Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

Approaches to the Middle Cerebellar Peduncle for Resection of Pontine Cavernomas.

INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: The expanded retrosigmoid approach with splitting of the horizontal cerebellar fissure provides a more direct and shorter route for central and dorsolateral pontine lesions while minimizing retraction of tracts, nuclei, and cerebellum. 1-4. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: The middle cerebellar peduncle is partially covered by the petrosal surface of the cerebellum. The horizontal cerebellar fissure (petrosal fissure) divides the petrosal surface of the cerebellar hemisphere into superior and inferior parts. Splitting the petrosal fissure separates the superior and inferior petrosal surfaces and exposes the posterolateral middle cerebellar peduncle (posterior and lateral to the root entry zone of CN5). 1-4. ESSENTIALS STEPS OF THE PROCEDURE: Expanded retrosigmoid craniotomy is performed, including unroofing of the sigmoid sinus; petrosal fissure is split to expose the posterolateral middle cerebellar peduncle; entry point for resection of the cavernoma is identified; nims stimulator stimulator is used to confirm the absence of tracts and nuclei; myelotomy is performed; and cavernoma and its draining vein (but not the developmental venous anomaly) are removed using a combination of traction and countertraction against gliotic plane. PITFALLS/AVOIDANCE OF COMPLICATIONS: Wide splitting of the horizontal cerebellar fissure minimizes retraction or resection of the cerebellum and offers the best angle of attack. Knowledge of brainstem anatomy and use of intraoperative navigation are critical to avoid complications. VARIANTS AND INDICATIONS FOR THEIR USE: Far lateral through the middle cerebellar peduncle is a variant that can be used to resect pontine cavernomas if a caudocranial trajectory is preferred.The patient consented to the procedure and to the publication of her image.

Treatment of Recurrent, Twice Coiled, Previously Ruptured Anterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Aneurysm With Excision and End-to-End Anastomosis: 2-Dimensional Operative Video.

Anterior inferior cerebellar artery-posterior inferior cerebellar artery (AICA-PICA) variant is a well-established variant of the vertebrobasilar system. AICA-PICA aneurysms are extremely rare.1-3 There are only 12 cases reported in the literature.1-3 Here, we are presenting a case of a previously ruptured AICA-PICA dissecting aneurysm which had undergone coil embolization twice at an outside institution. The aneurysm continued to grow, and therefore, the patient was transferred to our institution for definitive treatment. Placement of a flow diverter was felt not to be feasible because of the acute bend of the vessel at the neck of the aneurysm. After a retrosigmoid craniotomy, the aneurysm sac was opened to untether the coil mass from the neck of the aneurysm. Clip reconstruction was attempted but intraoperative blood flow measurements demonstrated no flow in the distal outflow artery, indicating that the clip was occluding the parent vessel at the neck because of the challenging geometry and atherosclerosis. We then proceeded with an excision and end-to-end anastomosis of the AICA-PICA. The details of vascular reconstruction while the inflow and outflow arteries are at acute angle are described. Intraoperative indocyanine video angiography demonstrated complete exclusion of the aneurysm from the circulation and patency of the bypass. Postoperative computed tomography angiography demonstrated bypass patency. Postoperatively, the patient required a temporary external ventricular drain for hydrocephalus; however, she was eventually discharged home without any neurological deficits. The patient gave informed consent for the surgery and video recording. Institutional Review Board approval was deemed unnecessary.

High-Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor.

BACKGROUND: Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. This study aimed to evaluate associations of outcomes with hospital characteristics in patients undergoing resection of malignant brain tumors. METHODS: The 2016-2020 National Inpatient Sample was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with caseloads >2 standard deviations above the mean (140 cases) were categorized as high-volume centers (HVCs). Value of care was evaluated by adding one point for each of the following: short length of stay, low total charges, favorable discharge disposition, and lack of major comorbidity or complication. RESULTS: In 3009 hospitals, 118,390 patients underwent resection of malignant brain tumors. HVC criteria were met by 91 (3%) hospitals. HVCs were more likely to treat patients of younger age or higher socioeconomic status (P < 0.01 for all). The Mid-Atlantic and South Atlantic regions had the highest percentage of cases and number of HVCs. Value of care was higher at HVCs (P < 0.01). Care at HVCs was associated with decreased complications (P < 0.01 for all) and improved patient outcomes (P < 0.01 for all). CONCLUSIONS: Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVCs. Trends of centralization may reflect the benefits of multidisciplinary treatment, geographic preferences, publicity, and cultural impact. Improvement of access to care is an important consideration as this trend continues.

