Search

Background: Neurosurgeons often use radiation to visualize blood vessels and implants intraoperatively. However, high exposure to radiation increases one's cancer risk. This study aims to investigate intraoperative ionizing radiation exposure awareness and associated morbidity among neurosurgeons., Methods: An anonymized 30-question survey about their intraoperative radiation exposure, protective measures, radiation knowledge, and any conditions that can arise from protracted radiation exposure was disseminated to 3344 American Association of Neurological Surgeons members., Results: A total of 227 (6.8%) neurosurgeons completed the survey. Most neurosurgeons (61, 27%) performed 2-4 surgeries per week necessitating radiation (61, 27%), did not use a dosimeter (134, 59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 7 (3%) of respondents could correctly identify the safety limit for occupational radiation. One hundred and thirty-four (59%) respondents correctly identified the relationship between distance and radiation dose reduction. Two hundred and thirteen (94%) neurosurgeons reported concern about occupational radiation exposure. No significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer. Multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure., Conclusions: There is a need for improved radiation safety awareness among neurosurgeons, especially in the context of rising usage of minimally invasive surgery. This can allow for a greater understanding of radiation-associated risks among neurosurgeons and guide the implementation of safer practices., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Middle meningeal artery embolization (MMAE) is an effective minimally invasive option for chronic subdural hematoma (cSDH). Dexamethasone and statins have been reported to improve the resolution of cSDH and reduce its recurrence. However, only 1 study has investigated the role of statins in patients treated with MMAE, and there is no such study on dexamethasone. Thus, we used the TriNetX research network to determine whether adding dexamethasone or statin along with primary MMAE is associated with a benefit in outcomes., Methods: We queried all primary MMAE cases for cSDH between January 1st, 2012, and July 1st, 2022, in the TriNetX research network. We included patients greater than or equal to 18 years old and separated them regarding statin and dexamethasone use around the time of MMAE. Outcomes were evaluated within 6 months and 3 years after MMAE, and analyses were performed before and after propensity score matching., Results: The study included 372 patients with chronic subdural hematoma who underwent MMAE and were on dexamethasone, 339 not on dexamethasone, 391 on statins, and 278 not on statins. After propensity score matching, the dexamethasone cohorts included 250 patients each and only headache remained more prevalent in the dexamethasone cohort at both 6 months (21.2% vs. 10.0%, P = 0.001) and 3 years (23.6% vs. 12.4%, P = 0.001). After propensity score matching, the statin cohorts included 150 patients each and no differences in outcomes were found at both 6 months and 3 months after MMAE., Conclusions: Patients treated with primary MMAE and were on dexamethasone or statins had no differences in mortality and functional/provider dependence compared to those who were not on dexamethasone or statins. Patients on dexamethasone had a higher prevalence of headaches., (Copyright © 2023. Published by Elsevier Inc.)

Objective: There are limited data evaluating the outcomes of attending neurosurgeons with different types of first assistants. This study considers a common neurosurgical procedure (single-level, posterior-only lumbar fusion surgery) and examines whether attending surgeons deliver equal patient outcomes, regardless of the type of first assistant (resident physician vs. nonphysician surgical assistant [NPSA]), among otherwise exact-matched patients., Methods: The authors retrospectively analyzed 3395 adult patients undergoing single-level, posterior-only lumbar fusion at a single academic medical center. Primary outcomes included readmissions, emergency department visits, reoperation, and mortality within 30 and 90 days after surgery. Secondary outcome measures included discharge disposition, length of stay, and length of surgery. Coarsened exact matching was used to match patients on key demographics and baseline characteristics known to independently affect neurosurgical outcomes., Results: Among exact-matched patients (n = 1402), there was no significant difference in adverse postsurgical events (readmission, emergency department visits, reoperation, or mortality) within 30 days or 90 days of the index operation between patients who had resident physicians and those who had NPSAs as first assistants. Patients who had resident physicians as first assistants demonstrated a longer length of stay (mean: 100.0 vs. 87.4 hours, P < 0.001) and a shorter duration of surgery (mean: 187.4 vs. 213.8 minutes, P < 0.001). There was no significant difference between the two groups in the percentage of patients discharged home., Conclusions: For single-level