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Background Limited literature exists on the morbidity and mortality of AVM associated intracerebral hemorrhage (ICH) compared with non-AVM ICH. Objective We examine morbidity and mortality in cAVM in a large nationwide inpatient sample to create a prognostic inpatient ruptured AVM mortality score. Methods This retrospective cohort study from 2008 to 2014 compares outcomes in cAVM related hemorrhages and ICH utilizing the National Inpatient Sample database. Diagnostic codes for ICH and AVM underlying ICH were identified. We compared case fatality according to medical complications. Multivariate analysis was used to derive hazard ratios and 95% confidence intervals to assess odds of mortality. Results We identified 6496 patients with ruptured AVMs comparing them to 627,185 admitted with ICH. Mortality was lower for ruptured AVMs (11%) compared to ICH (22%) [ p 60 (=1), Black race (=1), chronic liver failure (=1) diabetes mellitus (=1), pneumonia (=1), alcohol abuse (=1) and cerebral edema (=1). Mortality increased with score. No patient with 5 or more points survived. Conclusion The Ruptured AVM Mortality Score allows for risk stratification on patients with ICH due to ruptured AVM. This scale could prove useful in prognostication and patient education.

BACKGROUND Meningiomas are the most common intracranial tumors. According to the World Health Organization’s (WHO) classification guidelines, they can be classified into 15 subtypes with three grades of malignancy based on histology alone. In recent years, analysis of tumor methylomes that reflects both cell-origin methylation signatures and somatically acquired DNA methylation changes has been utilized to better classify meningiomas with great success. Method: In our case series, we report DNA methylation profiling on meningiomas from 17 patients. Formalin fixed paraffin embedded (FFPE) meningioma tumor samples were processed, loaded onto the Infinium Methylation EPIC array, and scanned using the Illumina IScan system. Raw IDAT files were then processed through the v12b6 version of the CNS tumor classifier developed by the Molecular Neuropathology group at the University of Heidelberg. Classifier output consisted of assigned methylation classifications along with confidence scores, with scores ≥0.84 classified as “high confidence.” Result: Among our meningioma samples from 17 patients (18 samples total), 14 samples are classified as “benign,” one sample is classified as “intermediate,” and the remaining three samples from two patients are classified as “malignant.” In addition to tumor methylation profiling, we also present information that includes patient demographics, clinical presentations, tumor characteristics (size, location), surgical approaches, and mutational analysis. Genomic analysis has revealed variants in NF2, SLX4, ARID1A, KDM4C, ERCC2, EP300, ERBB2, KMT2D, LRP1B, FANCE, CRKL, and SPEN in multiple patients. The three meningioma samples from the two patients that are classified as “malignant” all have a high MIB1 indexes consistent with WHO Grade II meningiomas. Both patients had tumor recurrence reflecting the aggressiveness of the tumor in their disease course. CONCLUSION In accordance with prior reports, our case series provides support that tumor DNA methylation profiling can provide useful classification information and can be correlated to both tumor pathology and patient clinical presentation.

Introduction Epidermoid cysts are rare intracranially occurring mainly in subarachnoid spaces such as parasellar cisterns, middle fossa and cerebellopontine angle. Only few cases of infundibular/sellar epidermoid cysts have been described. We present the case of a large sellar epidermoid cyst resulting in panhypopituitarism. Case 49 year old male with history of obesity and hypertension presented to the emergency department with acute onset progressively worsening headaches. He denied vision changes, nausea, vomiting or dizziness. Examination showed stable vital signs and ophthalmologic exam did not reveal any visual deficits. Further, he did not have any signs of pituitary hormone excess including hypercortisolemia or acromegaly. Brain MRI with and without IV contrast revealed a peripherally enhancing multilobulated cystic pituitary mass measuring 19.5 mm×17 mm×20.5 mm deviating the infundibulum to the left causing compression of the caudal aspect of the optic chiasm. Initial endocrinology work-up revealed noon time cortisol of 10.7 mcg/dL (range 7-23), 7 pm ACTH of 34.6 pg/mL (range 7.2-63.3), TSH of 1.71 mIU/mL (range 0.35- 4.94), free T4 of 0.93 ng/dL (range 0.5-1.39), FSH of 4.45 mIU/mL (range 1.27-19.26), LH 5.51 mIU/mL (range 1.24-8.62), IGF-1 level of 199 ng/mL (range 68-225), prolactin Conclusion Intracranial epidermoid cysts are uncommon benign congenital lesions arising from trapped surface of ectodermal elements. Very rarely, they are found in the sellar region. Sellar epidermoid cysts tend to present late and often after significant growth and mass effects. Complete resection is challenging and recurrence is a feared complication. Our patient presented with acute symptoms from expansion of a large epidermoid sellar cyst mimicking a pituitary macroadenoma. It also resulted in hypopituitarism. Although, a rare entity, early recognition and prompt management of such lesions is key. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

