Management of Pediatric Cavum Cysts: A Scoping Review and a Single Institution Case Series.

INTRODUCTION: Pediatric cavum cysts are a rare yet complicated pathology to manage. The literature is scarce, primarily consisting of case series, and lacking a consensus regarding clear management. In this scoping review, we aimed to compile existing information in the literature regarding the management of pediatric cavum cysts across the last 10 years. We also present our management of 19 patients, the largest case series to date, highlighting knowledge gaps surrounding the management of this salient pathology. METHODS: A literature search using PubMed and SCOPUS was conducted using the following search terms: (pediatric) AND (Cavum septum pellucidum) OR (cavum vergae) OR (cavum velum interpositum) AND (management). Eligibility criteria included peer-reviewed publication published in the last 10 years, pediatric population, cavum cyst, and English language. A retrospective search was conducted for all pediatric cavum cysts between 2013 and 2023 at our institution. Clinical and radiographic characteristics as well as intervention and outcome data were collected for both the scoping review and our cases. RESULTS: 330 total articles were populated using our search. 12 articles met our inclusion criteria. 41.7% (n = 5) of the articles were case series, 33.3% (n = 4) were case reports, 8.3% (n = 1) was a technical article, 8.3% (n = 1) was a systematic review, and 8.3% (n = 1) was a case questionnaire. Resolution of symptoms was noted in all articles of our scoping review, regardless of treatment modality. The average age in our case series was 9.84 years old and average age at diagnosis was 5.53 years old. 6 patients (31.6%) were female and 13 patients (68.4%) were male. 2 out of the 19 patients (10.5%) were surgically treated. CONCLUSION: There is no clear consensus on the management of cavum cysts. A prospective, multicenter study is needed to create standardized pediatric cyst management guidelines. The current thought is that surgical intervention should be saved for those patients with obstructive hydrocephalus and signs of intracranial hypertension.

Systematic content analysis of patient evaluations of START NOW psychotherapy reveals practical strategies for improving the treatment of opioid use disorder.

BACKGROUND: Clinical trials provide consistent evidence for buprenorphine's efficacy in treating opioid use disorder (OUD). While the Drug Addiction Treatment Act of 2000 requires physicians to combine medication-assisted treatment (MAT) with behavioral intervention, there is no clear evidence for what form or elements of psychotherapy are most effective when coupled with MAT to treat OUD. This investigation involves focus groups designed to collect patient opinions about a specific psychotherapy, called START NOW, as well as general beliefs about various elements of psychotherapy for treating OUD. Our analysis reveals trends about patient preferences and strategies for improving OUD treatment. METHODS: Subjects included patients enrolled in buprenorphine/naloxone MAT at our institution's office-based opioid treatment program. All subjects participated in a single START NOW group session, which was led by a provider (physician or nurse practitioner trained and standardized in delivering START NOW). Consented subjects participated in satisfaction surveys and audio-recorded focus groups assessing individual beliefs about various elements of psychotherapy for treating OUD. RESULTS: Overall, 38 different focus groups, 92 participation events, and 44 unique subjects participated in 1-to-6 different START NOW session/audio-recorded focus group sessions led by a certified moderator. Demographic data from 36/44 subjects was collected. Seventy-five percent (33/44) completed the START NOW Assessment Protocol, which revealed self-reported behavioral trends. Analysis of all 92 START NOW Satisfaction Questionnaire results suggests that subjects' opinions about START NOW improved with increased participation. Our analysis of audio-recorded focus groups is divided into three subsections: content strategies for new psychotherapies, implementation strategies, and other observations. For example, participants request psychotherapies to target impulsivity and to teach future planning and build positive relationships. CONCLUSIONS: The results of this study may guide implementation of psychotherapy and improve the treatment of OUD, especially as it relates to improving the modified START NOW program for treating OUD. Our study also reveals a favorable outlook of START NOW with increased participation, suggesting that any initial reticence to this program can be overcome to allow for effective implementation.

Contrast enhanced ultrasound for traumatic spinal cord injury: an overview of current and future applications.

