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Bilateral thalamic primary gliomas are an exceedingly rare entity. Symptomology heralding a workup and diagnosis of bithalamic gliomas is diverse and varies between the pediatric and adult populations. Herein, we present a case of a 63-year-old female patient who presented with progressive gait imbalance and fatigue, prompting an outpatient brain MRI, remarkable for marked expansion of the bilateral thalami secondary to non-enhancing, T2-weighted-fluid-attenuated inversion recovery (T2-FLAIR) bright bithalamic lesions. The patient underwent a right frontal frameless stereotactic biopsy of the right thalamic lesion, with immuno-histology indicating a high-grade anaplastic astrocytoma with molecular features of glioblastoma (GBM). The patient’s functional status declined precipitously in the month following her diagnostic biopsy, precluding any therapy, and the patient ultimately pursued home hospice care without further treatment. This case details the clinical management of a very rare tumor, supplementing the available literature on the progression and treatment of this rare disease.

Background The rosette-forming glioneuronal tumor (RGNT) is a rare World Health Organization grade I tumor, most often originating in the fourth ventricle and characterized by a predominant glial component, as well as a neurocytic component. Despite its benign grading, there are a few documented cases of RGNT displaying more aggressive behavior with malignant characteristics. Case Description Herein, we describe a uniquely aggressive presentation of RGNT in a 49-year-old man initially presenting with obstructive hydrocephalus with lesions in the right frontal lobe, fourth ventricle, and left lateral ventricle. The patient was found to have 2 distinct intracranial entities: a right frontal meningioma and disseminated intraventricular RGNT. He underwent an anatomically limited resection of the fourth ventricular lesion with fourth ventricle−to-subarachnoid space shunting. His disease progressed thereafter, with diffuse intracranial dissemination and drop metastases in the lumbar spine. He was treated with craniospinal radiation and remains on palliative care 5 months after completion of radiotherapy. Conclusions This case supplements and complements the handful of published cases available documenting the evolution of a particularly aggressive case of disseminated RGNT.

Flow diverters are new generation stents that have recently garnered a large amount of interest for use in treatment of intracranial aneurysms. Flow diverters reduce blood flow into the aneurysm, with redirection along the path of the parent vessel. Flow stagnation into the aneurysm and neck coverage with subsequent endothelialization are the important synergistic mechanisms by which the therapy acts. Several studies have examined the mechanisms by which flow diverters subsequently lead to aneurysm occlusion. This review aims to provide a general overview of the flow diverters and their mechanism of action and potential implications. ANN NEUROL 2019;85:793-800.

Urothelial cell carcinoma (UCC), the most common cancer of the urinary system, rarely metastasizes to the brain. 1-3 More rare still is the subset of patients with urothelial carcinoma brain metastases whose UCC primary is first diagnosed at the same time as their CNS metastatic disease, with oncologic workup prompted by CNS clinical manifestations.4 Paraneoplastic optic neuropathy (PON) is likewise a rare clinical entity, which has not yet been described in association with UCC brain metastases.Herein, we present the sentinel case of UCC believed to be of endometrial origin in an 81 year old woman initially presenting with symptoms of fatigue, nausea, vertigo, and rapidly deteriorating vision over the course of 1 month. Visual deterioration prompted neuro imaging remarkable for multiple supratentorial and infratentorial metastases as well as likely neoplastic inflammatory involvement of the bilateral optic nerves. The patient underwent a right temporal open brain biopsy, with pathology findings consistent with UCC. Subsequent PET scanning demonstrated a heavy burden of disease including an FDG-avid uterine mass with local and distal extension of disease including bilateral hydroureteronephrosis with obstruction of the distal ureters. The patient and her family elected to pursue home hospice without further workup or intervention.While this is the first such case presented, it is possible that UCC of the uterine wall represents a particularly aggressive form of the disease more prone to presenting with CNS metastases and PON.

