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Objective Clopidogrel is a commonly used antiplatelet agent for the prevention of thromboembolic complications following neuroendovascular procedures, but anecdotal data have raised concern for the possibility that clopidogrel may induce severe, intolerable fatigue. The purpose of this study is to systematically investigate this phenomenon. Methods We performed a dual-institution, 9-year, retrospective study of patients undergoing clopidogrel therapy for neuroendovascular procedures. Patients were included only if their response to clopidogrel was assessed by platelet function testing using the VerifyNow P2Y12 (VNP) assay. Hyperresponse to clopidogrel was defined as P2Y12 reaction units ≤60. Patients were considered to have had clopidogrel-induced severe fatigue if the onset of symptoms followed the initiation of clopidogrel therapy; symptoms improved following a reduction in the dose of clopidogrel; and symptoms could not be attributed to any other medical explanation. Results Data were collected on 349 patients. Five patients (1.4%) met criteria for clopidogrel-induced severe fatigue. All 5 patients were female, ages 39–68. VNP assessments obtained while patients were symptomatic revealed hyperresponse to clopidogrel (0–22 P2Y12 reaction units). Symptoms improved in all 5 patients when the dose of clopidogrel was reduced by half. Notably, 30% of patients (n = 103) demonstrated a hyperresponse to clopidogrel on at least 1 VNP assessment, but 98 of these patients did not suffer from severe fatigue. Conclusions A syndrome of severe fatigue and other constitutional symptoms is a rare but clinically significant side effect of hyperresponse to clopidogrel in patients undergoing neuroendovasular intervention.

Idiopathic intracranial hypertension (IIH) represents a clinical disease entity without a clear etiology, that if left untreated, can result in severe outcomes, including permanent vision loss. For this reason, early diagnosis and treatment is necessary. Historically, the role of cross-sectional imaging has been to rule out secondary or emergent causes of increased intracranial pressure, including tumor, infection, hydrocephalus, or venous thrombosis. MRI and MRV, however, can serve as valuable imaging tools to not only rule out causes for secondary intracranial hypertension but can also detect indirect signs of IIH resultant from increased intracranial pressure, and demonstrate potentially treatable sinus venous stenosis. Digital subtraction venographic imaging also plays a central role in both diagnosis and treatment, providing enhanced anatomic delineation and temporal flow evaluation, quantitative assessment of the pressure gradient across a venous stenosis, treatment guidance, and immediate opportunity for endovascular therapy. In this review, we discuss the multiple modalities for imaging IIH, their limitations, and their contributions to the management of IIH.

Background Esophageal perforation represents a rare but potentially life-threatening complication of an anterior cervical diskectomy and fusion (ACDF). Delayed presentations of esophageal perforation more than 10 years following surgery are exceedingly rare and difficult to diagnose. Here, we discuss the case of an 80-year-old man who presented to the emergency department with progressive dysphagia 15 years after his ACDF. Case Description While prior outpatient workup was suggestive of a diverticulum, there was no evidence of esophageal perforation. Progressive symptoms and repeat imaging on admission were suggestive of retropharyngeal phlegmon. Operative esophagoscopy revealed that the spinal hardware had eroded through the posterior wall of the esophagus, creating a traction diverticulum. The hardware was removed, and the esophageal perforation was closed primarily and buttressed with vascularized tissue from a supraclavicular artery island fascial flap. Conclusions This case emphasizes the importance of considering an esophageal perforation in patients who present with dysphagia at any interval following an ACDF, even in the extremely delayed setting. Furthermore, this is the first report, to the best of our knowledge, using a supraclavicular artery island fascial flap to reconstruct an esophageal perforation following an ACDF, and we introduce a novel strategy for managing these complicated injuries.

Little evidence supports acquisition of routine head imaging after uncomplicated elective neurosurgical procedures for patients with unchanged neurological examinations; however, imaging is still performed by some neurointerventionalists. We assessed the clinical utility of routine computed tomography of the head (CTH) following elective neuroendovascular interventions, including aneurysm coiling, aneurysm stent-assisted coiling, aneurysm flow diversion, arteriovenous malformation/fistula embolization, middle meningeal artery embolization for subdural hematoma, extracranial carotid artery stenting, and venous sinus stenting.Retrospective chart review identified patients undergoing neuroendovascular intervention from 2011 to 2021 at our institution. Demographic, clinical, and radiographic variables, including presenting signs and symptoms, antiplatelets and/or anticoagulant medications, intraprocedural complications, postprocedural CTH findings, and postprocedural neurological examinations, were recorded. Association of clinical variables with an abnormal postprocedural CTH was assessed with univariate analysis. Patients with ruptured vascular pathology, preoperative embolizations, and missing postprocedural CTH images and/or reports were excluded.Of 509 procedures identified, 354 were eligible for analysis; 4.8% of patients (17/354) had abnormal findings on postprocedural CTH. Nine patients had intraprocedural complications or new postprocedural neurological deficits that would have prompted imaging regardless of institutional practice. None of the remaining 8 (2.3%) patients required additional procedures. New postprocedural neurological deficit was the only significant predictor of abnormal postprocedural CTH (odds ratio = 6.79; 95% confidence interval, 2.01-20.32; P = 0.0009).In a large cohort of patients undergoing elective neuroendovascular intervention, no patients were identified for whom routine postprocedural CTH alone meaningfully altered their clinical care. Routine CTH is not necessary after uncomplicated elective neuroendovascular interventions performed with careful postprocedural neurological assessment.

