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OBJECTIVE Burnout and work-life balance have been noted to be problems for residents across all fields of medicine, including neurosurgery. No studies to date have evaluated how these factors may contribute to issues outside of the hospital, specifically residents’ home lives. This study aimed to evaluate the interplay between home life and work life of neurosurgical residents, specifically from the point of view of residents’ significant others. METHODS Online surveys were distributed to the significant others of neurosurgical residents at 12 US neurosurgery residencies. Residents’ partners were asked about relationship dynamics, their views on neurosurgery residency (work-life balance and burnout), and their views of neurosurgery as a career. RESULTS The majority of residents’ significant others (84%) reported being satisfied with their relationship. Significant others who reported dissatisfaction with their relationship were more likely to report frustration with work-life balance and more likely to report their resident partner as having higher levels of burnout. CONCLUSIONS From the perspective of neurosurgery residents’ significant others, higher perceived levels of burnout and lower satisfaction with work-life balance are correlated with lower levels of relationship satisfaction. These findings speak to the complex interplay of work life and home life and can be used to inform future interventions into improving the quality of life for both the resident and the significant other.

OBJECTIVE Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0–2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

BackgroundThe benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.MethodsThis is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.ResultsThe unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).ConclusionsComplete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

Background Spinal epidural abscess is a rare pathology with an incidence that has tripled in the past 2 decades. Ventral cervical epidural abscesses (vCEA) of the cervical spine pose particular treatment challenges because of the anatomical location. The aim of this report is to identify trends in the surgical management of these patients and to determine whether concomitant spondylodiscitis warrants fusion at the index surgery. Methods Patients presenting to a quaternary care institution from January 2009 to December 2018 with isolated vCEA were identified. Patients were excluded if they had dorsal or circumferential epidural abscesses. Clinical and radiographic data were collected. Patients with vCEA were stratified by the presence or absence of spondylodiscitis upon presentation. Clinical outcomes analyzed included neurological sequelae and the need for revision surgery. Results During the 10-year study period, 36 patients presented with symptomatic isolated vCEA and constituted the study cohort; 16 (44%) had concurrent spondylodiscitis. All 36 patients underwent surgical decompression; the initial surgical approach was anterior-only for 7 patients (19%), posterior-only for 27 patients (75%), and and a combined approach for 2 patients (6%). Four patients from the total cohort (11%) ultimately required a revision operation; all 4 were from the subset with concurrent spondylodiscitis (25% vs. 0%, P = 0.03). Conclusions vCEA can be evacuated safely and effectively by a variety of strategies in patients with neurologic deficits. Concomitant spondylodiscitis with cervical epidural abscess may warrant instrumented fusion as part of the initial surgical strategy.

OBJECTIVELarge interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.METHODSA prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.RESULTSTwenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.CONCLUSIONSiSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

BackgroundIn response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.MethodsA prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.Results458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (PConclusionWe observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

BackgroundCase series have described the safety and efficacy of LVIS Jr and Atlas stent-assisted aneurysm coiling, but their comparative clinical performance has not yet been formally studied.ObjectiveTo clinically compare LVIS Jr and Atlas stents, emphasizing comparative rates of technical success and complications.MethodsOur institutional endovascular database was queried for aneurysms treated by stent-assisted coiling with either the LVIS Jr or Atlas stents. Demographic data, aneurysm information, treatment technique, periprocedural and device-related complications, and initial and follow-up angiographic results were evaluated.ResultsThirty-seven patients underwent Atlas stent placement and 27 patients underwent LVIS Jr stent placement for aneurysm coiling. There was no significant difference in aneurysm location, size, coiling technique, and coil packing density between the two cohorts. The rate of initial Raymond 1 occlusion was significantly greater in the Atlas cohort (57% vs 41%, P=0.03). The rate of postoperative ischemic complications, both clinically apparent and as defined on postoperative MRI diffusion-weighted imaging, did not significantly differ between the two groups. Follow-up DSA demonstrated a significantly greater rate of Raymond 1 or 2 occlusion for the Atlas cohort (100% vs 81%, P=0.04), and a significantly lower rate of in-stent stenosis (0% vs 19%, P=0.04).ConclusionThis institutional analysis demonstrates greater obliteration rates and lower in-stent stenosis rates for aneurysms treated via Atlas stent-assisted coiling as compared with those treated via LVIS Jr stent-assisted coiling.