Pediatric Patients with Intracranial Arteriovenous Malformations: Trends in Emergency Room Presentation.

BACKGROUND: Pediatric intracranial arteriovenous malformation (AVM) patients are commonly admitted to the emergency room (ER). Increasing patient utilization of the ER has been associated with healthcare disparities and a trend of decreased efficiency. The aim of this study was to evaluate the trends of pediatric AVM ER admissions over recent years and identify factors associated with health care resource utilization and outcomes. METHODS: The 2016-2019 National Inpatient Sample was queried for patients under the age of 18 admitted with AVM. Cases of admission through the ER were identified. Demographic and severity factors associated with ER admission were explored using comparative and regression statistics. RESULTS: Of 3875 pediatric patients with AVM admitted between 2016 and 2019, 1280 (33.0%) were admitted via the ER. Patients admitted via the ER were more likely to be in the lowest median income category (P < 0.001), on Medicaid insurance (P = 0.008), or in the South (P < 0.001) than patients admitted otherwise. There was increased severity and increased rates of intracranial hemorrhage (ICH) in patients admitted via the ER (P < 0.001). Finally, there were increasing trends in ER admissions and ICH throughout the years. CONCLUSIONS: ER admission of pediatric AVM patients with ICH is increasing and is associated with a distinct socioeconomic profile and increased healthcare resource utilization. These findings may reflect decreased access to more advanced diagnostic modalities, primary care, and other important resources. Identifying populations with barriers to care is likely an important component of policy aimed at decreasing the risk of severe disease presentation.

Vertebral Artery Pseudoaneurysm After Extreme Lateral Transcondylar Transodontoid Approach for Clival Chordoma: 2-Dimensional Operative Video.

Chordomas can be treated surgically, with radiotherapy, and more recently, chemotherapy.1,2 A 22-year-old female patient presented with recurrence of a clival chordoma, after subtotal resection at an outside institution 3 months prior. MRI showed a predominantly midline lesion at the craniocervical junction with significant lateral extension eccentric to the left. A 3-staged operation was planned. A redo-endoscopic endonasal transclival transodontoid approach3-5 was used to resect the midline component, followed by an extreme lateral transcondylar transodontoid approach with transposition of the ipsilateral vertebral artery followed by drilling of the ipsilateral occipital condyle and C1 lateral mass to resect the lateral component, followed by occiput to C3 fusion given the induced craniocervical instability. Careful subperiosteal dissection with preservation of the periosteal sheath overlying the vertebral artery was performed. There was no overt evidence of vertebral artery injury intraoperatively or on immediate postoperative imaging. However, 3 weeks later, the patient presented with blood from the oral/nasal cavity. Computed tomography angiography showed an unexpected left vertebral artery pseudoaneurysm. Pseudoaneurysms can develop after microtears in the muscularis layer.6-8 Management is based on size, location, and vertebral artery dominance.9,10 This pseudoaneurysm was coiled. Postcoiling, the patient had left hypoglossal palsy. We demonstrate the step-by-step technique of an extreme lateral transcondylar transodontoid approach for a clival chordoma and the unfortunate complication of a vertebral artery pseudoaneurysm with discussion of its etiology and management options for this potentially devastating complication. The patient consented to the procedure/publication. Institutional Review Board approval not obtained as the patient was deidentified, and no additional risk is posed by the publication of this video.

Clinical Outcomes of Arteriovenous Fistula Treatment Using the Penumbra SMART COIL System: A Subgroup Analysis from the Multicenter SMART Registry.

