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Anterior inferior cerebellar artery (AICA) aneurysms present a challenge for neurosurgeons and neurointerventionalists alike. Cases of AICA aneurysms managed with endovascular flow diversion at our institute are reviewed with their angiographic outcomes. Both direct and indirect flow diversion provide complete aneurysm occlusion at follow-up. We propose a stratified method of approaching AICA aneurysms based on location, rupture status, and neck size. Careful evaluation of preoperative parameters is paramount in deciding between a surgical or a neuroendovascular approach. Low-profile stents in the future may assist in direct flow diversion of AICA trunk aneurysms. In addition, neurosurgeons need to be well versed in endovascular approaches. [ABSTRACT FROM AUTHOR]

The article discusses a case study of a patient who experienced subarachnoid hemorrhage (SAH) after undergoing super-selective cerebral angiography (SSCA). The patient had an anterior communicating artery (Acom) aneurysm, which was treated with a Woven Endo Bridge (WEB) device. However, after the procedure, the patient developed aphasia and showed signs of SAH on imaging. The article explores various possible causes for the SAH, including rupture of the embolized aneurysm, lenticulostriate aneurysm, vessel perforation, contrast-induced SAH, and iatrogenic SAH. The authors conclude that the most likely cause was iatrogenic SAH with parenchymal enhancement induced by contrast injection into the smaller M2 segment of the middle cerebral artery (MCA). [Extracted from the article]

Kasabach-Merritt syndrome is defined as a consumptive thrombocytopenia in the presence of a highly vascular tumor. Multiple treatment options, including transarterial embolization, have been described. We demonstrate that transarterial embolization is a viable option in the treatment of a rapidly progressive and debilitating Merkel cell tumor metastasizing to the head and neck presenting with Kasabach-Merritt syndrome. [ABSTRACT FROM AUTHOR]

Introduction: The presence of an aberrant internal carotid artery (ICA) in the middle ear is rare. Patients may be asymptomatic or complain of conductive hearing loss, otalgia, pulsatile tinnitus, or aural fullness. Otoscopic exam findings can include a pulsating erythematous lesion on the tympanic membrane (TM). It may be misdiagnosed as a glomus tumor, hemangioma, or serous otitis media, or go unrecognized until surgical exploration. Early recognition is important as intraoperative discovery carries risk of iatrogenic injury, hemorrhage and subsequent neurologic sequelae. Prevention requires adequate preoperative suspicion and can be confirmed with radiologic examination via computed tomography (CT) scan or magnetic resonance angiography (MRA). Management of iatrogenic injury of an aberrant ICA can include packing, vessel embolization and/or surgical ligation. Patient case: We report the case of an aberrant ICA injury in a pediatric patient undergoing a myringotomy with tube placement, who sustained neurologic deficits that eventually resolved following treatment with packing and coil embolization. Discussion and conclusions: An aberrant ICA can cause life-threatening complications without prior diagnosis in a routine myringotomy. Suspicious exam findings should prompt temporal bone CT to rule out aberrant ICA or other vascular pathology of the middle ear prior to surgery. In the case of iatrogenic injury of an aberrant ICA, there is no consensus in existing literature on optimal management. We reviewed 37 studies to compare therapeutic options and subsequent outcomes. Though complications are rare regardless of management, cases in which solely packing was utilized demonstrated an increased incidence of hemiparesis, aphasia, hearing loss, re-bleeding, and delayed pseudoaneurysm, as compared to an approach coupling packing with embolization or ligation, both of which have comparable outcomes. [ABSTRACT FROM AUTHOR]

In this article, we describe a rare and complex case of moyamoya syndrome in a 7-year-old boy with Down syndrome and atlantoaxial subluxation. The patient presented with an ischemic stroke in the left hemisphere and cervical cord compression with increased cord edema. Diagnostic digital subtraction angiography revealed unique patterns of vascular involvement, with retrograde flow through the anterior spinal artery, ascending cervical artery, occipital artery, and multiple leptomeningeal arteries compensating for bilateral vertebral artery occlusion. This case underscores the underreported phenomenon of upward retrograde flow through the anterior spinal artery in bilateral vertebral artery occlusion. We address the rare manifestation of posterior circulation involvement in moyamoya syndrome, highlighting the importance of considering atlantoaxial instability as a contributing factor, as the absence of atlantoaxial stability is a risk factor for vertebral artery dissection. This study contributes valuable insights into the intricate relationship of moyamoya syndrome, Down syndrome, and atlantoaxial instability, urging clinicians to consider multifaceted approaches in diagnosis and treatment. It also emphasizes the potential significance of the anterior spinal artery as a compensatory pathway in complex vascular scenarios. [ABSTRACT FROM AUTHOR]

