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Background and Purpose The goal of this study was to systematically review the utility of serum biomarkers in the setting of ischemic stroke (IS) to predict long-term outcome. Methods A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986-2018. All studies assessing long-term functional outcome (defined as 30 days or greater) following IS with respect to serum biomarkers were included. Data were extracted and pooled using a meta-analysis of odds ratios. Results Of the total 2928 articles in the original literature search, 183 studies were ultimately selected. A total of 127 serum biomarkers were included. Biomarkers were grouped into several categories: inflammatory (32), peptide/enzymatic (30), oxidative/metabolic (28), hormone/steroid based (23), and hematologic/vascular (14). The most commonly studied biomarkers in each category were found to be CRP, S100β, albumin, copeptin, and D-dimer. With the exception of S100β, all were found to be statistically associated with >30-day outcome after ischemic stroke. Conclusions Serum-based biomarkers have the potential to predict functional outcome in IS patients. This meta-analysis has identified CRP, albumin, copeptin, and D-dimer to be significantly associated with long-term outcome after IS. These biomarkers have the potential to serve as a platform for prognosticating stroke outcomes after 30 days. These serum biomarkers, some of which are routinely ordered, can be combined with imaging biomarkers and used in artificial intelligence algorithms to provide refined predictive outcomes after injury. Ultimately these tools will assist physicians in providing guidance to families with regards to long-term independence of patients.

Objective A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms. Methods A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included. Results A total of 74 studies were ultimately selected, including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%). Conclusion Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable between coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the last 2 decades. Ideally, further prospective research will be needed to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.

Women have historically been underrepresented in academic medicine, particularly in surgical subspecialties. This study investigated potential associations between gender and promoting practices in academic neurosurgery.Faculty data, including time from residency, professorship, specialty, and h-index, were obtained from websites of the institutions listed in the American Association of Neurological Surgeons Neurosurgical Residency Training Program Directory. Demographics, training, and appointments were compared between male and female neurosurgeons. Predictors of professorship, chair, directorship, and division leadership were identified using multivariable models.The study examined 1629 faculty members. Women were more likely to be assistant professors (P0.0001), while men were more likely to be full professors (P0.0001), hold chair positions (P = 0.007), lead subspecialty divisions (P = 0.008), and have a higher Scopus h-index (P0.0001). In a multivariable analysis, years from training (P0.001), fellowship (P = 0.009), h-index (P0.001), and chair/program director/division leadership position (P0.001) were significant positive predictors of full professorship. Holding additional advanced degrees (P = 0.010), leading a subspecialty division (P = 0.005), and having a higher h-index (P = 0.002) positively predicted chair position. However, when accounting for all other factors, gender was not a significant predictor of full professorship, division leadership, chair, or program directorship.While significantly more men hold leadership positions in U.S. academic institutions, after controlling for contributing variables, there did not appear to be an association between gender and full professorship, division leadership, chair, or program directorship in academic neurosurgery. While the field still has significant work to do to achieve gender equity, these results may serve as encouragement to women who are looking to advance their careers in academic neurosurgery.

Background Reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication after carotid endarterectomy (CEA). Only a limited number of prior cases of RCVS have been reported after CEA for asymptomatic carotid stenosis. Case Description In this report we present an unusual case of RCVS associated with multifocal intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and ischemic stroke after CEA for asymptomatic carotid stenosis. We review preexisting studies and draw correlations with implications for understanding the mechanisms of RCVS. Conclusions A high index of suspicion should be maintained in post-CEA patients presenting with headaches or focal neurologic deficits, and vigilance with serial vascular imaging may help minimize long-term complications.

Objective A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms. Methods A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included. Results A total of 73 studies were ultimately selected including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%). Conclusions Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable among coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the past 2 decades. Ideally, further prospective research will be necessary to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.

