress was identified as a difficulty, similar to national studies.