Clinical significance of increased clopidogrel response measured by VerifyNow P2Y12 assay is unclear; management guidelines are lacking in the context of neuroendovascular intervention. Our objective was to assess whether increased clopidogrel response predicts complications from endovascular aneurysm treatment requiring dual antiplatelet therapy. A single-institution, 9-year retrospective study of patients undergoing endovascular treatments for ruptured and unruptured aneurysms requiring aspirin and clopidogrel was conducted. Patients were grouped according to preoperative platelet inhibition in response to clopidogrel measured by the VerifyNow P2Y12 assay (VNP; P2Y12 reactivity units, PRU). Demographic and clinical features were compared across groups. Hemorrhagic complication rates (intracranial, major extracranial, minor extracranial) and thromboembolic complications (in-stent stenosis, stroke/transient ischemic attack) were compared, controlling for potential confounders and multiple comparisons. Data were collected from 284 patients across 317 procedures. Pre-operative VNP assays identified 9 % Extreme Responders (PRU ≤ 15), 13 % Hyper-Responders (PRU 16-60), 62 % Therapeutic Responders (PRU 61-214), 16 % Hypo-Responders (PRU ≥ 215). Increased response to clopidogrel was associated with increased risk of any hemorrhagic complication (≤60 PRU vs 60 PRU; 39 % vs 24 %, P = 0.050); all intracranial hemorrhages occurred in patients with PRU 60. Thromboembolic complications were similar between therapeutic and subtherapeutic patients (215 PRU vs ≥ 215 PRU; 15 % vs 16 %, P = 0.835). Increased preoperative clopidogrel response is associated with increased rate of extracranial hemorrhagic complications in endovascular aneurysm treatments. Hyper-responders (16-60 PRU) and Extreme Responders (≤15 PRU) were not associated with intracranial hemorrhagic or thrombotic complications. Hypo-responders who underwent adjustment of antiplatelet therapy and neurointerventions did not experience higher rates of complications.

Successful occlusion of cerebral aneurysms using coil embolization is contingent upon stable thrombus formation, and the quality of the thrombus depends upon the biomechanical environment. The goal of this study was to investigate how coil embolization alters the mechanical micro-environment within the aneurysm dome. Inertialess particles were injected in three-dimensional, computational simulations of flow inside patient aneurysms using patient-specific boundary conditions. Coil embolization was simulated as a homogenous porous medium of known permeability and inertial constant. Lagrangian particle tracking was used to calculate the residence time and shear stress history for particles in the flow before and after treatment. The percentage of particles entering the aneurysm dome correlated with the neck surface area before and after treatment (pretreatment: R2 = 0.831, P

Antimicrobial photodynamic therapy (PDT) effectively kills bacterial strains found in deep tissue abscess cavities. PDT response hinges on multiple factors, including light dose, which depends on patient optical properties.Computed tomography images for 60 abscess drainage subjects were segmented and used for Monte Carlo (MC) simulation. We evaluated effects of optical properties and abscess morphology on PDT eligibility and generated treatment plans.A range of abscess wall absorptions (μa , wall) and intra-cavity Intralipid concentrations were simulated. At each combination, the threshold optical power and optimal Intralipid concentration were found for a fluence rate target, with subjects being eligible for PDT if the target was attainable with2000 mW of source light. Further simulations were performed with absorption within the cavity (μa , cavity).Patient-specific treatment planning substantially increased the number of subjects expected to achieve an efficacious light dose for antimicrobial PDT, especially with Intralipid modification. The threshold optical power and optimal Intralipid concentration increased with increasing μa , wall (p 0.001). PDT eligibility improved with patient-specific treatment planning (p 0.0001). With μa , wall = 0.2 cm - 1, eligibility increased from 42% to 92%. Increasing μa , cavity reduced PDT eligibility (p 0.0001); modifying the delivered optical power had the greatest impact in this case.MC-based treatment planning greatly increases eligibility for PDT of abscess cavities.

BackgroundMost intracranial stents contain nickel alloy, and nickel allergy or hypersensitivity is common. Neurological injury following endovascular treatment with a nickel containing intracranial stent has been reported in patients with purported nickel allergy, but it is unclear whether these reactions represent true nickel hypersensitivity. We quantified nickel release from commonly used intracranial stents to investigate whether such stents should be avoided in patients with nickel allergy.MethodsWe examined nickel release from seven commonly used intracranial stents: Enterprise, LVIS Jr, Neuroform, Wingspan, Zilver, Pipeline Flex Embolization Device, and Surpass Evolve. We incubated each stent in human plasma-like media for 30 days. Dimethylglyoxime (DMG) spot testing was performed on each stent to detect released nickel at 0 and 30 days. Inductively coupled plasma–optical emission spectroscopy (ICP-OES) was then used to quantify the nickel concentration of the media at 30 days. Nickel currency and nickel standard for atomic absorption spectrometry were used as positive controls.ResultsDMG spot tests indicated nickel release only from nickel currency at 0 and 30 days of incubation. No nickel release was detected from any stent at 30 days using ICP-OES.ConclusionsNickel release from commonly used intracranial stents is negligible. These results suggest that previously reported hypersensitivity to these stents may be misattributed to nickel allergy, and that patients with nickel allergy may be safely treated with select nickel-containing stents.

Introduction: Preoperative functional MRI (fMRI) and intraoperative awake cortical mapping are established strategies to identify and preserve critical language structures during neurosurgery. There is growing appreciation for the need to similarly identify and preserve eloquent tissue critical for music production. Case Report: A 19-year-old female musician, with a 3- to 4-year history of events concerning for musicogenic seizures, was found to have a right posterior temporal tumor, concerning for a low-grade glial neoplasm. Preoperative fMRI assessing passive and active musical tasks localized areas of activation directly adjacent to the tumor margin. Cortical stimulation during various musical tasks did not identify eloquent tissue near the surgical site. A gross total tumor resection was achieved without disruption of singing ability. At 9-month follow-up, the patient continued to have preserved musical ability with full resolution of seizures and without evidence of residual lesion or recurrence. Conclusion: A novel strategy for performing an awake craniotomy, incorporating preoperative fMRI data for music processing with intraoperative cortical stimulation, interpreted with the assistance of a musician expert and facilitated gross total resection of the patient’s tumor without comprising her musical abilities.