Background Machine learning has emerged as a viable asset in the setting of pituitary surgery. In the past decade, the number of machine learning models developed to aid in the diagnosis of pituitary lesions and predict intraoperative and postoperative complications following transsphenoidal surgery has increased exponentially. As computational processing power continues to increase, big data sets continue to expand, and learning algorithms continue to surpass gold standard predictive tools, machine learning will serve to become an important component in improving patient care and outcomes. Methods Relevant studies were identified based on a literature search in PubMed and MEDLINE databases, as well as from other sources including reference lists of published articles. Results Radiomics and artificial neural networks comprise the majority of machine learning–based applications in pituitary surgery. Radiomics serves to quantify specific imaging features, which can then be used to noninvasively identify tumor characteristics and make definitive diagnoses, circumventing presurgical biopsy altogether. Neural networks can be adapted to predict intraoperative changes in visual evoked potentials or cerebral spinal fluid leak. In addition, these algorithms may be combined with others to predict tumor aggressiveness, gross total resection, recurrence and remission, and even total cost burden. Conclusions The field of machine learning is broad, with radiomics and artificial neural networks comprising 2 commonly used supervised learning methods in pituitary surgery. Given the large heterogeneity of pituitary and sellar lesions, the promise of machine learning lies in its ability to identify relationships and patterns that are otherwise hidden from standard statistical methods. While machine learning has great potential as a clinical adjunct during the surgical preplanning process and in predicting complications and outcomes, challenges moving forward include standardization and validation of these paradigms.

The overall safety and efficacy of flow diverting stents (FDSs) deployed in small caliber parent arteries (≤2.5 mm) for the treatment of intracranial aneurysms remains unclear. Recent studies have provided additional outcomes data to assess the use of FDSs for such arteries. In the present review, we have summarized the reported clinical and angiographic outcomes of FDS-treated brain aneurysms in small parent arteries.A systematic literature review was performed for outcomes data related to FDS-treated intracranial aneurysms using PubMed, Ovid Medline, and Web of Science. Procedural data, angiographic outcomes, and clinical outcomes at various time points were collected and summarized.The 19 studies included 580 patients with 604 aneurysms, of which 6.1% had been acutely ruptured and 28.3% had been previously treated. The procedural complication rate and symptomatic stroke rate was 9.8% and 7.5%. The complete occlusion rate at the last radiographic follow-up (mean, 12.1 months) was 73.6%. At the last clinical follow-up (mean, 10.6 months), the FDS-associated mortality was 2.5%.FDSs for the treatment of intracranial aneurysms located in small caliber arteries was associated with rates of long-term complete aneurysm occlusion, mortality, and permanent neurologic deficit comparable to the rates with FDS-treated aneurysms in larger parent arteries. However, the relatively increased risk of symptomatic stroke of these FDS-treated aneurysms should not be ignored. Direct comparisons with alternative endovascular approaches are necessary to further define the optimal use of FDS for these aneurysms.

From their origins as cardiovascular research tools, endovascular techniques have evolved to provide a minimally invasive means of diagnosis and therapy for individuals suffering from occlusive artery disease. The techniques were pioneered by William Harvey, whose work set the stage for all subsequent endovascular experiments. These included the bold self-catheterization procedure performed by Werner Forssmann in 1929, which would lead to his dismissal by his superiors, only to regain respect within the medical community in 1956 on receiving the Nobel Prize. Charles Dotter was the first to understand the true potential of endovascular approaches after a chance recanalization that would catapult arterial catheterization first into the cardiovascular surgical arena, then into neurosurgery for intracranial stenoses. Having been meticulously evaluated and compared with open vascular procedures, endovascular neurosurgery has continued to be refined and optimized. Understanding the history and development of these techniques and their applications in neurosurgery is necessary to appreciate the current clinical utility of these procedures, serving to provide the vascular neurosurgeon a greater array of treatment options for patients. Here we explore the major scientific and technological advancements that facilitated the development of the endovascular approach to cerebral revascularization, as well as current indications and ongoing clinical trials.

Cortical spreading depression (CSD) is a pathophysiologic phenomenon that describes an expanding wave of depolarization within the cortical gray matter. Originally described over 70 years ago, this spreading depression disrupts neuronal and glial ionic equilibrium, leading to increased energy demands that can cause a metabolic crisis. This results in secondary insult, further perpetuating brain injury and neuronal death. Initially not thought to be of clinical significance, the view of CSD was modified with the advent of intracranial electroencephalography, or electrocorticography. With these improved monitoring techniques, CSD has been identified as a major mechanism by which traumatic brain injury (TBI) imparts its negative sequalae. TBI is a heterogenous disease process that runs the gamut of clinical presentations. This includes concussion, epidural and subdural hematoma, diffuse axonal injury, and subarachnoid hemorrhage. Nonetheless, CSD appears to be frequently occurring among the various types of TBI, thus allowing for the potential development of targeted therapies in an otherwise ill-fated patient cohort. Although a complete understanding of the interplay between CSD and TBI has not yet been achieved, the authors recount the efforts that have been employed over the last several decades in an effort to bridge this gap. In addition, our current understanding of the role neuroimmune cells play in CSD is discussed in the context of TBI. Finally, current therapeutic strategies using CSD as a pharmacologic target are explored with respect to their clinical use in patients with TBI.

