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Background Microvascular Doppler (MVD) has been widely used for the detection of arterial blood flow in the brain, especially during aneurysm clipping, vascular malformation resection, or bypass surgeries. However, the benefits obtained from early identification of intracranial sinuses and deep draining veins during tumor resection has not been reported. Methods We reviewed the clinical data and imaging from our cases and conducted a systemic review of the medical literature using PubMed and keywords. Bibliographies of each result were evaluated to determine if additional reports describing the use of MVD during tumor resection could be found. Results No reports were found in the literature where MVD was specifically used for venous identification during the resection of deep-seated brain tumors. In our patient cohort, MVD was used successfully to detect and ultimately allow immediate protection of large dural venous sinuses as well as smaller deep cerebral veins during tumor resection. Each patient developed no new venous infarcts and made a satisfactory recovery with no new postoperative neurological deficits. Conclusion MVD is a reliable tool for the intraoperative detection of intracranial venous blood flow to allow for quick identification and protection of venous structures. MVD is an additional safety measure for the patient as its accuracy in detecting venous structures is less susceptible to many of the inherent weaknesses of stereotactic neuro-navigation including the accompanying brain shift or anatomical distortion produced by long duration deep seated brain tumor resection.

Background Central nervous system (CNS) tumors pose a substantial health problem. Although data on specific time periods and regions of Africa have been previously reported, no study has yet to provide a systematic review of CNS tumors for the entire continent of Africa. This study aims to analyze the frequency of CNS tumors in Africa from 1960 to 2017. Methods A comprehensive literature search on CNS tumors in Africa was performed using multiple online scientific databases. The following keywords were queried in combination with the phrase “CNS tumors in Africa”: incidence, frequency, epidemiology, prevalence, brain, and cancer. A total of 26 articles met the inclusion criteria. Each selected article reported incidence and mortality rates from different regions of Africa in a time period between 1960 and 2017. SPSS21 statistical software was used to analyze the data. Results Nigeria, Egypt, and Uganda were found to have the most of the cases of CNS tumors in Africa. Males made up 54% of the 5902 cases per 100 000 population. The most common CNS tumors found were astrocytoma (24.70%), meningioma (22.22%), pituitary adenoma (8.4%), medulloblastoma (4.26%), craniopharyngioma (4.07%), and other not specified (25.17%). Conclusions Given the large population of Africa, the total reported cases may be underestimated when compared with other continents due to the lack of a central brain tumor registry in Africa. A comprehensive knowledge of CNS tumors in Africa is critical to population-based research and improving the current healthcare system.

Performing coccygectomy procedures on patients with psychiatric disorders and/or chronic low back pain have been previously thought of as contributing factors leading to inconsistent and often poor results. To determine if these two variables affect the post-operative pain relief obtained after coccygectomy, an analysis of the opioid requirements and pain descriptions before and after surgery was undertaken in each patient studied.The hospital electronic medical records were searched, and only patients undergoing coccygectomy for chronic coccydynia were selected. A total of 8 patients were found. Each patient underwent a trial of conservative therapy prior to surgical evaluation.The average duration of symptoms prior to surgery was 41.3 months. In 7 out of 8 patients, at least one psychiatric disorder was present. In 6 out of 8 patients, chronic low back pain was present. Pain control with opioid-based medicines was required in 5 out of 8 patients prior to surgery. Of those, 4 were able to discontinue or reduce the amount of opioid-based medicines consumed after surgery. The average follow-up was 9 months.The results of this study indicate that patients with preexisting psychiatric disorders and/or chronic low back pain suffering from debilitating coccyx pain can obtain pain relief after coccygectomy as seen from a reduction in opioid requirements and pain burden. It should be noted that the obtained benefits from coccygectomy usually occur in a delayed fashion.

