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Objective: Neurosurgery has a high barrier of educational access for medical students. The Medical Student Neurosurgery Training Center (MSNTC) is a novel online learning platform that provides on-site and virtual training opportunities and resources that aim to increase student access to neurosurgical education. The objective of this article was to describe student-reported utility of Medical Student Neurosurgery Training Center educational resources., Methods: A Qualtrics survey was sent to attendees after the 2020 Virtual Neurosurgery Training Camp. Ratings were quantified on modified 5-point Likert scales and compared using Wilcoxon rank sum tests, with a P value of 0.05., Results: Response was obtained from 119 (25.2%) of 473 Virtual Neurosurgery Training Camp registrants. Of respondents, 65 (54.6%) reported prior use of Brain & Spine Report (BSR), 68 (57.14%) reported use of the Video Library (VL), and 78 (65.5%) reported use of the Global Events Calendar (GEC). Among respondents who previously used the BSR, VL, or GEC, mean ratings of usefulness were 3.94 ± 1.01, 4.06 ± 0.91, and 4.10 ± 0.99, respectively. Medical students with a neurosurgery interest group at their home institution reported greater utility of the BSR (P = 0.0008), VL (P = 0.0018), and GEC (P = 0.0250). Medical students with a home program reported greater utility of the BSR (P = 0.0079), and international students reported greater utility of the VL (P = 0.0447)., Conclusions: Medical Student Neurosurgery Training Center resources appear to have promising preliminary benefits for students. Increasing medical student awareness, continued development of these resources, and objectively assessing outcomes in neurosurgery education are warranted., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The novel Coronavirus Disease 2019 (COVID-19) pandemic has posed unprecedented new stressors to medical student education. This national survey investigated the prevalence of burnout in U.S. medical students interested in pursuing neurosurgical residency during the COVID-19 pandemic., Methods: A 24-question survey was sent to all American Association of Neurological Surgeons (AANS) medical student chapter members. The abbreviated Maslach Burnout Inventory (aMBI) was used to measure the following burnout metrics: emotional exhaustion, depersonalization, and personal accomplishment. Bivariate analyses were conducted and multivariate analyses were performed using a logistic regression models., Results: 254 medical students were included (response rate of 14.5%). The majority were male (55.1%), White (66.1%), and between their 2nd and 3rd years in medical school (62.6%). Burnout was identified in 38 (15.0%) respondents, a rate lower than reported in the pre-COVID era. In multivariate analysis, burnout was significantly associated with choosing not to pursue, or feeling uncertain about pursuing, a medical career again if given the choice (OR = 3.40, p = 0.0075), having second thoughts about choosing to pursue neurosurgery (OR = 3.47, p = 0.0025), attending a medical program in the Northeast compared to the Southeast (OR = 0.32, p = 0.027) or Southwest U.S. (OR = 0.30, p = 0.046), and indicating that one's future clinical performance will have worsened due to COVID-19 (OR = 2.71, p = 0.025)., Conclusions: Our study demonstrates relatively low rates of burnout among U.S. medical students interested in pursuing neurosurgery during the COVID-19 pandemic. Our findings also demonstrate multiple factors may aid in early identification of burnout, highlighting potential opportunities for intervention., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities., Methods: We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms., Results: A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324)., Conclusions: Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The novel coronavirus SARS-CoV-2 (COVID-19) pandemic has posed significant changes to physician workflow and healthcare delivery. This national survey investigated the impact of the pandemic on burnout and career satisfaction among U.S. attending neurosurgeons., Methods: A 24-question survey was sent electronically to all American Association of Neurological Surgeons (AANS) attending members. The abbreviated Maslach Burnout Inventory (aMBI) was used to measure the following burnout and career satisfaction indices: emotional exhaustion, depersonalization, and