posterior spinal fusion, in the setting described, there are no differences in short-term patient outcomes delivered by attending surgeons assisted by resident physicians versus NPSAs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The Pipeline Embolization Device (PED) has been the only flow-diverting device (FDD) approved by the Food and Drug Administration (FDA) in the U.S. market for nearly a decade, with more FDD choices in the United States following recent FDA approval of the Flow Redirection Endoluminal Device and Surpass. We sought to explore the integration patterns of these devices into practice by U.S. neurointerventionalists., Methods: A 34-question electronic survey was distributed to the U.S. neurointerventional community from different backgrounds (neurosurgery, neurology, radiology) through different organizational links, focusing on technical aspects of device selection and personal preferences/experiences regarding FDD in aneurysms treatment., Results: Responses were collected from 120 neurointerventionalists across the United States; operators from a neurosurgery background constituted the majority of respondents (47.5%; 85% of dual-trained). The largest age block was early-to mid-career operators (70.8% aged 36-50 years). Most participants (78.8%) treated a range of 25-100 aneurysms/year with FDDs, with 49.2% of respondents having all the FDA-approved FDDs available in their centers (80.8% academic practice). Femoral access was used by the 67.7% of respondents, without impact of FDD-device on access-type (89.2%). PED was the most commonly used device (70.9%), with 66.7% of respondents reporting using different FDD based on case specifics. Comparing devices preferences by training backgrounds, more neurosurgical operators endorsed PED as their most commonly used device, whereas more interventional neuroradiologists/neurologists reported Surpass and Flow Redirection Endoluminal Device as their most commonly used devices., Conclusions: The results of this survey identify common themes in FDD choices among neurointerventionalists in the U.S. market, along with their integration patterns of the newly introduced devices into clinical practice., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Despite increasing interest in endovascular therapy (EVT) for large-core strokes, little is known about the predictors of good outcome in these patients. The aim of this study was to analyze patients with large-core strokes post-EVT and to define the predictors of favorable outcome in this population., Methods: A retrospective analysis of prospectively collected data on anterior circulation strokes undergoing EVT between January 2015 and February 2018 was performed. Patients with good baseline functional status who underwent EVT for occlusion of an anterior circulation artery and achieved successful recanalization (modified Treatment in Cerebral Ischemia score ≥2b) but had large follow-up infarct volume (FIV ≥70 cm 3 ) were included in the study. Demographic characteristics, clinical and radiologic data, treatment and postprocedural outcomes were extracted and analyzed. The primary outcome was 90-day modified Rankin Scale (mRS) score, stratified by favorable (mRS 0-3) versus unfavorable (mRS 4-6)., Results: Of 355 patients meeting inclusion criteria, 85 (24%) had large FIV on follow-up imaging after EVT and constituted the study cohort. No patients achieved mRS score 0-2 at hospital discharge; 32% had 90-day mRS score 0-3. On multivariate logistic regression analysis, lower FIV (OR, -0.96 [0.95-0.99]; P = 0.007), male sex (OR, -1.29 [1.07-12.3]; P = 0.026), and intravenous tissue plasminogen activator use (OR, 3.6 [2.01-8.9]; P = 0.003) were independent predictors of favorable outcome. Independent predictors of mortality on multivariate analysis were higher FIV (OR, -1.01 [1.007-1.02]; P = 0.001) and female sex (OR, 4.08 [1.25-13.3]; P = 0.02)., Conclusions: For patients with large-core strokes (≥70 cm 3 ) after EVT, approximately one third have favorable outcome at 90 days. Independent predictors of favorable 90-day outcomes include male sex, intravenous tissue plasminogen activator use, and lower FIV., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Improving the comprehension and communication of patient education materials could augment patient participation in shared clinical decision making. Inadequate healthcare-oriented educational resources for patients with a newly diagnosed complex disease, such as a cerebral aneurysm, can lead to an insufficient understanding of their ailment. As such, we hypothesized that a PowerPoint-style educational intervention with grade-conscious (i.e., sixth grade level) written material accompanied by visual graphics would help improve patient health literacy and satisfaction., Methods: A randomized prospective pilot study was conducted during a 1-year period in 2018. Preclinic encounter knowledge assessment surveys were administered to 52 patients with brain aneurysms (newly diagnosed or during follow-up) presenting for their neurosurgery outpatient clinic visit. The patients were assigned to 1 of 2 cohorts, with 26 each