Search

BACKGROUND Aneurysm clipping simulation models are needed to provide tactile feedback of biological vessels in a nonhazardous but surgically relevant environment. OBJECTIVE To describe a novel system of simulation models for aneurysm clipping training and assess its validity. METHODS Craniotomy models were fabricated to mimic actual tissues and movement restrictions experienced during actual surgery. Turkey wing vessels were used to create aneurysm models with patient-specific geometry. Three simulation models (middle cerebral artery aneurysm clipping via a pterional approach, anterior cerebral artery aneurysm clipping via an interhemispheric approach, and basilar artery aneurysm clipping via an orbitozygomatic pretemporal approach) were subjected to face, content, and construct validity assessments by experienced neurosurgeons (n = 8) and neurosurgery trainees (n = 8). RESULTS Most participants scored the model as replicating actual aneurysm clipping well and scored the difficulty of clipping as being comparable to that of real surgery, confirming face validity. Most participants responded that the model could improve clip-applier-handling skills when working with patients, which confirms content validity. Experienced neurosurgeons performed significantly better than trainees on all 3 models based on subjective (P = .003) and objective (P

Background Out of Hospital Cardiac arrest (OHCA) survivors with ST elevation (STE) with or without shockable rhythms often benefit from coronary angiography (CAG) and, if indicated, percutaneous coronary intervention (PCI). However, the benefits of CAG and PCI in OHCA survivors with nonshockable rhythms (PEA/asystole) and no STE are debated. Methods Using the International Cardiac Arrest Registry (INTCAR 2.0), representing 44 centers in the US and Europe, comatose OHCA survivors with known presenting rhythms and post resuscitation ECGs were identified. Survival to hospital discharge, neurological recovery on discharge, and impact of CAG with or without PCI on such outcome were assessed and compared with other groups (shockable rhythms with or without STE). Results Total of 2113 OHCA survivors were identified and described as; nonshockable/no STE (Nsh-NST) (n = 940, 44.5%), shockable/no STE (Sh-NST) (n = 716, 33.9%), nonshockable/STE (Nsh-ST) (n = 110, 5.2%), and shockable/STE (Sh-ST) (n = 347, 16.4%). Of Nsh-NST, 13.7% (129) were previously healthy before CA and only 17.3% (161) underwent CAG; of those, 30.4% (52) underwent PCI. A total of 18.6% (174) Nsh-NST patients survived to hospital discharge, with 57.5% (100) of such survivors having good neurological recovery (cerebral performance category 1 or 2) on discharge. Coronary angiography was associated with improved odds for survival and neurological recovery among all groups, including those with NSh-NST. Conclusions Nonshockable initial rhythms with no ST elevation post resuscitation was the most common presentation after OHCA. Although most of these patients did not undergo coronary angiography, among those who did, 1 in 4 patients had a culprit lesion and underwent revascularization. Invasive CAG should be at least considered for all OHCA survivors, including those with nonshockable rhythms and no ST elevation post resuscitation. Brief abstract Out of hospital cardiac arrest (OHCA) survivors with ST elevation and/or shockable rhythms benefit from coronary angiography and revascularization. Nonshockable cardiac arrest survivors with no ST elevation have the worst prognosis and rarely undergo coronary angiography. Nonshockable rhythms with no ST elevation was the most common presentation after OHCA and among a small subgroup underwent coronary angiography, 1 in 4 patients with had culprit lesion and underwent revascularization. Coronary angiography was associated with high prevalence of acute culprit coronary lesions and should be considered for those with a probably cardiac cause for their arres.

Most existing anterior cervical discectomy and fusion (ACDF) outcome studies omit emergency department (ED) use. To our knowledge, this study on ED use following ACDF surgery is the first to use a direct patient chart review and the first to include revision patients, 1–5 levels of ACDFs, and performance of corpectomy in the analysis. This study examines the frequency and basis of hospital service use within 30 days of ACDF surgery, specifically ED visits, hospital readmissions, and returns to the operating room. A retrospective chart review was performed for 1273 consecutive patients who underwent ACDF surgery at one institution from July 2013 to June 2016. Of the 1273 patients with ACDF, 97 (7.6%) presented to the ED within 30 days after surgery. Of 43 patients with revision ACDF, 9 (20.9%) returned to the ED, compared with 88 (7.2%) of 1230 patients with primary ACDF (P = 0.001). Of the 111 ED visits by 97 patients, 40 (36%) were for cervicalgia, 13 (12%) were for dysphagia, 8 (7%) were for trauma, 7 (6%) were for nausea, 4 (4%) were for medication refill, 3 (3%) were for dehiscence, 3 (3%) were for pneumonia, and 3 (3%) were for urinary tract infection. Of the ED presentations, 8 (7%) occurred during the first 2 days after surgery, and 46 (41%) occurred within the first postoperative week.

The proliferation of data collected by modern tunnel-boring machines (TBMs) presents a substantial opportunity for the application of machine learning (ML) to support the decision-making process on-site with timely and meaningful information. The observational method is now well established in geotechnical engineering and has a proven potential to save time and money relative to conventional design. ML advances the traditional observational method by employing data analysis and pattern recognition techniques, predicated on the assumption of the presence of enough data to describe the physics of the modelled system. This paper presents a comprehensive review of recent advances and applications of ML to inform tunnelling construction operations with a view to increasing their potential for uptake by industry practitioners. This review has identified four main applications of ML to inform tunnelling – namely, TBM performance prediction, tunnelling-induced settlement prediction, geological forecasting and cutterhead design optimisation. The paper concludes by summarising research trends and suggesting directions for future research for ML in the tunnelling space.

OBJECTIVEThe objective of this study was to evaluate the existing Spetzler-Martin (SM), Spetzler-Ponce (SP), and Lawton-Young (LY) grading systems for cerebellar arteriovenous malformations (AVMs) and to propose a new grading system to estimate the risks associated with these lesions.METHODSData for patients with cerebellar AVMs treated microsurgically in two tertiary medical centers were retrospectively reviewed. Data from patients at institution 1 were collected from September 1999 to February 2013, and at institution 2 from October 2008 to October 2015. Patient outcomes were classified as favorable (modified Rankin Scale [mRS] score 0–2) or poor (mRS score 3–6) at the time of discharge. Using chi-square and logistic regression analysis, variables associated with poor outcomes were assigned risk points to design the proposed grading system. The proposed system included neurological status prior to treatment (poor, +2 points), emergency surgery (+1 point), age > 60 years (+1 point), and deep venous drainage (deep, +1 point). Risk point totals of 0–1 comprised grade 1, 2–3 grade 2, and 4–5 grade 3.RESULTSA total of 125 cerebellar AVMs of 1328 brain AVMs were reviewed in 125 patients, 120 of which were treated microsurgically and included in the study. With our proposed grading system, we found poor outcomes differed significantly between each grade (p < 0.001), while with the SM, SP, and LY grading systems they did not (p = 0.22, p = 0.25, and p = 1, respectively). Logistic regression revealed grade 2 had 3.3 times the risk of experiencing a poor outcome (p = 0.008), while grade 3 had 9.9 times the risk (p < 0.001). The proposed grading system demonstrated a superior level of predictive accuracy (area under the receiver operating characteristic curve [AUROC] of 0.72) compared with the SM, SP, and LY grading systems (AUROC of 0.61, 0.57, and 0.51, respectively).CONCLUSIONSThe authors propose a novel grading system for cerebellar AVMs based on emergency surgery, venous drainage, preoperative neurological status, and age that provides a superior prognostication power than the formerly proposed SM, SP, and LY grading systems. This grading system is clinically predictive of patient outcomes and can be used to better guide vascular neurosurgeons in clinical decision-making.