OBJECTIVEBlunt cerebrovascular injuries (BCVIs) following trauma carry risk for morbidity and mortality. Since patients with BCVI are often asymptomatic at presentation and neurological sequelae often occur within 72 hours, timely diagnosis is essential. Multidetector CT angiography (CTA) has been shown to be a noninvasive, cost-effective, reliable means of screening; however, the false-positive rate of CTA in diagnosing patients with BCVI represents a key drawback. Therefore, the authors assessed the role of DSA in the screening of BCVI when utilizing CTA as the initial screening modality.METHODSThe authors performed a retrospective analysis of patients who experienced BCVI between 2013 and 2015 at 2 Level I trauma centers. All patients underwent CTA screening for BCVI according to the updated Denver Screening Criteria. Patients who were diagnosed with BCVI on CTA underwent confirmatory digital subtraction angiography (DSA). Patient demographics, screening indication, BCVI grade on CTA and DSA, and laboratory values were collected. Comparison of false-positive rates stratified by BCVI grade on CTA was performed using the chi-square test.RESULTSA total of 140 patients (64% males, mean age 50 years) with 156 cerebrovascular blunt injuries to the carotid and/or vertebral arteries were identified. After comparison with DSA findings, CTA findings were incorrect in 61.5% of vessels studied, and the overall CTA false-positive rates were 47.4% of vessels studied and 47.9% of patients screened. The positive predictive value (PPV) for CTA was higher among worse BCVI subtypes on initial imaging (PPV 76% and 97%, for BCVI Grades II and IV, respectively) compared with Grade I injuries (PPV 30%, p < 0.001).CONCLUSIONSIn the current series, multidetector CTA as a screening test for blunt cerebrovascular injury had a high-false positive rate, especially in patients with Grade I BCVI. Given a false-positive rate of 47.9% with an estimated average of 132 patients per year screening positive for BCVI with CTA, approximately 63 patients per year would potentially be treated unnecessarily with antithrombotic therapy at a busy United States Level I trauma center. The authors’ data support the use of DSA after positive findings on CTA in patients with suspected BCVI. DSA as an adjunctive test in patients with positive CTA findings allows for increased diagnostic accuracy in correctly diagnosing BCVI while minimizing risk from unnecessary antithrombotic therapy in polytrauma patients.

Background: Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections. Methods: Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents. Patient demographics, clinical presentations, endovascular techniques, and clinical outcomes were reviewed. Results: In both cases, MAT achieved modified Treatment in Cerebral Ischemia scale 2B reperfusion, and complete endovascular reconstruction of the dissected extracranial loop was performed. Both patients had improved pre- to postintervention National Institutes of Health Stroke Scale scores (16 to 0 and 14 to 0), and both had modified Rankin scale scores of 1 at 3-month follow-up. Conclusions: Stent reconstruction of complex cerebrovascular anatomy is increasingly feasible with advancements in stent technology and catheter support system design. This technique may be of use to neuroendovascular surgeons who encounter variant ICA anatomy.

Introduction: Microcatheter selection is an infrequent focus of stroke thrombectomy technique evaluation. The Headway27 microcatheter strikes an excellent balance of microcatheter dimensions (156 cm length, 2.6 Fr distal OD, ID 0.027 inches) and visibility, making it ideal for stroke thrombectomy. Methods: We evaluated a prospectively maintained acute stroke thrombectomy database containing 50 consecutive cases using the Headway27 microcatheter. From the database, patient demographics, clinical and angiographic information as well as procedural technical details and complications were extracted. Results: Manual aspiration thrombectomy (MAT) was performed alone in 72% of cases, stentriever-assisted MAT was performed in 6% of cases, and a combination was used in 22% of cases. Median groin puncture to final recanalization time was 27 min and mTICI 2B/3 recanalization was achieved in 94% of cases. There were 2 intra-procedural complications, neither related to the microcatheter. In all cases, the Headway27 reached the intended target vessel: M1 (n = 4), M2 (n = 26), M3 (n = 13), P2 (n = 3), P3 (n = 1), and basilar artery (n = 3). There were no cases requiring usage of an additional or alternative microcatheter. In 45/47 cases of MAT, the reperfusion catheter tracked over the Headway to the clot/intended target; in two cases, the microcatheter was used to deploy a stentriever that then allowed the reperfusion catheter to track to the clot. Conclusion: The Headway27 microcatheter reliably facilitated rapid clot access in anterior and posterior circulation acute large vessel occlusions with no microcatheter-associated complications.