in the educational intervention group and control group, using a quasi-randomization method of alternating the assigned group for each successive patient. At the conclusion of their clinic encounter, all the patients completed a postclinic encounter knowledge assessment and satisfaction survey. Differences in covariates such as gender distribution, age, and family history of aneurysms were analyzed between the control and intervention groups., Results: The overall study cohort had a high baseline knowledge about cerebral aneurysms with an average preclinic encounter score of 5.37 on the 7-question survey. The educational intervention resulted in an upward trend in the patient knowledge scores. No statistically significant difference was detected in the patient satisfaction scores between the intervention and control groups. However, most of the patients receiving the educational intervention reported that the educational material was easy to understand (95.7%), helpful (86.9%), and relevant (87%) to their clinic visit., Conclusion: Overall, in the present prospective study, the use of a multimedia-based educational intervention resulted in an upward trend in knowledge without a statistically significant difference in patient satisfaction scores compared with the control patients. To better measure the effectiveness of multimedia-based patient education interventions, future studies should account for the patients' baseline education level, preexisting educational resources available to study patients, socioeconomic factors, and emotional state., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Burnout among physicians has been a topic of growing interest in both the scientific and the lay press. It has been well established that burnout and perceived inequity in work-life balance can contribute to poor physician work satisfaction and poorer patient outcomes. To better understand burnout among neurosurgery residents at our institution, we systematically surveyed residents for symptoms of burnout and enacted responsive protocols to try to combat its deleterious effects., Methods: Before and after the institution of a series of initiatives aimed at combating burnout, residents were surveyed to assess for symptoms of burnout, strength of relationships, and status of physical and mental health. Initiatives included gym access and group gym visits, a mentoring program, and a lecture series targeting multiple facets of health and well-being., Results: Nearly two thirds of neurosurgery residents demonstrated ≥1 signs of burnout at a moderate to severe level before and after the first year of our wellness initiative. Residents reported that work schedule and time availability were obstacles in focusing on their own personal health and wellness (utilization preventive health care visits, participation in group gym activities). Less than half of residents were content with their work-life balance., Conclusions: Making a significant change in burnout rates in neurosurgery will require a number of key factors, including targeted initiatives that focus on specific local needs, honest buy-in by departmental leaders, and recognition by the physicians themselves that a problem exists., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Thrombectomy with aspiration catheters has shown to be effective for treatment of intracranial large vessel occlusion (LVO). We present preclinical evaluation of the safety and efficacy of React68 and React71 (Medtronic PLC, Irvine, CA) catheters in animal models of LVO., Methods: In vivo evaluation of catheter safety was performed in superficial cervical, internal maxillary, and renal arteries in a porcine model with or without clot (LVO). Animals were survived for 3 days and 30 days. Angiographic outcomes, usability, and histological parameters were compared for treatment with React68, React71, and ACE68 (Penumbra, Alameda, CA) catheters., Results: The in vivo angiographic analysis in a porcine thrombectomy LVO model demonstrated that there was no statistically significant difference in the rate of Thrombolysis in Cerebral Infarction scale 2b/3 recanalization between React68, React71, and ACE68 catheters. There were no physical or neurologic deficits in any of the treated animals throughout the survival period. Histologic analysis showed statistically non-inferior safety profile of React68 and React71 catheters relative to ACE68 catheters, with minimal but similar mild internal elastic lamina disruption and smooth muscle loss, but a lack of inflammation, fibrin deposits, and changes in the adventitia at both time points examined., Conclusions: React68 and React71 aspiration catheters have an excellent safety, efficacy, and usability profile in animal models of LVO., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Three new 0.071-inch and 0.072-inch aspiration catheters have been introduced for stroke thrombectomy. Their comparative efficacy has not been clinically evaluated., Methods: We reviewed a prospectively maintained thrombectomy database for cases using 1 of these 3 catheters for proximal large vessel occlusion from September 2018 to February 