Mastery of lateral skull base (LSB) surgery requires thorough knowledge of complex, 3-dimensional (3D) microanatomy and techniques. While supervised operation under binocular microscopy remains the training gold standard, concerns over operative time and patient safety often limit novice surgeons' stereoscopic exposure. Furthermore, most alternative educational resources cannot meet this need. Here we present proof of concept for a tool that combines 3D-operative video with an interactive, stereotactic teaching environment. Stereoscopic video was recorded with a microscope during translabyrinthine approaches for vestibular schwannoma. Digital imaging and communications in medicine (DICOM) temporal bone computed tomography images were segmented using 3D-Slicer. Files were rendered using a game engine software built for desktop virtual reality. The resulting simulation was an interactive immersion combining a 3D operative perspective from the lead surgeon's chair with virtual reality temporal bone models capable of hands-on manipulation, label toggling, and transparency modification. This novel tool may alter LSB training paradigms.

Objective In ventriculoperitoneal shunt (VPS) placement, distal placement of the peritoneal catheter will typically be performed by a neurosurgeon. More recently, laparoscopic-assisted (LA) placement of the distal peritoneal catheter by general surgeons has become common. The present study examined whether LA placement of a VPS (LAVPS) is associated with a reduced operative time, lower hospital costs, and fewer distal revisions. Methods A retrospective review was performed of the data from all patients who had received a new VPS at our institution from 2013 to 2016. Age, sex, diagnosis, previous abdominal surgery, operative time, anesthesia grade, incidence of 30-day shunt failure, and total hospital charges were analyzed. Results A total of 680 patients had undergone first-time VPS placement, including 199 with LAVPS and 481 with non–LAVPS placement (non-LAVPS). The mean age of the LAVPS patients was significantly older than that of the non-LAVPS patients (64.1 vs. 59.3 years; P = 0.002). The mean operative time was shorter in the LAVPS group than in the non-LAVPS group (55 vs. 75 minutes; P Conclusions Compared with non-LAVPS, LAVPS was associated with significantly shorter operative times and fewer distal shunt revisions within 30 days. The findings from a subset analysis supported a decrease in total hospital charges. Additional studies are needed; however, these data suggest that LAVPS is a safer, less-expensive alternative to non-LAVPS.

Introduction Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been recommended in international guidelines since 2005. The TTM-trial published in 2013 showed no difference in survival or neurological outcome for patients randomised to 33 °C or 36 °C, and many hospitals have changed practice. The optimal utilization of TTM is still debated. This study aimed to analyse if a difference in temperature goal was associated with outcome in an unselected international registry population. Methods This is a retrospective observational study based on a prospective registry — the International Cardiac Arrest Registry 2. Patients were categorized as receiving TTM in the lower range at 32–34 °C (TTM-low) or at 35–37 °C (TTM-high). Primary outcome was good functional status defined as cerebral performance category (CPC) of 1–2 at hospital discharge and secondary outcome was adverse events related to TTM. A logistic regression model was created to evaluate the independent effect of temperature by correcting for clinical and demographic factors associated with outcome. Results Of 1710 patients included, 1242 (72,6%) received TTM-low and 468 (27,4%) TTM-high. In patients receiving TTM-low, 31.3% survived with good outcome compared to 28.8% in the TTM-high group. There was no significant association between temperature and outcome (p = 0.352). In analyses adjusted for baseline differences the OR for a good outcome with TTM-low was 1.27, 95% CI (0.94–1.73). Haemodynamic instability leading to discontinuation of TTM was more common in TTM-low. Conclusions No significant difference in functional outcome at hospital discharge was found in patients receiving lower- versus higher targeted temperature management.

Dural arteriovenous fistulas (DAVFs) are benign but may present with life-threatening hemorrhage or symptoms of venous hypertension (eg, progressive myelopathy).1-3 DAVFs follow well-described anatomic patterns.4 The marginal sinus is located between the layers of the dura, circumferentially around the foramen magnum. It communicates with the basal venous plexus of the clivus anteriorly and the occipital sinus posteriorly.5,6 Arterial supply to the dura in this region that fistulizes into the sinus arises from meningeal branches from the V3 or V4 segments. A man in his early 70s presented with chronic neck pain and new onset of left arm and face paresthesias. He had brisk patellar reflexes bilaterally and a marginal sinus DAVF, with numerous dilated veins around the cisterna magna, causing dorsal cervicomedullary compression. Angiography confirmed the diagnosis of DAVF rather than arteriovenous malformation. Endovascular embolization was considered, but surgery was preferable because of poor transarterial access. The patient underwent left far lateral craniotomy and C1 laminectomy with exposure of the condylar fossa. The dura was carefully elevated laterally, revealing a network of dilated tortuous veins, with multiple points of fistulous connection within the dura emanating in a large venous varix. Indocyanine green videoangiography showed the aberrant flow dynamics. The fistulous point was occluded with aneurysm clips on the venous side, then cauterized and interrupted. The patient was discharged within 3 d of surgery and had full resolution of symptoms at 6 wk. Angiography confirmed complete obliteration of the DAVF. The patient provided written informed consent for treatment. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

To evaluate surgical resection with brachytherapy placement as a salvage treatment in patients with recurrent high-grade meningioma who exhausted prior external beam treatment options. Single-center retrospective review of our institutional experience of brachytherapy implantation from 2012 to 2018. The primary outcome of the study was progression free survival (PFS). Secondary outcomes included overall survival (OS) and complications. A matched cohort of patients not treated with brachytherapy over the same time period was evaluated as a control group. All patients had received prior radiation treatment and underwent planned gross total resection (GTR) surgery. A total of 27 cases were evaluated. Compared with prior treatment, brachytherapy implantation demonstrated a statistically significant improvement in tumor control [HR 0.316 (0.101 − 0.991), p = 0.034]. PFS-6 and PFS-12 were 92.3% and 84.6%, respectively. Compared with the matched control cohort, brachytherapy treatment demonstrated improved PFS [HR 0.310 (0.103 − 0.933), p = 0.030]. Overall survival was not statistically significantly different between groups [HR 0.381 (0.073 − 1.982), p = 0.227]. Overall postoperative complications were comparable between groups, although there was a higher incidence of radiation necrosis in the brachytherapy cohort. Brachytherapy with planned GTR improved PFS in recurrent high-grade meningioma patients who exhausted prior external beam radiation treatment options. Future improvement of brachytherapy dose delivery methods and techniques may continue to prolong control rates and improve outcomes for this challenging group of patients.