STUDY DESIGN: Systematic review. OBJECTIVE: Contrast-enhanced ultrasound (CEUS) is an imaging modality that has only recently seen neurosurgical application. CEUS uses inert microbubbles to intraoperatively visualize vasculature and perfusion of the brain and spinal cord in real time. Observation and augmentation of spinal cord perfusion is vital component of the management of traumatic spinal cord injury, yet there are limited imaging modalities to evaluate spinal cord perfusion. CEUS provides an intraoperative imaging tool to evaluate spinal cord perfusion in real time. The objective of this review is to evaluate the current literature on the various applications and benefits of CEUS in traumatic spinal cord injury. SETTING: South Carolina, USA. METHODS: This review was written according to the PRISMA 2020 guidelines. RESULTS: 143 articles were found in our literature search, with 46 of them being unique. After excluding articles for relevance to CEUS and spinal cord injury, we were left with 10 papers. Studies in animal models have shown CEUS to be an effective non-invasive imaging modality that can detect perfusion changes of injured spinal cords in real time. CONCLUSION: This imaging modality can provide object perfusion data of the nidus of injury, surrounding penumbra and healthy neural tissue in a traumatized spinal cord. Investigation in its use in humans is ongoing and remains promising to be an effective diagnostic and prognostic tool for those suffering from spinal cord injury.

An early case of successful peripheral nerve repair in 1880: Francis L. Parker, MD.

The modern technique of epineural suture repair, along with a detailed reporting of functional restoration, came from Carl Hueter in 1873. While there is extensive information on peripheral nerve surgery throughout recorded history leading up to the 1800s, little early American scientific literature is available. While Schwann, Nissl, and Waller were publishing their work on nerve anatomy and physiology, Francis LeJau Parker was born. The South Carolina native would go on to describe one of the first American cases of peripheral nerve repair with the restoration of function. Francis Parker was born in 1836 in Abbeville, South Carolina. He gained local notoriety as one of the first American surgeons to suture a severed nerve, resulting in restored function. The case dates back to 1880, when a patient presented to his clinic with severing of the posterior interosseous nerve. The details of this case come from the archives of the South Carolina Medical Association. The authors reviewed these records in detail and provide a case description of nerve repair not previously reported in the modern literature. The history, neurological examination, and details of the case provide insight into the adroit surgical skills of Dr. Parker.

Transradial Angiography Skill Acquisition Using an Endovascular Simulation Program.

BACKGROUND: Given the benefits of neuroendovascular simulation to resident education, this study aimed to assess the efficacy of simulation-based training for neuroendovascular intervention with primary and secondary catheters using a transradial approach (TRA). METHODS: Five neurosurgical residents (PGY 1-3) from our institution enrolled in a standardized pilot training protocol. Trainees used the Mentice (Gothenburg, Vastra Gotaland, Sweden) Visit G5 simulator with a type II arch using a right TRA. RESULTS: All participants improved their total time to complete the task from the first trial to the last trial. Residents improved the overall time required to complete the task by 111.8 ± 57 seconds (52% improvement; P = 0.012). Participants reported improved knowledge of Simmons catheter formation from 1.6 ± 0.8 to 2.8 ± 1 (P = 0.035) and improved knowledge of transradial vessel selection technique from 1.6 ± 0.9 to 2.8 ± 1.1 (P = 0.035). All residents were able to illustrate a bovine arch and types 1-3 arches post-simulation. Residents rated the simulation usefulness as 4.6 ± 0.548 (scale 1 [not useful] to 5 [essential]) with 4 of the 5 residents (80%) identifying this exercise as essential. All residents rated the hands-on component of the training exercise as the most important. CONCLUSIONS: Residents demonstrated proficiency at Simmons catheter formation and vessel selection in a type II arch over a short time period (4 attempts and <1 hour total). Residents can use simulator-based training to increase their proficiency of vessel selection using a primary or secondary catheter for a TRA.

Thrombectomy in Stroke Patients With Low Alberta Stroke Program Early Computed Tomography Score: Is Modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 Superior to mTICI 2b?

