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Introduction Intracranial hemorrhage (ICH) causes often devastating brain injury. Predicting long-term motor prognosis and identifying neurosurgical candidates in cases of ICH has been an imprecise practice. Diffusion tensor tractography (DTT) is an imaging modality that may aid in this challenge. This literature review aimed to investigate DTT applications in patients with spontaneous ICH for either motor function prognosis or surgical intervention. Materials and methods A PubMed and Ovid literature review was performed to select and evaluate studies utilizing DTT for motor prognostication or analysis/optimization of surgical outcomes in patients with spontaneous hypertensive ICH. Studies investigating ICH due to suspected vascular anomalies were excluded. Results Forty-two studies met criteria. Six studies addressed surgical application. Surgery was not associated with increased mortality but was associated with decreased hematoma volume and CST compression and improved motor outcomes. Prognostic studies demonstrated that DTT correlates with motor function at multiple timepoints. Conclusion DTT is a relatively new imaging technique that may help predict prognosis of patients’ motor function after spontaneous ICH. Additionally, it could possibly serve as an adjunct for determining which patients would benefit from surgical decompression or even help guide surgical approach to hematomas that displace the CST.

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.

Glomus tumors are rare, painful, and usually benign neoplasms that typically occur at the subungual aspect of digits. Rarely, glomus tumors may arise in other areas of the body. We present a case of an extradigital glomus tumor on a forearm with prior trauma that presented with symptoms of an isolated peripheral neuropathy. Our review of literature reveals how upper or lower extremity glomus tumors can mimic neuropathies secondary to intrinsic nerve tumors (schwannoma, neurofibroma, or neuroma), radiculopathies, or manifestations of a complex regional pain syndrome (CRPS). We emphasize the need to consider a broad differential diagnosis that includes glomus tumor when evaluating patients with painful dermal masses producing peripheral neuropathy or radiculopathy signs owing to the infiltrative growth pattern into or mass effect exerted on nearby nerves.

Ewing sarcoma (ES) is an aggressive, high-grade neuroectodermal neoplasm that frequently manifests in children and young adults. Although ES without osseous involvement most commonly involves paravertebral regions of the spine, it very rarely presents as a primary intracranial tumor. This report discusses a unique presentation of an adult extraosseous ES arising from the pineal region with extension into the third and fourth ventricles and multiple drop metastases to the spine. This case demonstrates the application of current chemotherapeutic and adjuvant management and offers insight into possible treatment modalities for metastasis in an atypical extraosseous ES involving the brain and spine.

Background and Purpose— Predicting long-term functional outcomes after intracranial aneurysmal rupture can be challenging. We developed and validated a scoring system—the Southwestern Aneurysm Severity Index—that would predict functional outcomes at 1 year after clipping of ruptured aneurysms. Methods— Ruptured aneurysms treated microsurgically between 2000 and 2014 were included. Outcome was defined as Glasgow Outcome Score (ranging from 1, death, to 5, good recovery) at 1 year. The Southwestern Aneurysm Severity Index is composed of multiple prospectively recorded patient demographic, clinical, radiographic, and aneurysm-specific variables. Multivariable analyses were used to construct the best predictive models for patient outcomes in a random 50% of the cohort and validated in the remaining 50%. A scoring system was created using the best model. Results— We identified 527 eligible patients. The Glasgow Outcome Score at 1 year was 4 to 5 in 375 patients (71.2%). In the multivariable logistic regression, the best predictive model for unfavorable outcome included intracerebral hemorrhage (odds ratio [OR], 2.53; 95% CI, 1.55−4.13), aneurysmal size ≥20 mm (OR, 6.07; 95% CI, 1.92−19.2), intraventricular hemorrhage (OR, 2.56; 95% CI, 1.15−5.67), age >64 (OR, 3.53; 95% CI, 1.70−7.35), location (OR, 1.82; 95% CI, 1.10−3.03), and hydrocephalus (OR, 2.39; 95% CI, 1.07−5.35). The Southwestern Aneurysm Severity Index predicts Glasgow Outcome Score at 1 year with good discrimination (area under the receiver operating characteristic curve, derivation: 0.816, 95% CI, 0.759−0.873; validation: 0.803, 95% CI, 0.746−0.861) and accurate calibration ( R 2 =0.939). Conclusions— The Southwestern Aneurysm Severity Index has been internally validated to predict 1 year Glasgow Outcome Scores at initial presentation, thus optimizing patient or family counseling and possibly guiding therapeutic efforts.

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.

Background Differences among the top five races in Texas will be explored to determine if racial, geographic, and healthcare disparities exist in patients undergoing treatment for a primary malignant brain tumor. Methods Data were obtained from the Texas Cancer Registry from 1995 to 2013. SAS 9.3 (SAS Institute, Inc., Cary, NC) and SEER*Stat 8.3.2 (National Cancer Institute, Bethesda, MD) software were used to analyze death from malignant brain tumors and cause-specific survival. Survival rates were compared using Kaplan-Meier curves and Log-Rank tests. Hazard ratios were estimated using the Cox proportional hazards regression model. Results Median survival was highest among Asians at 92 months (95% CI: 72, 142) and least among Whites at 20 months (95% CI: 19, 21). Patients living in the Upper Gulf Coast region of Texas had the longest survival time at 31 months (95% CI 29-35%), while those patients in the Texas Panhandle had the shortest survival time at 18 months (95% CI 14-23%). Patients with a poverty index of 0-5% had the highest median survival time of 32 months (95% CI 29-35%), as compared to patients with a poverty index of 10-20% who had a median survival of 22 months (95% CI 21-24%). Conclusions Ethnic minorities and higher socioeconomic class demonstrated survival advantage. White males had the worst survival of those with primary malignant brain tumors. Other significant factors affecting a patient's survival rate included geographic location, poverty index, sex, and age, thus suggesting a potential genetic and environmental influence.