Background: Intraoperative neurophysiologic monitoring is a commonly used adjunct during many neurointerventional procedures. Objective: Here we describe the rare occurrence of a hemorrhagic complication secondary to a subdermal needle electrode. Methods: A 67 year old male with a left-sided fusiform vertebrobasilar aneurysm was scheduled to undergo placement of a pipeline embolization device. The patient had been administered aspirin 325 mg and Plavix 75 mg daily for greater than one week preoperatively. After successfully undergoing endotracheal intubation, 7 mm length and 0.4 mm diameter subdermal needle electrode intraoperative monitoring leads were placed in the scalp, mastoid and bilateral Erb's points Following successful completion of the procedure, but prior to extubation and closure of the femoral arterial site, the patient was noted to have a significant amount of swelling in the left neck and supraclavicular region in the immediate vicinity of the left Erb's point subdermal needle electrode. Review of the last angiographic run in the region noted active extravasation from a muscular branch of the suprascapular artery immediately subjacent to the aforementioned subdermal electrode. The literature has been reviewed and recommendations for management and surveillance are made. Results: This case underscores the importance of monitoring and risk minimization in regards to hemorrhagic complications, especially in patients who are anticoagulated and receiving dual antiplatelet therapy, during neurointerventional procedures. Conclusion: Hemorrhagic complications associated with subdermal needle electrodes, though rare, can have significant consequences in patients. Keywords: Neurophysiologic monitoring, Hemorrhage, Complication

Background Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed. Objective To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms. Methods This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve. Results In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92). Conclusion This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs.

Pregnancy and puerperium are risk factors for cerebral venous sinus thrombosis (CVST); however studies describing diagnosis and management in this population are limited. The objective of this study was to amalgamate published case reports and series regarding diagnosis and management of CVST in pregnancy and puerperium. Searches of PubMed and the Cochrane library were performed using search terms "pregnancy"/"puerperium" and "sinus occlusion"/"sinus thrombosis". Studies were included in our pooled analysis if they included individual patient symptoms, management approach and follow-up condition. Multivariate regression was utilized to assess the effect of non-modifiable factors on excellent outcome (mRS 0). Sixty-six patients were included. Mean duration of symptom onset to diagnosis was 5.9days (95% CI 4.2-7.6). Clot involvement of the superior sagittal sinus was seen in 67% of cases, the transverse/sigmoid in 64% and of the deep venous system in 15% of cases. Management approaches included anticoagulation (91% of patients), IA (intra-arterial) thrombolysis alone (26%), and IA thrombectomy with IA thrombolysis (8%). Fifty-nine percent of patients were mRS 0 at follow-up; 94% were mRS 0-2. Presentation with headache alone was associated with excellent outcome on multivariate analysis (p=0.04); coma/obtundation predicted against excellent outcome (p=0.03). As compared to IA thrombolysis alone, patients undergoing IA thrombolysis with IA thrombectomy demonstrated a trend toward better outcome (p=0.10).

Purpose Uveal metastases are ophthalmologic tumors that have historically been treated by fractionated external beam radiation therapy or invasive brachytherapy. The need for rapid response and less invasive management options led the authors to explore the use of Gamma Knife stereotactic radiosurgery (SRS) for this common problem. Design Interventional case series. Methods To prevent eye movement during the procedure, all 3 patients underwent a retrobulbar anesthetic block followed by magnetic resonance imaging to detect the target. All tumors were treated in a single procedure using the 4C or Perfexion Gamma Knife. The tumors received a minimal tumor dose of 14–20 Gy. Two patients also underwent SRS for additional intracranial metastases. Results At follow-up, performed between 4 and 15 months after SRS, all 3 patients demonstrated a reduction in uveal tumor volumes. One patient developed decreased visual acuity secondary to radiation retinopathy. Conclusion In this early experience, SRS was found to be an effective management option for uveal metastases associated with systemic cancer. Patients can be screened and treated effectively early after diagnosis using a joint approach between ophthalmologists and neurosurgeons. Systemic oncologic care can continue without interruption.

