Middle meningeal artery embolization associated with reduced chronic subdural hematoma volume and midline shift in the acute postoperative period.

BACKGROUND: Middle meningeal artery (MMA) embolization for endovascular treatment of chronic subdural hematoma (cSDH) is growing in popularity. cSDH volume and midline shift were analyzed in the immediate postoperative window after MMA embolization. METHODS: A retrospective analysis of cSDHs managed via MMA embolization from January 1, 2018 to March 30, 2021 was performed at a large quaternary center. Pre- and postoperative cSDH volume and midline shift were quantified with CT. Postoperative CT was obtained 12 to 36 hours after embolization. Paired t-tests were used to determine significant reduction. Multivariate analysis was performed using logistic and linear regression for percent improvement from baseline volume. RESULTS: In total, 80 patients underwent MMA embolization for 98 cSDHs during the study period. The mean (SD) initial cSDH volume was 66.54 (34.67) mL, and the mean midline shift was 3.79 (2.85) mm. There were significant reductions in mean cSDH volume (12.1 mL, 95% CI 9.32 to 14.27 mL, P<0.001) and midline shift (0.80 mm, 95% CI 0.24 to 1.36 mm, P<0.001). In the immediate postoperative period, 22% (14/65) of patients had a>30% reduction in cSDH volume. A multivariate analysis of 36 patients found that preoperative antiplatelet and anticoagulation use was significantly associated with an expansion in volume (OR 0.028, 95% CI 0.000 to 0.405, P=0.03). CONCLUSION: MMA embolization is safe and effective for the management of cSDH and is associated with significant reductions in hematoma volume and midline shift in the immediate postoperative period.

Minimally Invasive Transforaminal Interbody Fusion With Robotically Assisted Bilateral Pedicle Screw Fixation: 2-Dimensional Operative Video.

Minimally invasive surgery (MIS) techniques may enable faster patient recovery and reduce the incidence of postoperative infections. Image-guided approaches to spinal instrumentation and interbody fusion have gained popularity in MIS, reducing radiation exposure and improving screw placement accuracy. Use of a novel computed tomography (CT) navigation-based robotic arm provides for live image-guided surgery, with the potential for augmenting existing MIS approaches and improving the accuracy of instrumentation placement. We report on the surgical technique of MIS transforaminal lumbar interbody fusion (TLIF) performed with the assistance of a new robotic device (ExcelsiusGPS, Globus Medical Inc, Audubon, Pennsylvania) and intraoperative CT guidance in a patient with single-level lumbar spondylolisthesis. The patient gave written informed consent before treatment. Institutional review board approval was deemed unnecessary. The patient was positioned prone on the operating room table, and an intraoperative CT was obtained with stereotactic arrays placed bilaterally in the posterior superior iliac spine. Screw trajectories were planned using the ExcelsiusGPS software and placed percutaneously with the robotic arm without using a Kirschner wire. Interbody placement was performed via an expandable retractor after muscle dilation. Screw placement accuracy was determined with postoperative CT, which demonstrated good screw positioning without breach. The patient recovered well and was discharged home without complications. The combined use of the new robotic device and intraoperative CT enables accurate and safe fixation for the treatment of symptomatic lumbar spondylolisthesis. The operative video demonstrates the technical nuances of positioning, stereotactic marker placement, work flow, and screw placement. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Microsurgical treatment of pediatric intracranial aneurysms: long-term angiographic and clinical outcomes.

BACKGROUND: Pediatric aneurysms are rare and complex to treat. Long-term angiographic and clinical data after microsurgical or endovascular therapies are lacking. OBJECTIVE: To study the clinical and radiographic outcomes in aneurysms in pediatric patients treated with microsurgery. METHODS: Between 1989 and 2005, 48 patients

Posterior inferior cerebellar artery origin thrombosis with aneurysm of collateralized posterior meningeal artery presenting as subarachnoid hemorrhage: case report.

OBJECTIVE: This is the first report of a ruptured aneurysm involving a collateral branch to the posterior inferior cerebellar artery (PICA) in a patient who had a subarachnoid hemorrhage. CLINICAL PRESENTATION: A 56-year-old man initially presented with a subarachnoid hemorrhage and underwent 2 catheter-based 4-vessel angiograms with negative results. A delayed angiogram 4 weeks later revealed a dissecting aneurysm of the posterior meningeal artery, a branch of the vertebral artery. INTERVENTION: A 3-dimensional reconstruction of the vertebral angiogram showed proximal occlusion of the proximal left PICA and distal filling via a collateral branch from the posterior meningeal artery. A far-lateral approach was used for this patient. The aneurysm was found along the course of the collateral posterior meningeal artery and was clipped successfully. CONCLUSION: Aneurysms involving collateral branches of the PICA are rare. It is important to recognize such collateral flow preoperatively because inadvertent sacrifice of these vessels during a surgical approach could lead to stroke and neurological deficits of the PICA territory.