As local disease control improves, the public health impact of brain metastases (BrM) continues to grow. Molecular features are frequently different between primary and metastatic tumors as a result of clonal evolution during neoplasm migration, selective pressures imposed by systemic treatments, and differences in the local microenvironment. However, biomarker information in BrM is not routinely obtained despite emerging evidence of its clinical value. We review evidence of discordance in clinically actionable biomarkers between primary tumors, extracranial metastases, and BrM. Although BrM biopsy/resection imposes clinical risks, these risks must be weighed against the potential benefits of assessing biomarkers in BrM. First, new treatment targets unique to a patient’s BrM may be identified. Second, as BrM may occur late in a patient’s disease course, resistance to initial targeted therapies and/or loss of previously identified biomarkers can occur by the time of occult BrM, rendering initial and other targeted therapies ineffective. Thus, current biomarker data can inform real-time treatment options. Third, biomarker information in BrM may provide useful prognostic information for patients. Appreciating the importance of biomarker analyses in BrM tissue, including how it may identify specific drivers of BrM, is critical for the development of more effective treatment strategies to improve outcomes for this growing patient population.

OBJECTIVE In this article, the authors describe the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights. METHODS Anonymous surveys of neurosurgery program leaders (program directors and program chairs), program administrators (PAs), and 2020–2021 neurosurgery residency match applicants were distributed by the SNS, in conjunction with the Association of Resident Administrators in Neurological Surgery and AANS Young Neurosurgeons Committee. RESULTS Responses were received from 77 (67.0%) of 115 PAs, 119 (51.7%) of 230 program leaders, and 124 (44.3%) of 280 applicants representing geographically diverse regions. During the virtual application cycle relative to the previous year, programs received more Electronic Residency Application Service applications (mean 314.8 vs 285.3, p < 0.0001) and conducted more applicant interviews (mean 45.2 vs 39.9, p = 0.0003). More than 50% of applicants applied to > 80 programs; 60.3% received ≤ 20 interview invitations, and 9% received > 40 invitations. Overall, 65% of applicants completed ≤ 20 interviews, whereas 34.7% completed > 20 interviews. Program leaders described one 4-week home subinternship (93.3%) and two 4-week external subinternships (68.9%) as optimal neurosurgical exposure; 62.8% of program leaders found the standardized letter of recommendation template to be somewhat (47.5%) or significantly (15.3%) helpful. Applicants, PAs, and program leaders all strongly preferred a hybrid model of in-person and virtual interview options for future application cycles over all in-person or all virtual options. Ninety-three percent of applicants reported matching within their top 10–ranked programs, and 52.9% of programs matched residents within the same decile ranking as in previous years. CONCLUSIONS Optimizing a national strategy for the neurosurgery application process that prioritizes equity and reduces costs, while ensuring adequate exposure for applicants to gain educational opportunities and evaluate programs, is critical to maintain a successful training system.

Patients with cerebral vasospasm caused by aneurysmal subarachnoid hemorrhage (aSAH) are often treated with intra-arterial (IA) vasodilator infusion. However, the optimal drug regimen is yet to be elucidated.A retrospective review of patients with aSAH and cerebral vasospasm treated with IA vasodilator infusion was performed. Patients in group 1 (2008-2011) were treated with a single agent, either nicardipine or verapamil, and patients in group 2 (2010-2016) were treated with a regimen of nitroglycerin, verapamil, and nicardipine. The post-infusion improvement ratio (PIIR) was compared between groups. Adjusted multivariate logistic regression models were utilized to determine whether patients treated with multiple vasodilators had an improved functional outcome, defined by the modified Rankin Scale, at discharge and 90-day follow-up.Among 116 patients from group 1 (N = 47) and group 2 (N = 69), the median age was 54.5 years [IQR, 46-53 years] and 78% were female. Use of multiple-agent therapy resulted in a 24.36% improvement in vessel diameter over single-agent therapy (median PIIR: group 1, 10.5% [IQR, 5.3-21.1%] vs group 2, 34.9% [IQR, 21.4-66.0%]; p0.0001). In the adjusted multivariate logistic regression, the use of multiple-agent therapy was associated with a better functional outcome at discharge (OR 0.15, 95% CI [0.04-0.55]; p0.01) and at 90-day follow-up (OR 0.20, 95% CI [0.05-0.77]; p0.05) when compared to single-agent therapy.In this study, we found that patients treated for cerebral vasospasm with IA infusion of multiple vasodilators had an increased vessel response and better functional outcomes compared to those treated with a single agent.

