Rapid Ventricular Pacing for Clipping of Intracranial Aneurysms: A Single-centre Retrospective Case Series.

OBJECTIVE: Multiple strategies exist to facilitate microdissection and obliteration of intracranial aneurysms during microsurgical clipping. Rapid ventricular pacing (RVP) can be used to induce controlled transient hypotension to facilitate aneurysm manipulation. We report the indications and outcomes of intraoperative RVP for clipping of ruptured and unruptured complex aneurysms. METHODS: We completed a retrospective review of adult patients who underwent RVP-facilitated elective and emergent microsurgical aneurysm clipping by a single senior neurosurgeon between 2016 and 2023. Intraoperative RVP was performed at a rate of 150 to 200 beats per minute through a transvenous pacing wire and repeated as needed based on surgical requirements. Intraoperative procedural and pacing data and perioperative cardiac and neurosurgical variables were collected. RESULTS: Forty patients were included in this study. The median (interquartile range) number of pacing episodes per patient was 8 (5 to 14), resulting in a median mean arterial pressure of 37 (30 to 40) mm Hg during RVP. One patient developed wide complex tachycardia intraoperatively, which resolved after cardioversion. Fifteen out of 36 (42%) patients who had postoperative troponin measurements had at least one troponin value above the 99th percentile upper reference limit. One patient had markedly elevated troponin with anterolateral ischemia in the context of massive postoperative intracranial hemorrhage. There were no other documented intraoperative or postoperative cardiac events. CONCLUSIONS: This retrospective case series suggests that RVP could be an effective adjunct for clipping of complex ruptured and unruptured aneurysms, associated with transient troponin rise but rare postoperative cardiac complications.

Clinical Reasoning: A 24-Year-Old Woman With Penetrating Neck Injury From a Needlefish.

Evaluating patients with a traumatic spinal cord injury can be complicated by other injuries. In this case, a 24-year-old woman injured by a needlefish presented with combined motor and sensory defects, cranial nerve deficits, and a blunt vascular injury. This case highlights the importance of neurologic and vascular localizations and an understanding of spinal cord injuries involving various ascending and descending tracts. Appreciation of these anatomical considerations through this case illustrates the diagnostic approach to neurologic evaluation. While we present a traumatic etiology for multiple neurologic syndromes, this case gives readers an opportunity to develop a comprehensive differential diagnosis and tailor investigations for other relevant etiologies. Readers walking through this stepwise process will ultimately arrive at several distinct but related diagnoses.

Factors influencing withdrawal of life-supporting treatment in cervical spinal cord injury: a large multicenter observational cohort study.

BACKGROUND: Traumatic spinal cord injury (SCI) leads to profound neurologic sequelae, and the provision of life-supporting treatment serves great importance among this patient population. The decision for withdrawal of life-supporting treatment (WLST) in complete traumatic SCI is complex with the lack of guidelines and limited understanding of practice patterns. We aimed to evaluate the individual and contextual factors associated with the decision for WLST and assess between-center differences in practice patterns across North American trauma centers for patients with complete cervical SCI. METHODS: This retrospective multicenter observational cohort study utilized data derived from the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2020. The study included adult patients (> 16 years) with complete cervical SCI. We constructed a multilevel mixed effect logistic regression model to adjust for patient, injury and hospital factors influencing WLST. Factors associated with WLST were estimated through odds ratios with 95% confidence intervals. Hospital variability was characterized using the median odds ratio. Unexplained residual variability was assessed through the proportional change in variation between models. RESULTS: We identified 5070 patients with complete cervical SCI treated across 477 hospitals, of which 960 (18.9%) had WLST. Patient-level factors associated with significantly increased likelihood of WLST were advanced age, male sex, white race, prior dementia, low presenting Glasgow Coma Scale score, having a pre-hospital cardiac arrest, SCI level of C3 or above, and concurrent severe injury to the head or thorax. Patient-level factors associated with significantly decreased likelihood of WLST included being racially Black or Asian. There was significant variability across hospitals in the likelihood for WLST while accounting for case-mix, hospital size, and teaching status (MOR 1.51 95% CI 1.22-1.75). CONCLUSIONS: A notable proportion of patients with complete cervical SCI undergo WLST during their in-hospital admission. We have highlighted several factors associated with this decision and identified considerable variability between hospitals. Further work to standardize WLST guidelines may improve equity of care provided to this patient population.

"Instant 3D" Angiography: Novel Technique for Rapid Conversion of 2D Angiograms into 3D Stereoscopic Videos.