BACKGROUND The types of central nervous system (CNS) tumors in a patient population with a history of military service were compared to the types of CNS tumors in a similar patient population without a military service history to determine if a relationship exists between military service and CNS tumor type. METHODS This study analyzed data for adult patients diagnosed with an intra- or extra-axial CNS tumor from January 2016 to July 2019. One cohort was constructed of patients who had a history of military service (MIL), and the other cohort was made of patients who did not have a history of military service (NMIL). Appropriate parametric and non-parametric analyses were used to compare frequencies of tumor types between cohorts adjusting for potential confounders. RESULTS We identified 2001 patients (MIL, n = 190; NMIL, n = 1811). In the MIL cohort, most patients were males, younger, and more racially diverse. In the primary analysis, the MIL cohort showed higher diagnoses of metastatic tumors compared with the NMIL cohort (X2(1)= 3.71, p=.05). The MIL cohort also showed lower diagnoses of meningioma compared to the NMIL cohort. There was no statically significant difference between cohorts or tumors after adjusting for primary source by gender. CONCLUSIONS MIL experience was associated with lower diagnoses of meningioma but higher diagnoses of metastatic cancer, providing support that there may be potential differences in tumor types between patients with a history of military service and those without military history regarding primary CNS tumor frequency.

Biplane fluoroscopy in a hybrid operating room (OR) is commonly used for neuroendovascular and hybrid open/endovascular cases. The image quality is far superior to most C-arm fluoroscopy machines in the regular OR. This advantage can be particularly useful for upper and mid-thoracic percutaneous screw placement because the C-arm visualization in the regular OR is suboptimal due to shoulders absorbing the majority of the photons on lateral fluoroscopy. A 31-year-old man was ejected following a motor vehicle accident and sustained a T7 burst fracture with anterior translation on T8 and spinal cord transection. Following stabilization in the intensive care unit, the patient was taken to the biplane hybrid OR for percutaneous pedicle screw fixation. The patient had percutaneous instrumentation and fixation of T5-T10, and sequential reducers were also used to re-align T7 and T8. The use of biplane fluoroscopy enhanced safety and visualization. The patient tolerated the procedure well without complication. We believe this is an unrealized and underutilized function of a biplane hybrid OR that bears further investigation and study.

Most head and neck cancers require aggressive surgical resection followed by external beam radiation therapy. The carotid artery can be injured by surgery or radiation resulting in a delayed "blowout." A patient who had undergone orbital exenteration for a lacrimal adenoid cystic carcinoma (ACC) followed by external beam radiation presented 16 years later with arterial bleeding from the orbit caused by "blowout" of the cavernous internal carotid artery (ICA). We review the literature on carotid blowout syndrome (CBS) and treatment. The patient was emergently transferred to a hybrid operating room and underwent a balloon occlusion test (BOT) and endovascular sacrifice of the ICA with no neurological deficits postoperatively. Emergent endovascular embolization is an effective treatment for an intracranial ICA blowout in this first reported case of a blowout through the orbit. Elevated radiation dose and lack of tissue coverage may put the cavernous ICA at risk for this delayed complication.

Background: Rupture of a blood-blister like aneurysm (BBLA) of the internal carotid artery (ICA) is a rare etiology of subarachnoid hemorrhage (SAH). Historically, BBLAs have been difficult to treat. Open surgical clipping and endovascular coiling techniques have both had high rates of failure. Recently, flow-diverting stents (FDS) have been used to treat BBLAs with success, but concerns exist regarding the need for dual anti-platelet therapy, the delayed occlusion of the aneurysm that occurs with flow-diversion, and the potential difficulty of treating cerebral vasospasm and hydrocephalus. Methods: Clinical data and imaging from the index case were reviewed, and a systematic review of the medical literature was performed. Medical databases including PubMed and Medline were searched using multiple combinations of keywords. The bibliographies of each result were then used to identify additional publications. Only English language case reports of ruptured, intracranial ICA blood blister-like aneurysms treated exclusively with flow-diverting stents were included. Results: Given the results from our literature search and this patient's characteristics, we chose to treat her ruptured BBLA with a FDS. Although the FDS was deployed successfully, her clinical course was complicated by cerebral vasospasm, which was managed with induced hypertension. Subsequently, she developed hydrocephalus and underwent successful placement of a ventriculoperitoneal shunt while on dual antiplatelet therapy, which was briefly held. She had no operative complications and made an excellent recovery. Follow-up angiography performed at 3 and 6 months confirmed total occlusion of the aneurysm. Conclusions: A literature review revealed numerous successful treatments of ruptured BBLA with FDS monotherapy. A variety of different pharmacological treatment adjuncts were used; oral aspirin and clopidogrel being the most common. Overall, patients with ruptured BBLAs of the ICA treated only with FDS monotherapy had superior outcomes when compared to patients with ruptured BBLAs treated with open microsurgical clipping or endovascular coiling alone. Keywords: Blister aneurysm, Endovascular, Flow-diverting stent, Internal carotid artery, Pipeline, Subarachnoid hemorrhage