2019. Clinical and angiographic information was extracted., Results: Of 145 thrombectomies performed over the time period, 49 utilized 1 of the 3 new large-bore catheters (React 71, n = 21; Vecta 71, n = 19; Jet 7, n = 9) on the first pass. Mean patient age was 73 years (SD: 15). Mean presenting National Institute of Health Stroke Scale score was 19 (SD: 6, range: 5-33). Clot location was middle cerebral artery first segment in 59% of cases, internal carotid artery in 31%, and basilar in 10%. With or without a stentriever, clot access with the initially selected aspiration catheter was achieved in 47 of 49 (96%) cases. Excluding empiric stentriever usage, the aspiration catheter could be delivered to the clot without needing a stentriever in 87% of cases: 100% with React 71, 93% with Vecta 71, and 43% with Jet 7 (P = 0.002). Final Thrombolysis in Cerebral Infarction score 2b/3 was achieved in 92% of cases overall: 95% with React 71, 89% with Jet 7, and 89% with Vecta 71. Median procedure time was 28 minutes; mean total number of passes was 2.4 (SD: 1.6) with 39% of cases being single-pass cases. These rates did not significantly differ between aspiration catheters., Conclusions: In comparing the newest large bore aspiration catheters, similar angiographic efficacy is achieved., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Epidural hematomas (EHs) usually originate from traumatic injury to the middle meningeal artery (MMA). Although large EHs may need to be emergently evacuated, the management of smaller EHs is less clear, especially in the absence of significant mass effect or neurologic deficits. Endovascular treatment via MMA embolization for epidural hematomas has only been recently reported. Herein, we present a case whereby MMA embolization was performed to prevent further growth of an expanding, right-sided EH after a larger left EH was surgically evacuated., Case Description: A 31-year-old male patient was brought to the emergency department after he was found down by the police at his house. He was initially conversant but quickly became obtunded within a few minutes. An initial scan showed bilateral (left larger than right) acute EHs, and the patient was taken to the operating room for a left craniotomy. Immediate postoperative imaging demonstrated an expanding right-sided EH. The patient was emergently taken to the endovascular suite and obvious contrast extravasation was noticed from the parietal branch of the MMA. The MMA was embolized via a transradial approach. Follow-up imaging revealed stable hematoma size without the need for additional surgery. The patient was discharged without any neurologic deficits., Conclusions: Herein, we report the successful endovascular treatment of an expanding EH following a contralateral craniotomy. Active bleeding of the MMA was observed via angiography and may predict further EH expansion. Endovascular exploration and possible treatment can be justified in patients with EH that do not have a clear surgical indication., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intracranial hemorrhage can be a devastating complication of endovascular thrombectomy (ET) after acute ischemic stroke increasing disability and mortality. Patients with low platelet count were excluded from major ET trials. This study explores the association between platelet count and intracranial hemorrhage after ET., Methods: A retrospective review of patients undergoing ET for anterior circulation large vessel occlusions at a single comprehensive stroke center between January 2015 and February 2018 was performed. Demographic and clinical information including National Institutes of Health Stroke Scale score, intravenous tissue plasminogen activator administration, ASPECTS, platelet count, international normalized ratio, time from symptom onset to recanalization, and modified thrombolysis in cerebral infarction score were analyzed. Radiological imaging and clinical course in the hospital was evaluated to identify parenchymal hemorrhage and symptomatic intracranial hemorrhage (sICH). Univariable and multivariable analyses were conducted., Results: A total of 555 patients underwent ET and 43% were male. The mean age and National Institutes of Health Stroke Scale score were 71 ± 14 years and 17 ± 6, respectively. Parenchymal hemorrhage-2 and sICH (European-Australian Cooperative Acute Stroke Study-III criteria) were noted in 9.7% and 5.8% patients, respectively. Rates of sICH in patients with platelet count <100,000 (n = 15), 100,000 to <150,000 (n = 59), and ≥150,000 (n = 481) were 6.7% (n = 1), 10.1% (n = 6), and 5.2% (n = 25), respectively (P = 0.25), and rates of modified Rankin Scale 0-2 at 90 days were 26.7%, 23.7%, and 36.4%, respectively (P = 0.12). Low ASPECTS was a significant predictor of sICH per European-Australian Cooperative Acute Stroke Study-III definition (P value = 0.046). Platelet count was not a predictor (P = 0.386) of sICH., Conclusions: Risk of sICH after ET is low and comparable in patients with low and normal platelet counts. Low platelets should not exclude patients from undergoing intra-arterial therapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Subclavian