IntroductionTransradial access is increasingly used among neurointerventionalists as an alternative to the transfemoral route. Currently available data, building on the interventional cardiology experience, primarily focus on right radial access. However, there are clinical scenarios when left-sided access may be indicated. The purpose of this study was to evaluate the technical feasibility of left transradial access to cerebral angiography across three institutions.MethodsA retrospective chart review was performed for patients who underwent cerebral angiography accessed via the left radial artery at three institutions between January 2018 and July 2019. The outcome variables studied were successful catheterization, vascular complications, and fluoroscopic time.ResultsNineteen patients underwent a total of 25 cerebral angiograms via left transradial access for cerebral aneurysms (n=15), basilar occlusion (n=1), carotid stenosis (n=1), arteriovenous malformation (n=1), and cervical neurofibroma (n=1). There were 12 diagnostic angiograms and 13 interventional angiograms. The left transradial approach was chosen due to left vertebrobasilar pathology (n=22), right subclavian stenosis (n=2), and previous right arm amputation (n=1). There was one instance of radial artery spasm, which resolved after catheter removal, and one conversion to transfemoral access in an interventional case due to lack of distal catheter support. There were no procedural complications.ConclusionsLeft transradial access in diagnostic and interventional cerebral angiography is a technically feasible, safe, and an effective alternative when indicated, and may be preferable for situations in which pathology locations or anatomic limitations preclude right-sided radial access.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a systemic disease that affects nearly all organ systems through infection and subsequent dysregulation of the vascular endothelium. One of the most striking phenomena has been a coronavirus disease 2019 (COVID-19)-associated coagulopathy. Given these findings, questions naturally emerged about the prothrombotic impact of COVID-19 on cerebrovascular disease and whether ischemic stroke is a clinical feature specific to COVID-19 pathophysiology. Early reports from China and several sites in the northeastern United States seemed to confirm these suspicions. Since these initial reports, many cohort studies worldwide observed decreased rates of stroke since the start of the pandemic, raising concerns for a broader impact of the pandemic on stroke treatment. In this review, we provide a comprehensive assessment of how the pandemic has affected stroke presentation, epidemiology, treatment, and outcomes to better understand the impact of COVID-19 on cerebrovascular disease. Much evidence suggests that this decline in stroke admissions stems from the global response to the virus, which has made it more difficult for patients to get to the hospital once symptoms start. However, there does not appear to be a demonstrable impact on quality metrics once patients arrive at the hospital. Despite initial concerns, there is insufficient evidence to ascribe a causal relationship specific to the pathogenicity of SARS-CoV-2 on the cerebral vasculature. Nevertheless, when patients infected with SARS-CoV-2 present with stroke, their presentation is likely to be more severe, and they have a markedly higher rate of in-hospital mortality than patients with either acute ischemic stroke or COVID-19 alone.

Objective: Chronic subdural hematomas (cSDH) are an increasingly prevalent neurological disease that often requires surgical intervention to alleviate compression of the brain. Management of cSDHs relies heavily upon computed tomography (CT) imaging, and serial imaging is frequently obtained to help direct management. The volume of hematoma provides critical information in guiding therapy and evaluating new methods of management. We set out to develop an automated program to compute the volume of hematoma on CT scans for both preoperative and postoperative images. Methods: A total of 128 CT scans (21,710 images) were manually segmented and used to train a convolutional neural network to automatically segment chronic subdural hematomas. We included both preoperative and postoperative coronal head CTs from patients undergoing surgical management of cSDHs. Results: Our best model achieved a Dice score of 0.8351 on the testing dataset and an average Dice score of 0.806 +/- 0.06 on the validation set. This model was trained on the full data set with reduced volumes, a network depth of 4, and post activation residual blocks within the context modules of the encoder pathway. Patch trained models did not perform as well and decreasing the network depth from 5 to 4 did not appear to significantly improve performance. Conclusions: We successfully trained a convolutional neural network on a dataset of pre and postoperative head CTs containing cSDH. This tool could assist with automated, accurate measurements for evaluating treatment efficacy.

Although many programs to help family caregivers of people with dementia have research-based evidence of effectiveness, they are not available in most US communities and caregivers have difficulty finding the kinds of assistance they need. One reason for this problem is that healthcare and community organizations as well as funders that might provide or pay for one or more programs are not aware of them. Until now, there was no readily accessible source of information providers or funders could use to select programs that fit their organizations’ mission and resources. Best Practice Caregiving, a free, searchable database of comprehensive information about effective and feasible programs was released in early 2020. In this chapter, we describe our search for programs to include in Best Practice Caregiving, discuss our resulting observations about the current status of such programs in the United States, and identify several difficult issues that continue to interfere with increased awareness, availability, and use of the caregiver support programs.

Author(s): Reuben, David B; Gill, Thomas M; Stevens, Alan; Williamson, Jeff; Volpi, Elena; Lichtenstein, Maya; Jennings, Lee A; Tan, Zaldy; Evertson, Leslie; Bass, David; Weitzman, Lisa; Carnie, Martie; Wilson, Nancy; Araujo, Katy; Charpentier, Peter; Meng, Can; Greene, Erich J; Dziura, James; Liu, Jodi; Unger, Erin; Yang, Mia; Currie, Katherine; Lenoir, Kristin M; Green, Aval-NaʼRee S; Abraham, Sitara; Vernon, Ashley; Samper-Ternent, Rafael; Raji, Mukaila; Hirst, Roxana M; Galloway, Rebecca; Finney, Glen R; Ladd, Ilene; Rahm, Alanna Kulchak; Borek, Pamela; Peduzzi, Peter | Abstract: Background/objectivesAlthough several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown.DesignPragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad.SettingFour clinical trial sites (CTSs) based in academic and clinical health systems.ParticipantsA total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers.InterventionsEighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline.MeasurementsPrimary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales.Secondary outcomesNPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims.ResultsThe results will be reported in the spring of 2024.ConclusionD-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Objective Chronic subdural hematomas (cSDHs) are an increasingly prevalent neurologic disease that often requires surgical intervention to alleviate compression of the brain. Management of cSDHs relies heavily on computed tomography (CT) imaging, and serial imaging is frequently obtained to help direct management. The volume of hematoma provides critical information in guiding therapy and evaluating new methods of management. We set out to develop an automated program to compute the volume of hematoma on CT scans for both pre- and postoperative images. Methods A total of 21,710 images (128 CT scans) were manually segmented and used to train a convolutional neural network to automatically segment cSDHs. We included both pre- and postoperative coronal head CTs from patients undergoing surgical management of cSDHs. Results Our best model achieved a DICE score of 0.8351 on the testing dataset, and an average DICE score of 0.806 ± 0.06 on the validation set. This model was trained on the full dataset with reduced volumes, a network depth of 4, and postactivation residual blocks within the context modules of the encoder pathway. Patch trained models did not perform as well and decreasing the network depth from 5 to 4 did not appear to significantly improve performance. Conclusions We successfully trained a convolutional neural network on a dataset of pre- and postoperative head CTs containing cSDH. This tool could assist with automated, accurate measurements for evaluating treatment efficacy.