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.

PURPOSE Central Nervous System (CNS) tumors pose a substantial health problem. Although data on specific time periods and regions of Africa has been previously reported, no study has yet to provide a systemic review on the frequency 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 between 1960 to 2017. SPSS21 statistical software was used to analyze the data. RESULTS Nigeria, Egypt, and Uganda were found to have the highest incidence of CNS tumors in Africa. Total incidence was 5902, the majority were males, 3190 with mean rate 122.67 (95% CI: 29.27, 216.07) compared to females, 2501 with a mean rate of 96.19 (95% CI: 26.24, 166.15). 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%). CONCLUSION Given the large population of Africa, the reported total incidence may be underestimated when compared to other continents due to the lack of a central brain tumor registry in Africa. Comprehensive knowledge of CNS tumors in Africa is critical to research and the entire healthcare system.

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.

Objective: As COVID-19 spreads around the world, so does telemedicine across many medical specialties including neurosurgery. Given the unique patient population in neurosurgery, arising opportunities for integration and expansion of telemedicine into neurosurgery practice come with challenges for both the patient and the provider. Methods: A literature review has been performed, and a survey has been sent out to neurosurgery providers in Texas to determine if providers are satisfied with the current state of telemedicine in their clinical practice. Results: Patients who live far away from a medical center have cited increased convenience when routine postoperative visits have been converted to telemedicine. For providers, challenges have arisen in performing physical exams, especially when performing detailed neurological exams in the diagnosis of a spine disorder. Survey results of neurosurgery providers have revealed mixed opinions since the initiation of telemedicine. Conclusion: Although it is unclear what role telemedicine will have after the social distancing restrictions are lifted, many providers surveyed have expressed interest in keeping telemedicine in their clinical practice.

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

Wide neck basilar tip aneurysms are challenging to secure with coil embosurgery despite balloon remodeling and stent-assisted coiling. In patients with favorable posterior circle of Willis anatomy, the traditional antegrade placement of two stents that span the basilar apex to both proximal posterior cerebral arteries (P1s) can be avoided by implanting a single stent across the P1s and basilar apex via a retrograde posterior communicating artery approach. This case report details the first use of the high radial force Wingspan stent placed in this fashion during basilar aneurysm coiling repair.

Split cord malformations (SCMs) are rare congenital abnormalities arising from a primary neurulation defect during embryological development of the spinal cord. SCMs can lead to progressively worsening scoliosis and gait difficulties if left untreated. We report on two patients who atypically presented with SCM in adulthood and review previous reports.

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.

Background Anaplastic ependymoma with extraneural metastases is associated with a poor clinical outcome. Metastatic spread to the parotid gland is a rare clinical entity that requires multidisciplinary intervention. Herein, we present a systematic review of anaplastic ependymoma with extraneural metastases and report on a case with metastases to both parotid glands. Methods Electronic databases were searched from their inception to February 2019. Inclusion criteria included reports of anaplastic ependymoma with extraneural metastasis. Studies were excluded if the tumor grade was not reported. A case illustration is provided. Results The search yielded 15 cases of anaplastic ependymoma with extraneural metastases, including the present case. Mean age at diagnosis was 15 years. The initial tumor location was predominantly supratentorial (93.3%). All cases demonstrated leptomeningeal seeding before extraneural metastasis. Mean survival from initial diagnosis was 4.5 years. Metastasis to the parotid gland occurred in 2 cases, including the present case. We present a 17-year-old female patient who underwent gross total resection of a supratentorial, paraventricular anaplastic ependymoma followed by adjuvant external beam radiation therapy. The patient developed recurrent leptomeningeal seeding, treated with Gamma Knife radiosurgery over a 5-year period. She returned with a parotid mass and cervical lymphadenopathy and underwent parotidectomy and modified radical neck dissection. She continued to experience recurrences, including the left parotid gland, and was ultimately placed in hospice care. Conclusions Anaplastic ependymoma with extraneural metastasis is rare. A combination of repeated surgical resection, radiation therapy, and chemotherapy can be used to manage recurrent and metastatic disease, but outcomes remain poor.

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.

Introduction Vertebral artery (VA) stenosis can lead to recurrent posterior circulation transient ischemic attacks and strokes. Stenting is often used for symptomatic VA stenosis. As with carotid stenting, embolic protection devices (EPD) are increasingly used when stenting the proximal VA. EPDs can become lost in the circulation during stenting for different reasons. We report the only known case and treatment strategy for an irretrievable EPD during VA stenting. Methods Since there are no known reported cases of an irretrievable EPD in the VA, a systematic review of the medical literature was performed to search for irretrievable EPDs in the carotid artery. The bibliographies of each result were used to identify additional publications until this process was exhausted. Results A total of four cases were found where an EPD was lost in the carotid circulation. In two of the cases, a carotid arteriotomy was required to retrieve the EPD, while the other two cases used an endovascular approach. In our VA case, an endovascular EverFlex Biliary Stent was used to flatten and permanently implant the irretrievable EPD against the VA wall. Conclusions In all cases, complications in retrieving the EPD resulted from the inability to withdraw the EPD through the deployed stent. Nearby acutely branching vessels, severe vascular stenosis, and vessel angulation at the stent margin were shown to impair the ability to retrieve the EPD at the end of the case. In conclusion, compressing a lost VA EPD using an oversized self-expanding stent can successfully restore robust blood flow, especially in areas not readily accessible to open surgical techniques. Disclosures J. Soto: None. K. Lyon: None. W. Lesley: None.

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 (