BACKGROUND: Endovascular embolization procedures are typically the primary treatment modality for arteriovenous fistula (AVF). The objective of this subset analysis was to evaluate the prospective long-term clinical outcomes of AVF patients treated with the SMART COIL System. METHODS: Patients who had AVFs and underwent endovascular coiling using the Penumbra SMART COIL system were part of a subset analysis within the SMART registry. The SMART registry is a postmarket registry that is prospective, multicenter, and single-arm in design. After the treatment, these patients were monitored for a period of 12 ± 6 months. RESULTS: A total of 41 patients were included. No patients (0/41) had a procedural device-related serious adverse event (SAE). Reaccess involving a guidewire due to catheter kickout was unnecessary for 85.4% (35/41) of the patients. Complete occlusion after the procedure was achieved in 87.8% (36/41) of patients. The periprocedural SAE rate was 2.4% (1/41), and no periprocedural deaths occurred (0/41). During the follow-up period, there were instances of retreatment in 3.4% (1/29) of patients. At 1 year, the lesion occlusion was better or stable in 93.3% (28/30) of patients. The rate of SAE from 24 hours to 1 year (±6 months) following the procedure was 26.8% (11/41). The 1-year all-cause mortality rate stood at 2.4% (1/41), and at the 1-year follow-up, 90.9% (20/22) of patients had a modified Rankin Scale score within the range of 0 to 2. CONCLUSIONS: The coiling procedure for AVFs using the SMART COIL System proved to be safe and effective at the 1-year follow-up.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Using N-Butyl Cyanoacrylate With a D5W Push Technique: A Multicentric North American Study of 269 Patients.

BACKGROUND AND OBJECTIVES: As the aging population increases, the incidence of chronic subdural hematomas (cSDHs) is expected to rise. Surgical evacuation, though effective, sees up to 30% recurrence. Middle meningeal artery (MMA) embolization, particularly with n-butyl cyanoacrylate (n-BCA) glue diluted in D5W for distal penetration, has shown promise in reducing recurrences. Limited reports have investigated the safety and technical feasibility of n-BCA as a primary liquid embolic agent using the D5W push technique in cSDH. This series is the largest in the literature investigating the outcomes of this technique in cSDH. METHODS: A multicenter retrospective database analysis was conducted on consecutive patients who underwent MMA embolization using n-BCA embolisate. Data collected included patient demographics, procedural information, angiographic data, and periprocedural complications. RESULTS: The study included 269 patients with a median age of 76 years. Nearly half of the patients had previous surgeries, and 93 underwent contralateral embolization for bilateral cSDH. Successful MMA embolization with effective distal penetration was achieved in all cases. The complication rate was 2.2%. Significant improvements were noted at a 60-day follow-up, with a median reduction in cSDH diameter of 40.6% (P < .001) and 53% of patients showing neurological improvement. No recurrent cSDH or need for retreatment was observed in patients who underwent follow-up. CONCLUSION: MMA embolization using n-BCA with the D5W push technique is safe and technically feasible. It can be used adjunctively or as an alternative to surgery in patients with cSDH, resulting in decreased recurrence, high technical success, improved distal penetration, and low complication rates.

Management of a dural arteriovenous fistula versus arteriovenous malformation of the internal auditory canal with radiosurgery.