Introduction Despite advancements in endovascular treatment of intracranial aneurysms, up to 30% recur and require additional treatment. Predicting outcomes after aneurysm treatment with flow-diverting stents (FDS) could impact treatment strategy and avoid unnecessary follow-up. Computational fluid dynamics (CFD) techniques have been used to simulate the effect of treatment on the intracranial aneurysm hemodynamics, and to quantify change in certain hemodynamics factors that can be associated with treatment success or failure. We use CFD simulations, based on aneurysm anatomy and patient-specific blood flow and pressure data, to study which hemodynamics factors are predictive of six-month treatment outcomes. Materials and Methods Twenty-four patients with n=25 unruptured intracranial aneurysms treated with FDS were included (Table 1). 3-dimensional rotational angiographic anatomy was used to create the computational model and intraoperative blood velocity and blood pressure measurements proximal to the aneurysm, obtained with an endovascular dual-sensor microwire, were used as boundary conditions for CFD simulations before and after FDS treatment. For post-treatment calculations, a virtual stent based on the Pipeline Flex Embolization Device was deployed into the CFD simulations. Hemodynamics factors within the aneurysm dome including flow into aneurysm (Q), wall shear stress (WSS), wall shear stress gradient (WSSG), viscous dissipation, oscillatory shear index (OSI), and relative residence time (RRT) were calculated before and after FDS placement. Aneurysm treatment was classified as success or failure based on six-month follow-up angiography. Hemodynamics changes between immediate post-treatment and pre-treatment simulations were associated to treatment outcomes. Results Marked reduction in Q, WSS, WSSG, and OSI were seen in most cases immediately after FDS treatment compared to the pretreatment values, indicative of the redirection of blood flow along the neck plane. Reduction of Q at peak systole and increase in RRT in the aneurysm dome were strong predictors of FDS treatment success. Further multivariate analysis of hemodynamic predictors of treatment outcome will be presented. Conclusion Patient-specific CFD simulations using intraoperative physiological velocity and pressure data have been performed pre- and immediately post-treatment. Hemodynamics factors have the potential to predict aneurysm treatment outcomes, making them valuable for neurointerventionalists to consider in treatment planning. Disclosures D. Lim: None. L. March: None. M. Barbour: None. H. Haughn: None. S. Levy: None. K. Prijoles: None. D. Bass: None. G. Barros: None. C. Kelly: None. F. Chassagne: None. A. Aliseda: None. M. Levitt: 1; C; Philips Volcano. L. Kim: None.

Introduction Embolic coils are a preferred endovascular treatment technique for intracranial aneurysms, but approximately 34% of these treatments are unsuccessful, requiring re-treatment. To better understand why endovascular treatment fails, we used computational fluid dynamics (CFD) simulations to determine the changes in hemodynamics factors after coil embolization that were associated with treatment success versus those that led to failure. We incorporated patient-specific intravascular blood flow measurements as boundary conditions, which has been shown to improve simulation accuracy. Materials and Methods Adult patients presenting with unruptured intracranial aneurysms treated with coil embolization were enrolled. 3D-rotational angiograms taken before and immediately after treatment were used to create computational models of the patients’ vasculature. Intraoperative blood velocity and blood pressure measurements were obtained before and immediately after coil embolization by placing a dual-sensor microwire (ComboWire) in the proximal segment of the parent vessel. These measurements were incorporated as patient-specific boundary conditions for the CFD simulations to compute hemodynamics conditions before and after treatment. Hemodynamics variables including inflow rate (Q), wall shear stress (WSS), and wall shear stress gradient (WSSG) were calculated within each aneurysm. Treatment success or failure was determined by evaluating each patient’s most recent follow-up angiogram, and this outcome was then correlated to the changes in hemodynamics variables pre- and post-treatment. This statistical analysis aims to determine associations between immediate changes in post-treatment hemodynamics variables and treatment outcomes. Results Sixteen patients were included (table 1). Regardless of long-term treatment outcome, immediate post-treatment reductions were observed in Q, WSS and WSSG. Preliminary analyses suggest that an increase in shear stress at the aneurysm neck was associated with successful long-term outcome, representative of the significant redirection of blood flow velocity by the coil mass required to prevent aneurysm recanalization. Final multivariate analyses will be presented. Conclusion CFD simulations of aneurysm hemodynamics using patient-specific imaging and boundary conditions were performed in a large cohort of patients treated with coil embolization. Increases in neck plane shear and redirection of blood flow found immediately post-coil embolization have the potential to predict long-term treatment success. Disclosures S. Levy: None. L. Marsh: None. M. Barbour: None. K. Prijoles: None. D. Lim: None. H. Haughn: None. C. Kelly: None. F. Chassange: None. G. Barros: None. D. Bass: None. A. Aliseda: None. M. Levitt: 1; C; Philips Volcano. L. Kim: None.

The purpose of this article is to serve as a rational guide for the pediatric neurosurgeon in navigating common medicolegal issues that arise in the management of abusive head trauma (AHT). Many of these issues may be unfamiliar or unpleasant to surgeons focused on addressing disease. The authors begin with a brief history on the origins of the diagnosis of AHT and the controversy surrounding it, highlighting some of the facets of the diagnosis that make it particularly unique in pediatric neurosurgery. They then review some special medical considerations in these patients through the perspective of the neurosurgeon and provide several examples as illustration. The authors discuss how to appropriately document these cases in the medical record for expected legal review, and last, they provide an overview of the legal process through which the neurosurgeon may be called to provide testimony.

