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The anatomical relationship between clinoidal meningiomas and the optic nerve accounts for their frequent finding on visual disturbances. The goal of the surgery is to perform complete resection and obtain visual recovery. The aim of this study is to determine the factors associated with favorable visual outcome.We recorded clinical (including ophthalmological), imaging and surgical data of all patients operated on for clinoidal meningiomas between 2010 and 2020 in 2 French neurosurgical departments and we analyzed their impact on visual outcome.A total of 34 patients were included. At 3-4 months after surgery, 23 patients (68%) had favorable visual outcome. Factors associated with favorable visual outcome were duration of ophthalmologic symptoms 6 months, preoperative visual acuity 0.5, absence of optic atrophy, meningioma in high signal intensity on T2-weighted or FLAIR MRI, absence of optic canal involvement and absence of bone hyperostosis on pre-operative CT scan. A soft tumor and a clear brain/tumor border were intra-operative factor associated with favorable ophthalmological outcome.In clinoidal meningiomas, an early surgery should be performed to optimize visual improvement. Hyperintense lesion on T2-weighted/FLAIR preoperative MRI is correlated with a soft consistency which allows an easier surgery associated with a favorable visual outcome. Invasion of the optic canal and bone hyperostosis should reserve the visual prognosis.

With limited healthcare resources and risks associated with unwarranted interhospital transfers (IHT), it is important to select patients most likely to have improved outcomes with IHT. The present study analyzed the effect of IHT and frailty on postoperative outcomes in a large database of patients who underwent cranial neurosurgical operations.The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent cranial neurosurgical procedures (2015-2019, N = 47,736). Baseline demographics, clinical characteristics, and outcome variables were compared between IHT and n-IHT patients. Univariate and multivariable analyses analyzed the effect of IHT status on postoperative outcomes and the utility of frailty (modified frailty index-5 [mFI-5] stratified into "pre-frail, "frail", and "severely frail") as a preoperative risk factor. Effect sizes from regression analyses were presented as odds ratio (OR) with associated 95% confidence intervals (95% CI).Of 47,736 patients with cranial neurosurgical operations, 9612 (20.1%) were IHT. Patients with IHT were older, frailer, with a higher rate of functional dependence. In multivariable analysis adjusted for baseline covariates, IHT status was independent associated with 30-day mortality (OR: 2.0, 95% CI: 1.2-3.6), major complication (OR: 1.5, 95% CI: 1.1-2.1), extended hospital length of stay (eLOS) (OR: 3.8, 95% CI: 3.6-4.1), and non-routine discharge disposition (OR: 2.4, 95% CI: 1.8-3.2) (all p 0.05). Within the IHT cohort, increasing frailty ("pre-frail", "frail", "severely frail") was independently associated with increasing odds of 30-day mortality (OR: 1.4, 1.9, 3.9), major complication (OR: 1.4, 1.9, 3.3), unplanned readmission (OR: 1.1, 1.4, 2.1), reoperation (OR: 1.3, 1.5, 1.9), eLOS (OR: 1.2, 1.3, 1.5), and non-routine discharge (OR: 1.4, 1.9, 4.4) (all p 0.05). All levels of frailty were more strongly associated with postoperative outcomes than chronological age.This novel analysis suggests that patients transferred for cranial neurosurgery operations are significantly more likely to have worse postoperative health outcomes. Furthermore, the analysis suggests that frailty (as measured by mFI-5) is a powerful independent predictor of outcomes in transferred cranial neurosurgery patients. The findings support the use of frailty scoring in the pre-transfer and preoperative setting for patient counseling and risk stratification.

Neurosurgery inequity between High-Income Countries and Low- and Middle-Income Countries is striking. Currently, several models of education and training are available each has advantages and limitations. Our goal is to suggest an integrative model of Education and Training with international collaboration which will assure the most cost-effective Training Model.The authors reviewed the literature narratively and examined in broad stroke the different existing models of international education and training programs to analyze their strengths, limitations, and cost-effectiveness in addressing the needs of Neurosurgery in Low and middle-Income Countries.Several international institutions have been involved in Education and Training in Global Neurosurgery. The most common models for international education include short-term surgical mission and boot camps, a full residency training program in HICs, and a full residency training Program in Local or regional World Federation of Neurosurgical Societies (WFNS) reference centers in Low and Middle-Income Countries, and online education. In Africa, both Local residency training centers and WFNS reference centers are available and provide full training programs in Neurosurgery. Among them, WFNS Rabat Training Center is the first established center in Africa in 2002. This program is supported by the WFNS Foundation and by the Africa 100 Project. Some of these education models face currently challenges such as sustainability, financial support, and ethical issues.Training neurosurgeons from Low and Middle-Income countries in local and regional WFNS Training centers might be the most cost-effective model of training that helps close the gap in neurosurgery. This training Model is duplicable and may be integrated into a global cohesive and collaborative model of education with international institutions.