We present a case of a 61-year-old male who presented with an 8-month history of left hypacusis, tinnitus, and gait imbalance. MRI showed a vascular lesion in the left internal auditory canal (IAC). Angiogram showed a vascular lesion filling from the ascending pharyngeal and anterior inferior cerebellar artery (AICA) with drainage into the sigmoid sinus suggestive of either a dural arteriovenous malformation (dAVF) vs arteriovenous malformation (AVM) of the IAC. The decision was made to operate to prevent risk of future hemorrhage [1-5]. Endovascular options were not as ideal given access transarterially through the AICA would be risky, access transvenously would be difficult and it was unclear whether this lesion was a dAVF or AVM. The patient underwent a retrosigmoid approach. A tuft of arterialized vessels surrounding CN7/8 was identified and no true nidus was found so it was thought that this lesion was a dAVF. The plan was to clip the arterialized vein as is normally done for dAVF. However, there was engorgement of the vascular lesion upon clipping of the arterialized vein indicating risk of rupture if the clip was left insitu. It was too risky to drill the posterior wall of the IAC to expose the fistulous point more proximally. As a result, 2 clips were placed on the AICA branches. Postoperative angiogram showed some slowing of the vascular lesion but it was still present. Given the AICA feeder, it was decided that this lesion was a dAVF with mixed features of an AVM and the decision was made to gamma knife the lesion 3 months postoperatively. Patient underwent gamma knife targeting the dura superior to the IAC with 18 Gy at the 50 % isodose line. At 2 years follow up, the patient's symptoms improved and he remained neurologically intact. Imaging revealed complete obliteration of the dAVF. This case illustrates the step by step management of a dAVF that mimicked a true pial AVM. The patient consented to the procedure and participating in this surgical video.

Intraoperative venous congestion and brainstem venous hemorrhagic infarction during retrosigmoid for acoustic neuroma.

Venous hemorrhagic infarction is rare but can occur during acoustic neuroma resection [1-5]. We present the case of a 27-year-old male with 1.5 years of progressive headaches, tinnitus, imbalance and hearing loss. Imaging revealed a left Koos 4 acoustic neuroma. The patient underwent a retrosigmoid approach for resection. During surgery, a vein of significant size within the capsule of the tumor was encountered and was necessary to take to proceed with resection. After coagulation of the vein, intraoperative venous congestion with cerebellar edema and hemorrhagic infarction ensued, requiring resection of a portion of the cerebellum. Given the hemorrhagic nature of the tumor, continuing tumor resection was necessary to prevent postoperative hemorrhage. This was carried out until hemostasis was achieved. 85 % resection was achieved, leaving a residual against the brainstem and cisternal course of the facial nerve. Postoperatively, the patient required 5 weeks hospitalization followed by 1 month of rehabilitation. At discharge to rehabilitation, patient had trach, PEG, left House-Brackmann 5 facial weakness, left sided deafness, and right upper extremity hemiparesis (1/5). At 7 months follow up, he continued to have left House-Brackmann 5 facial weakness and left sided deafness but trach and PEG had been removed and strength had improved to 5/5. We demonstrate in this video the unfortunate and rare occurrence of intraoperative venous hemorrhagic infarction during acoustic neuroma resection - particularly for large tumors in young patients - and discuss its etiology and surgical steps that are necessary to partially remedy its devastating impact on the patient. The patient consented to the procedure and participating in this surgical video.

Macrovascular Decompression for Hemifacial Spasm Using Sling Technique.

Hemifacial spasm (HFS) is a painless, involuntary twitching of the facial muscles that usually involves the orbicularis oculi muscle.1,2 It is commonly caused by the anterior inferior cerebellar artery or posterior inferior cerebellar artery.1,2 However, a dolichoectatic vertebrobasilar artery (VBA) can impinge the facial nerve.1 Macrovascular decompression with sling transposition is a common management paradigm.1-9 We present a case of a 56-year-old male who presented with left-sided HFS, pulsatile tinnitus, and hearing loss for the past 2 years. The patient underwent a retrosigmoid craniotomy and Gore-Tex sling transposition of a dolichoectatic VBA (Video 1). Complete improvement of symptoms was noted postoperatively with no associated complications. We review the preoperative workup, operative technique, relevant anatomy, and literature and provide technical pearls for this procedure.

Combined venous and arterial access in the arm for treatment of a complex dural arteriovenous fistula: a technical video.