Peripheral nerve injuries (PNI) are caused by a range of etiologies and result in a broad spectrum of disability. While nerve autografts are the current gold standard for the reconstruction of extensive nerve damage, the limited supply of autologous nerve and complications associated with harvesting nerve from a second surgical site has driven groups from multiple disciplines, including biomedical engineering, neurosurgery, plastic surgery, and orthopedic surgery, to develop a suitable or superior alternative to autografting. Over the last couple of decades, various types of scaffolds, such as acellular nerve grafts (ANGs), nerve guidance conduits, and non-nervous tissues, have been filled with Schwann cells, stem cells, and/or neurotrophic factors to develop tissue engineered nerve grafts (TENGs). Although these have shown promising effects on peripheral nerve regeneration in experimental models, the autograft has remained the gold standard for large nerve gaps. This review provides a discussion of recent advances in the development of TENGs and their efficacy in experimental models. Specifically, TENGs have been enhanced via incorporation of genetically engineered cells, methods to improve stem cell survival and differentiation, optimized delivery of neurotrophic factors via drug delivery systems (DDS), co-administration of platelet-rich plasma (PRP), and pretreatment with chondroitinase ABC (Ch-ABC). Other notable advancements include conduits that have been bioengineered to mimic native nerve structure via cell-derived extracellular matrix (ECM) deposition, and the development of transplantable living nervous tissue constructs from rat and human dorsal root ganglia (DRG) neurons. Grafts composed of non-nervous tissues, such as vein, artery, and muscle, will be briefly discussed.

Glioblastoma is an aggressive disease that is difficult to treat, in large part due to the high level of molecular heterogeneity that limits the utility of targeted therapies. As such, population studies have been essential in characterizing the factors that promote survival. In this review, we summarize the findings in these studies. Demographic trends, molecular markers (IDH mutation, MGMT promoter methylation, TERT promoter mutation, chromosome 1p19q codeletion, PTEN, and p53 among others), radiographic correlates (peritumoral edema, enhancement, cyst formation, necrosis, and invasion among others), nonsteroidal anti-inflammatory drug (NSAID) and statin use, and ketogenic diet have been assessed. Overall, studies have found that IDH mutation and MGMT promoter methylation are positive prognostic markers and TERT is a negative prognostic marker, although subgroup analysis has revealed differential responses. NSAID and statin use have also suggested improved survival reaching significance in some studies. Ketogenic diet has not yet been adequately assessed. Further studies to characterize the interplay of these and other genetic and environmental factors are warranted.