OBJECTIVE Vessel tapering results in blood flow acceleration at downstream bifurcations (firehose nozzle effect), induces hemodynamics predisposing to aneurysm initiation, and has been associated with middle cerebral artery (MCA) aneurysm presence and rupture status. The authors sought to determine if vessel caliber tapering is a generalizable predisposing factor by evaluating upstream A1 segment profiles in association with aneurysm presence in the anterior communicating artery (ACoA) complex, the most prevalent cerebral aneurysm location associated with a high rupture risk. METHODS Three-dimensional rotational angiographic studies were analyzed for 68 patients with ACoA aneurysms, 37 nonaneurysmal contralaterals, and 53 healthy bilateral controls (211 samples total). A1 segments were determined to be dominant, codominant, or nondominant based on flow and size. Equidistant cross-sectional orthogonal cuts were generated along the A1 centerline, and cross-sectional area (CSA) was evaluated proximally and distally, using intensity-invariant edge detection filtering. The relative tapering of the A1 segment was evaluated as the tapering ratio (distal/proximal CSA). Computational fluid dynamics was simulated on ACoA parametric models with and without tapering. RESULTS Aneurysms occurred predominantly on dominant (79%) and codominant (17%) A1 segments. A1 segments leading to unruptured ACoA aneurysms had significantly greater tapering compared to nonaneurysmal contralaterals (0.69 ± 0.13 vs 0.80 ± 0.17, p = 0.001) and healthy controls (0.69 ± 0.13 vs 0.83 ± 0.16, p < 0.001), regardless of dominance labeling. There was no statistically significant difference in tapering values between contralateral A1 and healthy A1 controls (0.80 ± 0.17 vs 0.83 ± 0.16, p = 0.56). Hemodynamically, A1 segment tapering induces high focal pressure, high wall shear stress, and high velocity at the ACoA bifurcation. CONCLUSIONS Aneurysmal, but not contralateral or healthy control, A1 segments demonstrated significant progressive vascular tapering, which is associated with aneurysmogenic hemodynamic conditions at the ACoA complex. Demonstration of the upstream tapering effect in the communicating ACoA segment is consistent with its prior detection in the noncommunicating MCA bifurcation, which together form more than 50% of intracranial aneurysms. The mechanistic characterization of this upstream vascular tapering phenomenon is warranted to understand its clinical relevance and devise potential therapeutic strategies.

MINI: In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion. Among 18,833 patients who underwent anterior cervical decompression and fusion, 3% were readmitted to the hospital within 30 days. 39.5% of readmissions were for reasons related to surgical site.Retrospective review of a national database.In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion (ACDF).The safety profile of ACDF has been previously described with readmission rates typically between 2% and 4%. However no studies have investigated the primary diagnoses driving readmission, and whether these diagnoses are related to the surgical site.Demographics, comorbidities, and procedural characteristics were collected for all patients undergoing one or two-level ACDF for degenerative indications identified by Current Procedural Terminology (CPT) coding in the National Surgical Quality Improvement Program (NSQIP) database. The incidence of 30-day complications and readmissions was calculated, and the reasons for readmission as well as the timing of readmission were reviewed. Multivariate logistic regression analyses were performed to identify risk factors associated with complications or readmissions within 30 days of surgery.Eighteen thousand eight hundred thirty three patients underwent ACDF (15,464 single-level and 3369 two-level, mean age 53.7 yrs, standard deviation [SD]: 11.6; 50% male). Postoperative complication rate of was 4.3% in two-level fusions and 3.5% in single-level fusion (P = 0.027). Five hundred sixty nine unplanned readmissions were identified (3.0%), of which 39.5% were related to the surgical site and 49.7% were unrelated to the surgical site (10.5% unknown cause of readmission). The most frequent reason for 30-day readmission was pneumonia (9.3%, mean time to readmission of 11.3 d) followed by dysphagia (7.4%, 6.3 d), and acute postoperative pain (7.2%, 11.4 d).In this nationwide analysis of 18,833 ACDF cases, 3.0% of patients were readmitted within 30 days, of which at least 49.7% were for reasons unrelated to the surgical site.3.Retrospective review of a national database. In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion (ACDF). The safety profile of ACDF has been previously described with readmission rates typically between 2% and 4%. However no studies have investigated the primary diagnoses driving readmission, and whether these diagnoses are related to the surgical site. Demographics, comorbidities, and procedural characteristics were collected for all patients undergoing one or two-level ACDF for degenerative indications identified by Current Procedural Terminology (CPT) coding in the National Surgical Quality Improvement Program (NSQIP) database. The incidence of 30-day complications and readmissions was calculated, and the reasons for readmission as well as the timing of readmission were reviewed. Multivariate logistic regression analyses were performed to identify risk factors associated with complications or readmissions within 30 days of surgery. Eighteen thousand eight hundred thirty three patients underwent ACDF (15,464 single-level and 3369 two-level, mean age 53.7 yrs, standard deviation [SD]: 11.6; 50% male). Postoperative complication rate of was 4.3% in two-level fusions and 3.5% in single-level fusion (P = 0.027). Five hundred sixty nine unplanned readmissions were identified (3.0%), of which 39.5% were related to the surgical site and 49.7% were unrelated to the surgical site (10.5% unknown cause of readmission). The most frequent reason for 30-day readmission was pneumonia (9.3%, mean time to readmission of 11.3 d) followed by dysphagia (7.4%, 6.3 d), and acute postoperative pain (7.2%, 11.4 d). In this nationwide analysis of 18,833 ACDF cases, 3.0% of patients were readmitted within 30 days, of which at least 49.7% were for reasons unrelated to the surgical site. Level of Evidence: 3.