Reports find that magnetic resonance elastography (MRE) and shear wave elastography (SWE) can classify intracranial tumors according to stiffness. However, systematic syntheses of these articles are lacking. In this report, a systematic review and meta-analysis was performed to evaluate whether SWE and MRE can predict meningioma and glioma grades. PubMed and Scopus were searched between February 10, 2022. and March 2, 2022. using manual search criteria. Eight out of 106 non-duplicate records were included, encompassing 84 patients with low-grade tumors (age 42 ± 13 years, 71% female) and 92 patients with high-grade tumors (age 50 ± 13 years, 42% female). Standardized mean difference in stiffness between high-grade and low-grade tumors were measured using a forest plot. The I2, χ2, and t tests were performed, and bubble plots were constructed to measure heterogeneity. An adapted QUADAS-2 scale evaluated study quality. Additionally, a funnel plot was constructed, and an Egger's intercept test determined study bias. Low-grade tumors were stiffer than high-grade tumors (Cohen's D = –1.25; 95% CI –1.88, –0.62). Moderate heterogeneity was observed (I2 = 67%; P = 0.006) but controlling for publication year (I2 = 0.2%) and age (I2 = 0.0%–17%) reduced heterogeneity. Included studies revealed unclear or high bias for the reference standard and flow and timing (>50%). Elastography techniques have potential to grade tumors intraoperatively and postoperatively. More studies are needed to evaluate the clinical utility of these technologies. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic led to stringent guidelines to restrict the conduct of non-emergent surgical procedures. Consequently, neurosurgery departments experienced a decline in case volumes and greater educational time being spent on virtual research projects. In our report, we reveal how neurosurgical research has changed during the pandemic compared to the pre-pandemic phase. The WebOfScience database was searched for neurosurgical articles published between 2012–2019 (pre-pandemic) and 2020–2022 (pandemic). From this data, the keywords, terms, and countries were analyzed using networks formed by the VOS Viewer software. In addition, the analysis was repeated for neurosurgical articles specific to COVID-19. Network analyses of terms and keywords revealed an increased popularity of virtual research projects, including case reports, meta-analyses, reviews, surveys, and database studies. Additionally, there was increased interest in research pertaining to neurosurgical education during the post-pandemic era, including topics regarding virtual training modalities, mental health, and telemedicine. Our bibliometrics analysis suggests that the impact of COVID-19 restrictions on hospital systems affected neurosurgical training programs. Future investigations should explore the effects of the trainee experience during the COVID-19 pandemic on the outlook for neurosurgical education. [ABSTRACT FROM AUTHOR]

Aneurysms of persistent primitive trigeminal artery (PPTAAs) are increasingly reported and commonly managed by endovascular (EN) techniques. There are no systematic reviews or meta-analyses which analyse outcomes and complications of treatment modalities for PPTAAs. We aim to highlight the change in trend of management of PPTAAs and to identify clinical and radiological parameters which may influence management paradigms.A systematic search of literature was done in PubMed, Embase, Google Scholar, Cochrane library and Medline using keywords ‘persistent primitive trigeminal artery’, ’aneurysms’, ‘embolization’, ‘surgical clipping’, etc. Only cases reporting aneurysms of PPTA were included. Three subgroups, such as conservative, open surgical (OS) and EN interventional, were studied for outcome evaluation. In the EN subgroup, relation of clinical and radiological parameters with outcome (complete/partial occlusion) was analysed using Microsoft Excel Data Analysis ToolPak.Of the 101 articles found eligible for assessment, 54 were analysed quantitatively. Mortality in the conservative group was 12.5% and OS group was 9.09%. After EN treatment, complete angiographic occlusion was seen in 88.89% PPTAAs and 5.5% warranted retreatment. In the EN subgroup, location (p=0.17), shape (p=0.69), Saltzman circulation (p=0.26) or status of rupture (p=0.08) did not significantly impact angiographic occlusion outcome. Multivariate regression analysis showed 6.6% influence of independent variables, that is, age, gender, aneurysm location, side, shape (saccular/fusiform), rupture status and type of Saltzman circulation on aneurysm occlusion outcome [F(7,27) =1.34] (p=0.27). Total mortality reported in the EN group was 8.57%.Clinical or radiological parameters do not influence angiographic occlusion outcome. Although EN techniques are successful, meticulous reporting of outcomes and complications is important. [ABSTRACT FROM AUTHOR]