steal phenomenon can cause retrograde flow through the ipsilateral vertebral artery as a result of atherosclerosis of the subclavian artery. Clinically this can present as intermittent vertebrobasilar ischemia or claudication of the affected extremity, but rarely it poses a serious risk of neurologic morbidity or mortality. Aneurysm formation at the vertebrobasilar junction is rare but may occur as a sequela of increased flow through 1 vertebral artery, as occurs in subclavian steal syndrome. Here, we present a rare case of subarachnoid hemorrhage from a vertebrobasilar junction aneurysm related to subclavian steal syndrome., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Metal allergies affect a significant portion of the population; intracranial flow diverters contain many of the most commonly allergenic metals. Prior literature has suggested patch testing for all patients with documented or suspected metal allergies before intracranial flow diverter placement; however, there remains a paucity of reports of patients with documented metal allergies undergoing intracranial flow diversion., Case Description: We report 2 patients with documented nickel allergies, confirmed via patch testing by a board-certified allergist, and unruptured intracranial aneurysms that underwent treatment with the PED. Both patients developed contact dermatitis when a PED was affixed to their skin during their preoperative workup. Follow-up arteriography at 12 and 36 months post PED placement showed no evidence of in-stent stenosis or intimal hyperplasia, and both patients never developed systemic allergic reactions., Conclusions: In 2 patients with known nickel allergies and intracranial aneurysms treated with the PED, there were no clinically or radiographically apparent allergic reactions at greater than 2 years of follow-up., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Although elderly patients have generally worse outcomes after acute ischemic stroke, they may derive significant incremental benefit from thrombectomy as compared with medical management. Although several case series for octogenarians have been reported, data for nonagenarians are scarce., Methods: A prospectively maintained institutional mechanical thrombectomy database was reviewed for nonagenarians who underwent thrombectomy between January 2013 and July 2017. Patient demographic data and clinical history data were extracted, and clinical and radiographic outcomes were assessed. Univariate analysis was used to determine correlation between treatment and radiographic data and outcome., Results: During the study period, 30 patients ≥90 years old underwent mechanical thrombectomy. Median National Institutes of Health Stroke Scale score on presentation was 20. Successful reperfusion (Thrombolysis In Cerebral Infarction 2b/3) was achieved in 27 patients (90%). One patient (3%) was discharged to home, and 9 patients (30%) were discharged to a rehabilitation facility. The 90-day mortality was 70%. Six patients (21%) returned to living at home. All 6 patients had successful reperfusion after the procedure; average infarct burden on postthrombectomy neuroimaging was 1.5 cm 3 , and infarct volume was <7 cm 3 in all cases. Final infarct volume of <10 cm 3 was a strong predictor of whether a patient returned to live at home (P = 0.002), with a trend toward better outcome as assessed by modified Rankin Scale (P = 0.076)., Conclusions: Large vessel thrombectomy in nonagenarians is safe and offers patients a chance at returning to functional baseline. All patients returning home in our cohort had successful recanalization and minimal stroke burden after thrombectomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Infectious intracranial aneurysms (IIAs) are a rare but potentially devastating complication of infective endocarditis. The clinical and radiographic findings that predispose patients to IIA remain poorly understood., Methods: We performed a retrospective review of a prospectively maintained database of consecutive endocarditis patients undergoing catheter-based angiography at a single tertiary-level academic center during the period of July 2013-December 2017. Patient records were reviewed for clinical and radiographic characteristics that may be associated with IIA. Multivariate regression models were used to evaluate the relationship between clinical and radiographic characteristics and presence of IIA on invasive imaging., Results: Of 92 patients included in this analysis, 12 of them with 19 IIAs were discovered. Univariate analysis identified age, male sex, presence of hemorrhage, and history of IV drug use (IVDU) as predictors of IIA presence. After multivariate analysis, only intracranial hemorrhage and IVDU remained as independent predictors of IIA., Conclusions: Presence of hemorrhage on noninvasive imaging and history of IVDU are independently predictive of IIA presence in patients with infectious endocarditis. Risk stratification using these 2 factors may help identify the most vulnerable populations for IIA formation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: This