personal accomplishment. Bivariate analyses were conducted and multivariate analyses were performed using logistic regression models., Results: 407 attending neurosurgeons were included in the present study, with an overall response rate of 17.7 %. The majority of respondents were male (88.7 %), White (84.3 %), and in practice for 15 years or more (64.6 %). The majority reported a decrease in work hours due to the pandemic (82.6 %), uncertainty about future earnings (80.3 %), and uncertainty regarding future healthcare reform (84.5 %). Burnout was identified in 83 (20.4 %) respondents, whereas career satisfaction was identified in 316 (77.6 %) respondents. Rate of burnout was decreased when compared to rates reported in the pre-COVID era. In multivariate analysis, burnout was associated with working in a hostile or difficult environment since the rise of COVID-19 (OR = 2.534, p = 0.008), not having children (OR = 3.294, p = 0.011), being in practice for 5-15 years (vs. < 5 years) (OR = 4.568, p = 0.014), spending increased time conducting non-neurosurgical medical care due to COVID-19 (OR = 2.362, p = 0.019), feeling uncertain about future earnings due to COVID-19 (OR = 4.031, p = 0.035), and choosing not to pursue or feeling uncertain about pursuing neurosurgery again if given the choice (OR = 7.492, p < 0.001). Career satisfaction was associated with cerebrovascular subspecialty training (OR = 2.614, p = 0.046) and a willingness to pursue neurosurgery again if given the choice (OR = 2.962, p < 0.001)., Conclusion: Factors related to the novel COVID-19 pandemic have contributed to changes in workflow among U.S. attending neurosurgeons. Despite these changes, we report decreased burnout and high career satisfaction among U.S. neurosurgeons. Understanding modifiable stressors among neurosurgeons during the pandemic may help to identify effective future interventions to mitigate burnout and improve career satisfaction., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Cone beam computed tomography (CBCT) imaging is used commonly in neurointerventional surgery for rapid intraprocedural assessment and planning of intracranial interventions. Our goal was to evaluate the ability of immediate postprocedural CBCT scan in assessing potential complications in pediatric patients., Methods: A retrospective review was completed to include all pediatric patients at our hospital with an immediate postprocedural CBCT scan with the Artis Q system. Demographic, clinical, and imaging data were examined. CBCT images were reviewed by 3 independent neurointerventionalists to assess ventricular system/subarachnoid spaces, gray-white differentiation, and ischemia or hemorrhage if present. Each assessment was rated qualitatively on a 4-point scale and was compared with conventional computed tomography (cCT) scan when available. Interrater reliability was assessed and radiation dose data were reviewed., Results: Thirty-five patients were included with an average age of 11.0 ± 5.1 years (median, 10.9; range, 1.1-18 years). Of the patients, 54.3% were boys; 34.3% were Hispanic and 34.3% were non-Hispanic white. Diagnoses included a variety of vascular pathologies. CBCT scan had a mean score of 2.69 ± 0.54 out of 3 for ventricular and subarachnoid space assessment with a combined interrater reliability of 0.82, 1.71 ± 1.38 for hemorrhage with a combined interrater reliability of 1.00, and 0.52 ± 0.60 for gray-white differentiation with a combined interrater reliability of 0.79., Conclusions: Immediate postprocedural CBCT images were adequate to detect ventricular size/subarachnoid spaces changes and large volume hemorrhage compared with cCT scan in pediatric patients. However, there are limitations using immediate CBCT images to detect small volume hemorrhage and ischemic changes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The Young Neurosurgeons Committee, founded in 1991 by Dr. Roberto C. Heros, has been a vital component of the American Association of Neurological Surgeons. It has grown from an opportunity for young neurosurgeons to network with senior neurosurgeons to becoming the major voice of young neurosurgeons and a training ground for the future leaders of organized neurosurgery. The present report has reviewed the leadership involvement of 168 previous Young Neurosurgeons Committee members and briefly highlighted the careers of 4 of these members who have attained leadership positions in neurosurgery., (Published by Elsevier Inc.)