Background Tandem occlusion resulting in acute ischemic stroke is associated with high morbidity and mortality and a poor response to thrombolytic therapy. The use of endovascular strategies for tandem stroke cases results in an improved outcome for this subgroup of patients. We present 2 cases with a pattern of tandem occlusion consisting of proximal obstruction at the origin of the common carotid artery (CCA) with concomitant intracranial occlusion treated by endovascular techniques. Methods The 2 patients presented each with occlusion at the left CCA origin and ipsilateral intracranial vessel (left middle cerebral artery and carotid terminus, respectively). A transfemoral anterograde approach was used to deliver a balloon-mounted stent across the proximal CCA origin occlusion to gain access to the distal cerebral vasculature. Subsequently, a stent retriever assisted mechanical aspiration thrombectomy was used to revascularize the intracranial occlusion. Results Complete revascularization with Thrombolysis in Cerebral Infarction scores of 2b and improvement in neurologic deficits occurred in both cases. Good clinical outcome was achieved for both patients at 3-month follow-up. Conclusions An anterograde transfemoral approach should be considered in cases of tandem occlusion of the proximal CCA and middle cerebral artery.

BACKGROUND Patients with symptomatic carotid stenosis remain at high risk of early recurrent stroke without revascularization. This risk must be balanced against a higher rate of periprocedural complications associated with early revascularization. OBJECTIVE To analyze prospectively recorded data from an institutional protocol that standardized the urgent (

Background and importance Flow diversion of intracranial aneurysms has been rarely described in the pediatric population. Here we discuss the technical and perioperative complexities inherent in the flow diversion of an infectious basilar apex aneurysm in a 2-yr-old child with significant medical comorbidities. Clinical presentation Following judicious oral administration of dual anti-platelet agents and intra-arterial administration of calcium channel blockers to treat vasospasm, standard endovascular procedures were used to place a flow diverting stent across the neck of a rapidly enlarging infectious aneurysm of the basilar apex.Following the uncomplicated procedure, the patient demonstrated progressive thrombosis of the previously noted basilar apex aneurysm over a 3-mo period. The patient was therefore felt to be safe to proceed with, and eventually underwent, uncomplicated orthotopic heart transplant. Conclusion Flow diversion of complex intracranial aneurysms in pediatric patients with significant medical comorbidities is feasible and safe; however, considerations have to be made in the pre- and perioperative care of these patients given the propensity for low-weight and complicated systemic disease processes.

Background Burnout among physicians has been a topic of growing interest in both the scientific and the lay press. It has been well established that burnout and perceived inequity in work-life balance can contribute to poor physician work satisfaction and poorer patient outcomes. To better understand burnout among neurosurgery residents at our institution, we systematically surveyed residents for symptoms of burnout and enacted responsive protocols to try to combat its deleterious effects. Methods Before and after the institution of a series of initiatives aimed at combating burnout, residents were surveyed to assess for symptoms of burnout, strength of relationships, and status of physical and mental health. Initiatives included gym access and group gym visits, a mentoring program, and a lecture series targeting multiple facets of health and well-being. Results Nearly two thirds of neurosurgery residents demonstrated ≥1 signs of burnout at a moderate to severe level before and after the first year of our wellness initiative. Residents reported that work schedule and time availability were obstacles in focusing on their own personal health and wellness (utilization preventive health care visits, participation in group gym activities). Less than half of residents were content with their work-life balance. Conclusions Making a significant change in burnout rates in neurosurgery will require a number of key factors, including targeted initiatives that focus on specific local needs, honest buy-in by departmental leaders, and recognition by the physicians themselves that a problem exists.