study aimed to determine risk factors for inpatient seizures and long-term epilepsy in patients receiving coil embolization for aneurysm-associated subarachnoid hemorrhage., Methods: A retrospective chart review was conducted for patients admitted to the University of Pittsburgh Medical Center from 2010 to 2014 for subarachnoid hemorrhage. Only patients with coil embolization were included. Variables such as subdural hematoma, cerebral infarction, postoperative vasospasm, cerebral edema, and mass effect were collected. After discharge, patients were followed up to determine whether epilepsy had developed. The χ 2 test was used to assess univariate associations. Multivariable associations were assessed with a binary logistic regression model., Results: The study included 175 patients, of whom 16 (9.1%) of the patients had seizures while they were inpatients. Five out of 73 patients met the criteria for epilepsy at follow-up. None of the patients with epilepsy after discharge had electrographic seizures while hospitalized. Vasospasm (odds ratio [OR] 6.88, 95% confidence interval [CI] 1.81-26.25), and Hunt and Hess grade 5 (OR 26.16, 95% CI 3.95-173.49) were significantly associated with in-hospital seizures in a multivariable analysis. Epileptiform discharges on electroencephalogram (EEG) were significantly associated with mass effect findings on brain imaging (OR 3.5, CI 1.05-11.69)., Conclusion: Hunt and Hess grade 5 and vasospasm are independent risk factors for in-hospital seizures. In addition, mass effect is an independent risk factor for epileptiform discharges on EEG. Patients with these risk factors may benefit from continuous EEG. Our results may indicate that there is no association between electrographic seizures and development of epilepsy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Intraoperative digital subtraction angiography (ioDSA) is touted as the gold standard imaging evaluation for aneurysm clip constructs. Candid evaluations of its limitations are sparse., Methods: A prospectively collected hospital billing database was queried to identify craniotomies for aneurysm clipping from January 2010 to December 2013. We evaluated the rate of occult residual and parent vessel stenosis determined on follow-up angiography for patients undergoing ioDSA and those not undergoing ioDSA. Comparisons were performed via Fisher exact test, with P < 0.05 considered statistically significant., Results: From our database search, we found 187 patients who underwent ioDSA after aneurysm clipping and an additional 91 patients who did not. Results from ioDSA influenced operative management in 17% of cases. Sixty-four patients with 70 treated aneurysms undergoing ioDSA had postoperative angiography; 7 occult residuals were discovered, yielding a 10% false-negative rate, with 10% of aneurysms showing residual. Occult residuals at the middle cerebral artery bifurcation represented most discovered residuals (6/7). Thirty-two patients with 37 treated aneurysms did not undergo ioDSA and had angiographic follow-up; 24% of patients were found to have residual aneurysms (P = 0.08 compared with patients undergoing ioDSA). Residuals at the anterior communicating artery (ACoA) represented 56% of all residuals, whereas the ACoA represented only 18% of aneurysms clipped. The rate of residuals was significantly higher than that for patients with clipped ACoA aneurysms undergoing ioDSA (P = 0.008)., Conclusions: ioDSA influenced management in nearly one fifth of cases. It can be particularly beneficial in detecting residuals for ACoA aneurysms; its benefit was less apparent for middle cerebral artery aneurysms., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In patients with supratentorial spontaneous intracerebral hemorrhage, intrahematomal catheter placement may allow for intraclot thrombolysis and drainage. Robotic assistance may be used for the stereotactic placement of catheters., Case Description: A 76-year-old male presented with altered mental status and left-sided weakness. Noncontrast computed tomography of the head showed a right ganglionic intraparenchymal hemorrhage with resultant entrapment of the temporal horn. Using Robotic Stereotactic Assistance, intrahematomal and intraventricular catheters were placed. The temporal horn was immediately decompressed, and the hematoma almost completely resolved with scheduled administration of intrathecal alteplase in the ensuing 48 hours postoperatively., Conclusion: Frameless image-guided placement of intraparenchymal hematoma catheter using Robotic Stereotactic Assistance is safe and efficient., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The rationale for treatment of dural arteriovenous fistulas (dAVFs) without cortical venous reflux is symptomatic resolution. Most studies of dAVF treatment, including those for stereotactic radiosurgery, have focused on angiographic obliteration instead of clinical symptomatic outcome., Methods: The authors evaluated their institutional experience with stereotactic radiosurgery for cerebral dAVFs without cortical venous reflux from 1991 to 2016, evaluating angiographic and clinical outcomes, focusing