Transvenous access is a necessary tool for numerous cerebrovascular pathologies.Transvenous access in the arm offers several benefits compared with transfemoral access, including patient comfort, the avoidance of transfemoral access complications, and the ability to close both radial arterial access and distal arm venous access with a single transradial compression band.1In this video we describe the indications, technical nuances, benefits, and limitations of transvenous access in the arm.neurintsurg;jnis-2023-020996v1/V1F1V1Video 1- Combined venous and arterial access in the arm for treatment of a complex dural arteriovenous fistulaWe present the case of a young patient who presented with pulsatile tinnitus and was found to have a Cognard type IIa dural arteriovenous fistula near the left transverse sigmoid junction.The patient was treated with transvenous embolization via the distal right basilic vein, and a single radial compression band served to close both the arterial and venous access sites.

Surgical resection of an intradural extramedullary spinal tumor.

Large ventrally located spinal meningiomas are typically resected via a posterolateral or lateral approach. Optimal outcomes are associated with good preoperative functional status (i.e., modified McCormick grade < 4), while recurrence rates may be predicted by degree and quality of resection (i.e., low Simpson grade). This video describes the operative techniques for resection of a large ventral C2 intradural extramedullary meningioma in a 71-year-old male presenting with hemibody sensory loss and abnormal gait. A paramedian approach was performed, allowing for adequate exposure and gross-total resection. The patient was discharged on postoperative day 2 and showed near-complete resolution of sensory deficits.

Modified Orbitozygomatic Craniotomy, Anterior Clinoidectomy, and Retrograde Suction Decompression "Dallas Technique" for Large Unruptured Clinoidal-Ophthalmic Segment Aneurysm.

Simple clip trapping may not adequately decompress giant paraclinoidal or ophthalmic artery aneurysms for safe permanent clipping.1-10 Full temporary interruption of the local circulation via clipping of the intracranial carotid artery with concomitant suction decompression via an angiocatheter placed in the cervical internal carotid artery as originally described by Batjer et al3 allows the primary surgeon to use both hands to clip the target aneurysm. Detailed understanding of skull base and distal dural ring anatomy is critical for microsurgical clipping of giant paraclinoid and ophthalmic artery aneurysms.2-4 Microsurgical approaches allow for direct decompression of the optic apparatus as opposed to endovascular coiling or flow diversion that may contribute to increased mass effect.11 We describe the case of a 60-year-old woman who presented with left-sided visual loss, a family history of aneurysmal subarachnoid hemorrhage, and a giant unruptured clinoidal-ophthalmic segment aneurysm with both extradural and intradural components.2 The patient underwent an orbitopterional craniotomy, Hakuba "peeling" of the temporal dura propria from the lateral wall of the cavernous sinus, and anterior clinoidectomy (Video 1). The proximal sylvian fissure was split, the distal dural ring was completely dissected, and the optic canal and falciform ligament were opened. The aneurysm was trapped, and retrograde suction decompression via the "Dallas Technique" was employed for safe clip reconstruction of the aneurysm.3,4 Postoperative imaging showed complete obliteration of the aneurysm, and the patient remained at her neurologic baseline. The technical considerations and literature regarding the suction decompression technique to treat giant paraclinoid aneurysms are reviewed.2-4 The patient and family provided informed consent for the procedure and consented to the publication of her images.

Contralateral transfalcine approach for resection of right medial frontal AVM.

Brain arteriovenous malformations (AVMs) are high flow vascular lesions that can cause significant morbidity and mortality [1-6]. We present a case of a 23-year-old woman who initially presented to an outside institution with a ruptured right medial frontal Spetzler Martin grade II AVM. An EVD was placed and a diagnostic angiogram with partial embolization was performed. She was then transferred to our institution two months post rupture for further care. On arrival, she was trached with eyes opening to voice and localizing in bilateral upper extremities and withdrawing in bilateral lower extremities. Diagnostic angiogram demonstrated arterial supply from the right pericallosal and callosomarginal artery, right posterior cerebral artery callosomarginal branch, distal left anterior cerebral artery (ACA) branches with venous drainage via a cortical vein to the superior sagittal sinus. The patient underwent preoperative embolization of the ACA feeders followed by a contralateral interhemispheric transfalcine approach. An interhemispheric dissection was performed down to the corpus callosum and AVM feeders and draining veins were identified. The falx was then incised to expose the right medial frontal lobe. The AVM was circumferentially dissected and resected. Postoperative imaging demonstrated complete resection of the AVM. She remained at her neurological baseline immediately postoperatively and was discharged to inpatient rehab. The patient made a remarkable recovery and at three months follow up, she no longer required a tracheostomy and was neurologically intact with no complaints except for mild memory difficulties. In this video, we demonstrate the step-by-step surgical technique and review the benefits of the contralateral transfalcine approach for resection of a ruptured right medial frontal Spetzler Martin grade II AVM. The patient consented to the procedure and to the publication of her imaging in this surgical video.

