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Telemedicine has received increased attention in recent years as a potential solution to expand clinical capability and patient access to care in many fields, including neurosurgery. Although patient and physician attitudes are rapidly shifting toward greater telemedicine use in light of the COVID-19 pandemic, there remains uncertainty about telemedicine's regulatory future. Despite growing evidence of telemedicine's utility, there remain a number of significant medicolegal barriers to its mass adoption and wider implementation. Herein, we examine recent progress in state and federal regulations in the United States governing telemedicine's implementation in quality of care, finance and billing, privacy and confidentiality, risk and liability, and geography and interstate licensure, with special attention to how these concern teleneurosurgical practice. We also review contemporary topics germane to the future of teleneurosurgery, including the continued expansion of reciprocity in interstate licensure, expanded coverage for homecare services for chronic conditions, expansion of Center for Medicare and Medicaid Services reimbursements, and protections of store-and-forward technologies. Additionally, we discuss recent successes in teleneurosurgery, stroke care, and rehabilitation as models for teleneurosurgical best practices. As telemedicine technology continues to mature and its expanse grows, neurosurgeons’ familiarity with its benefits, limitations, and controversies will best allow for its successful adoption in our field to maximize patient care and outcomes.

Background Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). Objective To determine the safety and efficacy of MMA embolization. Methods Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. Results A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. Conclusion MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

BACKGROUND Cerebral bypass has been an important tool in the treatment of complex intracranial aneurysms. The recent advent of flow-diverting stents (FDS) has expanded the capacity for endovascular arterial reconstruction. OBJECTIVE We investigated how the advent of FDS has impacted the application and outcomes of cerebral bypass in the treatment of intracranial aneurysms. METHODS We reviewed a consecutive series of cerebral bypasses during aneurysm surgery over the course of 10 years. FDS were in active use during the last 5 years of this series. We compared the clinical characteristics, surgical technique, and outcomes of patients who required cerebral bypass for aneurysm treatment during the preflow diversion era (PreFD) with those of the postflow diversion era (PostFD). RESULTS We treated 1061 aneurysms in the PreFD era (from July 2005 through June 2010) and 1348 in the PostFD era (from July 2010 through June 2015). Eighty-five PreFD patients (8%) and 45 PostFD patients (3%) were treated with cerebral bypass. PreFD patients had better baseline functional status compared to PostFD patients with average preoperative modified Rankin Scale score of 0.55 in PreFD and 1.18 in PostFD. CONCLUSION After the introduction of FDS, cerebral bypass was performed in a lower proportion of patients with aneurysms. Patients selected for bypass in the flow-diverter era had worse preoperative modified Rankin Scale scores indicating a greater complexity of the patients. Cerebral bypass in well-selected patients and revascularization remains an important technique in vascular neurosurgery. It is also useful as a rescue technique after failed FDS treatment of aneurysms.

Background Surgical resection of brainstem cavernous malformations (BSCMs) is challenging, and patient selection and timing of intervention remain controversial. Objective To evaluate the impact of surgical timing and predictors of neurological outcome after surgical resection of BSCMs. Methods Consecutive adult patients (≥18 years) with BSCMs undergoing surgical resection between 1985 and 2014 by the senior author (RFS) were retrospectively reviewed. Patient demographics, lesion characteristics, imaging results, surgical approach, and perioperative and long-term neurological morbidity were analyzed. Results Data were analyzed for a total of 397 adult patients (160, 40% male). On univariate analysis, a greater proportion of patients treated within 6 weeks of hemorrhage had an improved Glasgow Outcome Scale score (P = .06). On logistic regression analysis, patients treated within 6 weeks of hemorrhage experienced improved clinical outcomes (odds ratio = 1.73; 95% confidence interval = 1.06-2.83; P = .03). Conclusions Although BSCM surgery is associated with significant perioperative morbidity and mortality, favorable long-term hemorrhage rates and symptom resolution can be achieved in a carefully selected group of patients. Overall, patients treated acutely, within 6 weeks, benefited the most from surgical intervention.