Stereotactic radiosurgery using the Leksell Gamma Knife has proven to be a valuable alternative to orbital enucleation or fractionated radiation therapy for primary tumors of the orbit, metastatic tumors to the choroid, and primary uveal melanomas. With this approach in a single outpatient setting, the eye is immobilized by a local block after which high-definition MRI or CT is performed to define the target. After rapid dose planning, radiation delivery is completed before the local block dissipates. The tumor response is often dramatic. The risk of acute narrow-angle glaucoma, radiation-related retinopathy, or cataract formation has been relatively low. Other worldwide centers have confirmed that this approach is superior to either enucleation or fractionated radiation therapy for these relatively rare problems.

Stereotactic radiosurgery using the Leksell Gamma Knife has proven to be a valuable alternative to orbital enucleation or fractionated radiation therapy for primary tumors of the orbit, metastatic tumors to the choroid, and primary uveal melanomas. With this approach in a single outpatient setting, the eye is immobilized by a local block after which high-definition MRI or CT is performed to define the target. After rapid dose planning, radiation delivery is completed before the local block dissipates. The tumor response is often dramatic. The risk of acute narrow-angle glaucoma, radiation-related retinopathy, or cataract formation has been relatively low. Other worldwide centers have confirmed that this approach is superior to either enucleation or fractionated radiation therapy for these relatively rare problems.

Background Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke. Furthermore, successful mechanical thrombectomy using a variety of techniques has been documented in numerous children and adolescents. Patient Description We present a 15-year-old boy with altered mental status and left hemiparesis due to acute ischemic stroke secondary to blockage of the right internal carotid artery terminus, most likely precipitated by end-stage heart failure and cardiac embolism. Mechanical aspiration thrombectomy using the Penumbra aspiration catheter without any adjunct surgical equipment or thrombolytic therapy was used to remove thrombus and treat the patient's acute ischemic stroke. He experienced complete artery recanalization with a Thrombolysis in Cerebral Infarction (TICI) score of 2C after the procedure. He also exhibited an 8 point improvement in his pediatric National Institutes of Health Stroke Scale score within 24 hours. Conclusions Mechanical aspiration thrombectomy is commonly used in adult hospitals but infrequently employed in pediatric patients with arterial ischemic stroke. Given its efficacy in our patient, we encourage a larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric patients with acute ischemic stroke.

PHACE syndrome is a neurocutaneous disorder involving large facial hemangiomas in association with posterior fossa abnormalities, cerebral arterial anomalies, cardiac defects, and eye abnormalities. A recent consensus statement has delineated criteria necessary for the diagnosis of PHACE syndrome. Extracutaneous manifestations of PHACE syndrome predominately affect the cerebrovascular system. To date, there are no reports of cerebral cavernous malformations (CCMs) in children with PHACE syndrome. We reviewed the charts of children admitted to the Children’'s Hospital of Pittsburgh who met criteria for PHACE syndrome, and evaluated neuroimaging for cerebrovascular abnormalities, including the finding of CCMs. Six children met criteria for PHACE syndrome at our institution over a 10-year period. All children were female. All children had cerebrovascular abnormalities sufficient to meet major criteria for diagnosis. Four children (66.7 %) were found incidentally to have CCMs; all lesions measured less than 5 mm at the time of diagnosis and were asymptomatic. At present, CCMs are not listed among the diagnostic criteria for PHACE syndrome, and they have not previously been reported in association with PHACE syndrome. Hypoxic injury in utero may be the common denominator in the pathogenesis of many of the abnormalities already accepted in the criteria for PHACE syndrome and the formation of CCMs. In the setting of PHACE syndrome, we encourage clinicians to evaluate children for CCMs, which are readily apparent on the already-recommended screening MRIs.

Introduction Infectious intracranial aneurysms (IIAs) are a rare but potentially devastating complication of infective endocarditis. The clinical and radiographic findings that predispose patients to IIA remain poorly understood. Methods We performed a retrospective review of a prospectively maintained database of consecutive endocarditis patients undergoing catheter-based angiography at a single tertiary-level academic center during the period of July 2013–December 2017. Patient records were reviewed for clinical and radiographic characteristics that may be associated with IIA. Multivariate regression models were used to evaluate the relationship between clinical and radiographic characteristics and presence of IIA on invasive imaging. Results Of 92 patients included in this analysis, 12 of them with 19 IIAs were discovered. Univariate analysis identified age, male sex, presence of hemorrhage, and history of IV drug use (IVDU) as predictors of IIA presence. After multivariate analysis, only intracranial hemorrhage and IVDU remained as independent predictors of IIA. Conclusions Presence of hemorrhage on noninvasive imaging and history of IVDU are independently predictive of IIA presence in patients with infectious endocarditis. Risk stratification using these 2 factors may help identify the most vulnerable populations for IIA formation.

