Preoperative meningioma embolization reduces perioperative blood loss: a multi-center retrospective matched case-control study

BACKGROUND AND PURPOSE

The utility of preoperative embolization remains controversial within the literature. Here, we evaluate whether preoperative meningioma embolization is effective in reducing intraoperative blood loss, safe to perform, and cost-effective when compared with surgical resection without preoperative embolization.

METHODS

Twenty-nine patients with meningiomas were matched by tumor size and location to 29 control patients with meningiomas at another institution where preoperative embolization was not practiced. The variables evaluated were pre- and post-operative hemoglobin and hematocrit levels as a measure of operative blood loss and postoperative morbidity. The additional cost of undergoing angiography and embolization was calculated from hospital charges obtained from the billing department.

RESULTS

The mean decrease in perioperative hemoglobin and hematocrit was 0.9 and 2.7, respectively, in the embolization group and 2.8 and 10.0, respectively, in the control group for a significant decrease in operative blood loss as measured by change in hematocrit and hemoglobin levels after surgery. There was no significant difference in operative blood loss when subdividing patients based on tumor location. There were no angiogram-related complications. Twenty-two of 29 patients (76%) underwent embolization of a feeding artery, whereas 7 patients underwent only a diagnostic angiogram. The mean additional charge per patient in the embolization group was $88,767.

CONCLUSIONS

Preoperative embolization was safe and effective in reducing the overall perioperative blood loss in patients undergoing meningioma resection, as measured by the change in postoperative hemoglobin and hematocrit levels. However, the cost of embolization was significant.

Dual-center study comparing transradial and transfemoral approaches for flow diversion treatment of intracranial aneurysms

BACKGROUND

The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers.

MATERIALS AND METHODS

We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis.

RESULTS

There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays.

CONCLUSIONS

While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.

Total and partial posterior quadrant disconnection for medically refractory epilepsy: A systematic review

PURPOSE

Posterior quadrant disconnection (PQD) is a surgical procedure for medically refractory epilepsy (MRE) involving diffuse regions of the temporo-parieto-occipital lobes. We sought to compare factors and efficacy according to PQD extent.

METHODS

We performed a systematic review of the literature reporting the use of PQD since 2004. We analyzed various characteristics of pooled cases, including the role of preoperative studies in patient selection, intraoperative techniques, and outcomes.

RESULTS

Our review of 137 patients from nine studies revealed 66% undergoing total PQD and 34% undergoing partial PQD. Interictal electroencephalography (EEG) findings were predominantly characterized as lateralized for total PQD (56%) and localized within the ipsilateral posterior quadrant in patients undergoing partial PQD (53%). Metabolic functional studies [positron emission tomography (PET) or ictal single-photon emission computed tomography (SPECT)] played a role in surgical decision-making in 42% of patients who underwent total PQD. Wada and/or functional magnetic resonance imaging (fMRI) was more often utilized for partial PQD (22%) than total PQD (3%) as was intracranial electroencephalography (icEEG) (30% versus 13%, respectively). Overall, 75% of total PQD patients achieved seizure freedom [defined as Engel I or International League Against Epilepsy (ILAE) Class 1 outcome] in comparison to 63% of partial PQD patients (p = .078). New visual field deficits were seen in 12% and new or worsened hemiparesis in 6%. For patients in either cohort, concordance of interictal and ictal EEG findings was found to be predictive of seizure freedom (p = .048).

CONCLUSION

Both total and partial PQD represent effective alternatives for managing patients with MRE whose seizure onset zone (SOZ) involves a diffuse region within the posterior quadrant. While PET and/or SPECT frequently aided in the decision to proceed with total PQD, patients who underwent a tailored, partial multilobar resection were more likely to undergo Wada and/or fMRI testing as well as stage I icEEG studies.