The global increase in the "ultra-geriatric" population (aged 80 years and older) has led to higher demand for neurosurgical procedures in this vulnerable population. The objective was to evaluate the safety and efficacy of advanced microsurgical procedures on ultra-geriatric patients, in our modern era of neurosurgery, anesthesiology, and advanced medical care.The study examined 66 complex cranial procedures, performed on 65 ultra-geriatric patients, who constituted 3.8% of the 4461 consecutive neurosurgical procedures performed by a single neurosurgeon over 14-years in a tertiary care university hospital. Excluded from this study were intra- or extra-axial spontaneous hematomas or traumatic brain injuries, infections, biopsy-only cases and carotid endarterectomies.The most common indication for surgery for the 66 complex cranial procedures were meningiomas (23.9%), followed by gliomas (17.9%), and metastatic brain tumors (17.9%). Postoperative complications occurred in seven procedures (10.60%). No patient deaths were directly caused by intra- or postoperative events, and only one 30-day mortality occurred. All deceased patients had a statistically significant higher American Society of Anesthesiologists (ASA) class (p = 0.024). However, there was no significant correlation between ASA class and modified Rankin scale at discharge (p = 0.238).With the aging global population and increasing life expectancy, the number of ultra-geriatric patients with complex pathologies seeking advanced microsurgical treatment is growing. Therefore, neurosurgeons are confronting a growing number and variety of complex pathologies in ultra-geriatric patients in their daily practice. Regardless of advanced age, microsurgery provides safe and effective treatment, with age alone not being a barrier to proper neurosurgical treatment when other risk factors are adequately modified.

External ventricular drainage is a common and invaluable neurosurgical procedure and is one of the first procedures learned and performed independently by neurosurgical residents. As accuracy and precision are paramount to EVD placement, attention to technique is paid early in a resident's training. With the advancement of virtual technology, it has become increasingly possible to move away from traditional training situations and human error, and towards automated assistance and superior cyber learning environments. Although there is significant room for improvement, there are promising results with computerized placement guides and virtually augmented practice. Here, we provide a review of the updates on EVD placement techniques, technology and training, all of which serve to improve the precision, accuracy and efficiency of EVD placement.

Thoracic meningoceles and dural ectasia are less commonly recognized manifestations of neurofibromatosis 1 (NF1). Rarely, large thoracic meningoceles may become compressive and lead to respiratory compromise secondary to lung compression. Surgical goals aim to increase lung aeration through decreasing the size of the meningocele through shunting, excision or repair of the meningocele, and varying degrees of dural tube reconstruction. There is no agreement on the best approach for large, symptomatic meningoceles. Here, we discuss the case of a 41-year-old woman with NF1 who presented with dyspnea and enlargement of a large, 19 cm thoracic meningocele. A multidisciplinary team of thoracic, plastic, and neurological surgery participated in the operation to excise the meningocele and reconstruct the dural tube without the need for subsequent shunting of spinal fluid. We also systematically review the literature on thoracic meningoceles in NF1 to understand the optimal treatment of this pathology.

Purpose The safety of transsphenoidal surgery (TSS) for pituitary adenoma in elderly patients is becoming a new topic in our aging society. However, previous studies did not focus on the surgical procedures in elderly patients. We attempted to clarify the safety of TSS and the influence of pseudocapsular resection in elderly patients with non-functioning pituitary adenoma (NFPA). Methods A total of 272 patients undergoing initial surgery for NFPA were categorized into two groups as follows: 1) Elderly group (n = 66; age ≥ 70 years); and 2) Younger group (n = 206; age

Terson's Syndrome describes intraocular hemorrhage secondary to an acutely raised intracranial pressure (ICP). Although Terson’s Syndrome is common amongst patients with subarachnoid hemorrhage (SAH), it is underdiagnosed and often overlooked. This review discusses the current understanding of the etiopathogenesis, clinical features, and management of Terson's Syndrome and highlights the visual and prognostic implications to stress the importance of timely diagnosis and management. The origin of intraocular hemorrhage in Terson’s Syndrome has been debated. A recognized theory suggests that an acutely raised ICP induces effusion of cerebrospinal fluid into the optic nerve sheath which dilates the retrobulbar aspect of the sheath in the orbit. Dilatation mechanically compresses the central retinal vein and retinochoroidal veins resulting in venous hypertension and rupture of thin retinal vessels. A commonly reported clinical feature is decreased visual acuity and blurred vision. These may be accompanied by symptoms of increased ICP including loss of consciousness and headache. Diagnosis is established using evidence from the clinical presentation, ophthalmoscopy, and, when required, imaging including B-mode ultrasound, CT, MRI, and fluorescein angiography. Terson's Syndrome is managed conservatively by observation for mild cases and with vitrectomy for bilateral cases and for patients whose hemorrhage has not spontaneously resolved after an observational period. Terson's Syndrome can be used as a prognostic indicator of morbidity and mortality in underlying pathology like SAH. Fundoscopy of patients with SAH, acutely raised ICP or visual disturbance with unknown etiology can help establish a timely Terson’s Syndrome diagnosis. This may avoid the risk of permanent visual impairment.