on the course of pulsatile tinnitus and/or ocular symptoms after treatment. They subsequently pooled their results with those from a systematic literature review., Results: Pooled outcomes data from 349 low-risk dAVF (120 patients with pulsatile tinnitus and 229 patients with ocular symptoms) were analyzed. Over a mean follow-up of 2.6 years, 77% of patients presenting with pulsatile tinnitus experienced resolution and an additional 21% had improvement, with an angiographic obliteration rate of 70.9%. Among 229 patients with ocular symptoms from carotid-cavernous dAVFs, improvement or resolution of symptoms occurred in 95% of those with chemosis, 90% of those with ophthalmoparesis, and 96% of those with proptosis. The angiographic obliteration rate was 76.2%. There were six permanent complications in 349 total treated low-risk dAVF (1.7%)., Conclusions: Rates of clinically significant symptomatic improvement/resolution of symptoms referable to "low-risk" dAVFs are even greater than their angiographic obliteration rate, an important factor in patient counseling and when considering the optimal treatment approach for these dAVFs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Dural arteriovenous fistulas (dAVFs) often are treated via transarterial or transvenous embolization. Incomplete penetration of the draining vein/occult residual often will become apparent on follow-up angiography, requiring repeat embolization, or at times, surgical resection., Case Description: A 41-year-old woman presented with cerebellar hemorrhage from a tentorial dAVF treated with transvenous coil embolization. Follow-up angiography disclosed a residual/recurrent fistula treated with transvenous Onyx embolization. After further follow-up angiography demonstrated another occult residual/recurrence, the fistula was disconnected with the tentorial dura excised via a retrosigmoid approach. Six-month follow-up angiography demonstrated no recurrence., Conclusions: Although endovascular treatment of dAVFs is generally first-line therapy, surgical disconnection of fistulas, particularly high-risk residual/recurrent fistulas, is an excellent option in well-selected cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Temporary arterial occlusion (TAO) is valuable for minimizing intraoperative rupture risk during intracranial aneurysm microsurgery; however, it may be associated with ischemic injury. This study aims to identify surgical and intraoperative neurophysiologic monitoring factors that predict perioperative stroke risk after TAO., Methods: We performed a retrospective chart review of 177 intracranial aneurysm surgeries at our institution in which TAO was performed before placement of a permanent clip under monitoring with somatosensory evoked potentials (SSEPs) and electroencephalography. Perioperative stroke was defined as a new-onset neurologic deficit that developed within 24 hours postoperatively that was correlated with hypodensity on postoperative computed tomography., Results: Ten (6%) patients developed perioperative stroke in the vascular territory of TAO. SSEP changes were observed in 50% (5/10) of patients with perioperative stroke and in 14% (24/167) of patients without stroke (P = 0.003). Mean maximum single-episode TAO duration for patients who developed perioperative stroke was 12.6 minutes (95% confidence interval 8.1-17.1) and TAO duration for patients without stroke was 8.0 minutes (95% confidence interval 7.3-8.7; P = 0.026). In patients with SSEP changes, risk of stroke was particularly elevated with unruptured aneurysms (P = 0.013) compared with patients with ruptured aneurysms. Temporary clip location, number of occlusive episodes, onset and duration of intraoperative neurophysiologic monitoring changes, and rupture status were not predictive of perioperative stroke., Conclusions: SSEP changes and increased single-episode TAO duration are independently associated with increased perioperative stroke risk. SSEP changes are most predictive for perioperative stroke in unruptured cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This case report documents the natural history of intracranial absorbable gelatin powder. We depict the serial imaging of Surgifoam in the cavity of an intracranial hemorrhage cavity after surgical evacuation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Traumatic carotid cavernous fistula may occur as a complication of endovascular treatment of acute stroke. We report 3 cases of such lesions. All patients were initially managed conservatively. Two patients have remained asymptomatic. One patient became symptomatic with right eye proptosis, chemosis, and right lateral gaze diplopia 3 weeks post thrombectomy. He underwent endovascular embolization via transfemoral transvenous approach via the inferior ophthalmic vein., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction., Methods: We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year., Results: Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome., Conclusion: In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection., (Copyright © 2012 Elsevier Inc. All rights reserved.)