Objective Cystic vestibular schwannomas (CVSs) are anecdotally believed to have worse clinical and tumor-control outcomes than solid vestibular schwannomas (SVSs); however, no data have been reported to support this belief. In this study, we characterize the clinical outcomes of patients with CVSs versus those with SVSs. Design This is a retrospective review of prospectively collected data. Setting This study is set at single high-volume neurosurgical institute. Participants We queried a database for details on all patients diagnosed with vestibular schwannomas between January 2009 and January 2014. Main Outcome Measures Records were retrospectively reviewed and analyzed using univariate and multivariate analyses to study the differences in clinical outcomes and tumor progression or recurrence. Results Of a total of 112 tumors, 24% (n = 27) were CVSs and 76% (n = 85) were SVSs. Univariate analysis identified the extent of resection, Koos grade, and tumor diameter as significant predictors of recurrence (p ≤ 0.005). However, tumor diameter was the only significant predictor of recurrence in the multivariate analysis (p = 0.007). Cystic change was not a predictor of recurrence in the univariate or multivariate analysis (p ≥ 0.40). Postoperative facial nerve and hearing outcomes were similar for both CVSs and SVSs (p ≥ 0.47). Conclusion Postoperative facial nerve outcome, hearing, tumor progression, and recurrence are similar for patients with CVSs and SVSs. As CVS growth patterns and responses to radiation are unpredictable, we favor microsurgical resection over radiosurgery as the initial treatment. Our data do not support the commonly held belief that cystic tumors behave more aggressively than solid tumors or are associated with increased postoperative facial nerve deficits.

BACKGROUND The influence of the surgeon's preoperative goal regarding the extent of tumor resection on patient outcomes has not been carefully studied among patients with nonfunctioning pituitary adenomas. OBJECTIVE To analyze the relationship between surgical tumor removal goal and patient outcomes in a prospective multicenter study. METHODS Centrally adjudicated extent of tumor resection (gross total resection [GTR] and subtotal resection [STR]) data were analyzed using standard univariate and multivariable analyses. RESULTS GTR was accomplished in 148 of 171 (86.5%) patients with planned GTR and 32 of 50 (64.0%) patients with planned STR (P = .001). Sensitivity, specificity, positive predictive value, and negative predictive value of GTR goal were 82.2, 43.9, 86.5, and 36.0%, respectively. Knosp grade 0-2, first surgery, and being an experienced surgeon were associated with surgeons choosing GTR as the goal (P

Study Design: Description and evaluation of a novel surgical training platform. Objectives: The purpose of this study was to investigate the face, content, and construct validity of 5 novel surgical training models that simulate freehand and percutaneous (minimally invasive surgery [MIS]) pedicle screw placement. Methods: Five spine models were developed by residents: 3 for freehand pedicle screw training (models A-C) and 2 for MIS pedicle screw training (models D and E). Attending spine surgeons evaluated each model and, using a 20-point Likert-type scale, answered survey questions on model face, content, and construct validity. Scores were statistically evaluated and compared using means, standard deviations, and analysis of variance between models and between surgeons. Results: Among the freehand models, model C demonstrated the highest overall validity, with mean face (15.67 ± 5.49), content (19.17 ± 0.59), and construct (18.83 ± 0.24) validity all measuring higher than the other freehand models. For the MIS models, model D had the highest validity scores (face, content, and construct validity of 11.67 ± 3.77, 18.17 ± 2.04, and 17.00 ± 3.46, respectively). The 3 freehand models differed significantly in content validity scores ( P = .002) as did the 2 MIS models ( P < .001). The testing surgeons’ overall validity scores were significantly different for models A ( P = .005) and E ( P < .001). Conclusions: A 3-dimensional-printed spine model with incorporated bone bleeding and silicone rubber soft tissue was scored as having very high content and construct validity for simulating freehand pedicle screw insertion. These data has informed the further development of several surgical training models that hold great potential as educational adjuncts in surgical training programs.

Cerebellar arteriovenous malformations (CAVMs) are challenging to treat given their close proximity to the brain stem, greater propensity for rupture, and greater rates of morbidity and mortality than other brain arteriovenous malformations. The present investigation sought to describe and characterize the features of these rare and unique lesions.A retrospective review of CAVM cases treated at 2 tertiary medical centers was performed. Patients surgically treated at institution 1 from September 1999 to February 2013 and institution 2 from October 2008 to October 2015 were included.A total of 120 patients had been treated. Of the 120 patients, 85 (70.8%) had initially presented with hemorrhage, 45 (37.5%) of whom experienced hemorrhage requiring emergent surgery. A favorable neurological outcome was observed in 76 patients (63.3%; modified Rankin Scale score3). The perioperative mortality was 2.5% (n = 3). The long-term mortality rate was 7.5% (n = 9). The mean follow-up time was 1.82 years. On average, the patients with large CAVMs (≥3 cm; P ≤ 0.001), who had received embolization before surgery (P = 0.04), did not have an associated aneurysm (P ≤ 0.001), or had a residual CAVM after surgery (P = 0.008) were significantly younger. Female patients had fewer CAVMs with deep venous drainage (54.3% vs. 72.3%; P = 0.049), experienced decreased mortality (1.4% vs. 16.7%; P = 0.003), and were less likely to have worse neurological status after treatment (P = 0.003).CAVMs are rare lesions that exhibit unique disease characteristics. Although most patients will experience a favorable outcome, CAVMs frequently present with hemorrhage, result in high rates of morbidity and mortality, and characteristically differ depending on patient age and gender.

Objective Visual field (VF) outcomes are commonly reported in neurosurgical case series; however, substantial variability can exist in VF testing and outcome reporting. We aimed to evaluate the challenges of VF testing and to develop detailed recommendations for VF outcome reporting by analyzing results from an ongoing, multicenter study of transsphenoidal pituitary surgery. Methods VF testing results were collected during a prospective, multicenter clinical trial evaluating patient outcomes after transsphenoidal surgery for nonfunctioning pituitary adenomas (TRANSSPHER). Two independent ophthalmologists reviewed reliability and outcomes of all VF studies. Preoperative and postoperative VF studies were evaluated individually and as preoperative/postoperative pairs. Results Suboptimal perimetry field settings were reported in 37% of VF studies. Automated reliability criteria flagged 25%–29% of VF studies as unreliable, whereas evaluation by 2 independent ophthalmologists flagged 16%–28%. Agreement between automated criteria and raters for VF reliability was inconsistent (κ coefficients = 0.55–0.83), whereas agreement between the 2 raters was substantial to almost perfect (κ coefficients = 0.78–0.83). Most patients demonstrated improvement after surgery (rater 1, 67%; rater 2, 60%), with substantial rater agreement on outcomes for paired examinations (κ coefficient = 0.62). Conclusions VF outcome studies demonstrated significant variability of test parameters and patient performance. Perimetry field settings varied among patients and for some patients varied preoperatively versus postoperatively. Reliance on automated criteria alone could not substitute for independent ophthalmologist review of test reliability. Standardized guidelines for VF data collection and reporting could increase reliability of results and allow better comparisons of outcomes in future studies.