BACKGROUND: Rotational angiography, often referred to as a "spin", is typically presented in 2D. Since rotational angiograms are composed of images acquired from multiple angles, we took advantage of this property to develop a method for converting any rotational angiogram into a 3 dimensional (3D) video. METHODS: Our aim was to develop a low cost and easily distributable solution without requiring additional hardware or altering acquisition techniques. Six previously acquired rotational angiograms from our institution were imported using custom-written code and exported as anaglyph (red-cyan) videos. RESULTS: The resulting 3D videos convey anatomical depth that is not apparent from viewing the 2D images alone. Processing time was 1.3 ± 0.6 s (mean ± SD) per angiogram. The only associated cost was $10 for red-cyan 3D glasses. Using our software, any rotational angiogram with at least 0.3 frames per degree of rotation can be converted into 3D. CONCLUSIONS: Our solution is an inexpensive and rapid method for generating stereoscopic videos from existing angiograms. It does not require any additional hardware and is readily deployable in low-resource settings. Because the videos are in anaglyph format, they are viewable on any 2 dimensional (2D) display in the interventional suite or operating room, on a mobile device, or at home.

Direct Puncture of the Superficial Temporal Artery in Embolization of a Scalp Arteriovenous Fistula: A Case Report.

We describe a minimally invasive endovascular approach to treat an arteriovenous fistula of the scalp. We performed a direct puncture of the lesion through the patient's scalp for liquid embolic agent injection along with external compression of the superficial temporal artery to perform a "manual pressure-cooker technique." The combination of these minimally invasive techniques resulted in an excellent clinical and radiographic outcome.

The Scanning Fiber Endoscope: A Novel Surgical and High-Resolution Imaging Device for Intracranial Neurosurgery.

BACKGROUND: The scanning fiber endoscope (SFE) is a novel medical imaging device that has been used in various vascular beds as a form of angioscopy, as well as in tracts and duct systems for endoluminal imaging. Owing to its miniaturized form, high resolution, and flexibility, it has demonstrated success in imaging across a wide range of diagnostic applications. OBJECTIVE: To demonstrate, by performing a third ventriculostomy and visualizing the cranial nerves and brainstem anatomy, that, without modification, the SFE can be used through a transcranial approach in a therapeutic intraventricular neurosurgical application. METHODS: A 3.7 French SFE system was used without modification on a live porcine model to perform a third ventriculostomy and acquire high-resolution images of the animal's ventricular system, cranial nerves, and brainstem. A side-by-side comparison was made with one of the current standard-of-care rigid endoscopes as a context for size and image quality. RESULTS: High-resolution video-rate imaging was used to assist the successful, uncomplicated performance of a third ventriculostomy. High-resolution endoscopic images of the brainstem and cranial nerves were acquired. CONCLUSION: Although the SFE has been shown to be a superior device for imaging, here we demonstrate its first use as a potential therapeutic device in intracranial neurosurgery.

Hypertrophic Interstitial Neuropathy of the Trigeminal Nerve: Case Report and Literature Review.

BACKGROUND AND IMPORTANCE: Hypertrophic interstitial neuropathy (HIN) is an uncommon, non-neoplastic lesion typically affecting peripheral nerves. Cranial nerve (CN) involvement is exceedingly rare. We present a case of isolated trigeminal nerve HIN manifesting with V3 distribution neuralgia. CLINICAL PRESENTATION: A 50-yr-old male presented with left sided trigeminal neuralgia refractory to medical management. The patient underwent retromastoid craniectomy for possible microvascular decompression. Intra-operatively, the trigeminal nerve appeared to be focally enlarged with a sausage-like configuration. We selectively resected 1 fascicle which was predominantly involved. Histopathological examination revealed onion bulb formations composed of Schwann cells around centrally placed axons. A diagnosis of HIN was made. Postoperatively, the patient experienced complete resolution of symptoms. CONCLUSION: This is the third case of isolated trigeminal nerve HIN in the literature. We performed a selective resection in a patient presenting with trigeminal neuralgia, resulting in complete resolution of symptoms. It is reported here with intraoperative microscope images, along with a review and analysis of this topic as it related to CN.

Trigeminocardiac Reflex: Case Report and Literature Review of Intraoperative Asystole in Response to Manipulation of the Temporalis Muscle.

BACKGROUND: The trigeminocardiac reflex is a sudden onset of bradycardia, hypotension, apnea, or gastric hypermotility in response to stimulation of the trigeminal nerve. CASE DESCRIPTION: A 60-year-old female underwent a left orbitozygomatic craniotomy to debulk a large skull base epidermoid cyst compressing the brainstem and cranial nerves. Intraoperatively, retraction of the temporalis muscle consistently produced asystole. Cessation of retraction resulted in prompt return of sinus rhythm. CONCLUSIONS: Our report describes an unusual and extreme example of the trigeminocardiac reflex and explores possible etiologies. This is the third reported surgical case in which manipulation of the temporalis muscle alone was sufficient to elicit bradycardia and asystole, and the first such case within the context of neurosurgery. We emphasize the importance of surgical teams to be cognizant of such extreme examples of this reflex.