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While hemorrhage is commonly encountered in various intracranial tumors, it is relatively rare in benign meningiomas. We present an interesting case report of a 75-year-old male who fell during intoxication, sustaining right frontal cranial trauma, coincidentally directly overlying a previously undiagnosed right frontal meningioma. He experienced an acute neurological decline and was found to have an intracranial hematoma, causing significant mass effect and herniation. Based on the radiographic appearance, an underlying neoplasm with significant edema was suspected. Intraoperatively, the hematoma and mass were successfully evacuated, and post-operative pathology confirmed the presence of a World Health Organization Grade I meningioma with a microcystic and angiomatous pattern. We speculate on the mechanism of injury and hemorrhage in this patient through review of the literature and discussion of medical and pathological risk factors.

While deep brain stimulation (DBS) is now standard therapy for the treatment of Parkinson's disease, essential tremor, and dystonia, infections remain one of the most common perioperative complications. In this report, we describe a 58-year-old female with a history of medically refractory Parkinson's disease, who underwent magnetic resonance (MR)-guided bilateral subthalamic DBS. While the initial surgery and programming were successful, she returned in follow-up with signs of a generator pocket infection. She was taken to surgery for hardware explantation, and cultures revealed multispecies growth which included the rare Cupriavidus pauculus species. This is the first report of C. pauculus infection in conjunction with a neuromodulation device. We provide a literature review and discussion of C. pauculus, and its implications in the context of DBS surgery.

Background There is a significant upfront cost for the use of neuromodulation devices. The high cost of these devices may lead to disproportionate application in geographical regions with different levels of financial resources. The purpose of this study was to determine if there is geographic based economic inequity in the application of neuromodulation devices in the United States. Methods Population and average household income data by county from the year 2010 were obtained from publicly available databases on the US Census website. The number of stimulators sold by county in the years 2009 and 2010 were provided by two of the four neuromodulation companies with commercially available products. Pearson correlation and t-test statistics were performed. Results Of the 3142 U.S. counties analyzed, only 689 placed neuromodulation devices during this period of time. There was a difference in average household income between counties with device implants ($49,663) and counties with no device implants ($41,314), which was statistically significant (p

This index case report describes the intraoperative use of an eight-contact directional deep brain stimulation (DBS) lead to avoid adjustment and repeat microelectrode passes after the initial pass elicited side-effects that suggested a slightly anteriorly placed lead. While targeting the subthalamic nucleus (STN), intraoperative microelectrode recording (MER) confirmed that lead positioning and macrostimulation resulted in response at 1 mA but sustained dysarthria at 2 mA. This suggested a slightly anteriorly located electrode. The patient was becoming anxious, so instead of lead adjustment, an eight-contact directional DBS lead was placed to take advantage of the directional contacts, noting that a repeat pass could always then be performed. Segmented contact 11C showed symptom response at 0.5 mA and side-effect at 4 mA, resulting in a 3.5 mA therapeutic window. Though no substitute for an accurately placed lead, this result suggests that the flexibility of directional stimulation could be considered in the intraoperative setting.

This index case report describes a patient who presented with unilateral hyperkinetic choreiform movements of the left neck, arm, and leg caused by right-sided putamen and caudate calcification as the product of an underlying developmental venous anomaly (DVA). No underlying metabolic disorder or other calcium-related disorder was present. Calcification of the putamen and caudate has been described in relation to an underlying DVA which results in localized venous hypertension and other changes, and tends to spare the anterior limb of the internal capsule. This resulting unilateral choreiform movement disorder has not been described in the literature and represents the need for greater recognition of this entity in the differential for lateralizing hyperkinetic disorders.

On-call services provided by physicians are critical to the function of a robust healthcare delivery system, but such services are not generally accounted for by standard physician productivity metrics, such as the work relative value unit (wRVU). There is significant diversity on how physicians are compensated, if at all, for these on-call services. Simultaneously, there exists a considerable shortage, particularly in the surgical subspecialties, for on-call coverage - most commonly in rural and underserved communities. While we agree that "call" services should undergo standardized valuation, we suggest that the wRVU is an ill-posed metric for this purpose as its primary role is to value discrete physician services provided to patients. In contradistinction, "call" is a physician service to a hospital - the disproportionate beneficiary of the service. We maintain that systemic and regulatory factors undervalue physician on-call compensation relative to the hospital's value chain and lead to call shortages that impact patient care and foster inequity. Finally, we urge subspecialty professional organizations to develop guidelines for call valuation.

Cervical radiculopathy and peripheral nerve pathology often compete in the differential diagnosis of extremity pain, weakness, and numbness, and frequently, coexist. In this report, we describe a 73-year-old male with a previously asymptomatic left anteromedial proximal upper arm mass, who presented with progressive radicular arm pain, proximal and distal upper extremity weakness, and hand numbness. Clinical investigation revealed a prominent C6-7 disc herniation and a median nerve sheath tumor, with electromyography (EMG)/nerve conduction velocity (NCV) studies suggestive of acute radiculopathy. He was treated in a staged surgical fashion, with the nerve sheath tumor resection first, followed by a standard C6-7 anterior cervical discectomy and fusion (ACDF) two weeks later. The patient made a full recovery. We provide a literature review and discussion of the "double crush" hypothesis.

Objective Ventricular shunts are a mainstay of hydrocephalus treatment, but the detection of its clinical failure often relies on circumstantial evidence. A direct, non-interventional method for reliably evaluating cerebrospinal fluid (CSF) function does not exist due to the difficulty of measuring in vivo flow characteristics. The objective of this study is to apply a novel method of ultrasound monitoring to characterize the oscillation observed during pulsatile CSF flow and failure states in an in vitro and cadaveric model. Method In this proof-of-concept report, ultrasound is utilized to noninvasively monitor the shunt valve and characterize its mechanical response to different flow conditions. In vitro and in situ testing was carried out by running deionized water through a ventriculoperitoneal shunt (VPS) system using a pulsatile flow generator to replicate the flow rates expected in vivo. Different flow conditions were then tested: no flow, normal flow, proximal obstruction, and distal obstruction. Ultrasound data taken from the pressure relief valve were analyzed to determine differences in the displacement of valve components over time between flow states. Results Displacement patterns of the four different flow conditions were determined by directly tracking the changes from the M-mode plots. Each pattern was found to be distinct and repeatable with statistically significant results found when comparing the normal flow condition to distal and proximal obstruction cases. Conclusions Each of the flow conditions was found to have a distinct displacement profile, demonstrating that ultrasound imaging of the shunt valve can be used to accurately differentiate between flow and failure conditions. Ultrasound monitoring may be a promising adjunct approach in determining the need for surgical shunt exploration.