Transcranial Doppler (TCD) ultrasonography is an inexpensive, noninvasive means of measuring blood flow within the arteries of the brain. In this review, the authors outline the technology underlying TCD ultrasonography and describe its uses in patients with neurosurgical diseases. One of the most common uses of TCD ultrasonography is monitoring for vasospasm following subarachnoid hemorrhage. In this setting, elevated blood flow velocities serve as a proxy for vasospasm and can herald the onset of ischemia. TCD ultrasonography is also useful in the evaluation and management of occlusive cerebrovascular disease. Monitoring for microembolic signals enables stratification of stroke risk due to carotid stenosis and can also be used to clarify stroke etiology. TCD ultrasonography can identify patients with exhausted cerebrovascular reserve, and after extracranial-intracranial bypass procedures it can be used to assess adequacy of flow through the graft. Finally, assessment of cerebral autoregulation can be performed using TCD ultrasonography, providing data important to the management of patients with severe traumatic brain injury. As the clinical applications of TCD ultrasonography have expanded over time, so has their importance in the management of neurosurgical patients. Familiarity with this diagnostic tool is crucial for the modern neurological surgeon.

Objective Patients with medically intractable epilepsy often undergo sequential surgeries and are therefore exposed to an elevated risk for infection, resulting in unanticipated returns to the operating room. The goal of our study was to determine whether use of an osteoplastic bone flap technique would reduce the infection rate in these patients. Methods A single-institution, retrospective chart review of patients with medically intractable epilepsy for grid placement was performed. Univariate analyses and linear regression were used to assess primary outcomes, including infection and hematomas requiring surgical evacuation. Secondary outcomes included duration of treatment and other, unanticipated surgeries. Results A total of 199 patients were identified, 56 (28%) with osteoplastic flaps. Standard free flaps were associated with an increased rate of infection at the craniotomy site (n = 24, 17%, vs. 0, 0%, P = 0.003), whereas osteoplastic flaps were associated with more returns to operating room for hematoma evacuation (n = 5, 9% vs. 3.2%, P = 0.024). Overall, the rate of return to operating room for unanticipated surgeries was similar, but infectious complications prolonged the duration of treatment (median: 17 days vs. 2 days, χ2 = 13.97, P Conclusions Osteoplastic bone flaps markedly decreased the risk of craniotomy infections compared with free flaps in patients undergoing sequential surgeries. This decrease is offset, however, by an increase in intracranial hematoma requiring return to the operating room. Infection appeared to be a more significant complication as it was associated with increased duration of treatment. The osteoplastic technique is especially appealing in those patients likely to undergo multiple surgeries in short succession.

The Partners in Dementia Care (PDC) intervention has shown improved psychosocial outcomes while reducing overall inpatient and emergency department (ED) utilization among veterans with cognitive impairment and behavioral symptoms. However, veterans who use the Veterans Health Administration (VHA) also seek care from non-VHA sources, potentially reducing the effectiveness of care coordination. We evaluated whether PDC affected VHA and non-VHA inpatient and ED use by veterans with dementia.PDC is a telephone-based care coordination and support service program implemented in 2 VHA intervention sites that were compared with 3 VHA control sites. Veterans with a dementia diagnosis and their caregivers participated.Data came from administrative records and structured interviews with caregivers. We modeled the likelihood of site of care across 3 periods: preintervention (baseline), baseline to 6 months, and 6 months to 12 months.Compared with veterans at control sites, veterans at intervention sites who lived closer to VHA medical centers showed an increase over time (P ≤.01) in the likelihood of seeking VHA inpatient care as opposed to non-VHA care, whereas the likelihood of seeking non-VHA relative to VHA inpatient care increased for veterans living further away. ED visits did not show a comparable intervention effect.PDC intervention affected the choice of VHA versus non-VHA inpatient care, with its impact differing by distance from VHA medical centers. Site of ED care was not affected. Accountable care organizations share some of the VHA's vulnerabilities to out-of-system use; thus, the implications of our findings extend beyond the VHA system.

Recent research shows veterans with posttraumatic stress disorder (PTSD) are twice as likely as other veterans to develop dementia. However, no studies to date have examined the impact of co-existing PTSD and dementia on family caregivers, who provide the majority of care to these veterans. Using the Stress Process Model, the current investigation explored the similarities and differences in psychosocial, health, and service use outcomes among caregivers assisting veterans with PTSD and dementia compared with caregivers assisting veterans with dementia only. Caregivers of veterans with PTSD and dementia indicated that their relative exhibited more difficult behavior symptoms and used more community services. These caregivers also reported more difficulties understanding veterans' memory problems and more physical strain. Together, results suggested caregivers of veterans with both PTSD and dementia were at greater risk of negative caregiving consequences. Implications and suggestions for future research are discussed.

The present review highlights results from recent studies that delivered brief electrical stimulation to the basolateral complex of the amygdala in rats to reveal its capacity to prioritize declarative memories on a moment-to-moment basis even after the moment has passed. The results indicate that this memory enhancement depends on the hippocampus and elicits intrahippocampal gamma synchrony that possibly corresponds with sharpened hippocampal spike-timing dependent plasticity. These recent findings are discussed in relation to past studies of emotional memory in rodents and humans.

The amygdala is a key structure mediating emotional processing. Few studies have used direct electrical stimulation of the amygdala in humans to examine stimulation-elicited physiological and emotional responses, and the nature of such effects remains unclear. Determining the effects of electrical stimulation of the amygdala has important theoretical implications for current discrete and dimensional neurobiological theories of emotion, which differ substantially in their predictions about the emotional effects of such stimulation. To examine the effects of amygdala stimulation on physiological and subjective emotional responses we examined epilepsy patients undergoing intracranial EEG monitoring in which depth electrodes were implanted unilaterally or bilaterally in the amygdala. Nine subjects underwent both sham and acute monopolar electrical stimulation at various parameters in electrode contacts located in amygdala and within lateral temporal cortex control locations. Stimulation was applied at either 50 Hz or 130 Hz, while amplitudes were increased stepwise from 1 to 12 V, with subjects blinded to stimulation condition. Electrodermal activity (EDA), heart rate (HR), and respiratory rate (RR) were simultaneously recorded and subjective emotional response was probed after each stimulation period. Amygdala stimulation (but not lateral control or sham stimulation) elicited immediate and substantial dose-dependent increases in EDA and decelerations of HR, generally without affecting RR. Stimulation elicited subjective emotional responses only rarely, and did not elicit clinical seizures in any subject. These physiological results parallel stimulation findings with animals and are consistent with orienting/defensive responses observed with aversive visual stimuli in humans. In summary, these findings suggest that acute amygdala stimulation in humans can be safe and can reliably elicit changes in emotion physiology without significantly affecting subjective emotional experience, providing a useful approach for investigation of amygdala-mediated modulatory effects on cognition.