Olfactory groove meningiomas frequently present as large or giant-size tumors associated with marked frontal lobe edema and significant frontal lobe dysfunction. Simpson grade I removal was rare in early reports due to their invasion of the ethmoid sinuses and skull base bone,1 which resulted in high recurrence rates.2,3 Indeed, recurrence occurred in the most celebrated case of olfactory groove meningioma.4,5 To achieve Simpson grade I removal (tumor, dura, bone), protect the frontal lobes from additional injury, and provide the best chance for recovery, we demonstrate a few nuances for olfactory groove meningioma surgery: Utilizing a skull base approach with a low dural opening, the frontal veins are preserved, and the frontal lobe is protected from retraction, manipulation, and venous injury. By the time of diagnosis, although the patient's olfaction is often absent, there still remains a role to preserve at least 1 olfactory tract, which might yield some preservation in a limited number of patients. Emphasis has been rightly made on the preservation of the A2 segments, which can be dissected using microsurgical technique. Lastly, multilayer reconstruction of the skull base is required, using an inlay graft, resting on a vascularized pericranial flap, and occlusion of the sinuses with a fat graft. The endonasal endoscopic approach has fallen out of favor due to limitations for complete tumor resection and higher complication rates.6 We present a case of a relatively small olfactory groove meningioma in a 36-yr-old male with partial olfactory loss. The patient consented for surgery. Images at 2:07, 2:29, and 2:54 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission. Image at 8:31 public domain by age.

The safety of tunneling with shield tunnel boring machines largely depends on the tunnel face pressure, which is currently decided by human operators empirically. Face pressure control is vulnerable to human misjudgment and human errors can cause severe consequences, especially in difficult ground conditions. From a practical perspective, it is therefore beneficial to have a model capable of predicting the tunnel face pressure given operation and the changing geology. In this paper, we propose such a model based on deep learning. More specifically, a long short-term memory (LSTM) recurrent neural network is employed for tunnel face pressure prediction. To correlate with PLC data, linear interpolation is employed to transform the borehole geological data into sequential geological data according to the shield machine position. The slurry pressure in the excavation chamber (SPE) is taken as the output in the case study of Nanning Metro, which is confronted with the clogging problem due to the mixed ground of mudstone and round gravel. The LSTM-based SPE prediction model achieved an overall MAPE and RMSE of 3.83% and 10.3 kPa, respectively, in mudstone rich ground conditions. Factors that influence the model, including different kinds and length of input data and comparison with the traditional machine learning-based model, are also discussed.

Some skull base tumors can be extremely hypervascular, incorporating multiple vascular territories and demonstrating arteriovenous shunting. Devascularization is a critical step undertaken early in meningioma surgery, necessary before the debulking that is required in skull base tumors. While devascularization can often be achieved with appropriate approach selection, bony drilling, and microsurgical cautery, preoperative embolization of meningiomas has an invaluable role in selected cases.1,2 Embolization, however, does have added risk, magnified in large tumors by the potential infarction with subsequent edema that can potentially lead to acute deterioration and neurosurgical emergency. Hence, to achieve devascularization of an extremely vascular tumor, embolization and surgical resection should be performed concomitantly, as one operation, in which embolization might be the first stage, or might be performed after the craniotomy flap is raised, if necessary.3 Naturally, this requires the multifaceted neurosurgical expertise of embolization and microsurgical resection, and the facility to perform such. We present a case of a giant, hypervascular, radiation-induced, skull base meningioma with internal and external carotid artery supply in a young patient with deteriorating vision in his only eye. Selective embolization of the internal maxillary, middle meningeal, and middle cerebral artery blood supplies was performed. Microsurgical interruption of the ethmoidal artery blood supply was then performed. This hybrid approach safely and effectively devascularized the tumor and allowed for a complete resection of this high-risk tumor4 while minimizing risk to the ophthalmic artery and optic nerve. The patient was consented for surgery.

Introduction: The outcomes of ST elevation myocardial infarction (STEMI) patients with prior coronary bypass graft (CABG) surgery have received limited study. Methods: We compared the clinical and procedural characteristics and outcomes of STEMI patients with and without prior CABG surgery in a contemporary STEMI registry of consecutive STEMI patients with STEMI or new left bundle-branch block within 24 hours of symptom onset presenting between March 2003 and April 2020. Morality and major cardiac adverse events (MACE: death, MI or stroke) were the primary outcomes of the study. Survival curves are depicted using the Kaplan-Meier method and compared with log-rank test. Results: Of the 6,311 patients included in the analyses, 6.9% had history of prior CABG. Mean age was 63.4 ± 13.9 years and most of the patients were men (71%), 21% had prior MI and 19% had diabetes mellitus. Prior CABG patients were older (70.4±11.7 vs. 62.9±13.9 years, p Conclusions: Patients with STEMI and previous CABG represent a higher risk cohort with worse in-hospital and long-term outcomes compared to those without previous CABG.

The American College of Cardiology Interventional Council published consensus-based recommendations to help identify resuscitated cardiac arrest patients with unfavorable clinical features in whom invasive procedures are unlikely to improve survival.This study sought to identify how many unfavorable features are required before prognosis is significantly worsened and which features are most impactful in predicting prognosis.Using the INTCAR (International Cardiac Arrest Registry), the impact of each proposed "unfavorable feature" on survival to hospital discharge was individually analyzed. Logistic regression was performed to assess the association of such unfavorable features with poor outcomes.Seven unfavorable features (of 10 total) were captured in 2,508 patients successfully resuscitated after cardiac arrest (ongoing cardiopulmonary resuscitation and noncardiac etiology were exclusion criteria in our registry). Chronic kidney disease was used in lieu of end-stage renal disease. In total, 39% survived to hospital discharge. The odds ratio (OR) of survival to hospital discharge for each unfavorable feature was as follows: age85 years OR: 0.30 (95% CI: 0.15 to 0.61), time-to-ROSC30 min OR: 0.30 (95% CI: 0.23 to 0.39), nonshockable rhythm OR: 0.39 (95% CI: 0.29 to 0.54), no bystander cardiopulmonary resuscitation OR: 0.49 (95% CI: 0.38 to 0.64), lactate7 mmol/l OR: 0.50 (95% CI: 0.40 to 0.63), unwitnessed arrest OR: 0.58 (95% CI: 0.44 to 0.78), pH 7.2 OR: 0.78 (95% CI: 0.63 to 0.98), and chronic kidney disease OR: 0.96 (95% CI: 0.70 to 1.33). The presence of any 3 or more unfavorable features predicted 40% survival. Presence of the 3 strongest risk factors (age85 years, time-to-ROSC30 min, and non-ventricular tachycardia/ventricular fibrillation) together or ≥6 unfavorable features predicted a ≤10% chance of survival to discharge.Patients successfully resuscitated from cardiac arrest with 6 or more unfavorable features have a poor long-term prognosis. Delaying or even forgoing invasive procedures in such patients is reasonable.

This is the first study to assess confocal laser endomicroscopy (CLE) use within the transsphenoidal approach and show the feasibility of obtaining digital diagnostic biopsies of pituitary tumor tissue after intravenous fluorescein injection. We confirmed that the CLE probe reaches the tuberculum sellae through the transnasal transsphenoidal corridor in cadaveric heads. Next, we confirmed that CLE provides images with identifiable histological features of pituitary adenoma. Biopsies from nine patients who underwent pituitary adenoma surgery were imaged ex vivo at various times after fluorescein injection and were assessed by a blinded board-certified neuropathologist. With frozen sections used as the standard, pituitary adenoma was diagnosed as &ldquo, definitively&rdquo, for 13 and as &ldquo, favoring&rdquo, in 3 of 16 specimens. CLE digital biopsies were diagnostic for pituitary adenoma in 10 of 16 specimens. The reasons for nondiagnostic CLE images were biopsy acquisition &lt, 1 min or &gt, 10 min after fluorescein injection (n = 5) and blood artifacts (n = 1). In conclusion, fluorescein provided sufficient contrast for CLE at a dose of 2 mg/kg, optimally 1&ndash, 10 min after injection. These results provide a basis for further in vivo studies using CLE in transsphenoidal surgery.