BACKGROUND Approximately 17% of ruptured anterior communicating artery (ACoA) aneurysms were deemed unsuitable for coil embolization during the Barrow Ruptured Aneurysm Trial (BRAT), most commonly due to unfavorable dome-to-neck ratio or small size. OBJECTIVE To compare patients treated by coil embolization for ruptured ACoA aneurysms during the trial to those treated after the trial to determine whether advances in endovascular techniques have allowed for effective treatment of these lesions. METHODS All cases of ruptured ACoA aneurysms treated by endovascular modalities during BRAT (2003-2007) and post-BRAT (2007-2012) were reviewed for patient and aneurysm characteristics, treatment types, and clinical and angiographic outcomes at 3-yr or last follow-up. RESULTS The BRAT ACoA cohort included 39 patients treated with coiling (excluding those crossed over to clipping). The post-BRAT cohort included 93 patients who were significantly older (mean age, 59.5 vs 52.8 yr, P = .005) than the BRAT cohort; there were no significant cohort differences in sex, Hunt and Hess grade, or mean aneurysm size. The use of balloon remodeling was significantly higher in the post-BRAT cohort (31.2% [29/93] vs 5.1% [2/39], P = .001), as was the proportion of wide-necked aneurysms treated (66.7% [62/93] vs 30.8% [12/39], P < .001). There was no significant difference in clinical outcome or retreatment rate between the 2 cohorts (P = .90 and P = .48, respectively). CONCLUSION ACoA lesions thought unamenable to endovascular therapy in an earlier randomized trial are now successfully coiled with increased use of adjunctive techniques, without sacrificing patient outcome or treatment durability.

BACKGROUND Recent studies have questioned the utility of surgical resection of unruptured brain arteriovenous malformations (bAVMs). OBJECTIVE We performed an assessment of outcomes and complications of surgical resection of low-grade bAVMs (Spetzler-Martin grade I or II) at a single high-volume neurosurgical center. METHODS We reviewed all unruptured low-grade bAVMs treated with surgery (with or without preoperative embolization) between January 2004 and January 2014. Stroke rate, mortality, and clinical and radiographic outcomes were examined. RESULTS Of 95 patients treated surgically, 85 (25 grade I, 60 grade II) met inclusion criteria, and all achieved radiographic cure postoperatively. Ten patients (11.8%) were lost to follow-up; the mean follow-up of the remaining 85 was 3.3 years. Three patients (3.5%) with grade II bAVMs experienced a stroke; no patients died. Although 20 patients (23.5%) had temporary postoperative neurological deficit, only 3 (3.5%) had new clinical impairment (modified Rankin Scale score ≥2) at last follow-up. Eight of the 13 patients (61.5%) with preexisting clinical impairment had improved modified Rankin Scale scores of 0 or 1; and 17 of 30 patients (56.7%) with preoperative seizures were seizure-free without antiepileptic medication postoperatively. No significant differences existed in stroke rate or clinical outcome between grades I and II patients at follow-up (Fisher exact test, P = .55 and P > .99, respectively). CONCLUSION Surgical resection of low-grade unruptured bAVMs is safe, with a high rate of improvement in functional status and seizure reduction. Although transient postoperative neurological deficit was observed in some patients, permanent treatment-related neurological morbidity was rare. ABBREVIATIONS ARUBA, A Randomized Trial of Unruptured Brain Arteriovenous MalformationsbAVM, brain arteriovenous malformationmRS, modified Rankin Scale.

Background In the endovascular treatment of wide-necked unruptured aneurysms, there is controversy over which adjunctive device (stent vs balloon) is appropriate. At the payer level it has been posited that stents and balloons treat the same aneurysms, and, as such, the more expensive stents should not be reimbursed. Objective We challenge this assertion, and instead hypothesize that aneurysms treated with stent assistance are morphologically different than those selected for balloon assistance. Methods Retrospective review of unruptured aneurysms treated with an adjunctive device between 2008 and 2010. Morphological analysis was performed on the pretreatment 2-D catheter angiogram. The immediate posttreatment Raymond score was compared with that seen on the 12-month follow-up angiogram. Results One hundred six unruptured aneurysms were treated with an adjunctive device and followed for a mean of 24.5 months. Morphological analysis revealed a lower dome-to-neck ratio (1.5 vs 1.2) and aspect ratio (1.44 vs 1.16) in the aneurysms treated with stent assistance vs balloon assistance. Of the 15.3% that were worse on follow-up angiography, there was no statistical difference between those treated with a stent vs a balloon (17.1% vs 14.2%). The overall re-treatment rate was 10.2% and was not statistically different between the 2 groups (12.7% vs 5.7%). Conclusion We found that unruptured aneurysms selected for treatment with stent-assisted coiling are morphologically different from those selected for treatment with balloon assistance. Despite the more challenging morphology, Raymond scores and re-treatment rates at 1 year were not statistically different between the 2 groups, suggesting an important role for stents in the treatment of unruptured aneurysms.