Cerebral aneurysms in patients with extreme proximal tortuosity may contraindicate endovascular therapy as a result of both the approach and an inability to navigate a coil-compatible microcatheter into the aneurysm due to microcatheter length. We present a 72 year-old male with multiple medical comorbidities admitted with a grade 3, ruptured pericallosal aneurysm. Aortoiliac disease contraindicated a transfemoral approach and thus a 6 French 105 cm guide catheter was advanced through a 6 French short radial sheath into a bovine left common carotid artery. After straightening proximal access anatomy with an Amplatz wire to allow advancement of the guide catheter into the internal carotid artery, a 167 cm 0.013 in. headway duo was advanced through a 5 French Sofia through the guide catheter and “hubbed” to enter the aneurysm. The aneurysm was then successfully coil embolized with 4 Target Ultrasoft coils. This case illustrates the utility of a 167 cm microcatheter for coil embolization of a pericallosal aneurysm with significant proximal tortuosity via a transradial approach. Despite its 0.013 in. inner diameter and length, common Target coils were compatible and deployed without incident.

Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement—and misplacement—is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.

Objective Intraoperative digital subtraction angiography (ioDSA) is touted as the gold standard imaging evaluation for aneurysm clip constructs. Candid evaluations of its limitations are sparse. Methods A prospectively collected hospital billing database was queried to identify craniotomies for aneurysm clipping from January 2010 to December 2013. We evaluated the rate of occult residual and parent vessel stenosis determined on follow-up angiography for patients undergoing ioDSA and those not undergoing ioDSA. Comparisons were performed via Fisher exact test, with P Results From our database search, we found 187 patients who underwent ioDSA after aneurysm clipping and an additional 91 patients who did not. Results from ioDSA influenced operative management in 17% of cases. Sixty-four patients with 70 treated aneurysms undergoing ioDSA had postoperative angiography; 7 occult residuals were discovered, yielding a 10% false-negative rate, with 10% of aneurysms showing residual. Occult residuals at the middle cerebral artery bifurcation represented most discovered residuals (6/7). Thirty-two patients with 37 treated aneurysms did not undergo ioDSA and had angiographic follow-up; 24% of patients were found to have residual aneurysms ( P = 0.08 compared with patients undergoing ioDSA). Residuals at the anterior communicating artery (ACoA) represented 56% of all residuals, whereas the ACoA represented only 18% of aneurysms clipped. The rate of residuals was significantly higher than that for patients with clipped ACoA aneurysms undergoing ioDSA ( P = 0.008). Conclusions ioDSA influenced management in nearly one fifth of cases. It can be particularly beneficial in detecting residuals for ACoA aneurysms; its benefit was less apparent for middle cerebral artery aneurysms.

Background Radiation therapy (RT)-induced effects in children treated for low grade glioma (LGG) can result in worsening of neurologic symptoms and clinical and radiographic deterioration. Treatment for radiation-induced tumor enlargement is based on symptom control and usually involves steroids. Procedure We conducted a retrospective review of children with LGG treated with RT who developed symptomatic radiation-induced tumor enlargement and were managed with bevacizumab. Charts were abstracted for onset and duration of RT changes, toxicity and doses of dexamethasone and bevacizumab. Tumor volumes prior to RT, at maximal size following RT, after bevacizumab administration, and at follow-up were evaluated. Results Five children were treated with bevacizumab for symptomatic radiation-induced tumor enlargement following RT for LGG at a median of 4.2 months (range, 1–11 months) after completion of RT. The median increase in volume of tumor was 195.4% (range, 115.5–309%) compared to the pre-RT volume. Bevacizumab 5–10 mg/kg was administered IV q 2–4 weeks as primary treatment (n = 1) or to assist in weaning patients off steroids (n = 4). All children on high dose steroids (n = 4) were weaned off or to physiologic doses of hydrocortisone. Two children developed avascular necrosis after prolonged steroid use and while on bevacizumab. Radiographically, all children showed significant improvement and are now a median of 31 months (range, 18–50 months) from the completion of radiation without requiring additional tumor-related therapy. Conclusions Bevacizumab can play an important role in children with symptomatic radiation changes following LGG treatment, allowing patients to avoid or minimize the toxicity of long-term steroid use. Pediatr Blood Cancer 2015;62:240–245. © 2014 Wiley Periodicals, Inc.