OBJECTIVE Hospital readmission and the reduction thereof has become a major quality improvement initiative in organized medicine and neurosurgery. However, little research has been performed on why neurosurgical patients utilize hospital emergency rooms (ERs) with or without subsequent admission in the postoperative setting. METHODS This study was a retrospective, single-center review of data for all surgical cranial procedures performed from July 2013 to July 2016 in patients who survived to discharge. The study was approved by the institutional review board of the participating medical center. RESULTS The authors identified 7294 cranial procedures performed during 6596 hospital encounters in 5385 patients. The rate of postoperative ER utilization within 30 days after surgical hospitalization across all procedure types was 13.1 per 100 surgeries performed. The two most common chief complaints were pain (30.7%) and medical complication (18.2%). After identification of relevant surgical and patient factors with univariable analysis, a multivariable backward elimination logistic regression model was constructed in which Ommaya reservoir placement (OR 2.65, p = 0.0008) and cranial CSF shunt placement (OR 1.40, p = 0.0001) were associated with increased ER utilization. Deep brain stimulation electrode placement (OR 0.488, p = 0.0004), increasing hospital length of stay (OR 0.935, p < 0.0001), and increasing patient age (OR 0.988, p < 0.0001) were associated with lower rates of postoperative ER utilization. One-half (50%) of ER visit patients were readmitted to the hospital. New/worsening neurological deficit chief complaint (OR 1.99, p = 0.0088), fever chief complaint (OR 2.41, p = 0.0205), altered mentation chief complaint (OR 2.71, p = 0.0002), patient chronic kidney disease (OR 3.31, p = 0.0037), brain biopsy procedure type (OR 3.50, p = 0.0398), and wound infection chief complaint (OR 31.4, p = 0.0008) were associated with increased rates of readmission to the hospital from the ER in multivariable analysis. CONCLUSIONS The authors report the rates of and reasons for ER utilization in a large cohort of postoperative cranial neurosurgical patients. Factors identified were associated with both increased and decreased use of the ER after cranial surgery, as well as variables associated with readmission to the hospital after postoperative ER visitation. These findings may direct future quality improvement via prospective implementation of care pathways for high-risk procedures.

BACKGROUND We sought to describe changes in demographic variables, process of care measures, and outcomes of patients treated in a regional ST-segment elevation myocardial infarction (STEMI) program over the last 15 years. METHODS We describe demographic variables, process of care measures, and outcomes of patients treated in the program in various 5-year time periods: 2003-2007 (n = 1,821), 2008-2012 (n = 1,968), and 2013-2018 (n = 2,223). The primary outcome measures were in-hospital and 30-day mortality. RESULTS Among 6,012 STEMI patients treated from 2003 to 2018 we observed a significant increase in mean age at presentation (62 ± 14 to 64 ± 13 years) and diabetes (14-22%, p

Background Anterior cerebral artery (ACA) bypasses for complex aneurysms are infrequently performed, yet previous experience demonstrates the importance of intracranial-intracranial bypasses. Here we describe technical advances in intracranial-intracranial bypass techniques and their clinical results. Methods Twenty-three patients with complex aneurysms requiring ACA bypasses were retrospectively studied. Ten patients were treated in period 1 (1997–2013) and 13 in period 2 (2014–2018). Results There were 3 precommunicating, 8 communicating, and 8 postcommunicating ACA aneurysms, plus 4 middle cerebral artery aneurysms. ACA in situ bypass was the most commonly performed (9 patients; 39%). The classic left A3 ACA–right A3 ACA in situ bypass was performed in 5 patients, but 3 new in situ variations emerged in period 2: left pericallosal artery (PcaA)–right PcaA (n = 1), left callosomarginal artery (CmaA)–right CmaA (n = 2), and left CmaA–right A3 ACA (n = 1). The sole reimplantation in period 1 was the ipsilateral and vertical PcaA-CmaA reimplantation, whereas reimplantations in period 2 were contralateral and horizontal (left PcaA–right PcaA and right A3 ACA–left anterior internal frontal artery). The A1 ACA was used as a donor only in period 2 in 4 patients with middle cerebral artery bifurcation aneurysms. Bypass patency was 91%, and 21 patients (91%) improved or remained at neurologic baseline (mean [standard deviation] follow-up duration, 26 [8.2] months). Conclusions ACA bypass techniques continue to evolve with the addition of several variations. These variations push bypass techniques beyond the standard constructs and add important alternatives to our bypass arsenal.

To evaluate surgical resection with brachytherapy placement as a salvage treatment in patients with recurrent high-grade meningioma who exhausted prior external beam treatment options. Single-center retrospective review of our institutional experience of brachytherapy implantation from 2012 to 2018. The primary outcome of the study was progression free survival (PFS). Secondary outcomes included overall survival (OS) and complications. A matched cohort of patients not treated with brachytherapy over the same time period was evaluated as a control group. All patients had received prior radiation treatment and underwent planned gross total resection (GTR) surgery. A total of 27 cases were evaluated. Compared with prior treatment, brachytherapy implantation demonstrated a statistically significant improvement in tumor control [HR 0.316 (0.101 − 0.991), p = 0.034]. PFS-6 and PFS-12 were 92.3% and 84.6%, respectively. Compared with the matched control cohort, brachytherapy treatment demonstrated improved PFS [HR 0.310 (0.103 − 0.933), p = 0.030]. Overall survival was not statistically significantly different between groups [HR 0.381 (0.073 − 1.982), p = 0.227]. Overall postoperative complications were comparable between groups, although there was a higher incidence of radiation necrosis in the brachytherapy cohort. Brachytherapy with planned GTR improved PFS in recurrent high-grade meningioma patients who exhausted prior external beam radiation treatment options. Future improvement of brachytherapy dose delivery methods and techniques may continue to prolong control rates and improve outcomes for this challenging group of patients.

Diffusion MRI (dMRI) tractography has been successfully used to study the trigeminal nerves (TGNs) in many clinical and research applications. Currently, identification of the TGN in tractography data requires expert nerve selection using manually drawn regions of interest (ROIs), which is prone to inter-observer variability, time-consuming and carries high clinical and labor costs. To overcome these issues, we propose to create a novel anatomically curated TGN tractography atlas that enables automated identification of the TGN from dMRI tractography. In this paper, we first illustrate the creation of a trigeminal tractography atlas. Leveraging a well-established computational pipeline and expert neuroanatomical knowledge, we generate a data-driven TGN fiber clustering atlas using tractography data from 50 subjects from the Human Connectome Project. Then, we demonstrate the application of the proposed atlas for automated TGN identification in new subjects, without relying on expert ROI placement. Quantitative and visual experiments are performed with comparison to expert TGN identification using dMRI data from two different acquisition sites. We show highly comparable results between the automatically and manually identified TGNs in terms of spatial overlap and visualization, while our proposed method has several advantages. First, our method performs automated TGN identification, and thus it provides an efficient tool to reduce expert labor costs and inter-operator bias relative to expert manual selection. Second, our method is robust to potential imaging artifacts and/or noise that can prevent successful manual ROI placement for TGN selection and hence yields a higher successful TGN identification rate.