Objective Lumbar spinal stenosis (LSS) in octogenarians and beyond has a significant impact on quality of life requiring surgical decompression and hence impact on health care utilization. Risk of surgical failure and impact on health care resources is always a concern in this patient population (more so in nonagenarians). The aim of our study was to compare clinical outcomes and healthcare utilization in patients (80–89 vs.90+) undergoing decompression for LSS. Patients and methods Data was extracted using ICD9/10 and CPT codes from MarketScan (2001–2015) in this retrospective study. We defined the comparative groups based on the age groups (80–89 and 90+), in patients with LSS. Outcomes of interest were: length of hospital stay, discharge disposition and utilization in the index hospitalization, 6- months, 12 months following index procedure as well as the associated health care utilization. Patient characteristics and outcomes among cohorts were compared using univariate tests. Outcomes were further compared using adjusted multivariable regression models. Statistical analysis was performed with SAS 9.4. Results A cohort of 5387 was identified from the database, 96.38% were in the 80–89 age group and 3.62%were in the 90+ age group. The proportion of patients undergoing surgery for LSS among 80–89 (95.7–98.5%) and 90+ age group (1.5–4.3%) remained constant through the years. Interestingly, 13.83% and 16.92% of patients had Elixhauser comorbidity index of 3+ in 80–89 age group and 90+ age groups respectively. Decompression with fusion was performed in 19.4% of patients in 80–89 age group, compared to 9.74% of patients in 90+ age group. There was no difference in median length of hospital stay (3 days, p = 0.19) and complications across the cohorts (80–89: 16.7%; 90+: 18.46% p = 0.51). 70.6% of patients in 80–89 age groups were discharged to home compared to 60.5% in 90+ age group (p = 0.0023). At 6 months follow-up, overall rate of new decompression, new fusion, re-fusion at index level were 2.38%, 0.59% and 0.33% only, with no differences across the cohorts. Interestingly, patients in 80–89 age group incurred higher outpatient services, number of medication refills and related payments at 6-months and 12-months follow-up, compared to patients in 90+ age group. Overall, combined median post-discharge payments at 12 months were similar across the groups [80–89 (median $ 40,257) and 90+ (median$ 36,161), p = 0.14]. Conclusion Using MarketScan database, there has been a gradual decline in the number of decompressions being performed for LSS in elderly patients (>80 years of age), however there is no change in the proportion of octogenarians and nonagenarians undergoing decompression for LSS. There was no difference in rate of reoperations and overall health care utilization among the groups. Surgery for LSS can be offered to nonagenarians (in appropriately selected patients) with no difference in clinical outcomes and health care utilization, compared to octogenarians.

Objective: The LACE + index (Length of stay, Acuity of admission, Charlson Comorbidity Index (CCI) score, and Emergency department visits in the past 6 months) is a tool utilized to predict 30–90 day readmission and other secondary outcomes. We sought to examine the effectiveness of this predictive tool in patients undergoing brain tumor surgery. Patients and methods: Admissions and readmissions for patients undergoing craniotomy for supratentorial neoplasm at a single, multi-hospital, academic medical center, were analyzed. Key data was prospectively collected with the Neurosurgery Quality Improvement Initiative (NQII)-EpiLog tool. This included all supratentorial craniotomy cases for which the patient was alive at 90 days after surgery (n = 238). Simple logistic regression analyses were used to assess the ability of the LACE + index and subsequent single variables to accurately predict the outcome measures of 30–90 day readmission, 30–90 day emergency department (ED) visit, and 30–90 day reoperation. Analysis of the model’s or variable’s discrimination was determined by the receiver operating characteristic curve as represented by the C-statistic. Results: The sample included admissions for craniotomy for supratentorial neoplasm (n = 238) from 227 patients, of which 50.00% were female (n = 119). The average LACE + index score was 53.48 ± 16.69 (Range 9–83). The LACE + index did not accurately predict 30–90 day readmissions (P = 0.127), 30–90 day ED visits (P = 0.308), nor reoperations (P = 0.644). ROC confirmed that the LACE + index was little better than random chance at predicting these events in this population (C-statistic = 0.51−0.58). However, a single unit increase in LACE + leads to a 0.97 times reduction in the odds of being discharged home with fair predictive accuracy (P Conclusion: The results of this study show that the LACE + index is ill-equipped to predict 30–90 day readmissions in the brain tumor population and further analysis of significant covariates or other prediction tools should be undertaken.

Br(E)-MsEP monitoring is widely used in spinal surgery for detection of spinal cord injury. However, Br(E)-MsEP waveform derivation requires high-intensity stimulation, and this raises a concern of adverse effects due to the immature corticospinal tract in pediatric patients. The purpose of this study is to determine the optimal stimulation intensity required for derivation of Br(E)-MsEP waveforms at baseline in pediatric spinal surgery.The subjects were 85 pediatric patients (4-15 years old, mean age at surgery: 11.1 years old) who were treated with spinal surgery using a posterior only approach under Br(E)-MsEP monitoring. The main diagnoses were adolescent idiopathic scoliosis (n = 44), syndromic and neuromuscular scoliosis (n = 23), and congenital scoliosis (n = 12). A total of 1513 muscles in the lower extremities were chosen for monitoring.A baseline waveform was obtained in all 85 cases and baseline Br(E)-MsEP responses were obtained from 1437/1513 muscles (95%). The mean stimulation intensity for baseline waveform derivation was 156.4 mA (range: 100-200 mA), and the stimulation intensity was significantly correlated with age (p 0.05). The mean stimulation intensities were 129 ± 12, 138 ± 20, and 167 ± 25 mA for children5, 6 to 10, and 11 to 15 years old, respectively.There are no criteria for derivation of Br(E)-MsEP waveforms in pediatric patients undergoing spinal surgery. The stimulation intensity increased with age, and starting at a lower stimulation strength than that used in adults is appropriate for younger children.