Cerebral arteriovenous malformations (AVMs) are complicated lesions representing a wide spectrum of pathology. They are frequently associated arterial aneurysms and venous varices, the latter of which carry a particularly high risk of rupture. AVM rupture commonly results in hydrocephalus, but there are a rare number of cases in which hydrocephalus develops as a result of an unruptured AVM. An elderly woman with a benign medical history presented to an outside hospital with 5 days of progressively worsening headaches that she described as retroorbital, dull, and lateralizing to the right. Workup at an outside hospital with a brain magnetic resonance image (MRI) and a head computed tomography angiogram (CTA) revealed concern for a tectal AVM with an associated venous varix abutting the tectal plate. Four weeks later, her headaches and diplopia had significantly improved. A diagnostic cerebral angiogram revealed that venous varix had decreased in size and a subsequent CTA showed interval improvement of her hydrocephalus. By the following month, her clinical signs and symptoms had completely resolved. Resolution of the patient’s symptoms clearly correlated with multiple radiographic findings, and therefore it seems reasonable to assume that expansion of the varix was the inciting event that lead to the development of her symptoms. Although this case reflects an exceptional series of events, it helps emphasize the point that a shunt or a ventriculostomy may not be necessary in a patient presenting with hydrocephalus from an unruptured AVM.

Iatrogenic dissection of the internal carotid artery is a well-known complication that can occur during mechanical thrombectomy for acute stroke. The vast majority of these injuries are limited to the cervical segment, and only in exceptional circumstances do they require surgical intervention. In the present case, extension of the lesion into the petrous segment of the carotid artery resulted in an acute neurologic decline necessitating emergent endovascular repair. We discuss the nuances of managing an exceptionally rare presentation of this complication.

The Diverse Elders Coalition, in partnership with its six member organizations and the Benjamin Rose Institute on Aging, completed a national survey of 840 family and friend caregivers from diverse racial, ethnic, and sexual orientation communities to understand their unique caregiving issues and challenges. Data from a subsample of 404 caregivers identifying as Hispanic/Latino, Asian, Southeast Asian or from multiple ethnicities were examined to determine the relationship between difficulties performing culture-related care tasks (i.e., assisting with immigration issues and language barriers) and a variety of caregiver outcomes. Regression analysis controlling for background and context characteristics showed caregivers experiencing more culture-related task difficulties had significantly higher levels of several negative caregiving consequences, including health strain (B=.19, p=.001), relationship strain (B=.17, p=.005), work strain, (B=.24, p=.000) isolation (B=.17, p=.002), and symptoms of depression (B=.29, p=.000). Moreover, higher levels of strain and depression among caregivers who reported high levels of culture-related task difficulties ranged from 26%-54%. More difficulties with culture-related tasks also were significantly related to dissatisfaction with support resources, including lower ratings of the quality of care receivers’ healthcare (B=-.20, p=.001), and lower satisfaction with support they and their care receivers received from family and friends (B=-.17, p=.006 and B=-.16, p=.011, respectively). Results suggest caregivers from diverse communities struggling with culture-related tasks experience more negative consequences of caregiving and less helpful social support. Service providers working with caregivers from diverse communities should assess for culture-related task difficulties, recognizing these problems may be a window into a variety of adverse caregiving effects.

This study describes engagement of veterans with dementia in an evidence-based care coordination intervention called Partners in Dementia Care (PDC). PDC uses a person-centered approach that encourages participation by individuals with dementia (IWDs), despite their cognitive impairment. PDC also targets primary family or friend caregivers, who often are the main user of the program. Of the total 316 IWDs, 202 passed a mental status screening and were considered to have engagement potential. The study of actual engagement was based on data from IWDs’ PDC records, combined with data from structured research interviews. Approximately 80% of IWDs with engagement potential had a minimum level of actual engagement in PDC. A smaller subsample was more actively engaged, as indicated by assigned and/or accomplished action steps. Younger IWDs and those self-reporting more memory difficulties had higher levels of engagement. Results describe one example of the extent and limits of IWD engagement in psychosocial interventions.

This study examines whether the delivery of three components, (a) exercise training, (b) behavior management skill building, and (c) dementia-related education, in an evidence-based program are differentially associated with changes in outcomes for individuals with dementia (IWDs) after 3 months. Data come from 508 IWDs participating in the community replication of the evidence-based “Reducing Disability in Alzheimer’s Disease” program. Regression results indicate that after 3 months, more exercise sessions are associated with improvements in physical functioning, mobility, minutes exercising, and symptoms of depression; more dementia education sessions are related to fewer restricted activity days; and more behavior management sessions are related to more symptoms of depression. As resource-strapped agencies look to best serve participants, further analysis and consideration is needed to determine the ideal balance of program efficacy, feasibility, and resources, as well as program benefits for IWDs and caregivers.

Activation of the amygdala either during emotional arousal or by direct stimulation is thought to enhance memory in part by modulating plasticity in the hippocampus. However, precisely how the amygdala influences hippocampal activity to improve memory remains unclear. In the present study, brief electrical stimulation delivered to the basolateral complex of the amygdala (BLA) following encounters with some novel objects led to better memory for those objects one day later. Stimulation also elicited field-field and spike-field CA3-CA1 synchrony in the hippocampus in the low gamma frequency range (30-55 Hz), a range previously associated with spike timing and good memory. Additionally, the hippocampal spiking patterns observed during BLA stimulation reflected recent patterns of activity in the hippocampus. Thus, the results indicate that amygdala activation can prioritize memory consolidation of specific object encounters by coordinating the precise timing of CA1 membrane depolarization with incoming CA3 spikes to initiate long-lasting spike-timing dependent plasticity at putative synapses between recently active neurons.