Purpose: Takayasu arteritis (TA) is a rare, chronic, inflammatory large-vessel vasculitis that affects the aorta and its main branches, including the cerebrovascular system. This review analyzes current knowledge and patient outcomes concerning the cerebrovascular implications of TA.A literature search, with publications from 1994 to 2024, identified pertinent studies through PubMed. An illustrative case report details a 19-year-old female with Type 1 TA, illustrating the complex decision required in the absence of surgical or endovascular options.Our results offer a demographic analysis of 1,698 TA patients, highlighting a female predominance of 89.99% and a mean symptom onset at 33 years. The clinical spectrum of cerebrovascular involvement presented varied symptoms, most notably dizziness, with significant incidences of ischemic events and bilateral stenosis primarily affecting the carotid and subclavian arteries. The most common type of TA was Type V, affecting 40% of patients studied. Endovascular treatment had a 95% initial success rate, with a 67% restenosis rate. Surgical treatment was successful in 84% of cases, but 21% had notable post-operative complications. Similar to the endovascular population, those treated with stand-alone conservative therapy saw a 93% initial remission rate with 52% having relapsed.Assessing the disease activity of TA is crucial when planning vascular intervention due to its significant impact on treatment outcomes. Despite its greater initial invasiveness, surgical interventions showed lower restenosis rates compared to either endovascular interventions or standalone conservative management. We emphasize advancements in TA management and the pressing need for continued research into diagnostic and treatment protocols for improved patient outcomes.Methods: Takayasu arteritis (TA) is a rare, chronic, inflammatory large-vessel vasculitis that affects the aorta and its main branches, including the cerebrovascular system. This review analyzes current knowledge and patient outcomes concerning the cerebrovascular implications of TA.A literature search, with publications from 1994 to 2024, identified pertinent studies through PubMed. An illustrative case report details a 19-year-old female with Type 1 TA, illustrating the complex decision required in the absence of surgical or endovascular options.Our results offer a demographic analysis of 1,698 TA patients, highlighting a female predominance of 89.99% and a mean symptom onset at 33 years. The clinical spectrum of cerebrovascular involvement presented varied symptoms, most notably dizziness, with significant incidences of ischemic events and bilateral stenosis primarily affecting the carotid and subclavian arteries. The most common type of TA was Type V, affecting 40% of patients studied. Endovascular treatment had a 95% initial success rate, with a 67% restenosis rate. Surgical treatment was successful in 84% of cases, but 21% had notable post-operative complications. Similar to the endovascular population, those treated with stand-alone conservative therapy saw a 93% initial remission rate with 52% having relapsed.Assessing the disease activity of TA is crucial when planning vascular intervention due to its significant impact on treatment outcomes. Despite its greater initial invasiveness, surgical interventions showed lower restenosis rates compared to either endovascular interventions or standalone conservative management. We emphasize advancements in TA management and the pressing need for continued research into diagnostic and treatment protocols for improved patient outcomes.Results: Takayasu arteritis (TA) is a rare, chronic, inflammatory large-vessel vasculitis that affects the aorta and its main branches, including the cerebrovascular system. This review analyzes current knowledge and patient outcomes concerning the cerebrovascular implications of TA.A literature search, with publications from 1994 to 2024, identified pertinent studies through PubMed. An illustrative case report details a 19-year-old female with Type 1 TA, illustrating the complex decision required in the absence of surgical or endovascular options.Our results offer a demographic analysis of 1,698 TA patients, highlighting a female predominance of 89.99% and a mean symptom onset at 33 years. The clinical spectrum of cerebrovascular involvement presented varied symptoms, most notably dizziness, with significant incidences of ischemic events and bilateral stenosis primarily affecting the carotid and subclavian arteries. The most common type of TA was Type V, affecting 40% of patients studied. Endovascular treatment had a 95% initial success rate, with a 67% restenosis rate. Surgical treatment was successful in 84% of cases, but 21% had notable post-operative complications. Similar to the endovascular population, those treated with stand-alone conservative therapy saw a 93% initial remission rate with 52% having relapsed.Assessing the disease activity of TA is crucial when planning vascular intervention due to its significant impact on treatment outcomes. Despite its greater initial invasiveness, surgical interventions showed lower restenosis rates compared to either endovascular interventions or standalone conservative management. We emphasize advancements in TA management and the pressing need for continued research into diagnostic and treatment protocols for improved patient outcomes.Conclusion: Takayasu arteritis (TA) is a rare, chronic, inflammatory large-vessel vasculitis that affects the aorta and its main branches, including the cerebrovascular system. This review analyzes current knowledge and patient outcomes concerning the cerebrovascular implications of TA.A literature search, with publications from 1994 to 2024, identified pertinent studies through PubMed. An illustrative case report details a 19-year-old female with Type 1 TA, illustrating the complex decision required in the absence of surgical or endovascular options.Our results offer a demographic analysis of 1,698 TA patients, highlighting a female predominance of 89.99% and a mean symptom onset at 33 years. The clinical spectrum of cerebrovascular involvement presented varied symptoms, most notably dizziness, with significant incidences of ischemic events and bilateral stenosis primarily affecting the carotid and subclavian arteries. The most common type of TA was Type V, affecting 40% of patients studied. Endovascular treatment had a 95% initial success rate, with a 67% restenosis rate. Surgical treatment was successful in 84% of cases, but 21% had notable post-operative complications. Similar to the endovascular population, those treated with stand-alone conservative therapy saw a 93% initial remission rate with 52% having relapsed.Assessing the disease activity of TA is crucial when planning vascular intervention due to its significant impact on treatment outcomes. Despite its greater initial invasiveness, surgical interventions showed lower restenosis rates compared to either endovascular interventions or standalone conservative management. We emphasize advancements in TA management and the pressing need for continued research into diagnostic and treatment protocols for improved patient outcomes. [ABSTRACT FROM AUTHOR]

Endovascular coiling techniques have emerged as an alternative and effective approach for treating intracranial aneurysms. However, in some cases, previously coiled aneurysms may require secondary treatment with surgical clipping, presenting a more complex challenge compared with the initial intervention. 1,2 We present the case of a 39-year-old man with a residual class III Raymond-Roy occlusion partially coiled aneurysm at the left middle cerebral artery bifurcation (Video 1). Faced with the risks of rerupture, the patient underwent microsurgical treatment after providing consent. Despite successful initial microsurgical clipping, postoperative complications arose due to coil protrusion into the middle cerebral artery bifurcation, resulting in thrombotic occlusion of the frontal M2 branch. Emergency repeat microsurgical intervention and administration of a thrombolytic agent were performed to address complications, ultimately preserving blood flow. Subsequent endovascular placement of a flow-diverting stent 7 weeks after discharge confirmed complete occlusion of the aneurysm. The patient had no neurological deficit on follow-up. When planning microsurgical clipping of an aneurysm previously treated with coils, it is critical to consider coil placement, as there is a risk of prolapse if the coil is in the neck of the aneurysm. Thrombosis of the cerebral arteries is a potential complication of microsurgical clipping of partially coiled intracranial aneurysms, and injection of a fibrinolytic agent into thrombosed arterial branches may be an effective intraoperative method for treating intra-arterial thrombosis. 3 This case illustrates the challenges associated with treating partially coiled aneurysms, highlighting the significance of careful planning when considering microsurgical treatment. [ABSTRACT FROM AUTHOR]