Acute Cerebrovascular Disorders and Vasculopathies Associated with Significant Mortality in SARS-CoV-2 Patients Admitted to The Intensive Care Unit in The New York Epicenter

The current Coronavirus pandemic due to the novel SARS-Cov-2 virus has proven to have systemic and multi-organ involvement with high acuity neurological conditions including acute ischemic strokes. We present a case series of consecutive COVID-19 patients with cerebrovascular disease treated at our institution including 3 cases of cerebral artery dissection including subarachnoid hemorrhage. Knowledge of the varied presentations including dissections will help treating clinicians at the bedside monitor and manage these complications preemptively.

Parasitic infections of the spine: case series and review of the literature

OBJECTIVEAlthough parasitic infections are endemic to parts of the developing world and are more common in areas with developing economies and poor sanitary conditions, rare cases may occur in developed regions of the world.METHODSArticles eligible for the authors' literature review were initially searched using PubMed with the phrases "parasitic infections" and "spine." After the authors developed a list of parasites associated with spinal cord infections from the initial search, they expanded it to include individual diagnoses, using search terms including "neurocysticercosis," "schistosomiasis," "echinococcosis," and "toxoplasmosis."RESULTSTwo recent cases of parasitic spinal infections from the authors' institution are included.CONCLUSIONSKey findings on imaging modalities, laboratory studies suggestive of parasitic infection, and most importantly a thorough patient history are required to correctly diagnose parasitic spinal infections.

The effect of prophylactic vancomycin powder on infections following spinal surgeries: a systematic review

OBJECTIVEThe use of vancomycin powder in spine surgery for prophylaxis against surgical site infections (SSIs) is well debated in the literature, with the majority of studies demonstrating improvement and some studies demonstrating no significant reduction in infection rate. It is well known in certain populations that vancomycin powder reduces the general rate of infection, but its effects on reducing the rate of infection due to gram-negative pathogens are not well reviewed. The goal of this paper was to review studies that investigated the efficacy of vancomycin powder as a prophylactic agent against SSI and demonstrate whether the rate of infections by gram-negative pathogens is impacted.METHODSAn electronic search of the published literature was performed using PubMed and Google Scholar in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A variety of combinations of the search terms "vancomycin powder," "infection," "spine," "gram-negative," "prophylaxis," and "surgical site" was used. Inclusion criteria were studies that 1) described an experimental group that received intraoperative intrawound vancomycin powder; 2) included adequately controlled groups that did not receive intraoperative intrawound vancomycin powder; 3) included the number of patients in both the experimental and control groups who developed infection after their spine surgery; and 4) identified the pathogen-causing infection. Studies not directly related to this review's investigation were excluded from the initial screen. Among the studies that met the criteria of the initial screen, additional reasons for exclusion from the systematic review included lack of a control group, unspecified size of control groups, and inconsistent use of vancomycin powder in the experimental group.RESULTSThis systematic review includes 21 studies with control groups. Vancomycin powder significantly reduced the relative risk of developing an SSI (RR 0.55, 95% CI 0.45-0.67, p < 0.0001). In addition, the use of vancomycin powder did not significantly increase the risk of infection by gram-negative pathogens (RR 1.11, 95% CI 0.66-1.86, p = 0.701).CONCLUSIONSThe results of this systematic review suggest that intrawound vancomycin powder is protective against SSI. It is less clear if this treatment increases the risk of gram-negative infection. Further studies are required to investigate whether rates of infection due to gram-negative pathogens are affected by the use of vancomycin powder.