Background: Chronic subdural hematoma is a very common neurosurgical condition. Although conventional surgical methods, such as burr hole irrigation, have been the mainstay of treatment, middle meningeal artery (MMA) embolization has emerged as a promising adjunctive or alternative treatment. The aim of this article was to present a meta-analysis and systematic review of this topic., Methods: A literature search using keywords "chronic subdural hematoma," "chronic subdural hemorrhage," "refractory subdural hematoma," "refractory subdural hemorrhage," and "middle meningeal artery embolization" was conducted through October 2018. Outcome variables of hematoma recurrence, surgical complications, and modified Rankin Scale score were analyzed and compared between MMA embolization and conventional surgery cohorts., Results: Three double-arm studies comparing embolization and conventional surgery groups and 6 single-arm case series were identified and analyzed. Hematoma recurrence rate was significantly lower in the embolization group compared with conventional treatment group (2.1% vs. 27.7%; odds ratio = 0.087; 95% confidence interval, 0.026-0.292; P < 0.001; I 2  = 0%); surgical complication rates were similar between groups (2.1% vs. 4.4%; odds ratio = 0.563; 95% confidence interval, 0.107-2.96; P = 0.497; I 2  = 27.5%). Number of patients with modified Rankin Scale score >2 in the embolization (12.5%) versus conventional treatment (9.1%) group showed no statistical difference (P = 0.689). A composite hematoma recurrence rate of 3.6% was found after summing the 6 case series. Composite recurrence and complication rates in the embolization cohorts of the double-arm studies and the case series were lower than literature values for conventional surgical treatments., Conclusions: MMA embolization is a promising treatment for chronic subdural hematoma. Future randomized clinical trials are needed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Cognitive sequelae frequently follow subarachnoid hemorrhage (SAH) and include deficits across multiple domains of executive function. This factor affects overall functional outcomes negatively, especially in younger patients. Several clinical correlates predict development and severity of cognitive dysfunction after SAH. Hypothetical mechanisms of cognitive dysfunction in the absence of radiographic lesion include cerebral hypoperfusion and blood breakdown products, resulting in perturbed interneuronal communication and network synchrony, excitotoxicity, and altered microRNA expression., Methods: The PubMed database was searched for articles discussing cognitive outcomes in patients with unruptured and ruptured intracranial aneurysmal disease, sequelae of treatment, and modalities for neuropsychologic testing., Results: Treatment of unruptured intracranial aneurysms, although capable of preventing SAH, comes with its own set of complications and may also affect cognitive function. Neuropsychological tests such as the Montreal Cognitive Assessment, Mini-Mental Status Examination, and others have proved useful in evaluating cognitive decline. Studies using functional neurologic imaging modalities have identified regions with altered activation patterns during various cognitive tasks. The sum of research efforts in this field has provided useful insights and an initial understanding of cognitive dysfunction after aneurysm treatment and SAH that should prove useful in guiding and rendering future investigations more fruitful., Conclusions: Development of finer and more sensitive neuropsychological tests in evaluating the different domains of cognitive function after aneurysm treatment and SAH in general will be useful in accurately determining outcomes after ictus and comparing efficacy of different therapeutic strategies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The incidence of acute ischemic stroke is highest in the elderly. Information regarding outcomes of elderly patients undergoing different modalities of intra-arterial therapy (IAT) for acute ischemic stroke (AIS) is scarce and conflicting. This study compares the safety, technical efficacy and outcomes of elderly patients (≥80 years) to non-elderly patients (<80 years) who underwent multimodality IAT., Methods: From a registry of consecutive patients treated with IAT for AIS at our institution over a 3.5-year period, patients with anterior circulation occlusions aged ≥80 years were compared to the patients <80 years., Results: Between 2008 and 2012, 24 patients ≥80 years (elderly) and 95 patients <80 years (non-elderly) received IAT for anterior circulation occlusions. In the elderly, there were more females (66.7% vs. 28.4%, p=<0.001) and atrial fibrillation (58.3% vs. 25.2%, p=0.003). Between the 2 groups, there was no difference in NIHSS score (17.2 vs. 16.3, p=0.17), THRIVE score (4.21 vs. 4.39, p=0.633), recanalization rate (70.1% vs. 85.3%, p=0.13), or severe reperfusion hemorrhages (8.3% vs. 4.2%, p=0.425). There was no significant difference in 3-month mortality (33.3% vs. 16.8%, p=0.28); however, fewer elderly patients reached good 3-month outcome (0% vs. 40.0%, p=<0.001). After controlling for baseline factors, only female gender (OR 5.3, 95% CI 1.7-16.7; p=0.04) and higher 3-month mRS (OR 1.6; 95% CI 1.1-2.40; p=0.008) were independently associated with elderly age., Conclusion: Despite similar safety profiles and recanalization rates, elderly patients had poor functional outcomes after IAT. Intra-arterial therapy in the elderly should be pursued very cautiously only after careful analysis of the risks and benefits for each patient., (Copyright © 2014. Published by Elsevier B.V.)