Introduction: Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. The American Heart Association convened an Evidence Review Committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke. Methods: The Medline, Embase, and Cochrane databases were searched on November 1, 2016, to identify randomized controlled trials (RCTs) comparing dysphagia screening protocols or quality interventions to increased dysphagia screening rates, and reporting outcomes of pneumonia, death or dependency. Results: Three RCTs were identified. One RCT (n=1,126) found that a combined nursing quality improvement intervention targeting fever and glucose management as well as dysphagia screening reduced death and dependency (42% vs. 58%, p=0.002), but without reducing the pneumonia rate (2.1% vs. 2.7%, p=0.82). Another RCT (n=311) failed to find evidence that pneumonia rates were reduced by adding the cough reflex test to routine dysphagia screening (26% vs. 21%, p=0.38). A smaller RCT (n=162) randomly assigned 2 hospital wards to a stroke care pathway including dysphagia screening or regular care, and found that patients on the stroke care pathway were less likely to require intubation and mechanical ventilation (7.8% vs. 20%, p=0.03 after adjustment); however, the study was small and at risk for bias. Conclusions: There were insufficient RCT data to determine the effect of dysphagia screening protocols on reducing rates of pneumonia, death, or dependency after stroke. Additional trials are needed to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia.

Cavernous Malformations are low flow vascular lesions characterized by dilated vascular capillary channels with no intervening neural tissue. They can occur in the brain and spinal cord. The blood vessels forming these cavernomas are abnormal and leaky and hence tend to hemorrhage. They can present with seizures, headaches, and neurologic deficits depending on where they are located. Three genes namely CCM 1,2 and 3 participating in endothelial cell signaling are implicated in their formation. Cavernous Malformations are safely and effectively treated with surgery if they hemorrhage and are symptomatic. A thoughtful approach to cavernoma resection is necessary for lesions in eloquent locations such as the brainstem. Only hemorrhagic lesions that present to the pial or ventricular surface and within safe corridors should be operated on. Operative Navigation and neurophysiologic monitoring are important operative adjuncts. Radio surgery for cavernous malformation is controversial and has not proven to be beneficial across all studies.

Background and Purpose: Tandem Internal Carotid Artery and Middle Cerebral Artery or “TIM” occlusions are highly resistant to conventional therapy (systemic thrombolysis) and independently predicts poor patient outcome. Recent evidence suggests that patients treated more aggressively with either endovascular stenting of occluded carotid arteries and/or intra-arterial tissue plasminogen activator (tPA) may have superior outcomes. Here we evaluate all the available data to help assess the best intervention for this patient population that currently has limited treatment options. Methods: Data from Medline and the Cochrane database of systemic reviews was searched. The search terms used includes (tandem OR combined) AND (middle cerebral OR internal carotid) AND (OCCLU* or lesion or stenos* or blocka*). All studies had to be in English. All duplicates were identified and removed. To be included the studies needed to report on three key aspects: 1) baseline characteristics (age; NIHSS at presentation); 2) treatment (time to treatment; modality); and 3) outcome (report of patient state at discharge or follow up on the Modified Rankin Scale). Patients were grouped according to whether they received endovascular intervention or stand alone IV tPA. Patients were considered independent if they had a Modified Rankin Scale score of ≤ 2 at follow up or discharge. Results: Over 2,500 studies were evaluated. Seventeen studies met the inclusion criteria, with a total of 219 patients. Patients treated with endovascular therapy (n=60) (stenting and/or intra-arterial tPA) were 32% more likely to be independent (p Conclusion: Endovascular therapy appears to be superior compared with systemic thrombolysis in treating patients with TIM occlusions. The risk of iatrogenic complications with more aggressive intervention does not appear to outweigh the outcome benefit. Further and larger studies are needed to assess the benefits and risks of endovascular therapy in patients with TIM lesions.

Progressive injury to the mammalian CNS often reduces the severity of lesion-induced deficits or spares the behavior from deficits altogether. The mechanism(s) underlying this behavioral sparing is not clearly understood, but axonal sprouting is a likely candidate. To test this possibility, unilateral, two-stage (progressive) lesions of the entorhinal cortex, which are known to accelerate sprouting by the crossed temporodentate pathway and spare spatial memory function, were made in rats. We examined the changes in synaptic efficacy (as measured by the amplitude and slope of evoked population EPSPs) of the crossed temporodentate projection after either one-stage or progressive unilateral lesions of the entorhinal area. Whereas the synaptic efficacy of the one-stage group did not differ significantly from the control group at 4, 6, or 8 d after the lesion, the synaptic efficacy of the crossed temporodentate pathway in the progressive lesion group significantly increased above the control values as early as 4 d after the lesion and remained stable thereafter. Axonal sprouting thus may provide a mechanism by which to account for behavioral sparing after progressive brain damage.