Chondromyxoid Fibroma of the Sacral Spine

Background and Importance. Chondromyxoid fibromas are rare tumors of cartilaginous origin typically found in long bones. They usually present during the second and third decades of life. In this case report, we describe the case of a 60-year-old male who presented with back pain and was later found to have a sacral mass. Further immunohistochemical analysis determined that the mass was a chondromyxoid fibroma. Clinical Presentation. A 60-year-old male presented with worsening lower back pain over the course of 2 years. Magnetic resonance imaging demonstrated a destructive mass centered at S4 with heterogeneous enhancement. The patient underwent an S3-to-Co1 laminectomy for gross total resection of the tumor. Histology demonstrated a biphasic, lobulated appearance, characteristic of a chondromyxoid fibroma. The tissue stained faintly positive for multicytokeratin, and it was negative for markers S-100 protein and brachyury, indicating that it was not a chordoma. Conclusion. Only 8 cases have documented sacral chondromyxoid fibroma. As these are exceedingly rare tumors, especially within the sacral spine, the differential diagnosis includes other malignant tumors more likely to be found in the spine, particularly chordomas and chondrosarcomas. Immunohistochemistry and histology are essential in making a definitive diagnosis. This case provides a comprehensive illustration of the clinical presentation, radiographic findings, and immunohistochemistry of sacral chondromyxoid fibroma.

Epidermoid Cyst of the Lumbar Spine After Lumbar Puncture: A Clinical, Radiographic, and Pathologic Correlation

BACKGROUND

Epidermoid cysts can rarely arise as a late complication of lumbar puncture. We describe a young man who had a remote history of a lumbar puncture and who was subsequently found to have a lumbar spinal epidermoid cyst on imaging, after presenting with lower extremity radicular pain.

CASE DESCRIPTION

A 24-year-old man with a remote history of lumbar puncture presented with lower back pain and radicular leg pain which had been ongoing for over a year. Despite conservative management, the patient's symptoms progressed to worsening back pain and left L4 radiculopathy. Magnetic resonance imaging of the lumbar spine demonstrated a peripherally enhancing, intradural, extramedullary lesion at L4-5. Diffusion-weighted imaging revealed diffusion restriction within the lesion, characteristic of an epidermoid cyst. The patient underwent an L4-5 laminectomy for resection of the intradural tumor. The lesion was noted to contain pearly white granules consistent with the appearance of an epidermoid cyst. Histopathology confirmed the diagnosis. On follow-up examination, the patient demonstrated improvement of his back pain and resolution of radicular symptoms.

CONCLUSIONS

Lumbar spinal epidermoid cysts may be either congenital or secondary to an iatrogenic cause. This patient had a remote history of lumbar puncture during workup for meningitis as a child. As a complication of a lumbar puncture, the formation of an epidermoid cyst can occur and is thought to be the result of implanted cutaneous tissue. This case provides a comprehensive illustration of the clinical, radiographic, intraoperative, and pathologic findings consistent with an iatrogenic epidermoid cyst.

First case series of the transradial approach for neurointerventional procedures in pediatric patients

OBJECTIVE

The transradial approach (TRA) has been widely adopted by interventional cardiologists but is only now being accepted by neurointerventionalists. The benefits of the TRA over the traditional transfemoral approach (TFA) include reduced risk of adverse clinical events and faster recovery. The authors assessed the safety and feasibility of the TRA for neurointerventional cases in the pediatric population.

METHODS

Pediatric patients undergoing cerebrovascular interventions since implementation of the TRA at the authors' institution were retrospectively reviewed. Pertinent patient information, procedure indications, vessels catheterized, fluoroscopy time, and complications were reviewed.

RESULTS

There were 4 patients in this case series, and their ages ranged from 13 to 15 years. Each patient tolerated the procedure performed using the TRA without any postprocedural issues, and only 1 patient experienced radial artery spasm, which resolved with the administration of intraarterial verapamil. None of the patients required conversion to the TFA.

CONCLUSIONS

The TRA can be considered a safe alternative to the TFA for neurointerventional procedures in the pediatric population and provides potential advantages. However, as pediatric patients require special consideration due to their smaller-caliber arteries, routine use of ultrasound guidance is advised when attempting the TRA.