OBJECTIVEPenetrating cerebrovascular injury (PCVI) is a subset of traumatic brain injury (TBI) comprising a broad spectrum of cerebrovascular pathology, including traumatic pseudoaneurysms, direct arterial injury, venous sinus stenosis or occlusion, and traumatic dural arteriovenous fistulas. These can result in immediate or delayed vascular injury and consequent neurological morbidity. Current TBI guidelines recommend cerebrovascular imaging for detection, but there is no consensus on the optimum modality. The aim of this retrospective cohort study was to compare CT angiography (CTA) and digital subtraction angiography (DSA) for the diagnosis of PCVI.METHODSThe records of all patients presenting to two level I trauma centers in the United States between January 2010 and July 2016 with penetrating head or neck trauma were reviewed. Only those who had undergone both CTA and DSA were included. Clinical and neuroimaging data were collected, and PCVIs were stratified using a modified Biffl grading scheme. DSA and CTA results were then compared.RESULTSOf 312 patients with penetrating trauma over the study period, 56 patients (91% male, mean age 32 years) with PCVI met inclusion criteria and constituted the study cohort. The mechanism of injury was a gunshot wound in 86% (48/56) of patients. Twenty-four (43%) patients had sustained an angiographically confirmed arterial or venous injury. Compared with DSA as the gold standard, CTA had a sensitivity and specificity of 72% and 63%, respectively, for identifying PCVI. CTA had a positive predictive value of 61% and negative predictive value of 70%. Seven patients (13%) required immediate endovascular treatment of PCVI; in 3 (43%) of these patients, the injury was not identified on CTA. Twenty-two patients (39%) underwent delayed DSA an average of 25 days after injury; 2 (9%) of these patients were found to harbor new pathological conditions requiring treatment.CONCLUSIONSIn this retrospective analysis of PCVI at two large trauma centers, CTA demonstrated low sensitivity, specificity, and positive and negative predictive values for the diagnosis of PCVI. These findings suggest that DSA provides better accuracy than CTA in the diagnosis of both immediate and delayed PCVI and should be considered for patients experiencing penetrating head or neck trauma.

Intracranial aneurysms (IAs) are a result of complex interactions between biochemical and mechanical forces and can lead to significant morbidity if they rupture and cause subarachnoid hemorrhage. This review explores the role of matrix metalloproteinases (MMPs) in the pathogenesis and progression of IAs. In addition to providing a review of the normal function of MMPs, it is intended to explore the interaction between inflammation and abnormal blood flow and the resultant pathological vascular remodeling processes seen in the development and rupture of IAs. Also reviewed is the potential for the use of MMPs as a diagnostic tool for assessment of aneurysm development and progression.

Background and Purpose— The utility of prophylactic antiepileptic drug (AED) administration after spontaneous subarachnoid hemorrhage remains controversial. AEDs have not clearly been associated with a reduction in seizure incidence and have been associated with both neurological worsening and delayed functional recovery in this setting. Methods— We retrospectively analyzed a prospectively collected database of subarachnoid hemorrhage patients admitted to our institution between 2005 and 2010. Between 2005 and 2007, all patients received prophylactic AEDs upon admission. After 2007, no patients received prophylactic AEDs or had AEDs immediately discontinued if initiated at an outside hospital. A propensity score–matched analysis was then performed to compare the development of clinical and electrographic seizures in these 2 populations. Results— Three hundred and fifty three patients with spontaneous subarachnoid hemorrhage were analyzed, 43% of whom were treated with prophylactic AEDs upon admission. Overall, 10% of patients suffered clinical and electrographic seizures, most frequently occurring within 24 hours of ictus (47%). The incidence of seizures did not vary significantly based on the use of prophylactic AEDs (11 versus 8%; P =0.33). Propensity score–matched analyses suggest that patients receiving prophylactic AEDs had a similar likelihood of suffering seizures as those who did not ( P =0.49). Conclusions— Propensity score–matched analysis suggests that prophylactic AEDs do not significantly reduce the risk of seizure occurrence in patients with spontaneous subarachnoid hemorrhage.