The Tigertriever is a novel, radially adjustable stentriever that addresses limitations in traditional mechanical thrombectomy devices by providing enhanced user control over clot integration. This provides the ability to adapt to patient-specific factors such as varying vessel sizes and clot compositions and may be particularly crucial for ensuring efficacy and safety in distal locations. This consensus paper synthesizes the clinical techniques from a consortium of experienced international operators. It outlines the current data on the Tigertriever, discusses the new operator-controlled capabilities, and provides a recommended approach for both proximal and distal mechanical thrombectomy, emphasizing the “FLEX” approach (Fast Controlled Expansion with Relaxation) for optimal integration and reduced clot disruption. [ABSTRACT FROM AUTHOR]

Background: Congenital aortic arch anomalies are commonly encountered during neurointerventional procedures. While some anomalies are identified at an early age, many are incidentally discovered later in adulthood during endovascular evaluations or interventions. Proper understanding of the normal arch anatomy and its variants is pivotal to safely navigate normal aortic arch branches and to negotiate the catheter through anomalies during neurointerventional procedures. This is particularly relevant in the increasingly "transradial first" culture of neurointerventional surgery. Moreover, some of these anomalies have a peculiar predilection for complications including aneurysm formation, dissection, and rupture during the procedure. Therefore, an understanding of these anomalies, their underlying embryological basis and associations, and pattern of circulation will help endovascular neurosurgeons and interventional radiologists navigate with confidence and consider relevant pathologic associations that may inform risk of cerebrovascular disease. Methods: Here, we present a brief review of the basic embryology of the common anomalies of the aortic arch along with their neurological significances and discuss, through illustrative cases, the association of aortic arch anomalies with cerebral vascular pathology. Conclusions: Understanding the aortic arch anomalies and its embryological basis is essential to safely navigate the cerebral vascular system during neurointerventional surgeries. [ABSTRACT FROM AUTHOR]

Medium vessel occlusions (MeVOs), defined as occlusion of the M2/M3 and A2/A3 segments of the middle cerebral artery (MCA) and anterior cerebral artery, can be challenging to visualize on CT angiography (CTA) and MR angiography (MRA), given the anatomic complexity of the mid- and distal intracranial vasculature and smaller vessel caliber (Leary MC, Kidwell CS, Villablanca JP, et al. Validation of computed tomographic MCA “dot” sign: an angiographic correlation study. Stroke 2003; 34: 2636–2640; Luijten SPR, Wolff L, Duvekot MHC, et al. Diagnostic performance of an algorithm for automated large vessel occlusion (LVO) detection on CTA. J Neurointerv Surg 2022; 14: 794–798). In turn, the appearance of a sudden vessel cutoff in these vascular distributions on CTA or MRA is not always straightforward and may represent true occlusion, variant anatomy, and/or artifact (Leary MC, Kidwell CS, Villablanca JP, et al. Validation of computed tomographic MCA “dot” sign: an angiographic correlation study. Stroke 2003; 34: 2636–2640; Luijten SPR, Wolff L, Duvekot MHC, et al. Diagnostic performance of an algorithm for automated LVO detection on CTA. J Neurointerv Surg 2022; 14: 794–798). Given the importance of rapidly establishing an accurate diagnosis in the setting of stroke, combined with recent clinical trials and movements promoting the efficacy of endovascular therapeutic approaches to treat MeVOs, it remains imperative to detect such occlusions accurately and quickly on imaging. In turn, we present five imaging patterns of the Sylvian Triangle on sagittal reformatted images from CTA Head examinations, which our practice has utilized to assess patency of the M2 and M3 divisions. This approach is rapidly deployable and can be utilized by radiology and non-radiology healthcare providers alike, thus facilitating rapid and accurate diagnosis of MeVO, timely evaluation of candidacy for endovascular therapy, and ultimately supporting favorable door-to-intervention time and successful patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric vein of Galen malformations (VOGMs) are fistulous intracranial malformations arising congenitally within the choroidal fissure that can present with an array of neurological and cardiac sequelae. Associated venous stenosis may result in intracranial venous hypertension and ischemia leading to severe, irreversible cerebral injury. Management of neonatal VOGMs typically involves staged embolization and angioplasty/stenting for relief of venous stenosis. Rarely, jugular foraminal narrowing has been identified as causing jugular bulb stenosis. Case Presentation: We present the case of a 22-month-old female diagnosed with VOGM prenatally who displayed persistent intracranial venous hypertension despite multiple neuroembolization procedures during the neonatal period. Following initial reduction in arteriovenous shunting, she once again developed venous hypertension secondary to jugular bulb stenosis for which angioplasty was attempted. Failure of angioplasty to relieve the venous hypertension prompted skull base imaging, which revealed jugular foraminal ossification and stenosis. Microsurgical jugular foraminotomy followed by balloon angioplasty and stenting significantly reduced jugular pressure gradients. Restenosis requiring re-stenting developed postoperatively at 9 months, but the patient has remained stable with significant improvement in cortical venous congestion. Discussion/Conclusion: This case demonstrates the efficacy of microsurgical decompression of the jugular foramen and endovascular angioplasty/stenting as a novel treatment paradigm for the management of intracranial venous hypertension in the setting of VOGM. [ABSTRACT FROM AUTHOR]