Objective Despite the development of 4 grading scales of angiographic outcome after flow diversion for cerebral aneurysms, none have been widely adopted in the neurosurgical literature, nor have any been validated in an independent dataset. We evaluated the reported grading scales for their ability to predict aneurysm occlusion at follow-up. Methods Four reported grading scales were applied in a retrospective analysis of our prospectively maintained institutional database of patients with intracranial aneurysms treated with flow-diverting stents. Analysis of patient factors, aneurysm factors, and outcomes was made to compare the grading scales' ability to predict aneurysm occlusion. Results Ninety-nine aneurysms in 90 patients treated at our institution between 2011 and 2018 were included in the analysis. Lower Flow-Diverting Stent Score (FDSS) scores were associated with higher rates of aneurysm occlusion at final follow-up (P=0.004). The OKM, Kamran-Byrne, and SMART scales scores were not associated with aneurysm occlusion at final follow-up even after adjustments for baseline differences. Area under the receiver operating characteristic curve for the FDSS was 0.675 (0.534–0.816). Conclusions Although the FDSS was the only reported grading scale that was significantly associated with occlusion at follow-up, its ability to predict occlusion fell below the typical level for widespread clinical utility. The high rate of eventual occlusion of most aneurysms after flow diversion likely limits the clinical utility of a grading score for this application.

Background Neoplastic cerebral aneurysms are exceedingly rare. We describe a case of a ruptured, distal middle cerebral artery aneurysm as the presenting symptom leading to the identification of metastatic lung cancer. Case Description The patient underwent an uncomplicated surgical trapping and ligation of the aneurysm. Histopathologic examination of the aneurysm confirmed the neoplastic cerebral aneurysm was due to a metastatic lung adenocarcinoma with neuroendocrine features. The patient subsequently underwent stereotactic radiosurgery to the resection cavity. Conclusions Neoplastic cerebral aneurysms are rare, and there are insufficient data to support specific guidelines for management. This case is novel as the patient received adjuvant stereotactic radiosurgery to the operative bed, as well as systemic chemotherapy, and has maintained good functional status as of last follow-up at 6 months.

Background Precisely defining complications, which are used to measure overall quality, is necessary for critical review of delivery of care and quality improvement in endovascular neurosurgery, which lacks common definitions for complications. Furthermore, in endovascular interventions, events that may be labeled complications may not always negatively affect outcome. Our objective is to provide precise definitions for quality evaluation within endovascular neurosurgery. Thus, we propose an endovascular-specific classification system of complications based on our own patient series. Methods This single-center review included all patients who had endovascular interventions from September 2013 to August 2015. Complication types were analyzed, and a descriptive analysis was undertaken to calculate the incidence of complications overall and in each category. Results Two hundred and seventy-five endovascular interventions were performed in 245 patients (65% female; mean age, 55 years). Forty complications occurred in 39 patients (15%), most commonly during treatment of intracranial aneurysms (24/40). Mechanical complications (eg, device deployment, catheter, or closure device failure) occurred in 8/40, technical complications (eg, failure to deploy flow diverter, unintended embolization, air emboli, retroperitoneal hemorrhage, dissection) in 11/40, judgment errors (eg, patient or equipment selection) in 9/40, and critical events (eg, groin hematoma, hemorrhagic or thromboembolic complications) in 12/40 patients. Only 12/40 complications (30%) resulted in new neurologic deficits, vessel injury requiring surgery, or blood transfusion. Conclusions We propose an endovascular-specific classification system of complications with 4 categories: mechanical, technical, judgment errors, and critical events. This system provides a framework for future studies and quality control in endovascular neurosurgery.