Object Helmet use has been associated with fewer hospital visits among injured skiers and snowboarders, but there remains no evidence that helmets alter the intracranial injury patterns. The authors hypothesized that helmet use among skiers and snowboarders reduces the incidence of head injury as defined by findings on head CT scans. Methods The authors performed a retrospective review of head-injured skiers and snowboarders at 2 Level I trauma centers in New England over a 6-year period. The primary outcome of interest was intracranial injury evident on CT scans. Secondary outcomes included the following: need for a neurosurgical procedure, presence of spine injury, need for ICU admission, length of stay, discharge location, and death. Results Of the 57 children identified who sustained a head injury while skiing or snowboarding, 33.3% were wearing a helmet at the time of injury. Of the helmeted patients, 5.3% sustained a calvarial fracture compared with 36.8% of the unhelmeted patients (p = 0.009). Although there was a favorable trend, there was no significant difference in the incidence of epidural hematoma, subdural hematoma, intraparenchymal hemorrhage, subarachnoid hemorrhage, or contusion in helmeted and unhelmeted patients. With regard to secondary outcomes, there were no significant differences between the 2 groups in percentage of patients requiring neurosurgical intervention, percentage requiring admission to an ICU, total length of stay, or percentage discharged home. There was no difference in the incidence of cervical spine injury. There was 1 death in an unhelmeted patient, and there were no deaths among helmeted patients. Conclusions Among hospitalized children who sustained a head injury while skiing or snowboarding, a significantly lower number of patients suffered a skull fracture if they were wearing helmets at the time of the injury.

The term dual-diagnosis refers to a person with mental retardation and a psychiatric disorder. Most children with Down syndrome (DS) do not have a psychiatric or neurobehavioral disorder. Current prevalence estimates of neurobehavioral and psychiatric co-morbidity in children with DS range from 18% to 38%. We have found it useful to distinguish conditions with a pre-pubertal onset from those presenting in the post-pubertal period, as these are biologically distinct periods each with a unique vulnerability to specific psychiatric disorders. Due to the increased recognition that psychiatric symptoms may co-occur with mental retardation, and are not inextricably linked to cognitive impairment, these conditions are considered treatable, in part, under a medical model. Improvement in physiologic regulation, emotional stability, and neurocognitive processing is one of the most elusive but fundamental goals of pharmacologic intervention in these disorders.

Radiation therapy (RT)-induced effects in children treated for low grade glioma (LGG) can result in worsening of neurologic symptoms and clinical and radiographic deterioration. Treatment for radiation-induced tumor enlargement is based on symptom control and usually involves steroids.We conducted a retrospective review of children with LGG treated with RT who developed symptomatic radiation-induced tumor enlargement and were managed with bevacizumab. Charts were abstracted for onset and duration of RT changes, toxicity and doses of dexamethasone and bevacizumab. Tumor volumes prior to RT, at maximal size following RT, after bevacizumab administration, and at follow-up were evaluated.Five children were treated with bevacizumab for symptomatic radiation-induced tumor enlargement following RT for LGG at a median of 4.2 months (range, 1-11 months) after completion of RT. The median increase in volume of tumor was 195.4% (range, 115.5-309%) compared to the pre-RT volume. Bevacizumab 5-10 mg/kg was administered IV q 2-4 weeks as primary treatment (n = 1) or to assist in weaning patients off steroids (n = 4). All children on high dose steroids (n = 4) were weaned off or to physiologic doses of hydrocortisone. Two children developed avascular necrosis after prolonged steroid use and while on bevacizumab. Radiographically, all children showed significant improvement and are now a median of 31 months (range, 18-50 months) from the completion of radiation without requiring additional tumor-related therapy.Bevacizumab can play an important role in children with symptomatic radiation changes following LGG treatment, allowing patients to avoid or minimize the toxicity of long-term steroid use. Pediatr Blood Cancer 2015;62:240-245. © 2014 Wiley Periodicals, Inc.