Background Although rare, primary central nervous system (CNS) tumors are associated with significant morbidity and mortality. Texas is a representative sample of the United States population given its large population, ethnic disparities, geographic variations, and socio-economic differences. This study used Texas data to determine if variations in incidence trends and rates exist among different ethnicities in Texas. Methods Data from the Texas Cancer Registry from 1995 to 2013 were examined. Joinpoint Regression Program software was used to obtain the incidence trends and SEER*Stat software was used to produce average annual age-adjusted incidence rates for both nonmalignant and malignant tumors in Texas from 2009 to 2013. Results The incidence trend of malignant primary CNS tumors in whites was stable from 1995 to 2002, after which the annual percent change decreased by 0.99% through 2013 (95% CI, -1.4, -0.5; P = .04). Blacks and Asian/Pacific Islanders showed unchanged incidence trends from 1995 to 2013. Hispanics had an annual percent change of -0.83 (95% CI, -1.4, -0.2; P = .009) per year from 1995 through 2013. From 2009 to 2013, the incidence rates of nonmalignant and malignant primary CNS tumors were highest among blacks, followed by whites, Hispanics, Asians, and American Indians/Alaskan Natives. Conclusions Consistent with the 2016 Central Brain Tumor Registry of the United States report, the black population in Texas showed the highest total incidence of CNS tumors of any other race studied. Many factors have been proposed to account for the observed differences in incidence rate including geography, socioeconomic factors, and poverty factors, although the evidence for these external factors is lacking.

Ruptured intracranial aneurysms are extremely rare in infants. The optimal treatment strategy is not well established. Both microsurgical and endovascular techniques and strategies have been tried, and in the literature there is a significant variability in outcome. The authors report the presentation and successful endovascular treatment of a large, ruptured, middle cerebral artery bifurcation aneurysm in a 5-week-old girl, one of only a few reported in the literature. Clinical and radiological findings at follow-up are also presented. The authors then review the literature on aneurysmal subarachnoid hemorrhage in infants, with particular regard to outcome after either endovascular or open surgical management. They also provide recommendations for follow-up in pediatric patients whose intracranial aneurysms have been treated with coil embolization.

We report a case of glioblastoma multiforme that presented as a large, spontaneous intracerebral hemorrhage (ICH). A 52-year-old woman developed headaches associated with photophobia and nausea. Computed tomography scan revealed a large ICH in the right temporal lobe. Further imaging, including magnetic resonance imaging and catheter-based arteriography, did not demonstrate an underlying lesion. She had 2-month follow-up imaging that was consistent with resolution of her hematoma and, again, no evidence of an associated mass. Six months after the initial ICH, she presented with worsening headaches. Magnetic resonance imaging of her brain at that time clearly demonstrated a large enhancing mass in the area of prior hemorrhage. Following tumor resection, histological diagnosis indicated glioblastoma multiforme. This case highlights the benefit of neurosurgical follow-up for patients with cryptogenic ICH and maintaining a high index of suspicion for brain tumor.

Objectives: Glioblastoma is the most common primary malignant brain tumor in adults, and despite decades of intensive research regarding its pathophysiology and treatment, the prognosis for glioblastoma patients remains poor. While many studies have analyzed various factors that may influence survival outcomes, the focus of this brief review is to discuss the influence that apatient's race/ethnicity has on survival. This factor has been investigated in large population-based studies and in smaller institutional analyses, but the prognostic utility of this factor has been inconsistent. Discussion of this topic is therefore warranted to better equip providers to counsel and treat patients with glioblastoma, as well as to identify areas of future research. Methods: A comprehensive literature search is performed to identify studies that reported GBM survival outcomes by race/ethnicity. Results: Although some discrepancies exist, asignificant survival benefit is associated with the Asian or Pacific Islander (API) race, whereas white patients have the poorest survival and highest incidence. Hispanic patients tend to fare better than white patients but have worse survival than APIs. Discussion: Further analysis into the differences in survival among different races may lead to an increased understanding of potential molecular and genetic targets, thus guiding future treatment plans for these patients. Abbreviations: AAAIR: Average Annual Age-Adjusted Incidence Rate; AI/AN: American Indian or Alaska Native; API: Asian or Pacific Islander; CBTRUS: Central Brain Tumor Registry of the United States; CUMC: Columbia University Medical Center; EOR: Extent of Resection; Exc: Excluded; GBM: Glioblastoma; GTR: Gross Total Resection; IDH-1: Isocitrate Dehydrogenase 1; MGMT: O6-Methylguanine DNA Methyltransferase; NCDB: National Cancer Database; OS: Overall Survival; O/U: Other/Unknown; PFS: Progression-Free Survival; SEER: Surveillance, Epidemiology, and End Results; SW UCLA: University of California Los Angeles; UM: University of Miami.