BACKGROUND AND PURPOSE: Outcomes following mechanical thrombectomy (MT) are strongly correlated with successful recanalization, traditionally defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b. This retrospective cohort study aimed to compare the outcomes of patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS; 2-5) who achieved mTICI 2b versus those who achieved mTICI 2c/3 after MT. METHODS: This study utilized data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combined databases from 32 thrombectomy-capable stroke centers between 2013 and 2023. The study included only patients with low ASPECTS who achieved mTICI 2b, 2c, or 3 after MT for internal carotid artery or middle cerebral artery (M1) stroke. RESULTS: Of the 10,229 patients who underwent MT, 234 met the inclusion criteria. Of those, 98 (41.9%) achieved mTICI 2b, and 136 (58.1%) achieved mTICI 2c/3. There were no significant differences in baseline characteristics between the two groups. The 90-day favorable outcome (modified Rankin Scale score: 0-3) was significantly better in the mTICI 2c/3 group than in the mTICI 2b group (adjusted odds ratio 2.35; 95% confidence interval [CI] 1.18-4.81; P=0.02). Binomial logistic regression revealed that achieving mTICI 2c/3 was significantly associated with higher odds of a favorable 90-day outcome (odds ratio 2.14; 95% CI 1.07-4.41; P=0.04). CONCLUSION: In patients with low ASPECTS, achieving an mTICI 2c/3 score after MT is associated with a more favorable 90-day outcome. These findings suggest that mTICI 2c/3 is a better target for MT than mTICI 2b in patients with low ASPECTS.

Functional MRI-Guided Motor Cortex and Deep Brain Stimulation for Intractable Facial Pain: A Novel, Personalized Approach in 1 Patient.

BACKGROUND: Facial neuropathic pain syndromes such as trigeminal neuralgia are debilitating disorders commonly managed by medications, vascular decompression, and/or ablative procedures. In trigeminal neuralgia cases unresponsive to these interventions, trigeminal deafferentation pain syndrome (TDPS) can emerge and remain refractory to any further attempts at these conventional therapies. Deep brain stimulation (DBS) and motor cortex stimulation are 2 neuromodulatory treatments that have demonstrated efficacy in small case series of TDPS yet remain largely underutilized. In addition, functional MRI (fMRI) is a tool that can help localize central processing of evoked stimuli such as mechanically triggered facial pain. In this study, we present a case report and operative technique in a patient with TDPS who underwent fMRI to guide the operative management and placement of dual targets in the sensory thalamus and motor cortex. OBJECTIVE: To evaluate the safety, efficacy, and outcome of a novel surgical approach for TDPS in a single patient. METHODS: The fMRI and operative technique of unilateral DBS targeting the ventroposteromedial nucleus of the thalamus and facial motor cortex stimulator placement through a single burr hole is illustrated as well as the patient's clinical outcome. RESULTS: In less than 1 year, the patient had near complete resolution of his facial pain with no postoperative complications. CONCLUSION: We present the first published case of successful treatment of TDPS using simultaneous DBS of the ventroposteromedial and motor cortex stimulation. fMRI can be used as an effective imaging modality to guide neuromodulation in this complex disorder.

Giant Pediatric Dural Arteriovenous Fistula Management Using a Combined Operative Approach in a Hybrid Neuroendovascular Surgery Suite: Technical Nuances and Review of Literature.

BACKGROUND: Pediatric intracranial dural arteriovenous fistulas (dAVFs) are rare, complex entities usually presenting with macrocephaly from increased intracranial pressures at a young age. In the setting of a symptomatic intracranial dAVF that has undergone multiple endovascular treatments with subsequent recurrence or failed embolization attempts, the intracranial venous system can become inaccessible by traditional transvenous and transarterial routes. Direct puncture of the venous sinus for endovascular access after surgical exposure is a viable option. OBJECTIVE: To describe the technical nuances and available literature for direct puncture of the venous sinus for endovascular access in a pediatric patient with dAVF. METHODS: The clinical characteristics were reviewed and reported for a patient who underwent direct puncture of the venous sinus for endovascular access. In addition, a literature review was conducted for relevant literature pertaining to this technique and its associated indications, outcomes, and complications. RESULTS: Only 2 other reports of direct puncture of venous sinus for endovascular access after surgical exposure were found in the literature. Our patient achieved a favorable outcome with complete dAVF obliteration. CONCLUSION: Direct puncture of the venous sinus for endovascular access after surgical exposure for complex dAVFs that are inaccessible by transvenous or transarterial routes is a practical and safe approach to intracranial venous access that should be part of the vascular neurosurgeon's arsenal.