Highlights • Investigation of the performance of multiple dMRI acquisitions and fiber models for trigeminal nerve (TGN) identification. • Expert rating study of over 1000 TGN visualizations using seven proposed expert rating anatomical criteria. • The two-tensor tractography method had better performance on identifying true positive structures, while generating more false positive streamlines in comparison to the single-tensor tractography method. • TGN tracking performance was significantly different across the three b-values for almost all structures studied., Background The trigeminal nerve (TGN) is the largest cranial nerve and can be involved in multiple inflammatory, compressive, ischemic or other pathologies. Currently, imaging-based approaches to identify the TGN mostly rely on T2-weighted magnetic resonance imaging (MRI), which provides localization of the cisternal portion of the TGN where the contrast between nerve and cerebrospinal fluid (CSF) is high enough to allow differentiation. The course of the TGN within the brainstem as well as anterior to the cisternal portion, however, is more difficult to display on traditional imaging sequences. An advanced imaging technique, diffusion MRI (dMRI), enables tracking of the trajectory of TGN fibers and has the potential to visualize anatomical regions of the TGN not seen on T2-weighted imaging. This may allow a more comprehensive assessment of the nerve in the context of pathology. To date, most work in TGN tracking has used clinical dMRI acquisitions with a b-value of 1000 s/mm2 and conventional diffusion tensor MRI (DTI) tractography methods. Though higher b-value acquisitions and multi-tensor tractography methods are known to be beneficial for tracking brain white matter fiber tracts, there have been no studies conducted to evaluate the performance of these advanced approaches on nerve tracking of the TGN, in particular on tracking different anatomical regions of the TGN. Objective We compare TGN tracking performance using dMRI data with different b-values, in combination with both single- and multi-tensor tractography methods. Our goal is to assess the advantages and limitations of these different strategies for identifying the anatomical regions of the TGN. Methods We proposed seven anatomical rating criteria including true and false positive structures, and we performed an expert rating study of over 1000 TGN visualizations, as follows. We tracked the TGN using high-quality dMRI data from 100 healthy adult subjects from the Human Connectome Project (HCP). TGN tracking performance was compared across dMRI acquisitions with b = 1000 s/mm2, b = 2000 s/mm2 and b = 3000 s/mm2, using single-tensor (1T) and two-tensor (2T) unscented Kalman filter (UKF) tractography. This resulted in a total of six tracking strategies. The TGN was identified using an anatomical region-of-interest (ROI) selection approach. First, in a subset of the dataset we identified ROIs that provided good TGN tracking performance across all tracking strategies. Using these ROIs, the TGN was then tracked in all subjects using the six tracking strategies. An expert rater (GX) visually assessed and scored each TGN based on seven anatomical judgment criteria. These criteria included the presence of multiple expected anatomical segments of the TGN (true positive structures), specifically branch-like structures, cisternal portion, mesencephalic trigeminal tract, and spinal cord tract of the TGN. False positive criteria included the presence of any fibers entering the temporal lobe, the inferior cerebellar peduncle, or the middle cerebellar peduncle. Expert rating scores were analyzed to compare TGN tracking performance across the six tracking strategies. Intra- and inter-rater validation was performed to assess the reliability of the expert TGN rating result. Results The TGN was selected using two anatomical ROIs (Meckel's Cave and cisternal portion of the TGN). The two-tensor tractography method had significantly better performance on identifying true positive structures, while generating more false positive streamlines in comparison to the single-tensor tractography method. TGN tracking performance was significantly different across the three b-values for almost all structures studied. Tracking performance was reported in terms of the percentage of subjects achieving each anatomical rating criterion. Tracking of the cisternal portion and branching structure of the TGN was generally successful, with the highest performance of over 98% using two-tensor tractography and b = 1000 or b = 2000. However, tracking the smaller mesencephalic and spinal cord tracts of the TGN was quite challenging (highest performance of 37.5% and 57.07%, using two-tensor tractography with b = 1000 and b = 2000, respectively). False positive connections to the temporal lobe (over 38% of subjects for all strategies) and cerebellar peduncles (100% of subjects for all strategies) were prevalent. High joint probability of agreement was obtained in the inter-rater (on average 83%) and intra-rater validation (on average 90%), showing a highly reliable expert rating result. Conclusions Overall, the results of the study suggest that researchers and clinicians may benefit from tailoring their acquisition and tracking methodology to the specific anatomical portion of the TGN that is of the greatest interest. For example, tracking of branching structures and TGN-T2 overlap can be best achieved with a two-tensor model and an acquisition using b = 1000 or b = 2000. In general, b = 1000 and b = 2000 acquisitions provided the best-rated tracking results. Further research is needed to improve both sensitivity and specificity of the depiction of the TGN anatomy using dMRI.

Ruptured aneurysms causing intraventricular hemorrhage (IVH) are associated with high morbidity. The presence of blood that completely fills the fourth ventricle (cast fourth ventricle, CFV) is thought to be particularly ominous, but studies documenting the outcome of such cases are lacking.To investigate the outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and CFV.We reviewed 406 patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT, NCT01593267, clinicaltrials.gov); 238 patients with aSAH and IVH were identified, and imaging was reviewed for the presence of CFV. Outcome was evaluated at the 1-yr follow-up. A poor outcome was defined as modified Rankin Scale score 2.CFV was identified in 25 patients. Admission Glasgow Coma Score was lower in CFV patients, 7.8 versus 11.5 (P .001). At discharge and the 1-yr follow-up, patients with CFV had a greater risk of a poor outcome (P .001 and P = .002, respectively). In a subgroup analysis of 79 patients with IVH and initial Glasgow Coma Score ≤ 8, almost 50% of the patients with IVH but without CFV had made a good recovery versus 7% of patients with CFV (odds ratio [OR] 15, P = .002). On multivariate analysis, CFV was a greater predictor of a poor prognosis at 1 yr post-aSAH than Hunt and Hess grade 3 (6.4 OR vs 2.9 OR [P .001], respectively).The presence of CFV is a predictor of poor outcome in patients with aSAH. When compared to other patients with IVH and aSAH, CFV is a stronger predictor of a poor outcome than a poor Hunt and Hess Grade.

Confocal laser endomicroscopy (CLE) is an advanced optical fluorescence technology undergoing assessment for applications in brain tumor surgery. Despite its promising potential, interpreting the unfamiliar gray tone images of fluorescent stains can be difficult. Many of the CLE images can be distorted by motion, extremely low or high fluorescence signal, or obscured by red blood cell accumulation, and these can be interpreted as nondiagnostic. However, just one neat CLE image might suffice for intraoperative diagnosis of the tumor. While manual examination of thousands of nondiagnostic images during surgery would be impractical, this creates an opportunity for a model to select diagnostic images for the pathologists or surgeon's review. In this study, we sought to develop a deep learning model to automatically detect the diagnostic images using a manually annotated dataset, and we employed a patient-based nested cross-validation approach to explore generalizability of the model. We explored various training regimes: deep training, shallow fine-tuning, and deep fine-tuning. Further, we investigated the effect of ensemble modeling by combining the top-5 single models crafted in the development phase. We localized histological features from diagnostic CLE images by visualization of shallow and deep neural activations. Our inter-rater experiment results confirmed that our ensemble of deeply fine-tuned models achieved higher agreement with the ground truth than the other observers. With the speed and precision of the proposed method (110 images/second; 85% on the gold standard test subset), it has potential to be integrated into the operative workflow in the brain tumor surgery., The related work was updated

Studies suggest out-of-hospital cardiac arrest (OHCA) patients treated with therapeutic hypothermia (TH) are at increased risk of infection; however, the optimal use of antibiotics in thes...