Claustrophobia remains a challenging barrier for a significant number of patients to successfully complete a Magnetic Resonance Imaging (MRI) examination. While use of wide-bore machines and pre-exam administration of a low-dose benzodiazepine are commonly employed, there is little published research to determine which modality is the most efficacious based on the patient's specific degree of claustrophobia. This retrospective case-control study examines the efficacy of using a low-dose oral benzodiazepine and wide-bore magnet to successfully aid the claustrophobic patient in completing an MRI Brain examination. 3966 non-contrast MRI brain examinations were considered for this study. The sample was filtered to include only patients who were older than 18 years of age, not currently experiencing symptoms which may hinder MRI examination, and did not undergo any additional MR studies at the time of their exam, resulting in a final sample of 2358 examinations for analysis. Patients were then sub-divided based on severity of claustrophobia and analyzed using logistic regression analysis. Use of wide-bore magnet increased odds of successfully completing the MRI Brain examination in mild, moderately, and severely claustrophobic patients (OR: 1.79, 95% CI: 1.17–2.75). The administration of pre-examination low-dose oral benzodiazepine increased odds of successfully completing the MRI Brain examination in severely claustrophobic patients (OR: 6.21, 95% CI: 1.63–19.28). Use of a wide-bore magnet is effective in assisting mild, moderately, and severely claustrophobic patients in completing an MRI Brain exam. However, the efficacy of low-dose oral benzodiazepine is limited to severely claustrophobic patients. • Wide-bore MRI machines are useful for patients suffering all degrees of claustrophobia. • Efficacy of oral anxiolytics in MRI Brain exams is limited to severely claustrophobic patients. • Further prospective analysis of other claustrophobia-reducing modalities is suggested. [ABSTRACT FROM AUTHOR]

The article presents the case of a 57-year-old male who was presented to the emergency department due to worsening positional headache and decline in activities of daily living to discuss chronic spontaneous intracranial hypotension (SIH) and multiple perineural cysts. Topics include his medical history of polycythemia vera and obstructive sleep apnea and the possible effects of cerebrospinal fluid (CSF) on his condition.

Evidence for improved first-pass effect with the novel radially adjustable radio-opaque stent retriever Tigertriever is lacking.To compare improvement in first pass success with Tigertriever using two different techniques—rapid inflation deflation (RID) and suction thrombectomy (ST).Retrospective analysis of patients with acute ischemic stroke who underwent mechanical thrombectomy with Tigertriever at a single comprehensive stroke center.Thirty patients were included. Mean age was 72.8 years. Twelve patients (48%) experienced successful first passes with Tigertriever. Successful revascularization (modified thrombolysis in cerebral infarction (mTICI) 2b/3) was achieved in all (100%) patients who received RID or ST technique for thrombectomy. Good clinical outcome (modified Rankin score = 0–2) was noted in 40% (n = 10). Total mortality in the cohort was 8% (n = 2). RID and ST groups comprised of 10 and 15 patients, respectively. Five patients underwent MT with Tigertriever as a rescue device.No difference was noted in mean age (p = 0.27), gender (p = 0.29), location of occlusion (p = 0.46), and device used for first pass (p = 0.57). A 70% first-pass success rate in RID group and 37.5% in ST group was noticed (p = 0.06). Mean time from groin puncture to reperfusion (TICI 2b//3) was statistically similar (p = 0.29, RID: 19.9 min vs ST: 25 min). Both groups noted a 100% complete recanalization rate. The rate of mortality between the two groups were not statistically different (p = 0.46).The preliminary first-pass success rates of RID technique with Tigertriever compared to ST technique, are encouraging. Longitudinal studies with longer follow up are needed to elucidate the smaller learning curve with this device. [ABSTRACT FROM AUTHOR]

Cutis verticis gyrata (CVG) is a rare condition of the scalp in which thickening of the dermis induces rigid folds and furrows resembling the cerebral cortex. Two forms of primary CVG exist: essential, in which CVG is the only presenting problem, and nonessential, in which the scalp condition occurs along with neuropsychiatric ailments. CVG can also occur secondary to a variety of causes including inflammatory, neoplastic, and metabolic conditions or drug use. A review of the available literature, including description of the epidemiology, pathophysiology, histology, and typical management of CVG, is provided. However, we identified no literature describing the complications of CVG in the setting of a craniotomy. The patient presented here is a 54-year-old man with CVG who presented with occlusion of the M2/M2 branches of the middle cerebral artery, resulting in malignant cerebral edema, requiring emergent management via decompressive craniectomy. Because of the thickening of the scalp, skin incision was complicated by bleeding and difficulty in achieving hemostasis using Raney clips. Plastic surgery was consulted intraoperatively for assistance with complex closure of the wound in a multilayered fashion. Despite this, the patient's postoperative course was complicated by cerebrospinal fluid leakage due to difficulty in approximating the incision during closure. Subsequent cranioplasty was performed jointly between neurosurgery and plastic surgery. Despite its rarity, CVG is an important issue for neurosurgeons to understand as it can present complications in performing craniotomy, most notably during the scalp exposure and closure. CVG may also complicate the postoperative course if adequate approximation of the tissues cannot be achieved, resulting in wound infection and/or cerebrospinal fluid leak. The presented patient benefited from a combined neurosurgical and plastic surgical approach that was implemented intraoperatively and continued through the postoperative stages and the subsequent cranioplasty. [ABSTRACT FROM AUTHOR]