Proneurotrophins Induce Apoptotic Neuronal Death After Controlled Cortical Impact Injury in Adult Mice

The p75 neurotrophin receptor (p75NTR) can regulate multiple cellular functions including proliferation, survival, and apoptotic cell death. The p75NTR is widely expressed in the developing brain and is downregulated as the nervous system matures, with only a few neuronal subpopulations retaining expression into adulthood. However, p75NTR expression is induced following damage to the adult brain, including after traumatic brain injury, which is a leading cause of mortality and disability worldwide. A major consequence of traumatic brain injury is the progressive neuronal loss that continues secondary to the initial trauma, which ultimately contributes to cognitive decline. Understanding mechanisms governing this progressive neuronal death is key to developing targeted therapeutic strategies to provide neuroprotection and salvage cognitive function. In this study, we demonstrate that a cortical impact injury to the sensorimotor cortex elicits p75NTR expression in apoptotic neurons in the injury penumbra, confirming previous studies. To establish whether preventing p75NTR induction or blocking the ligands would reduce the extent of secondary neuronal cell death, we used a noninvasive intranasal strategy to deliver either siRNA to block the induction of p75NTR, or function-blocking antibodies to the ligands pro-nerve growth factor and pro-brain-derived neurotrophic factor. We demonstrate that either preventing the induction of p75NTR or blocking the proneurotrophin ligands provides neuroprotection and preserves sensorimotor function.

Distal Transradial Access in the Anatomic Snuffbox for Diagnostic Cerebral Angiography

The aim of this study was to describe the feasibility, technique, and safety of distal transradial access in the anatomic snuffbox for diagnostic cerebral angiography. A retrospective review of diagnostic cerebral angiograms obtained during a 6-month period with distal transradial access was performed. Thirty-four successful procedures were performed via distal transradial access. There were 4 failed attempts. This single-center experience using distal transradial access suggests that this technique is safe and effective.

Artificial intelligence in neurocritical care

BACKGROUND

Neurocritical care combines the management of extremely complex disease states with the inherent limitations of clinically assessing patients with brain injury. As the management of neurocritical care patients can be immensely complicated, the automation of data-collection and basic management by artificial intelligence systems have garnered interest.

METHODS

In this opinion article, we highlight the potential artificial intelligence has in monitoring and managing several aspects of neurocritical care, specifically intracranial pressure, seizure monitoring, blood pressure, and ventilation.

RESULTS

The two major AI methods of analytical technique currently exist for analyzing critical care data: the model-based method and data driven method. Both of these methods have demonstrated an ability to analyze vast quantities of patient data, and we highlight the ways in which these modalities of artificial intelligence might one day play a role in neurocritical care.

CONCLUSIONS

While none of these artificial intelligence systems are meant to replace the clinician's judgment, these systems have the potential to reduce healthcare costs and errors or delays in medical management.

Endoscopic Fourth Ventriculostomy: Suboccipital Transaqueductal Approach for Fenestration of Isolated Fourth Ventricle: Case Report and Technical Note

BACKGROUND

Trapped or isolated fourth ventricle is a known, late sequela after lateral ventricular shunt placement for hydrocephalus, particularly after infection or hemorrhage. It may cause brainstem compression and insidiously present with ataxia, dysarthria, and intracranial hypertension, further delaying diagnosis. There is no universally agreed on treatment algorithm, and options include open fenestration through a suboccipital craniotomy, fourth ventricle shunting, and minimally invasive options including endoscopic stenting and fenestration through a precoronal approach.

CASE DESCRIPTION

We describe a young child with epilepsy and symptomatic brainstem compression from a dilated fourth ventricle, with a history of streptococcal parietal abscess and posthemorrhagic hydrocephalus requiring shunt placement. Given his history of infection and nearly neurologically intact examination, we pursued minimally invasive endoscopy through a suboccipital, transaqueductal approach to fenestrate his fourth ventricle.