Traumatic Brain Injury (TBI) is the most frequent cause of death and disability in young adults and children in the developed world, occurring in over 1.7 million persons and resulting in 50,000 deaths in the United States alone. The Centers for Disease Control and Prevention estimate that between 3.2 and 5.3 million persons in the United States live with a TBI-related disability, including several neurocognitive disorders and functional limitations. Following the primary mechanical injury in TBI, literature suggests the presence of a delayed secondary injury involving a variety of neuroinflammatory changes. In the hours to days following a TBI, several signaling molecules and metabolic derangements result in disruption of the blood-brain barrier (BBB), leading to an extravasation of immune cells and cerebral edema. The primary, sudden injury in TBI occurs as a direct result of impact and therefore cannot be treated, but the timeline and pathophysiology of the delayed, secondary injury allows for a window of possible therapeutic options. The goal of this review is to discuss the pathophysiology of the primary and delayed injury in TBI as well as present several preclinical studies that identify molecular targets in the potential treatment of TBI. Additionally, certain recent clinical trials are briefly discussed to demonstrate the current state of TBI investigation.

OBJECTIVEDespite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage.METHODSPatients presenting to the authors’ institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed.RESULTSOf 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33–1364 days). The total “at risk” period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month.CONCLUSIONSIt is the authors’ practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors’ treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.

In North America alone, spinal cord injury affects well over 1 million patients, with the average annual incidence expected to rise secondary to an increasing amount of falls in an aging population.1,2 Spinal cord injury (SCI) has detrimental health consequences that can frequently leave the injured patient with a lifetime of medical expenses exceeding $4 million.2 Although the current practice in treating SCI is to elevate a patient's mean arterial pressure (MAP) to 85–90 mm Hg for the first 7 days in an effort to maintain spinal cord perfusion, this treatment strategy has uncertain efficacy, as the actual spinal cord perfusion pressure (SCPP) remains unknown.3 In this issue of Neurology® , Squair et al.4 propose an improved treatment approach using the calculated SCPP that can provide patients with an increased likelihood of having restoration of function after an SCI.

Emergent surgery on a ruptured brain arteriovenous malformation (AVM) is indicated for a large hematoma in an acutely deteriorating patient. The majority of ruptured AVMs, however, present in clinically stable patients with neurological deficits. Controversy exists with respect to the timing of treatment for ruptured AVMs in these stable patients. This study aims to determine the safety of delaying AVM treatment in clinically stable patients by investigating the rate of rehemorrhage in a cohort of patients with ruptured brain AVMs. Patients presenting to our institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in the analysis. Exclusion criteria were ruptured AVMs that required emergent surgery involving AVM resection, previous treatment at another institution, or subacute AVM treatment. The primary outcome measure was time from initial hemorrhage to rehemorrhage. Patient follow-up data were included up until the point of AVM treatment. Of the 103 ruptured AVMs (49 M:54 F) meeting inclusion criteria, the median time from rupture to treatment or rehemorrhage was 112 days (interquartile range [IQR]: 110). Six (5.8%) patients rehemorrhaged in a median of 248 days (IQR: 1331). Two of these patients rehemorrhaged on the same day of their index hemorrhage. The total at-risk period was 19 445 patient-days, yielding a rehemorrhage risk of 11.3% per patient-year, or 0.93% per patient-month. Our data support stabilizing a patient after the initial AVM rupture. It is safe to closely monitor the patient, initiate the rehabilitation process, and then, in a semielective manner, bring the patient back for treatment. Delaying intervention for 4 weeks after initial hemorrhage subjects the patient to a low (