Osteoporosis is a skeletal condition characterized by low bone mineral density (BMD). Common in older patients undergoing spinal fusion, it is a significant risk factor for instrumentation failure and related complications. The objective of this review is to articulate clear suggestions for screening and medical/surgical management strategies in patients with osteoporosis. A thorough review of the literature was conducted using PubMed. Varied search terms were applied to yield published manuscripts on osteoporosis and spine surgery. Biomechanical studies and studies conducted in animal models were excluded. Screening should be considered in those that present with multiple risk factors for low BMD. Dual-energy x-ray absorptiometry (DEXA) remains the gold standard, but Hounsfield Units (HU) have emerged as a powerful complement to DEXA. While both bisphosphonates and teriparatide have been investigated in the perioperative setting and have a positive impact on outcomes, teriparatide maintains an advantage in comparative studies. Surgical treatment need not be postponed. Standard surgical modifications such as using multiple points of fixation, varied fixation equipment, anterior/posterior instrumentation, and modified screw design/trajectories should all be considered. However, recent clinical studies focus on cement augmentation and expandable pedicle screws. All have been shown to improve bone-screw interface strength, but extravasation remains a risk of cement augmentation, and hydroxyapatite cement (HAC), while an emerging alternative to polymethyl methacrylate (PMMA), is not as well investigated in the setting of osteoporosis. Furthermore, research on expandable pedicle screws is limited. To conclude, optimizing spine surgery outcomes in the osteoporotic patient is possible with a thorough preoperative workup, medical management, and a tailoring of the surgical technique. This is especially important when performing complex spinal instrumentation.

Objective Osteoporotic vertebral compression fracture (OVCF) is a common disease in the aged population that can greatly affect the quality of life. Percutaneous kyphoplasty (PKP) has become a mainstream approach for treating OVCF, but the optimal surgical timing for treating OVCF with PKP remains controversial. In the current study, we retrospectively studied patients with OVCF that underwent PKP, and aimed to find out whether surgical timing could affect the clinical and radiological outcomes. Patients and methods We retrospectively studied 62 patients who underwent PKP for OVCF. Patients were divided into 2 groups based on the timing of PKP: operation within 4 weeks (group A) and operation later than 4 weeks (group B). VAS, ODI, height of fracture vertebra, restored height rate, local kyphosis angle and complications were assessed preoperatively and throughout the follow-up. Results There were 36 cases (58 fracture vertebra) in the group A and 26 cases (40 fracture vertebra) in the group B. There was no significant difference between the two groups regarding to the demographic data before surgery. In terms of the VAS and ODI, no statistical difference was observed before operation, after operation and at the 6th month follow-up between the two groups. The HRR after operation and at the 6th month follow-up in the group A was 17.5 ± 5.3% and 10.5 ± 3.7%, and that in the group B was 7.2 ± 3.2% and 3.6 ± 1.1%, and there is significant difference between the two groups (p Conclusion Both surgical timings of PKP showed similar outcomes in terms of the VAS and ODI. Early PKP could result in better restoration of vertebral body height and reduced rate of subsequent fracture compared to late PKP.

Objectives The aim of this study was to analyze the accuracy and positive predictive value (PPV) of preoperative lumbar MRI grading for successful outcome after outpatient endoscopic decompression for lumbar foraminal and lateral recess stenosis. Lumbar MRI is commonly employed in preoperative decision making to identify symptomatic pain generators amenable to surgical decompression. However, its accuracy and positive predictive value for successful postoperative pain relief after endoscopic transforaminal decompression for sciatica-type back and leg pain has not been reported. Patients and methods A retrospective study of 1839 consecutive patients with a mean follow-up of 33 months that underwent lumbar endoscopic transforaminal decompression at 2076 lumbar levels was conducted. The sensitivity, specificity, accuracy, and positive predictive value of preoperative MRI grading correctly identifying the symptomatic surgical level were calculated based on the recorded intraoperatively visualized pathology and clinical outcomes assessed by both Macnab criteria and VAS score reduction. Results Of the 1839 patients evaluated, 1750 had intraoperatively visualized stenosis in the lateral recess at the surgical level whereas 89 patients did not. Analysis of radiologist grading of exiting nerve root compression in the lumbar MRI reports in patients with visualized compressive pathology: true positive (1196), false negative (554); as compared with patients without visualized compressive pathology showed: false positive (30), and true negative (59); and allowed for calculation of sensitivity (68.34%), specificity (68.29%), accuracy (68.24%) and the positive predictive value (97.38%) in relation to successful clinical outcome of the subsequent endoscopic decompression surgery. Sensitivity (87.2%), specificity (73.03%), and accuracy (86.51%) improved when the treating surgeon graded same MRI scan for traversing nerve root compression. Taking different spinal stenosis classification systems by the radiologist and surgeon into consideration, Kappa statistic assessment of agreement between radiology and surgeon reporting of stenosis showed different degrees of concordance for extruded herniated disc (κ = 0.42; 331 patients), contained disc herniation (κ = -0.01; 648 patients), and stenosis (κ = 0.25; 860 patients). Disagreement (κ = 0.216; 440 patients) predominantly existed in grading the relevance of foraminal stenosis in the entry- (κ = 0.18; 278/440 patients), mid- (κ = -0.036; 121/440 patients), and less so in the exit zone (κ = -0.036; 41/440 patients) associated with contained (κ = -0.10; 178/440 patients), extruded disc herniations (κ = 0.4; 62/440 patients), and stenosis (κ = 0.25; 200/440 patients). Conclusion The grading of a preoperative MRI scan for lumbar foraminal and lateral recess stenosis may significantly differ between radiologist and surgeon. The endoscopic spine surgeon should read and grade the lumbar MRI scan independently to aid in appropriate patient selection for successful transforaminal endoscopic decompression surgery. More contemporary MRI reporting criteria are needed to describe the surgical anatomy in the neuroforamen and lateral recess relevant during the minimally invasive endoscopic transforaminal decompression.