The purpose of this study is to determine if sequential interventional therapy can become a mainstay option in providing palliation from fastidious osseous neoplasms in patients with pain refractory to oral analgesia and radiotherapy. This retrospective monocentric study was approved by our institutional review board. Between July 2012 and August 2014, we reviewed 15 patients (6 women, 9 men; age range of 36-81 years) who underwent embolization followed by cryoablation, with or without osteoplasty. Patient demographics and tumor characteristics, including primary histology and the location of metastasis, were included in our review. Pain intensity at baseline, after radiotherapy, and after sequential interventional therapy was reviewed using the hospital electronic medical record. The use of oral analgesia and procedural complications was also noted. Data was then assessed for normality and a two-tailed Student's t-test was performed on mean pain scores for difference phases of treatment. While radiotherapy offers pain relief with a mean pain score of 7.25 ±1.5 (p =<.0001), sequential interventional therapy results in better comfort as demonstrated by a mean pain score of 3.9 ± 2.6 (p=.0015). Moreover, all patients who reported oral analgesic use at presentation reported a decrease in their requirement after sequential interventional therapy. Embolization and cryoablation were performed in all patients, while osteoplasty was indicated in 6 cases. There was no difference in postprocedural pain intensity between patients who required osteoplasty and patients who did not (p = 0.7514). There were no complications observed during treatment. This retrospective study shows that sequential intervention with transarterial embolization, cryoablation, and osteoplasty is both safe and efficacious for bone pain refractory to the current standard of care. We demonstrated that this combination therapy has the potential to become an effective mainstay treatment paradigm in the palliative care of osseous neoplasm to improve quality of life. [ABSTRACT FROM AUTHOR]

Control of bleeding in the confined area of the skull is imperative for successful neurosurgery and the prevention of devastating complications such as postoperative hemorrhage. This paper reviews the historical evolution of methods to achieve successful hemostasis in neurosurgery from the early 1800s to today. The major categories of hemostatic agents (mechanical, chemical, and thermal) are delineated and discussed in chronologic order. The significance of this article is in its detailed history of the kinds of hemostatic methods that have evolved with our accumulating medical and surgical knowledge, which may inform future innovations and improvements. [ABSTRACT FROM AUTHOR]

Objective Intracranial arterial dissection (IAD) is a rare cerebrovascular disease that is likely underdiagnosed because of the inherent difficulty of visualizing the subtle radiographic signs of the pathologic small intracranial arteries. No widespread consensus exists on the treatment of IAD, and thus it is often managed empirically because of the absence of major randomized controlled trials. In this study, we conducted a systematic review to evaluate the management and treatment options for IAD. Methods We performed a systematic review in accordance with the PRISMA guidelines using the following databases: MEDLINE (PubMed) and Cochrane Library. Included studies were limited to human patients with dissections in intracranial vessels only. Results A total of 82 studies were included in this systematic review. The most common complications of IAD were cerebral infarction and subarachnoid hemorrhage, and thus, patients with IAD can be subdivided into those presenting with either ischemia or hemorrhage, respectively. Those with ischemia were predominantly managed with antiplatelet therapy, whereas patients presenting with hemorrhage often were amenable to treatment with endovascular techniques. Conclusions Given these findings, clinicians should prescribe antiplatelet therapy for patients with IAD presenting with ischemia and consider endovascular treatment for those presenting with hemorrhage. However, further investigation is required given the heterogeneity of methods and reporting outcomes in the investigated studies. Highlights • IAD is likely an underdiagnosed condition. • In the anterior circulation, IAD often presents with ischemia. • IAD presenting with ischemia can be treated with antiplatelet agents. • IAD in the posterior circulation often presents with hemorrhage. • Those with hemorrhage can be treated by endovascular techniques. [ABSTRACT FROM AUTHOR]

Although significant advancements have been made in the detection, surveillance, and treatment of intracranial aneurysms, research and care can differ vastly based on location. Currently, there is lack of knowledge regarding the trends in literature and how the field is evolving with new technology. Here, we use bibliometric analysis to visualize the knowledge structure of the field and identify global research trends in intracranial aneurysm treatment. The Web of Science Core Collection was queried for primary research and review articles related to intracranial aneurysm treatment. Four thousand seven hundred and 2 relevant documents were collected and publications over time on different treatment types and publications and citations of journals were collected. VOS viewer was used for the following: 1) identify relationships between keywords, 2) identify co-authorship patterns among organizations and countries, and 3) analyze citation patterns of countries, organizations, and journals. Our results show that research in flow diversion increased at a rapid rate but tended to have low link strength with keywords related to evaluating patient risk and mortality. The highest publication producing countries were the United States of America, Japan, and China, although China had fewer citations relative to its peers. Korean organizations showed less international collaboration. The USA has been the leader in terms of productivity and collaboration in the field, as have several US-based journals such as Journal of Neurosurgery , Neurosurgery , and World Neurosurgery. Evaluating the safety of flow diversion treatment remains a pressing area of research. Chinese and Korean organizations may be of interest for global collaborations. [ABSTRACT FROM AUTHOR]

Purpose: Medically refractory reversible cerebral vasoconstriction syndrome (RCVS), a rare variant of RCVS, poses a significant therapeutic challenge. Herein we describe a case of medically refractory RCVS that required treatment with intra-arterial (IA) verapamil and subsequent nimodipine, resulting in both angiographic and clinical improvement after failing to respond to hemodynamic augmentation. We also supplement a description of our case with a review of other case studies and case series in which IA calcium channel blockers were used to treat RCVS. We propose that the case we outline below demonstrates that neurointerventional management with IA verapamil is appropriate and effective as an early intervention of medically refractory RCVS. Methods and Materials: Using PubMed and Google Scholar, we performed a search of the English language literature with several combinations of the keywords “intra-arterial”, “calcium channel blockers”, “reversible cerebral vasoconstriction syndrome”, “RCVS”, “nimodipine”, “verapamil”, “milrinone”, and “nicardipine” to identify studies in which RCVS was treated with IA calcium channel blockers. Results: We identified eight case studies and case series that met our inclusion criteria. Eighteen patients are encompassed in these eight studies. Conclusions: IA administration of calcium channel blockers has been shown to return cerebral vessels to their normal caliber in patients with medically refractory RCVS. However, there are no randomized controlled trials of the treatment of RCVS, and further studies are needed to elucidate the optimal treatment protocol for medically refractory RCVS. [ABSTRACT FROM AUTHOR]