Objective: The degree of coronary artery calcification has been shown to predict outcomes in coronary artery disease. The impact of intracranial carotid artery calcification on the prognosis of acute ischemic stroke (AIS) is unknown. The authors sought to examine if the degree of intracranial carotid artery calcification influences reperfusion or outcomes in AIS intervention., Methods: All anterior circulation large vessel occlusion AIS cases that underwent intra-arterial therapy from January 2009 to July 2012 were reviewed. Clinical and radiographic data were collected. Non-contrast brain CT scans were assigned a Calcium Extent Score (degree of calcification of the carotid wall circumference), Calcium Thickness Score (thickness of the calcified plaque), and total Carotid Siphon Calcium (CSC) Score (8-point scale)., Results: One-hundred seventeen patients met inclusion criteria. The mean age was 65.4±15.6 years and 36% were male. Calcification was present in the intracranial carotid artery of 84 patients (71%). Inter-rater agreement for total CSC score was strong (Spearman's rho=0.883, p<0.001). The mean Calcium Extent Score was 1.5±1.3, Calcium Thickness Score 1.3±1.0 and total CSC Score 2.8±2.2. Reperfusion and mRS were not associated with CSC. Multivariate linear regression analysis revealed that older age, history of coronary disease and cervical internal carotid occlusion/near-occlusion were independently associated with higher total CSC scores., Conclusion: Extensive calcification on the intracranial carotid artery does not have impact on reperfusion or clinical outcomes in AIS patients undergoing endovascular therapy. Higher CSC scores are associated with coronary artery disease, increasing age and cervical internal carotid artery occlusion/near-occlusion., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: Preoperative embolization of hypervascular head and neck tumors is frequently performed to reduce operative times and blood loss. While traditional transarterial embolization is commonly used, direct tumoral puncture has also been advocated as an alternative. We report our series of head and neck tumors embolized with onyx via direct tumoral puncture to ascertain the safety and efficacy of embolization using this technique., Methods: We prospectively collected data on all head and neck tumors embolized with onyx at our institution during a 24-month period., Results: A total of 18 patients underwent preoperative embolization via direct tumoral puncture. Tumors included nine carotid body tumors, three glomus vagale tumors, five juvenile nasopharyngeal angiofibromas (JNAs), and one intracranial frontal parasagittal meningioma. All embolizations were completed in a single session. Mean fluoroscopy time was 40 minutes. The overall mean percent tumor devascularization was 87%. Inadvertent transtumoral migration of onyx into the superior sagittal sinus occurred during intraoperative embolization of the meningioma using single-plane fluoroscopy and resulted in a large postoperative hemorrhagic venous infarct. There were no other endovascular-related complications in the remaining patients embolized using biplanar fluoroscopy., Conclusion: Embolization of hypervascular head and neck tumors with onyx via direct tumoral puncture can be performed safely and efficiently. Tumor embolization by direct puncture may theoretically lower the risk of inadvertent migration of onyx through nontarget arterial vessels, but may increase the risk of inadvertent transtumoral embolization of venous structures. Caution should be exercised when using this technique for intracranial pathologies, and the importance of biplanar fluoroscopy to allow better visualization of the onyx migration cannot be overemphasized., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Preoperative embolization of juvenile nasopharyngeal angiofibromas (JNA) has been shown to reduce operative times and blood loss. Although traditional transarterial (TA) embolization is commonly used, direct tumoral puncture (DTP) has also been advocated as an alternative. We report our series of JNAs embolized with Onyx and compare the two embolization techniques., Methods: We retrospectively reviewed all JNAs embolized with Onyx at our institution during a 20-month period. The fluoroscopy time, percent of tumor devascularization, periprocedural complications, and intraoperative blood loss were compared between the two groups., Results: A total of 10 patients with JNA underwent preoperative embolization by a TA route (n = 5) or DTP (n = 5). Mean fluoroscopy time was 50 and 39 minutes in the TA and DTP groups, respectively. The mean percent tumor devascularization in the TA group was 77% compared with 93% in the DTP group. Intraoperative estimated blood loss in tumors embolized transarterially was higher than those embolized by DTP (862 mL vs. 412 mL); however, this difference did not reach statistical significance. There were no neurological complications related to the embolization procedures in either group., Conclusions: Embolization of JNAs with Onyx can be performed safely by either method. Direct puncture is associated with shorter embolization procedure times and results in a greater degree of tumor devascularization. Although there was a trend toward lesser blood loss in patients embolized by DTP, it did not reach statistical significance in this small series. Larger series are needed to determine whether the improved tumor penetration achieved with DTP translates into clinical benefit., (Copyright © 2011 Elsevier Inc. All rights reserved.)