Introduction “Partners in Dementia Care” (PDC) tested a care-coordination program based on partnerships between Veterans Affairs (VA) medical centers and Alzheimer's Association chapters. The hypothesis posited PDC would reduce the likelihood and number of veterans' hospital admissions and emergency department (ED) visits, particularly for those with more cognitive impairment or behavioral symptoms. Methods The sample included 328 veterans with dementia and their primary family or friend caregivers from five matched sites (two randomly selected treatment sites). Data came from VA records; supplemented by caregiver research interviews. Regression analyses using the likelihood and number of hospital and ED visits as outcomes tested for overall treatment-comparison group differences and statistical interactions with cognitive impairment and behavioral symptoms. Results Consistent with the hypothesis, three significant interactions showed treatment-group veterans, with more cognitive impairment and behavioral symptoms, had fewer hospital admissions and ED visits than comparison-group veterans. There were no differences in the likelihood of hospital or ED use. Discussion PDC, a low-cost program for veterans and caregivers, was effective in reducing the number, but not the likelihood, of hospital admissions and ED visits. Reductions in service use were greater when caregivers reported more difficulties with veterans' symptoms, which in the absence of PDC would place veterans at risk of being high-volume, high-cost service users. Clinical Trial Registration: ClinicalTrials.gov : NCT00291161 .

Emotional events are often remembered better than neutral events, a benefit that many studies have hypothesized to depend on the amygdala's interactions with memory systems. These studies have indicated that the amygdala can modulate memory-consolidation processes in other brain regions such as the hippocampus and perirhinal cortex. Indeed, rodent studies have demonstrated that direct activation of the amygdala can enhance memory consolidation even during nonemotional events. However, the premise that the amygdala causally enhances declarative memory has not been directly tested in humans. Here we tested whether brief electrical stimulation to the amygdala could enhance declarative memory for specific images of neutral objects without eliciting a subjective emotional response. Fourteen epilepsy patients undergoing monitoring of seizures via intracranial depth electrodes viewed a series of neutral object images, half of which were immediately followed by brief, low-amplitude electrical stimulation to the amygdala. Amygdala stimulation elicited no subjective emotional response but led to reliably improved memory compared with control images when patients were given a recognition-memory test the next day. Neuronal oscillations in the amygdala, hippocampus, and perirhinal cortex during this next-day memory test indicated that a neural correlate of the memory enhancement was increased theta and gamma oscillatory interactions between these regions, consistent with the idea that the amygdala prioritizes consolidation by engaging other memory regions. These results show that the amygdala can initiate endogenous memory prioritization processes in the absence of emotional input, addressing a fundamental question and opening a path to future therapies.

The Diverse Elders Coalition, in partnership with its six member organizations and the Benjamin Rose Institute on Aging, completed a national survey of 840 family and friend caregivers from diverse racial, ethnic, and sexual orientation communities to understand their unique caregiving issues and challenges. Data from a subsample of 369 caregivers identifying as Hispanic/Latino, Asian, Southeast Asian or multiple ethnicities were analyzed to understand similarities and differences between caregivers born in the US and who immigrated to the US. The Stress Process Conceptual Model guided selection of characteristics used for comparative analysis. Results of logistic regression revealed that caregivers born in the US were younger (B=-.08, p

Family members and friends are the main providers of care for persons living with dementia. However, dementia caregivers are at greater risk than other caregivers of experiencing negative caregiving consequences. Despite the development of evidence-based programs to support dementia caregivers, few health or social service organizations offer any of these programs due, in part, to a lack of knowledge about their availability. Best Practice Caregiving is a newly launched website where professionals can get detailed information about these programs. Data collected to develop Best Practice Caregiving are analyzed for a sample of 42 evidence-based dementia caregiving programs to describe similarities and differences among programs including gaps in assistance available from these programs. Results show 64% of programs are delivered to caregivers only while the remaining are delivered to the caregiver and/or persons with dementia. Nearly half (43%) of the 42 programs are delivered in-person, 38% by phone, with 17% delivered all or in part online. Most programs are delivered by professionals (86%) followed by trained lay leaders (40%) and self-guided (12%). Most programs (95%) provide assistance with coping with illness/caregiving and the relationship of the dyad. Fewer than half of the programs assist caregivers with issues regarding finances (45%), end-of-life care (43%), and medical care (40%). Data from 233 delivery organizations show the most common challenge was getting caregivers to accept and complete the program (86%). Delivery sites reported more success with funding the program (mean=8.2 on a scale of 1-10) than with marketing and recruiting participants (mean=6.7).

Background: We examined emergency room (ER) utilization by persons with dementia (PWDs) using caregiver and patient characteristics as predictors. Methods: A secondary analysis of 296 veteran–caregiver dyads. Caregivers recorded PWD baseline characteristics and noted ER visits over the next year. Two sets of regression models analyzed categorical ER use and repeat ER use. Results: In the univariate analysis, categorical use of the ER was predicted by patients’ functional status ( P ≤ .008) and Veterans Affairs priority grouping ( P ≤ .02). Repeat ER admissions were predicted by functional status ( P ≤ .04), number of chronic conditions ( P ≤ .01), and caregiver-reported relationship strain ( P ≤ .04). In multivariate analysis, categorical ER use was predicted by functional status ( P ≤ .02), priority grouping ( P ≤ .03), and number of chronic conditions ( P ≤ .06). Conclusions: Functional status most strongly predicted ER use, highlighting the promise of home-based interventions to improve activities of daily living. Number of chronic conditions and caregiver-reported relationship strain are potential targets of intervention during discharge process.