Background Cases of nail gun injuries to the head and neck are rare, and treatment approach varies with each case based on location and extent of injury. Case Description We present a case of a 52-year-old male who fell off a roof holding a pneumatic nail gun and accidentally shot himself with a nail through the right frontal neck region. The nail penetrated the right sternocleidomastoid muscle and extended intracranially through the right occipital condyle with its tip embedded in the right cerebellar hemisphere. The nail coursed between the right distal cervical internal jugular vein and right internal carotid artery. There was no evidence of vascular injury on initial imaging. The barbs of the nail abutted the right sigmoid sinus, making for high risk of tear and intracranial hemorrhage on manual nail extraction. Therefore preemptive coil embolization of the right dural venous sigmoid and occipital sinuses and internal jugular bulb was performed before attempted nail removal. Using biplane fluoroscopy, orthopedic screw removal plyers were successful in snaring the head of the nail. On initial removal attempt, the head of the nail injured the distal right cervical internal carotid artery, requiring endovascular coil embolization. The nail was then successfully extracted from the neck without further immediate complications. Conclusion Use of biplane fluoroscopy and preemptive endovascular embolization makes a nonsurgical approach to penetrating skull base injuries feasible. Despite improving right visual loss related to the right internal carotid artery embolization, the patient had no new focal neurologic deficits on 1-month outpatient follow-up. [ABSTRACT FROM AUTHOR]

Surpass Streamline (SS; Stryker©) is an over-the-wire first-generation flow diverter (FD). There is a scarcity of data on real-world outcomes and complications of this FD.A retrospective review of consecutive cases between January 2019 and July 2021 at two high-volume comprehensive stroke centers, involving SS was conducted.Fifty-five patients harbored 69 treated aneurysms, of which 96% were in the internal carotid petrous to terminus segments and 88% were <10 mm in size, and 12% measuring 10–24 mm. Raymond Roy Grade 1 occlusion was noted in 55 aneurysms (79.7%) at 1 year. Median follow-up duration was 26 months (mean = 26.06). Major complications were seen in eight patients (14.5%; 95% CI 6.5–26.7) and mortality attributable to SS stenting complications occurred in two (4.3%) patients. Four (7.2%) had ophthalmologic thromboembolic complications and two had (3.6%) ischemic complications. Procedural complications occurred in 10 patients (18.18%; 95% CI 9.1–30.9). Technical complications during procedure (n = 3, 5.3%) were: “confirmed” distal middle cerebral artery (MCA) guidewire perforation; “suspected” distal MCA guidewire perforation causing post-procedural subarachnoid hemorrhage and internal carotid artery dissection causing ischemic stroke. Seizures were seen in 5 (9.09%) and carotid-cavernous fistula in 1 (1.8%). Multivariate regression analysis showed technical challenges significantly predicted occurrence of major complications (p = 0.001; R2 = 0.39, F(13,43) = 2.15, p = 0.029). Univariate analysis showed technical challenges significantly predicted ophthalmological complications (R2 = 0.06, F(1,55) = 4.04, p = 0.049) and major complications (R2 = 0.21, F(1,55) = 15.11, p = 0.0002).Large-scale future registry should focus on national data regarding SS safety, technical challenges, and procedural complications. We present one of the longest follow-ups for SS in literature. [ABSTRACT FROM AUTHOR]

Neurosurgery residency programs are the most competitive among the surgical specialties for applicants to match into. U.S. Medical Licensing Examination (USMLE) step 1 scores are staple and pivotal in narrowing down applicants for granting interviews and ranking in the match process. The upcoming transition from a numeric to binary step 1 scoring shifts the emphasis on using the status quo Step 2 Clinical Knowledge numeric scoring as the only objective measure. It can prove insubstantial for accurate assessment of competencies, further urging residency programs to widen their selection protocols to allow multiple assessments of competency. Research experience has consistently proved to result in higher successful match rates, and a positive correlation is seen with the number of research publications and Hirsch indices. However, with a predicted emphasis on research with the shift in scoring practices, these tools provide inadequate insight into authorship, contributions, type of publications, and community impact, warranting the need to include supplementary modifications, surrogates, or alternatives to such tools for a more comprehensive and equitable assessment of research. This study summarizes the role of research in the neurosurgical match process, describes nuances in research evaluation, and introduces novel Hirsch indices and additional strategies to address these nuances for equitable evaluation of research productions. [ABSTRACT FROM AUTHOR]

Background Isolated abducens nerve palsy can be the presenting sign of a ruptured PICA aneurysm. Few cases have been reported in the literature. In the majority of cases, cranial nerve VI resolved following microsurgical clipping. Case Description Here, we report a 56-year-old female who presented with a ruptured 4 mm × 3 mm left PICA aneurysm associated with a left abducens nerve palsy. The patient underwent endovascular coil embolization of the aneurysm and had complete resolution of her abducens nerve palsy. Conclusions Here, we present the first case of an abducens nerve palsy associated with a ruptured PICA aneurysm to completely resolve following endovascular coil embolization. The direction and amount of subarachnoid hemorrhage extravasation from the ruptured aneurysm are most likely responsible for cranial nerve palsy. Highlights • Isolated abducens nerve palsy can be the presenting sign of a ruptured PICA aneurysm. • The direction and amount of SA hemorrhage extravasation from ruptured aneurysm are likely responsible for CN VI deficit. • Abducens nerve palsy associated with ruptured PICA aneurysm resolved post endovascular coil embolization. [ABSTRACT FROM AUTHOR]