Objective To assess inferior vena cava (IVC) filter retrieval rates and clinical outcomes in neurosurgical patients and to determine patient characteristics associated with filter retrieval. Patients and methods This single-center retrospective study included 204 consecutive neurosurgical patients (120 men, 84 women; mean age 60 ± 13 years) who underwent retrievable IVC filter insertion between 1/2011-9/2013. Institutional IVC filter database review was used to identify demographic and clinical data, indication for IVC filtration, and IVC filter type. Patients were followed clinically by the neurosurgical, hematology, and interventional radiology services until removal or conversion to a permanent device. Measured outcomes included filter retrieval rates and parameters associated with device removal. Results The majority of filters were placed for venous thromboembolism (200/204, 98%). Of 204 filters, 38(19%) were retrieved at median 186 days post-placement (range 3–665 days), 112(55%) converted to permanent devices, 44(22%) patients were deceased, and 10(5%) patients were lost to follow-up after transfer to an outside healthcare facility. Patients with subarachnoid hemorrhage (18% vs. 35%, p = 0.025) and malignancy (5% vs. 25%, p = 0.009) were less likely to have filters removed. Filter type (p = 0.475), gender (p = 0.221), neurosurgical procedure (p = 0.639), and insurance status (p = 0.207) did not demonstrate a significant association with filter retrieval. Conclusion IVC filter retrieval rates in neurosurgical patients are low despite tracking patients clinically in a multidisciplinary setting. Those neurosurgical patients with intracranial hemorrhage or malignancy requiring IVC filters have a lower likelihood of filter retrieval and may benefit from use of permanent devices.

Objective To see what happens on PET hypometabolism on the temporal lobe contralateral to the side of surgery in patients with bitemporal hypometabolism (BTH). Patients and Methods This retrospective study with prospectively defined data evaluated the pre- and post-surgical PET hypometabolism on the contralateral temporal lobe after resection of ipsilateral temporal lobe in 10 patients with BTH operated between January, 2010 and May, 2018. On PET we compared standard uptake values (SUV) and relative metabolic activities as compared to normal subjects by means of Z-scores of hypometabolism of unresected temporal lobes before and after surgery. Results Surgery did not lead to satisfactory seizure outcome and only 3 patients were seizure free. All but one were still using anti-epileptic drug. No significant change was noted on PET hypometabolism related to the contralateral temporal lobe at the last follow-up. Regarding the mean SUV, comparisons showed that the difference with respect to the mesial structures was significant (p = 0.04). But lateral cortex showed insignificant difference (p = 0.21) before and after surgery. Regarding the mean Z-score, no significant differences were found between both the mesial temporal structures (p = 0.23) and lateral temporal cortex (p = 0.18). Conclusion Surgery does not lead to improvements on PET hypometabolism of the temporal lobe contralateral to the side of surgery and hypometabolism on the contralateral side may be due to structural damage rather than functional deficits secondary to propagation of repetitive seizures. Seizure outcome is not satisfactory and before surgery patients or their next of kin should be informed in detail.

Spinal angiolipomas (SALs) are rare extradural tumors frequently located at the level of the thoracic spine and they are associated with spinal cord compromise that might result in severe myelopathy. While the first macroscopic description dates 1890, histologically these tumors where not described as angiolipomas until 1986 by Haddad et al. Occurrence in pregnancy is even more infrequent. Since their first macroscopic description, spinal angiolipomas were reported anecdotally in pregnant women. We present a case of spinal angiolipoma in pregnancy with confirmed histologic diagnosis. In the present paper, we reviewed the literature regarding spinal angiolipomas in order to characterize their clinical manifestation, natural history, radiologic and histologic appearance. We add also a further case of spinal angiolipoma in a pregnant woman. Finally, we provide suggestions for the management of such rare tumors in pregnancy.