CONCLUSIONS

Magnetic resonance imaging (MRI) demonstrated complex, loculated hydrocephalus and a dilated fourth ventricle. Under electromagnetic navigation, we endoscopically fenestrated his fourth ventricle using a rarely described suboccipital, transaqueductal approach. He tolerated the procedure without complication and improved neurologically, although his follow-up MRI demonstrated no change in fourth ventricular dilation at 1 year. Although there was no decrease in size of the fourth ventricle on follow-up MRI, we describe an alternative, well-tolerated, suboccipital approach for the management of a trapped fourth ventricle. Fenestration of a web of tissue in the aqueduct of Sylvius provided long-term clinical improvement and may provide a rescue approach for patients who are not candidates for standard approaches.

Neuroendovascular Cerebral Sinus Stenting in Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) is a rare, ill-understood disease of significant morbidity. Because the pathophysiology is poorly understood, treatment protocols are not uniform and are directed towards alleviating the most common symptoms: headache and visual loss. In this review, we analyze 25 case series, all of which included IIH patients (n = 408) who were treated with placement of a venous sinus stent. Among 342 patients who had headache, 240 patients (70.2%) had improvement or resolution of headache after the stent insertion. Of the 217 patients documented to have visual problems, visual acuity was improved or stabilized in 161 patients (74.2%). Of the 304 patients with papilledema, 257 showed resolution or improved (84.5%). Of the 124 patients who presented with pulsatile tinnitus, it was resolved in 110 patients (88.7%) after stent placement. Endovascular management of dural sinus stenosis is therefore clinically efficacious in patients with IIH who have failed medical and surgical therapy.

Admission neutrophil–lymphocyte ratio predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage

Background

Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) has a multifactorial pathophysiology, with immune dysregulation being an important component. The neutrophil–lymphocyte ratio (NLR) is an established prognostic marker in patients with cancer, cardiac disease, and sepsis.

Objective

To determine whether there is a relationship between NLR and DCI in patients with aSAH.

Methods

We evaluated 1067 patients with aSAH between 2006 and 2015 enrolled in a single-center, prospective, observational cohort study. Admission white blood cell differentials (NLR) were analyzed using a cut-off point of ≥5.9. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment, or a decrease in at least two points on the Glasgow Coma Scale, which was not apparent immediately after aneurysm occlusion, and could not be attributed to other causes. Cerebral infarct was defined as a new infarct on CT that was not visible on the admission or immediate postoperative scan, when the cause was thought to be vasospasm by the research team. Logistic regression models were generated.

Results

We found that 768 (72%) patients had an admission NLR ≥5.9. In a multivariable model, elevated NLR was associated with poor admission Hunt-Hess grade (OR=1.6, 95% CI 1.2 to 2.6, p=0.005), Caucasian ethnicity (OR=2.6, 95% CI 1.9 to 3.7, p<0.001), anterior aneurysm location (OR=1.7, 95% CI 1.2 to 2.4, p=0.004), loss of consciousness at ictus (OR=1.4, 95% CI 1.0 to 2.0, p=0.055), and thick SAH (modified Fisher grade ≥3) (OR=1.8, 95% CI 1.3 to 2.4, p<0.001). Admission NLR predicted development of delayed cerebral ischemia (DCI) (OR=1.7; 95% CI 1.1 to 2.5, p=0.008) after controlling for known predictors such as age, poor admission clinical grade, thick SAH blood, and elevated admission mean arterial pressure.

Conclusions

This study provides further evidence of the association between inflammation and DCI. Admission NLR is a readily available and convenient biomarker that may be a clinically useful tool for prognostication when evaluating aSAH.

Endovascular Management of Epistaxis Secondary to Dissecting Pseudoaneurysm of the Descending Palatine Artery Following Orthognathic Surgery

Orthognathic surgeries such as Le Fort I are widely used in clinical practice. Postoperative internal maxillary artery pseudoaneurysm is a very rare complication, which can lead to significant postoperative bleeding. In this article, we report a case of early postoperative bleeding secondary to pseudoaneurysm following Le Fort I surgery with a novel endovascular treatment approach.

Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary.

Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.”

A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion

Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.