BACKGROUND Patient out-of-pocket (OOP) spending is an increasingly discussed topic; however, there is minimal data available on the patient financial burden of surgical procedures. OBJECTIVE To analyze hospital and surgeon expected payment data and patient OOP spending in neurosurgery. METHODS This is a retrospective cohort study of neurosurgical patients at a tertiary-referral center from 2013 to 2016. Expected payments, reflecting negotiated costs-of-care, as well as actual patient OOP payments for hospital care and surgeon professional fees were analyzed. A 4-tiered model of patient OOP cost sharing and a multivariate model of patient expected payments were created. RESULTS A total of 13 673 consecutive neurosurgical cases were analyzed. Patient age, insurance type, case category, severity of illness, length of stay (LOS), and elective case status were significant predictors of increased expected payments (P < .05). Craniotomy ($53 397 ± 811) and posterior spinal fusion ($48 329 ± 864) were associated with the highest expected payments. In a model of patient OOP cost sharing, nearly all neurosurgical procedures exceeded yearly OOP maximums for Healthcare Marketplace plans. Mean patient payments for hospital care and surgeon professional fees were the highest for anterior/lateral spinal fusion cases for commercially insured patients ($1662 ± 165). Mean expected payments and mean patient payments for commercially insured patients increased significantly from 2013 to 2016 (P < .05). CONCLUSION Expected payments and patient OOP spending for commercially insured patients significantly increased from 2013 to 2016, representing increased healthcare costs and patient cost sharing in an evolving healthcare environment. Patients and providers can consider this information prior to surgery to better anticipate the individual financial burden for neurosurgical care.

OBJECTIVEThe objective of this study was to evaluate the feasibility of using confocal reflectance microscopy (CRM) ex vivo to differentiate adenoma from normal pituitary gland in surgical biopsy specimens. CRM allows for rapid, label-free evaluation of biopsy specimens with cellular resolution while avoiding some limitations of frozen section analysis.METHODSBiopsy specimens from 11 patients with suspected pituitary adenomas were transported directly to the pathology department. Samples were immediately positioned and visualized with CRM using a confocal microscope located in the same area of the pathology department where frozen sections are prepared. An H & E–stained slide was subsequently prepared from imaged tissue. A neuropathologist compared the histopathological characteristics of the H & E–stained slide and the matched CRM images. A second neuropathologist reviewed images in a blinded fashion and assigned diagnoses of adenoma or normal gland.RESULTSFor all specimens, CRM contrasted cellularity, tissue architecture, nuclear pleomorphism, vascularity, and stroma. Pituitary adenomas demonstrated sheets and large lobules of cells, similar to the matched H & E–stained slides. CRM images of normal tissue showed scattered small lobules of pituitary epithelial cells, consistent with matched H & E–stained images of normal gland. Blinded review by a neuropathologist confirmed the diagnosis in 15 (94%) of 16 images of adenoma versus normal gland.CONCLUSIONSCRM is a simple, reliable approach for rapidly evaluating pituitary adenoma specimens ex vivo. This technique can be used to accurately differentiate between pituitary adenoma and normal gland while preserving biopsy tissue for future permanent analysis, immunohistochemical studies, and molecular studies.

As described by Cushing1 in the chiasmatic syndrome, tuberculum sellae meningiomas induce progressive asymmetrical, incongruous visual loss, which would lead to blindness. The surgical removal of these lesions has been rewarding in regard to visual preservation, or recovery, and has passed the test of time. Optic canal extension, in one or both canals, is a consistent feature of these tumors, and removing the tumor from the optic canals is paramount in the treatment of these lesions.2 Despite the small target volume, radiosurgery is not applicable because of the lack of safe distance from the optic pathways. Tuberculum sella meningioma has been distinguished with good surgical outcomes and low recurrence rates; thus, Simpson grade I removal (tumor, dura, and bone invasion) confers a prospect of cure. Safe and successful resection of tuberculum meningiomas is achieved through the skull base supraorbital approach3 with several critical objectives: (1) visualization of the tumor without brain retraction; (2) 270° opening of the optic canal proximally and distally for safe tumor removal; (3) preservation of the vascular supply to the optic pathways and pituitary; (4) microsurgical dissection under high magnification on a short working distance to the encased carotid and anterior cerebral arteries; (5) complete resection of involved dura and bone at the skull base, particularly laterally; and (6) a robust skull base reconstruction with a vascularized pericranial flap.4 We present the case of a 45-yr-old female with a tuberculum sella meningioma who underwent Simpson grade I removal with an uneventful outcome. The patient consented for surgery. Image at 2:59 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998; Image at 9:33 public domain.4.

Complete resection of skull base chondrosarcomas offers the potential for a durable, or even lifelong, cure and is best achieved at the first surgery.1,2 When a skull base chondrosarcoma is located at the upper clivus and in the interpeduncular cistern and invading laterally toward the petrous apex and cavernous sinus, the traditional approaches, ie, endonasal endoscopic or middle fossa approaches, are not adequate for the exposure and resection. The transcavernous sinus approach has been utilized to remove tumor from the cavernous sinus and as a corridor to the interpeduncular cistern and upper clivus, originally described for the clipping of basilar apex aneurysms. We present a case of a chondrosarcoma centered in the upper clivus and eroding the right posterior clinoid, analogous to the location of a giant basilar apex aneurysm. Detailed study of the tumor extension, bony invasion, and relationship with neuroanatomy dictated the most effective surgical approach.3,4 Neuronavigation and intraoperative magnetic resonance imaging (MRI) facilitated the gross total resection of the tumor in the Advanced Multimodality Image-Guided Operating (AMIGO) suite. Achieving a gross total tumor removal of this World Health Organization (WHO) grade I chondrosarcoma, adjuvant irradiation can be withheld1 and the patient monitored with serial imaging. The patient did well after the surgery. The patient consented for surgery and the use of photography.

Giant basilar apex aneurysms are associated with significant therapeutic challenges.1-6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7-9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Preoperative careful evaluation of the sigmoid transverse sinus and its tributary veins is paramount for the safe surgical planning of petroclival lesions.1,2 When the vein of Labbé is running within the tentorium, classic petrosal approach involving transection of the tentorium is modified to avoid the risk of postoperative morbid temporal lobe venous infarcts.1-3 Thus, the surgical plan should be tailored to the specific patient anatomy as demonstrated in the presented case during which a transmastoid approach was followed, in the same surgical setting, by a middle fossa approach to resect a large petroclival clear cell meningioma with extension into Meckel cave. These meningiomas are WHO grade II tumors with a propensity to local recurrence and cerebrospinal fluid seeding.4 SMARCE1 mutations define this subtype of meningioma, with frequent familial inheritance, and predispose patients to both skull base and spinal clear cell meningiomas.5,6 Maximal surgical resection is the best initial treatment option allowing to withhold or delay the use of radiation in tumors frequently encountered in young patients.7 In this report, we demonstrate the microsurgical techniques deployed to achieve maximal resection of a petroclival clear cell meningioma and associated lumbar and sacral spinal meningiomas in a 20-yr-old patient with a familial SMARCE1 mutation. The patient agreed to the surgical intervention and to the use of her image.

Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House–Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1–4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House–Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.

Cadaveric feasibility study. To assess the anatomic and technical feasibility of rotating a clavicular segment on a sternocleidomastoid muscle (SCM) pedicle into the ventral cervical spine using a cadaveric model and to provide the first clinical case description of performing this procedure. Reconstruction of the anterior cervical spine in patients with a high risk of pseudoarthrosis may require the use of a vascularized bone graft (VBG). A vascularized clavicular graft rotated on an SCM pedicle would afford all the benefits of a VBG without the added morbidity of free-tissue transfer; however, this technique has not been described. A multidisciplinary team hypothesized that it would be anatomically and technically feasible to rotate a pedicled clavicular bone graft from the bottom of C2 to the top of T2 via an anterior approach. Five cadavers underwent bilateral anterior neck dissections for a total of 10 clavicular graft assessments. A case report describes the use of a clavicular VBG in a patient with a 3-level corpectomy defect and a history of failed fusion. Ten clavicles were rotated on an SCM pedicle. The grafts were either harvested as an entire segment or as the superior two-thirds of clavicle, leaving the inferior one-third in situ with pectoralis attachments intact. All grafts reached from the bottom of C2 to the top of T2. When the entire length of exposed clavicle was mobilized, it could cover 5–6 levels. The case report highlights technical challenges of this procedure in a living patient and provides clinical context for its potential utility in reconstruction of the ventral cervical spine. This surgical technique is best suited for patients with long-segment cervical defects and an increased risk of pseudarthrosis. Further clinical experience with this technique is required before definitive conclusions can be made. Level of Evidence: 5

Confocal microscopy utilizing fluorescent dyes is widely gaining use in the clinical setting as a diagnostic tool. Reflectance confocal microscopy is a method of visualizing tissue specimens without fluorescent dyes while relying on the natural refractile properties of cellular and subcellular structures. We prospectively evaluated 76 CNS lesions with confocal reflectance microscopy (CRM) to determine cellularity, architecture, and morphological characteristics. A neuropathologist found that all cases showed similar histopathological features when compared to matched hematoxylin and eosin-stained sections. RNA isolated from 7 tissues following CRM imaging retained high RNA integrity, suggesting that CRM does not alter tissue properties for molecular studies. A neuropathologist and surgical pathologist masked to the imaging results independently evaluated a subset of CRM images. In these evaluations, 100% of images reviewed by the neuropathologist and 95.7% of images reviewed by the surgical pathologist were correctly diagnosed as lesional or nonlesional. Furthermore, 97.9% and 91.5% of cases were correctly diagnosed as tumor or not tumor by the neuropathologist and surgical pathologist, respectively, while 95.8% and 85.1% were identified with the correct diagnosis. Our data indicate that CRM is a useful tool for rapidly screening patient biopsies for diagnostic adequacy, molecular studies, and biobanking.

A study was performed on the University Link and Northgate Link projects in Seattle, WA, to investigate the use of apparent density evaluation methods for the identification of air pockets and plugging issues in the chamber of EPB TBMs. Both air pockets and plugging issues can result from improper soil conditioning and the TBM’s inability to mix the soil properly with the conditioning agents. An apparent density below unity indicates the formation of an air pocket in the top part of the chamber and an apparent density above the virgin soil density points to developing plugging issues in the cutterhead bays and pressurized chamber. From the conducted study it can be concluded that the presented apparent density evaluation methods are an effective way to identify issues in the excavation chamber of an EPB TBM and can be used as a mean to improve the soil conditioning process.

Objectives The Hardy classification is used to classify pituitary tumors for clinical and research purposes. The scale was developed using lateral skull radiographs and encephalograms, and its reliability has not been evaluated in the magnetic resonance imaging (MRI) era. Design Fifty preoperative MRI scans of biopsy-proven pituitary adenomas using the sellar invasion and suprasellar extension components of the Hardy scale were reviewed. Setting This study was a cohort study set at a single institution. Participants There were six independent raters. Main Outcome Measures The main outcome measures of this study were interrater reliability, intrarater reliability, and percent agreement. Results Overall interrater reliability of both Hardy subscales on MRI was strong. However, reliability of the intermediate scores was weak, and percent agreement among raters was poor (12–16%) using the full scales. Dichotomizing the scale into clinically useful groups maintained strong interrater reliability for the sellar invasion scale and increased the percent agreement for both scales. Conclusion This study raises important questions about the reliability of the original Hardy classification. Editing the measure to a clinically relevant dichotomous scale simplifies the rating process and may be useful for preoperative tumor characterization in the MRI era. Future research studies should use the dichotomized Hardy scale (sellar invasion Grades 0–III versus Grade IV, suprasellar extension Types 0–C versus Type D).

OBJECTIVEThe goal of this study was to determine the interrater and intrarater reliability of the Knosp grading scale for predicting pituitary adenoma cavernous sinus (CS) involvement.METHODSSix independent raters (3 neurosurgery residents, 2 pituitary surgeons, and 1 neuroradiologist) participated in the study. Each rater scored 50 unique pituitary MRI scans (with contrast) of biopsy-proven pituitary adenoma. Reliabilities for the full scale were determined 3 ways: 1) using all 50 scans, 2) using scans with midrange scores versus end scores, and 3) using a dichotomized scale that reflects common clinical practice. The performance of resident raters was compared with that of faculty raters to assess the influence of training level on reliability.RESULTSOverall, the interrater reliability of the Knosp scale was “strong” (0.73, 95% CI 0.56–0.84). However, the percent agreement for all 6 reviewers was only 10% (26% for faculty members, 30% for residents). The reliability of the middle scores (i.e., average rated Knosp Grades 1 and 2) was “very weak” (0.18, 95% CI −0.27 to 0.56) and the percent agreement for all reviewers was only 5%. When the scale was dichotomized into tumors unlikely to have intraoperative CS involvement (Grades 0, 1, and 2) and those likely to have CS involvement (Grades 3 and 4), the reliability was “strong” (0.60, 95% CI 0.39–0.75) and the percent agreement for all raters improved to 60%. There was no significant difference in reliability between residents and faculty (residents 0.72, 95% CI 0.55–0.83 vs faculty 0.73, 95% CI 0.56–0.84). Intrarater reliability was moderate to strong and increased with the level of experience.CONCLUSIONSAlthough these findings suggest that the Knosp grading scale has acceptable interrater reliability overall, it raises important questions about the “very weak” reliability of the scale's middle grades. By dichotomizing the scale into clinically useful groups, the authors were able to address the poor reliability and percent agreement of the intermediate grades and to isolate the most important grades for use in surgical decision making (Grades 3 and 4). Authors of future pituitary surgery studies should consider reporting Knosp grades as dichotomized results rather than as the full scale to optimize the reliability of the scale.