To investigate clinical characteristics and outcomes of chronic subdural hematomas (CSDHs) in different age ranges.A retrospective collection of data from CSDH patients ≤40 years, 41-79 years, and ≥80 years of age between August 2011 and May 2017 was performed. The differences and similarities of clinical data and outcomes among three groups were analyzed.A total of 1118 CSDH patients were included. We found that 64.5% patients had arachnoid cyst/ventriculoperitoneal shunt in patients ≤40 years, 4.3% in the 41-79 years group, and 3.2% in the ≥80 years group (P 0.001). Headache was the most frequent symptom in the ≤40 years group (88.2%) and the 41-79 years group (60.9%), while the most frequent symptom in the ≥ 80 years group was limb weakness (80.4%). The history of head trauma was not significantly different between the three groups. After burr hole drainage craniostomy, the disappearance or alleviation of symptoms, duration of catheter drainage, and length of hospital stay were not significantly different, while the recurrence rate was also not significantly different between the three groups. Post-operation complications are an independent risk factor contributing to the death of patients of 41-79 years (P0.001, B = 3.140, Exp (B) = 23.103, 95% CI = 5.142-103.809) and of ≥ 80 years (P = 0.001, B=2.831, Exp (B) = 16.970, 95% CI = 3.365-85.567). The history of antithrombotic drug was an independent risk factor of complications in patients of 41-79 years (P = 0.042, B =1.341, Exp (B) =3.823, 95% CI = 1.048-13.942) and patients of ≥ 80 years (P = 0.026, B=1.399, Exp (B) = 4.052, 95% CI = 1.178-13.933), while complications were also an independent risk factor contributing to the outcome in patients of 41-79 years (P 0.001, B =2.254, Exp (B) =0.314, 95% CI = 0.089-1.103) and patients of ≥ 80 years (P = 0.006, B=2.074, Exp (B) = 7.953, 95% CI = 1.791-35.313). In the ≤40 years group, all patients had a good outcome (MRS score 0-3), while 98.2% (851/867) of the cases in the 41-79 years group and 94.3% (149/158) of the cases in the ≥ 80 years group saw a good outcome (P = 0.001).Our results clearly display the common and different clinical data of CSDH in all age ranges, which is crucial to improve the management and treatment of patients with CSDH.

Objectives The aim of this study was to analyze the clinical data concerning the loosening and tilting of the recovered bone flap after encephalo-myo-synangiosis (EMS) and explore the potential underlying mechanisms. Patients and methods Clinical data of all patients who underwent an EMS procedure from January 1, 2014 to April 30, 2018 at our hospital were collected. The cases with postoperative tilting of the recovered bone flap were identified and the clinical characteristics of the patients involved were analyzed. Results There were totally 204 patients who underwent EMS, among whom 12 patients (Male/Female = 6/6) experienced tilting of the recovered bone flap after craniotomy. The average age was 44.3 years. The average height of the tilt was 8.3 ± 3.1 mm. The shortest time for the bone flap to tilt to a height of 5 mm was found to be one day after surgery and the longest was up to 7 months. In cases in which maximum height was observed in a short duration after surgery, the average time for the tilted bone flap to reach the maximum height was 6.1 ± 3.6 days. In addition, a second craniotomy on the opposite side might be an important factor, and three cases were noted with second surgeries (Cases 2, 7, and 9). Conclusion Recovered bone flap tilting after EMS should be listed as a complication after roofing of the temporal muscle. This complication may be related to the temporal muscle edema, the increase of intracranial pressure and no bandage compression.

The interest and potential use of augmented reality (AR) in several medical fields since the early 90′s has increased consistently. It provides intraoperative guidance for surgical procedures by rendering visible what cannot be seen directly, possibly affecting surgical outcomes. Our objective was to conduct a systematic review of the intraoperative clinical application of augmented reality in neurosurgery, in studies published during the last five years. We carried out an electronic search in the PUBMED database using the terms “Augmented Reality” and “Neurosurgery.” After exclusions, 12 published articles that evaluated the utility of intraoperative clinical applications in surgical settings were included in our review. The results evaluated involved AR technique and visualization, time, complications, projection error, and located structures. We can conclude that the neurovascular application is the most frequent type of use for AR in neurosurgery (47.3%), followed by applications in neuro-oncological pathologies (46.7%), and non-vascular and non-neoplasic lesions (5.9%). The use of AR also allows a surgeon to maintain their view on the operative site permanently, and is useful for locating structures, guiding resections, and planning the craniotomy with more precision, decreasing the risk of injury. The intraoperative application of an augmented reality system helps to improve the quality and characteristics of the surgical field image. The injection of 3D images with AR allows for the successful integration of images in vascular, oncological and other lesions without the need of look away from the surgical field, improving safety, surgical experience, or clinical outcome. However, comparative studies are still required to determine its effectiveness.

The resection of insular gliomas remains a neurosurgical challenge due to the close proximity of functionally-important cortical, white matter tracts, and vasculature structures. More recently, the feasibility of resection has gained traction, however, there is a lack of consolidated neurological deficit metrics. Thus, the aim of this study was to determine the incidences of neurological deficits following insular glioma resection to better guide selection algorithms and resource allocations. Searches of seven electronic databases from inception to August 2018 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted and pooled using meta-analysis of proportions. Meta-regression was used to identify potential sources of heterogeneity. Nineteen observational studies reported the neurological outcomes of 890 insular glioma patients. The pooled incidences of new temporary and permanent motor deficits were 11% (95% CI, 6-17%) and 4% (95% CI, 2-7%) respectively, and new temporary and permanent language deficits were 11% (95% CI, 6-17%) and 2% (95% CI, 0-4%) respectively. Single-surgeon series reported significantly lower incidences of both permanent motor (2% vs 7%; P 0.001) and language (1% vs 3%; P = 0.03) deficits. The incidences of motor and language neurological deficits following insular glioma resection have been quantified, and will assist in determining the suitability and appropriateness of pursuing surgical resection for insular glioma. We note that permanent neurological deficits are lowest when reported by series describing outcomes of a single surgeon, indicating most optimal outcomes may be best achieved after intense training and/or greater experience.