Background: Angiography allows for excellent characterization and treatment of traumatic pseudoaneurysms. However, ultrasound-guided thrombin injection for pseudoaneurysm thrombosis allows for radiation-free treatment of superficial pseudoaneurysms and superficial expanding hematomas. Methods: A retrospective review of 5 patient cases treated under this paradigm was performed following institutional review board approval. Outcomes following intervention were recorded and compared amongst the patient cohort. Results: Ultrasound-guided closure of traumatic pseudoaneurysms allowed for reduced procedural times and procedural invasiveness. Conclusions: As demonstrated by the following cases, ultrasound guided thrombin injection is a good method of primary treatment for superficial pseudoaneurysms, or as an alternative treatment in cases where transcatheter embolization fails. [ABSTRACT FROM AUTHOR]

Classification of pediatric brain tumors with unusual histologic and clinical features may be a diagnostic challenge to the pathologist. We present a case of a 12-year-old girl with a primary intracranial tumor. The tumor classification was not certain initially, and the site of origin and clinical behavior were unusual. Genomic characterization of the tumor using a Clinical Laboratory Improvement Amendment (CLIA)-certified next-generation sequencing assay assisted in the diagnosis and translated into patient benefit, albeit transient. Our case argues that next generation sequencing may play a role in the pathological classification of pediatric brain cancers and guiding targeted therapy, supporting additional studies of genetically targeted therapeutics. [ABSTRACT FROM AUTHOR]

The neurotoxic effects of therapy for childhood acute lymphoblastic leukemia can result in leukoencephalopathy or measurable deficits in cognitive function. However, there are no validated biomarkers that allow the identification of those patients at greatest risk. With the objective of identifying such predictors, cerebrospinal fluid collected from 53 patients over 2.5 years of therapy for childhood acute lymphoblastic leukemia was retrospectively studied. Cerebrospinal fluid folate, concentrated relative to serum folate prior to therapy, dropped during the first month of therapy and remained below baseline throughout treatment. Cerebrospinal fluid homocysteine was inversely related to cognitive function prior to treatment. Oral methotrexate was associated with decreased cerebrospinal fluid folate and increased cerebrospinal fluid homocysteine, but these changes were not seen with oral aminopterin. Of 36 patients who had imaging after completion of therapy, 9 had periventricular or subcortical white matter abnormalities consistent with leukoencephalopathy. Peak cerebrospinal fluid tau concentrations during therapy were higher among patients who had leukoencephalopathy after completion of therapy than among those with normal imaging studies at the end of therapy. If confirmed prospectively, these markers may allow the identification of those patients at greatest risk of developing treatment-induced neurocognitive dysfunction, thus guiding preventive interventions. [Copyright &y& Elsevier]

Purpose: Chronic cellular inflammation closely associated with epilepsy without an active infection is a hallmark of Rasmussen encephalitis (RE). RE has typical and defining features lacking in other rare epilepsy patients who also have neocortical lymphocytes without an identifiable cause. A patient with malformations of cortical development had an abrupt change in frequency and epileptic focus after 22 years of a stable seizure disorder. Functional neurosurgery yielded a specimen showing a mixed cellular meningoencephalitis in the absence of a demonstrable infection. Methods: Historical, neurologic, electroencephalographic, pathologic, and literature data were correlated. Results: There was a subarachnoid mixed infiltrate including evidence of dendritic cells in our patient and also cytotoxic T lymphocytes adjacent to karyolytic neurons that corresponded to cells previously demonstrated to damage neurons in RE. Literature review disclosed 42 other cases similar to RE but with heterogeneous findings. The course was more protracted and often more benign than in RE. The inflammation that would have markedly decreased or disappeared in RE over that period was generally still well represented. Conclusions: Our patient has heterogeneous features similar to, yet with differences from, RE. Literature review of chronic cellular inflammatory epileptic encephalopathy cases also similar to RE discloses important differences that may reflect idiosyncratic reactions and pace of the disease rather than a different disease. Comorbidity factors, genetic population traits, and secondary effects of the seizure disorder may lead to an expansion of the initial site of damage by an autoimmune reaction. These cases might best be grouped, probably along with RE, as secondary autoimmune diseases. [ABSTRACT FROM AUTHOR]

Tentorial dural arteriovenous fistulas have an increased risk of rupture and hemorrhage, and therefore require urgent treatment to occlude the fistula and proximal venous drainage. This is usually accomplished via endovascular treatment. We present a case of a Cognard grade IV dural arteriovenous fistula that presented as trigeminal neuralgia. This video showcases the angiographic vascular composition of the lesion with main feeders coming from the middle meningeal artery and the tentorial artery of Bernasconi and Cassinari. Details, benefits, and risks of the procedure were thoroughly discussed with the patient and consent was obtained prior to the procedure. We performed endovascular Onyx embolization through a distal branch of the right middle meningeal artery. We were able to successfully occlude the lesion using Onyx embolization and the patient had significant improvement of her pretreatment trigeminal neuralgia. [ABSTRACT FROM AUTHOR]

The article discusses the case of a 62-year old man who suffered an almost loss of consciousness after being struck in the head by a conveyor belt. A traumatic subarachnoid hemorrhage with extension into the right sylvian fissure and multiple skull base fractures were detected in a computed tomographic angiography (CTA). A pseudoaneurysm at the tip of the basilar artery was revealed in a CTA weeks following the patient was transferred to inpatient brain trauma rehabilitation. Rapid treatment is employed to the patient because of the high morbidity and mortality linked with basilar artery pseudoaneurysms.