Infratentorial retroclival and tentorial subdural hematoma from posterior communicating artery aneurysm rupture: A case report and systematic review of literature.

Background: The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural hematoma (SDH) of the infratentorial space without associated subarachnoid hemorrhage (SAH). Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature review was conducted in PubMed and Scopus electronic databases for relevant published cases of aneurysmal SDH (AnSDH) of the infratentorial compartment without associated SAH. The presentation, treatment, clinical course, and outcome of identified cases are compiled. In addition, a patient suffering from an infratentorial SDH following aneurysm rupture is presented with an illustrative case. Results: Three articles were identified and met inclusion criteria. All cases occurred from ruptured posterior communicating artery aneurysms. All patients arrived with a Hunt and Hess classification of 2 or less. Only one case was managed with operative aneurysm clipping and hematoma evacuation while the other three cases were managed endovascularly. There were no reported postoperative complications, vasospasm, or seizures reported. All patients had a final Modified Rankin score of 3 or less at last reported follow-up. Conclusion: Infratentorial AnSDH without associated SAH is an etiology rarely reported in the literature. Here, we present a case report and systematic review demonstrating a relatively benign clinical course and outcome compared to report aneurysm rupture associated with SAH or mixed SAH and SDH. Moreover, there appear to be lower rates of vasospasm and improved outcomes in patients with isolated AnSDH compared to the literature aneurysmal SAH rates.

Surgical management of Currarino syndrome in elderly patient with infected pre-sacral mass: Technical nuances and review of literature.

OBJECTIVE: Currarino Syndrome (CS) is a rare autosomal dominant genetic disorder that is defined by a triad of: presacral mass, anorectal malformations, and sacral bone dysplasia. Once discovered, these lesions are often surgically treated to avoid life threatening complications such as meningitis and malignant transformation of a sacral teratoma. As this syndrome is usually diagnosed in childhood, accurate diagnosis in adults presenting with this syndrome can be challenging and delay treatment. We present a case report with diagnostic and surgical management strategies of CS presenting in an elderly patient with accompanying review of literature. METHODS: We performed a literature review by searching PubMed, Ovid Embase, and Scopus electronic databases with the predetermined inclusion criteria of cases of CS in the adult population. RESULTS: A 70-year-old male with newly diagnosed CS and meningitis successfully underwent resection of his lesion as an interdisciplinary case between neurosurgery and colorectal surgery. At six-month follow up, the patient reports resolution of constipation and urinary symptoms, no longer has signs of infection, and remains neurologically full strength in his lower extremities. A review of literature revealed only 5 previously reported cases of CS presenting in the adult population with 3 of these cases requiring surgical intervention. CONCLUSION: Currarino Syndrome (CS) is an autosomal dominant genetic disorder characterized by a presacral mass, sacral bony deformities, and anorectal malformations. It is usually diagnosed in pediatric age group. In this article, we present a case of a 70-year-old male presenting with meningitis, encephalopathy, and gastrointestinal disturbances.

Molecular Classification and Therapeutic Targets in Ependymoma.

Ependymoma is a biologically diverse tumor wherein molecular classification has superseded traditional histological grading based on its superior ability to characterize behavior, prognosis, and possible targeted therapies. The current, updated molecular classification of ependymoma consists of ten distinct subgroups spread evenly among the spinal, infratentorial, and supratentorial compartments, each with its own distinct clinical and molecular characteristics. In this review, the history, histopathology, standard of care, prognosis, oncogenic drivers, and hypothesized molecular targets for all subgroups of ependymoma are explored. This review emphasizes that despite the varied behavior of the ependymoma subgroups, it remains clear that research must be performed to further elucidate molecular targets for these tumors. Although not all ependymoma subgroups are oncologically aggressive, development of targeted therapies is essential, particularly for cases where surgical resection is not an option without causing significant morbidity. The development of molecular therapies must rely on building upon our current understanding of ependymoma oncogenesis, as well as cultivating transfer of knowledge based on malignancies with similar genomic alterations.