Objectives Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated. Patients and methods We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6–12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months. Results One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%). Conclusions Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.

Identifying peripheral nerve surgery procedure (PNSP) competencies is crucial to ensure adequate resident training. We examine PNSP training at neurosurgical centers in the US and Canada to compare resident-reported competence, PNSP exposure, and resident technical abilities in performing 3 peripheral nerve coaptations (PNC).Resident-reported PNSP competence and PNSP exposure data were collected using questionnaires from neurosurgical residents at North American neurosurgical training centers. Exposure and self-reported competency were correlated with technical skills. Technical PNC variables collected included: time-to-completion, nerve-handling from video-analysis, independent and blinded visual-analog-scale (VAS) PNC quality grading by 3 judges, and training level.A total of 40 neurosurgical residents participated in the study. Although self-reported competency scores correlated with procedural exposure (P 0.01, rs = 0.88), a discrepancy was found between the degree of self-reported competency and amount of exposure. The discrepancy was greater in senior residents. A significant VAS difference was found between PNC types with the direct-suture and connector-assister groups scoring higher than connector-only (P = 0.02, P 0.01, respectively). No difference was observed between training level and VAS grading, nor time-to completion (P = 0.33 and 0.25, respectively). No correlation was found between self-reported competency performing PNSPs and PNC VAS scores, nor nerve handling.Despite more exposure and a higher self-reported PNSP competency in senior residents, no difference was seen between senior/junior residents in PNC quality. A discrepancy in PNSP exposure and self-reported competency exists. This information will provide guidance for the direction of resident PNS training.

Normal pressure hydrocephalus (NPH) and degenerative cervical myelopathy (DCM) can each lead to gait dysfunction and urinary incontinence and may occur concurrently in some patients. In patients presenting with NPH and DCM, there is a paucity of literature describing the medical and surgical complications of treatment and the potential consequences of the sequence of surgical procedures. The aim of this study is to evaluate patients with DCM, NPH, and dual pathology to determine epidemiology and how the order of surgical intervention for both conditions may impact complications and patient outcomes.The PearlDiver Mariner database was queried between 2010 and 2020 to identify patients by their diagnosis of NPH, DCM, or both. Additional groups were created to identify cohorts of patients who underwent ventriculoperitoneal (VP) shunting, DCM surgery, or both surgeries, as determined by the CPT, ICD9, and ICD10 codes included in the dataset. Overall demographics were reported for these cohorts of patients including age, gender, and region. Multivariable logistic regression, controlling for age, sex, and Charlson Comorbidity Index, was used to calculate odds ratios for the rates of perioperative complications within 1 year of initial ventriculoperitoneal (VP) shunt and/or DCM surgery.A total of 825,989 patients were identified with DCM and/or NPH: 725,433 (87.8%) had myelopathy alone, 96, 411 (11.7%), had NPH alone, and 4145 patients (0.5%) had both NPH and DCM. Of all patients with NPH, 4.8% underwent DCM surgery. Of all patients with DCM, 0.08% underwent VP shunting. Compared to NPH only patients who underwent VP shunting, patients with both pathologies undergoing VP shunting had higher odds of revision at 1-year (OR: 1.33, p-value: 0.04) and 5-years (OR: 1.36, p-value: 0.011), as well as spinal cord injury (OR: 7.77, p-value 0.016), dysphonia (OR: 2.88, p-value: 0.004), cervicalgia (OR: 2.95, p-value: 0.004), cervical kyphosis (OR: 17.49, p-value: 0.004), and limb paralysis (OR: 2.02, p-value: 0.002). Compared to DCM only patients who underwent DCM surgery, patients with both pathologies undergoing DCM surgery had higher odds of cardiac complications (OR: 1.12, p-value: 0.002), dural tear (OR: 1.66, p-value: 0.029), and dysphagia (OR: 1.28, p-value:0.001). Patients who underwent VP shunting prior to DCM surgery had higher odds of revision shunting surgery at 1-year (OR:1.61, p-value:0.03) and 5- years (OR:2.16, p-value:0.001).This is the largest study to date examining patients with dual cervical myelopathy and normal pressure hydrocephalus. Surgeons should carefully consider the order of VP shunting and DCM surgery, as complication rates differ depending on the order in which these surgeries are performed. Shunt revision is more common when VP shunting is performed prior to spinal decompression.