Anterior cerebral artery amputation and salvage repair of internal carotid artery tear: technical case report.

OBJECTIVE: We describe a novel technique used to repair an unanticipated tear of the internal carotid artery (ICA) requiring anterior cerebral artery (ACA) amputation to allow primary repair of the arteriotomy. CLINICAL PRESENTATION: A 59-year-old woman underwent an orbitozygomatic craniotomy to treat a large, suprasellar, thyroid-stimulating hormone-secreting adenoma. During resection, an incidental ICA tear occurred opposite the exit of the middle cerebral artery. TECHNIQUE: After an ICA tear on the wall opposite the middle cerebral artery occurred, clips were placed on the ICA, middle cerebral artery, and ACA. Primary closure was not feasible without critically stenosing the ICA. The ipsilateral ACA was clipped and amputated just distal to its origin. The relaxation afforded by amputating the ACA allowed primary suture repair of the arteriotomy. A clip was placed on the proximal ACA stump. The distal ACA stump revealed good backflow and was also clipped. CONCLUSION: When an arteriotomy of a large intracranial artery cannot be repaired primarily, creative alternatives must be considered. Amputation of a branch artery with sufficient collateral flow is a method to afford adequate relaxation for primary repair of an arteriotomy. This novel method should be considered in the armamentarium of neurosurgeons to minimize the impact of potentially disastrous vascular complications.

Safety and accuracy of bedside external ventricular drain placement.

OBJECTIVE: To study the safety and accuracy of ventriculostomy by neurosurgical trainees. METHODS: Initial computed tomographic studies of 346 consecutive patients who underwent bedside ventriculostomy were reviewed retrospectively. Diagnosis, catheter tip location, midline shift, and procedural complications were tabulated. To analyze catheter placement, we used a new grading system: Grade 1, optimal placement in the ipsilateral frontal horn or third ventricle; Grade 2, functional placement in the contralateral lateral ventricle or noneloquent cortex; and Grade 3, suboptimal placement in the eloquent cortex or nontarget cerebrospinal fluid space, with or without functional drainage. Statistical analysis was performed using Fisher's exact test and a weighted kappa coefficient. RESULTS: Diagnoses included the following: subarachnoid hemorrhage, n = 153 (44%); trauma, n = 64 (18%); intracerebral hemorrhage/intraventricular hemorrhage, n = 63 (18%); and other, n = 66 (20%). There were 266 (77%) Grade 1, 34 (10%) Grade 2, and 46 (13%) Grade 3 catheter placements. Hemorrhagic complications occurred in 17 (5%). Four patients (1.2%) were symptomatic, with two (0.6%) requiring surgery. Inter- and intraobserver agreement was almost perfect (kappa = 0.846 and 0.922, respectively) as applied to our grading system. Rates of suboptimal placement were highest in patients with midline shift (P = 0.059) and trauma (P = 0.0001). Rates of optimal placement were highest in patients with subarachnoid hemorrhage (P = 0.003) and when the catheter was placed ipsilateral to the side of midline shift (P = 0.063). Neither the resident's training experience nor the side of placement seemed to affect accuracy. CONCLUSION: Bedside ventriculostomy is a safe and accurate procedure for intracranial pressure monitoring and cerebrospinal fluid drainage.

Operative intracranial infection following craniotomy.