Epidermoid cysts of the pineal region are a rare entity. Herein, the authors describe the endoscopic resection of a recurrent pineal region epidermoid by way of a supracerebellar infratentorial approach. The patient was positioned in the semiseated upright position with head tilted to the right and slightly flexed, maximizing gravity-based cerebellar retraction, and a paramedian craniotomy was performed owing to the gradual flattening of the tentorium from medial to lateral. This setup, in tandem with the enlarged viewing window achieved by use of 0°, 30°, and 70° endoscopes, afforded the necessary access to achieve a satisfactory resection through this anatomical corridor. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2131.

The cerebellopontine angle (CPA) is the most common location of posterior fossa tumors. Common pathologic entities in the CPA include vestibular schwannomas, which account for 10% of all primary brain neoplasms, meningiomas, and arachnoid cysts. Surgical approaches to the CPA vary depending on the tumor size, location, and preoperative neurologic function of the patient. The retrosigmoid approach is perhaps the most versatile approach, affording excellent visualization for large tumors and allowing for hearing preservation. Radiosurgery plays an increasing role in the treatment of CPA pathology due to high rates of facial nerve function preservation and tumor growth arrest.

BACKGROUND CONTEXT Unplanned hospital readmissions after surgery are increasingly scrutinized as markers of health care quality. Thus there is great incentive in understanding and reducing readmissions for both the surgeon and the hospital. PURPOSE In this study we analyze rates of readmission, and the timing and reasons for readmission after 1-2 level anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients undergoing one or two-level ACDF for degenerative indications in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012 to 2016. OUTCOME MEASURES Complications and readmissions within 30 days, reasons for readmission, timing of readmission METHODS Demographics, comorbidities, and procedural characteristics were collected for all patients undergoing one or two-level ACDF identified by CPT coding in the NSQIP database. Patients undergoing surgery for oncologic, traumatic, infectious, or revision indications and patients undergoing combined anterior-posterior cervical fusion were excluded. The incidence of 30-day complications and readmissions was calculated, and the reasons for readmission as well as the timing of readmission was reviewed. Multivariate logistic regression analyses were performed to identify risk factors associated with complications or readmissions within 30 days of surgery. RESULTS A total of 18,833 patients who underwent ACDF were identified (15,464 single-level and 3,369 two-level). Mean age was 53.7 years (SD:11.6) and 50% of patients were male. The overall rate of any postoperative complication was 4.3% in two-level fusions and 3.5% in single-level fusion (p=.027). In total, 569 unplanned readmissions were identified (3.0%), of which 39.5% were related to the surgical site and 49.7% were unrelated to the surgical site (10.5% unknown cause of readmission). The most frequent reason for 30-day readmission was pneumonia (9.3%, mean time to readmission of 11.3 days) followed by dysphagia (7.4%, 6.3 days), acute postoperative pain (7.2%, 11.4 days) and edema, hematoma or seroma (7.0%, 7.4 days). The most influential independent risk factors for readmission identified via multivariate analysis American Society of Anesthesiology (ASA) score ≥3 (Odds Ratio [OR] 1.96, 95% Confidence Interval [CI] 1.6–2.4, p CONCLUSIONS In this nationwide analysis of 18,833 ACDFs, 3.0% of patients were readmitted within 30 days, of which at least 49.7% were for reasons unrelated to the surgical site. Follow-up with primary care providers in the immediate postoperative period may improve quality in preventing unplanned readmissions in high-risk patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.