Background Unruptured aneurysms of the cavernous and paraclinoid internal carotid artery can be approached via microsurgical and endovascular approaches. Trends in treatment reflect a steady shift toward endovascular techniques. Objective To analyze our results with multimodal treatment. Methods We reviewed patients with unruptured cavernous and paraclinoid internal carotid artery aneurysms proximal to the posterior communicating artery treated at a single center from 2007 to 2012. Treatment included 4 groups: (1) stent-assisted coiling, (2) pipeline endovascular device (PED) flow diverter, (3) clipping, and (4) trapping/bypass. Follow-up was 2 to 60 months. Results The 109 aneurysms in 102 patients were studied with the following treatment groupings: 41 were done with stent-assisted coiling, 24 with Pipeline endovascular device, 24 by microsurgical clipping, and 20 by trap/bypass. Group: (1) two percent had delayed significant intraparenchymal hemorrhage; (2) thirteen percent had central nerve palsies, 8% had small asymptomatic infarcts, and 4% had small, asymptomatic remote-site hemorrhages; (3) twenty-nine percent of patients suffered from transient central nerve palsies, 4% experienced major stroke, and 8% had small intracerebral hemorrhages; (4) thirty-five percent had transient central nerve palsies, 10% had strokes, and 10% had intracerebral hemorrhages. In terms of follow-up obliteration, 83% had complete/nearly complete obliteration at last follow-up, 17% had residual aneurysms, and 10% required retreatment. Ninety-six percent of group 1 (35/38), 100% of group 2 (23/23), 100% of group 3 (21/21), and 95% of group 4 had modified Rankin Scale scores of 0 to 1. Conclusion Treatment of these aneurysms can be carried out with acceptable rates of morbidity. Careful patient selection is crucial for optimal outcome. Endovascular treatment volumes likely will continue to predominate over microsurgical techniques as changing skill sets evolve in neurosurgery, but individualized application of all available treatment options will continue.

Background Ruptured anterior communicating artery (ACoA) aneurysms are heterogeneous intracranial aneurysms whose diverse morphological features influence treatment modality. Objective To compare clinical outcomes and complications of all ruptured ACoA aneurysms treated by clipping or coiling in a modern institutional trial. Methods All patients with ruptured ACoA aneurysms in the Barrow Ruptured Aneurysm Trial were included. Clinical follow-up at 1 and 3 years was analyzed; charts were reviewed for patient demographics, aneurysm characteristics, and in-hospital complications. Results This cohort included 130 patients (mean age, 52.5 years). Mean aneurysm size was 5.8 mm. Most aneurysm domes projected anteriorly (n = 52). After randomization and crossover, 91 ACoA aneurysms (70%) were clipped and 39 (30%) were coiled. Twenty-two patients (16.9%) initially randomized to coiling crossed over to clipping after evaluation. No patients crossed over from clipping to coiling. Characteristics precluding aneurysms from coiling included unfavorable dome-to-neck ratio, lesions difficult to access by catheter, and branch vessel involvement. Aneurysm size and dome projection were not significantly associated with treatment group, clinical outcome, or retreatment. No significant difference existed in clinical outcome (modified Rankin Scale scores) between groups at discharge or at 1-year or 3-year follow-up using as-treated and intention-to-treat analyses. Retreatment was performed in 3 clipped patients (2.3%) and 3 coiled patients (2.3%). Conclusion Ruptured ACoA aneurysms, regardless of size and projection, were safely treated by both treatment modalities in a large-scale randomized clinical trial. Clinical outcomes and stroke rates did not differ significantly in as-treated or intention-to-treat analyses.

BACKGROUND AND IMPORTANCE Propionibacterium acnes is an uncommon pathogen in delayed surgical site infection, and its indolent course can complicate diagnosis and treatment. We report the longest delay between neurosurgery and P acnes infection reported. CLINICAL PRESENTATION Asymptomatic postoperative P acnes osteomyelitis and tumor recurrence occurring 23 years after initial craniotomy. Initial presentation was of tumor recurrence only, without signs or symptoms of infection. Calvarial osteomyelitis was unexpectedly discovered intraoperatively. Craniectomy and debridement were performed, and there was prolonged antibiotic therapy. CONCLUSION The longest delay between neurosurgery and asymptomatic P acnes infection is reported. We review the literature for P acnes infection and discuss biofilm formation and its role in delayed surgical infection.