The aim of study is to evaluate the general performance and efficiency of the using real time intraoperative ultrasound system with Volume Navigation system technology in glioma. Compare glioma intraoperative ultrasound and contrast agent ultrasound images to obtained preoperative MRI with fusion image in a real-time.Fifteen patients had been performed fusion imaging involved intraoperative real-time ultrasound and contrast agent ultrasound with preoperative MR imaging including preoperative gadolinium-enhanced MRI from March 2017 to December 2017. The number of tumor was counted online fusion imaging in real time ultrasound with and without preoperative MR. We analyzed ultrasound coplanar MR modalities in real time including tumor location, margin (obscure or defined). In addition, intraoperative ultrasound enhancement pattern was analyzed compare it to preoperative reconstruction gadolinium-enhanced T1-weighted MRI. Two radiologists who made planning ultrasound assessment for the focus lesion based on a 4 scoring system according to the degree of confidence.Thirteen of fifteen patients whose automatically registration successful intraoperative neurosurgery accepted preoperative MR examination. Seven of fifteen fine-tuning registration phase were performed and satisfactory with fusion image substantially. Intraoperatively, 73.3% (11/15) glioma nodules were definite on conventional B-mode US by a radiologist who doesn't know the MR result before fusion US with MRI. However, 100% tumors were detected on fusion B-mode ultrasound imaging with MRI. Two radiologists evaluated the score between fusion B-mode ultrasound and CEUS with coplanar MRI and had a result that score was upgraded in 69.2% (9/13) and 84.6% (11/13) patients. Inter-observer agreement was significant (kappa value = 1.0, p 0.001) in B-mode ultrasound fusion image with MRI. Inter-observer agreement was moderate (kappa value = 0. 0.618, p 0.001) in CEUS fusion image with MRI.Fusion imaging is very useful to detect poor sonographic visibility tumor on fusion B-mode US imaging with MR images. Fusion image may demonstrate multiplane images including same standard and nonstandard MRI and US images to help localize tumor. The additional real time fusion CEUS mode image with MR is a safe method for neurosurgery and the use of CEUS should be considered when fusion B-mode ultrasound imaging alone is not satisfactory for margin.

Background Although the superiority of clipping compared to coiling on the oculomotor nerve palsy (ONP) recovery for ruptured posterior communicating artery aneurysms (PcomAAs) has been widely accepted, which treatment modality is better in the treatment of ONP induced by unruptured PcomAAs still remains unclear. Methods A meta-analysis of studies that compared clipping with coiling was performed after a literature search. Perioperative data and clinical outcome were extracted. Analysis on the effect of the two treatment modalities was then performed. Results Nine eligible studies with a total of 136 patients met the inclusion criteria. There was a significant difference in the total efficiency (any degree of improvement) on ONP favoring clipping [RR= 1.21, 95%CI (1.01, 1.44), p = 0.04], the effect was most notable for complete recovery of ONP after having suffered preoperative partial palsy [RR= 0.72, 95%CI (0.55, 0.95), p = 0.02]. There was neither a significant difference regarding the complete recovery of ONP [RR= 1.11, 95%CI (0.77, 1.61), p = 0.58] nor the frequency of complications [RR= 0.07, 95%CI (0.00, 1.10), p = 0.06]. Also when subdividing there was no significant difference in complete recovery of ONP in patients who had initially suffered a complete ONP [RR= 0.79, 95%CI (0.38, 1.64), p = 0.53] and partial ONP [RR= 1.16, 95%CI (0.65, 2.08), p = 0.61] between clipping and coiling. Conclusions A superiority of clipping over coiling for the improvement of ONP secondary to unruptured PcomAAs was found. Patients with partial ONP were more likely to attain a complete resolution of ONP, as compared to complete ONP.

OBJECTIVE For individuals with severe disability requiring spine surgery, appropriate discharge destination is a challenging and complex decision. Past studies have found associations between discharge destination and postoperative outcomes but were limited by biases in sampling characteristics. The purpose of this study was to explore whether there is an association between discharge destination and odds of worse postoperative outcomes in high-risk individuals with severe/crippling/bedbound disability who received lumbar spine surgery. METHODS This was an observational study using the Quality Outcomes Database Spine Registry. Subjects were limited to age ≥18 years, primary lumbar spine surgery, and severe disability at baseline (Oswestry Disability Index [ODI] ≥50%). Discharge destination was dichotomized to home or healthcare institution. RESULTS Of the 13,050 patients, 11,859 patients (90.9%) were discharged home and 1191 (9.1%) patients were discharged to a healthcare institution. Individuals who were discharged to a healthcare institution were older (68.6 vs 56.9 p

Introduction Meningiomas are usually considered benign lesions, however a proportion of them shows a more aggressive behavior, defined high-grade meningiomas (HGM). Effective medical treatments are lacking, especially at the time of recurrence. Methods Through a retrospective analysis, we examined epidemiological, diagnostic, therapeutic, recurrence information and survival data of HGM treated at our institution between 2010 and 2018. Results 183 patients (105 females and 78 males), with median age of 58 years (25–88), were included; 168 were atypical, 12 anaplastic, 3 rhabdoid. Overall, m-PFS was 4.2 years, and m-OS was 10.3 years. Gross-total resection had a 5-year survival rate of 95% compared with subtotal/partial resection (86% and 67%) (p = 0.002). Higher expression of Ki-67/MIB-1 seems associated with higher risk of death (HR:1.06 with 95% CI, 1.00–1.12, p = 0.03). No statistically significant differences were seen in survival between the group managed with a wait-and-see strategy vs the group treated with RT while a difference on PFS was seen (4.1 years vs 5.2 years p = 0.03). After second recurrence, the most employed treatments were systemic therapies with a very limited effect on disease control. Conclusions Data confirmed the aggressive behavior of HGM. The extent of resection seems to correlate with a favorable outcome regardless histological subtypes. The role of RT remains controversial, with no statistically significant impact on OS but a possible role on PFS. Recurrent HGM remains the real challenge, to date no chemotherapies are able to achieve disease control. Future research should focus on biological/molecular predictors in order to achieve a patient-tailored treatment.