OBJECT: Postoperative infection after cranial surgery is a serious complication that requires immediate recognition and treatment. In certain cases such as postoperative meningitis, the patient can be treated with antibiotics only. In cases that involve a bone flap infection, subdural empyema, or cerebral abscess, however, reoperation is often needed. There has been significant disagreement regarding the incidence of postoperative central nervous system (CNS) infections following cranial surgery. In this paper the authors' goal was to perform a retrospective review of the incidence of CNS infection after cranial surgery at their institution. They focused their review on those patients who required repeated surgery to treat the infection. METHODS: The authors reviewed the medical records and imaging studies in all patients who underwent a craniotomy or stereotactic drainage for CNS infection over the past 10 years. Subgroup analysis was then performed in patients whose infection was a result of a previous cranial operation to determine the incidence, factors associated with infection, and the type of infectious organism. Patients treated nonoperatively (that is, those who received intravenous antibiotics for postoperative meningitis or cellulitis) were not included. Patients treated for wound infection without intracranial pus were also not included. RESULTS: During the study period from January 1997 through December 2007, approximately 16,540 cranial surgeries were performed by 25 neurosurgeons. These included elective as well as emergency and trauma cases. Of these cases 82 (0.5%) were performed to treat postoperative infection in 50 patients. All 50 patients underwent their original surgery at the authors' institution. The median age was 51 years (range 2-74 years). There were 26 male and 24 female patients. The most common offending organism was methicillin-sensitive Staphylococcus aureus, which was found in 10 of 50 patients. Gram-negative rods were found in 15 patients. Multiple organisms were identified in specimens obtained in 5 patients. Six patients had negative cultures. Most craniotomies leading to subsequent infection were performed for tumors or other mass lesions (23 of 50 patients), followed by craniotomies for hemorrhage and vascular lesions. Almost half of the patients underwent > 1 cranial operation before presenting with infection. CONCLUSIONS: Postoperative infection after cranial surgery is an important phenomenon that needs immediate recognition. Even with strict adherence to sterile techniques and administration of antibiotic prophylaxis, a small percentage of these patients will develop an infection severe enough to require reoperation.

Brain abscess formation at the site of intracerebral hemorrhage secondary to central nervous system vasculitis.

Brain abscess is a rare but very dangerous neurosurgical lesion. Prompt diagnosis and emergency surgical evacuation are the hallmarks of therapy. Brain abscess following ischemic and hemorrhagic stroke is a rare entity. These cases are often preceded by episodes of bacteremia, sepsis, and local infection. The authors report the case of a 30-year-old woman who presented with a cerebral abscess at the site of a recent intraparenchymal hemorrhage.

Juvenile intradural chordoma: case report.

OBJECTIVE: We report the youngest known case of a prepontine intradural chordoma. These tumors are exceedingly rare. Unlike their more common extradural counterparts, no recurrence of an intradural chordoma has been reported. CLINICAL PRESENTATION: A 9-year-old boy underwent diagnostic imaging for evaluation of headaches. Although neurologically intact, a magnetic resonance imaging scan revealed a large prepontine mass with focal enhancement. INTERVENTION: Endoscopic-assisted gross total resection was attained with staged bilateral retrosigmoid approaches. There were no additional adjuvant therapies. At the time of the 1-year follow-up evaluation, the patient had no recurrence. CONCLUSION: By using an endoscopic-assisted procedure, we achieved complete resection of an intradural chordoma offering a potential for surgical cure. Resection is particularly advantageous because it spares the young child the need for radiation treatment. Close follow-up is warranted because we postulate that this tumor exists in a biological continuum between benign notochordal hamartomatous remnants and typical invasive chordomas.

Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases.

OBJECT: The authors evaluated the mechanisms and patterns of thoracic, lumbar, and sacral spinal injuries in a pediatric population as well as factors affecting the management and outcome of these injuries. METHODS: The records of 89 patients (46 boys and 43 girls; mean age 13.2 years, range 3-16 years) with thoracic, lumbar, or sacral injuries were reviewed. Motor vehicle accidents were the most common cause of injury. Eighty-two patients (92.1%) were between 10 and 16 years old, and seven (7.9%) were between 3 and 9 years old. Patient injuries included fracture (91%), fracture and dislocation (6.7%), dislocation (1.1%), and ligamentous injury (1.1%). The L2-5 region was the most common injury site (29.8%) and the sacrum the least common injury site (5%). At the time of presentation 85.4% of the patients were neurologically intact, 4.5% had incomplete injuries, and 10.1% had complete injuries. Twenty-six percent of patients underwent surgery for their injuries whereas 76% received nonsurgical treatment. In patients treated surgically, an anterior approach was used in six patients (6.7%), a posterior approach in 16 (18%), and a combined approach in one (1.1%). Postoperatively, six patients (26.1%) with neurological deficits improved, one of whom recovered fully from an initially complete injury. CONCLUSIONS: Thoracic and lumbar spine injuries were most common in children older than 9 years. Multilevel injuries were common and warranted imaging evaluation of the entire spinal column. Most patients were treated conservatively. The prognosis for neurological recovery is related to the initial severity of the neurological injuries. Some pediatric patients with devastating spinal cord injuries can recover substantial neurological function.