The objective is to test the effectiveness of Partners in Dementia Care (PDC), a care-coordination program that integrates and improves access to medical and nonmedical services, while strengthening the informal care network and providing information, coaching, and emotional support. PDC was delivered via a partnership between Veterans Affairs (VA) Medical Centers (VAMCs) and Alzheimer's Association chapters, for caregivers of veterans with dementia living in the community and receiving primary care from the VA. The initial sample was 486 caregivers of 508 veterans with diagnosed dementia. Outcomes were evaluated for 394 and 324 caregivers who completed 6- and 12- month follow-up, respectively. PDC had a standardized protocol that included assessment and reassessment, action planning, and ongoing monitoring. It was delivered by telephone and e-mail for cost efficiency and the ability to handle caseloads of 100 to 125. Care coordinators from VAMCs and Alzheimer's Association chapters worked as a team using a shared computerized record. A variety of caregiver outcomes was measured after 6 and 12 months. Intervention group caregivers had significant improvements in outcomes representing unmet needs, three types of caregiver strains, depression, and two support resources. Most improvements were evident after 6 months, with more-limited improvements from Months 6 to 12. Some outcomes improved for all caregivers, whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more-severe impairments. PDC is a promising model that improves linkages between healthcare services and community services, which is a goal of several new national initiatives such as the National Plan to Address Alzheimer's Disease and a proposed amendment to the Older Americans Act.

This study examined the characteristics of caregivers and persons with dementia (PWD) to determine their association with caregiver depression. Participants included 508 PWD (veterans) and 486 caregivers from Boston, Houston, Providence, Beaumont (Texas), and Oklahoma City, identified from diagnoses from medical records and recruited from February 2007 to July 2009, for a larger study evaluating Partners in Dementia Care, a care-coordination intervention. Characteristics evaluated for PWD included activities of daily living, instrumental activities of daily living, cognitive impairment, and disruptive behavior. Caregiver characteristics evaluated included caregiver unmet needs, support-service use, and number of informal helpers. Caregiver depression was measured using the Iowa form 11-item Center for Epidemiologic Studies Depression Scale. Depressed caregivers reported significantly more unmet needs than the nondepressed caregivers. Depressed caregivers also reported a high frequency of disruptive behavior in their PWD. Caregiver perceptions of unmet needs may be an important target for intervention.

Purpose This study examined the efficacy of a newly developed intervention, Acquiring New Skills While Enhancing Remaining Strengths (ANSWERS), for family caregivers of individuals with dementia. ANSWERS was designed for dyads comprised of an individual with dementia and his/her family caregiver. Using a strength-based approach, ANSWERS combined educational skills (traditionally used with caregivers) and cognitive rehabilitation skills training (traditionally used with individuals with dementia) into a single protocol for addressing the dyad's care issues and needs. Key domains addressed by the intervention included: education about dementia and memory loss; effective communication; managing memory; staying active; and recognizing emotions and behaviors. This analysis focused on outcomes for caregivers. Design & methods The Stress Process Model guided the study's hypotheses and design. Caregiving dyads were randomly assigned to the control or intervention conditions. Intervention dyads received 6-curriculum guided sessions with an intervention specialist. Data came from in-person baseline interviews with caregivers conducted prior to randomization and follow-up interviews conducted approximately 14.56 weekspost-baseline. Results Intervention caregivers, compared to controls, had decreased care-related strain as indicated by lower emotional health strain, dyadic relationship strain, role captivity, and higher caregiving mastery. Additionally, intervention caregivers had improved well-being as indicated by fewer symptoms of depression and anxiety. Implications ANSWERS was efficacious in improving key strain and psychosocial outcomes for caregivers. Features essential to the success of ANSWERS included a strength-based approach for selecting, developing, and implementing care goals, as well as teaching caregivers educational and cognitive rehabilitation skills for addressing care needs.

We studied perceptions of dementia diagnosis and treatment in patient-caregiver dyads enrolled in a care coordination intervention trial for veterans with dementia. We compared patient and caregiver perceptions of diagnosis and treatment to information in the medical record and assessed concordance between patient and caregiver perceptions. Data were derived from medical record abstraction and structured interviews with 132 patients and 183 caregivers. Most caregivers, but only about one fourth of patients, reported having received information about a diagnosis related to memory loss. Caregivers were more accurate than patients in recalling the patient’s use of memory-enhancing medications. Within dyads there was poor agreement regarding a diagnosis of dementia. Our findings suggest that there is substantial room for improvement in disclosure and education of dementia diagnosis, especially at the level of the patient-caregiver dyad.

Arteriovenous malformations (AVMs) are typically considered congenital lesions, although there is growing evidence for de novo formation of these lesions as well. The authors present the case of an AVM in the same cerebral cortex that had been affected by a severe traumatic brain injury (TBI) more than 6 years earlier. To the best of the authors' knowledge, this is the first report attributing the formation of an AVM directly to TBI.

Background Colonoscopy has been adopted as the preferred method to screen for colorectal neoplasia in the United States. However, lesions can be missed because of numerous factors, including location on the proximal aspect of folds or flexures, where they may be difficult to detect with the forward-viewing colonoscope. The Third Eye Retroscope (TER) is a disposable device that is passed through the instrument channel of a standard colonoscope to provide a retrograde view that complements the forward view of the colonoscope during withdrawal. Objective To evaluate whether experience with the TER affects polyp detection rates and procedure times in experienced endoscopists who had not previously used the equipment. Design, Setting, Patients This was an open-label, prospective, multicenter study at 9 U.S. sites, involving 298 patients presenting for colonoscopy, evaluating the use of the TER in combination with a standard colonoscope. Interventions After cecal intubation, the TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor. Main Outcome Measurements Primary outcome measures were the number and size of adenomas and all polyps detected with the standard colonoscope and with the colonoscope combined with the TER. Secondary outcome measures were withdrawal phase time and total procedure time. Each endoscopist examined 20 subjects, divided into quartiles according to the order of their procedures, and results were compared among quartiles. Results Overall, 182 polyps were detected with the colonoscope and 27 additional polyps with the TER, a 14.8% increase ( P P P P P = .044). Limitations There was no randomization or separate control group. The endoscopists judged whether each lesion could have been detected with the colonscope alone by using their standard technique. Conclusions Polyp detection rates improved significantly with the TER, especially after 15 procedures, when the mean additional detection rate for adenomas was 25.0%. Additional detection rates with the TER for medium-size and large adenomas were greater than for smaller lesions. These results suggest that, compared with a colonoscope alone, a retrograde-viewing device can increase detection rates for clinically significant adenomas without detriment to procedure time or procedure complications. (Clinical trial registration number: NCT00969124 .)