Risk Factors for Hepatitis E Virus Infection and Eating Habits in Kidney Transplant Recipients.

There is a significant risk for ongoing and treatment-resistant courses of hepatitis E virus (HEV) infection in patients after solid organ transplantation. The aim of this study was to identify risk factors for the development of hepatitis E, including the dietary habits of patients. We conducted a retrospective single-center study with 59 adult kidney and combined kidney transplant recipients who were diagnosed with HEV infection between 2013 and 2020. The outcomes of HEV infections were analyzed during a median follow-up of 4.3 years. Patients were compared with a control cohort of 251 transplant patients with elevated liver enzymes but without evidence of an HEV infection. Patients' alimentary exposures during the time before disease onset or diagnosis were assessed. Previous intense immunosuppression, especially treatment with high-dose steroids and rituximab, was a significant risk factor to acquire hepatitis E after solid organ transplantation. Only 11 out of 59 (18.6%) patients reached remission without further ribavirin (RBV) treatment. A total of 48 patients were treated with RBV, of which 19 patients (39.6%) had either viral rebounds after the end of treatment or did not reach viral clearance at all. Higher age (>60 years) and a BMI ≤ 20 kg/m2 were risk factors for RBV treatment failure. Deterioration in kidney function with a drop in eGFR (p = 0.046) and a rise in proteinuria was more common in patients with persistent hepatitis E viremia. HEV infection was associated with the consumption of undercooked pork or pork products prior to infection. Patients also reported processing raw meat with bare hands at home more frequently than the controls. Overall, we showed that the intensity of immunosuppression, higher age, a low BMI and the consumption of undercooked pork meat correlated with the development of hepatitis E.

Malignant Transformation of an Intracranial Epidermoid Cyst 25 Years After Initial Surgery: A Case Report and Systematic Review.

OBJECTIVE: We report a unique case of a suspected recurrent intracranial epidermoid cyst (EDC) that was found on pathology to have undergone malignant transformation to squamous cell carcinoma (SCC) approximately 25 years after initial resection. Additionally, we performed a systematic review including 94 studies reporting intracranial EDC to SCC transformation. METHODS: Ninety-four studies were included in our systematic review. PubMed, Scopus, Cochrane Central, and EMBASE were searched in April 2020 for studies regarding histologically confirmed SCC arising within an EDC. Kaplan-Meier estimations were used to estimate time to event including survival, and log rank tests were used to test for significance. All analyses were conducted using STATA 14.1 (StataCorp, College Station, Texas, USA); tests were two-sided, and statistical significance was defined using the alpha threshold of 0.05. RESULTS: The overall median time to transformation was 60 months (95% confidence interval {CI}, 12-96). Transformation time was significantly shorter in the no surgery group (10 months, 95% CI undefined) versus the other 2 groups (60 months, 95% CI, 12-72 in surgery only and 70 months, 95% CI, 9-180 in surgery + adjuvant therapy group, both P < 0.01). Overall survival was significantly longer in the surgery + adjuvant therapy group (13 months, 95% CI, 9-24) versus the other 2 groups (3 months, 95% CI, 1-7 in surgery only and 6 months, 95% CI, 1-12 in the no surgery group, both P < 0.01). CONCLUSIONS: We report a rare case of delayed malignant transformation of an intracranial EDC to SCC, occurring nearly 25 years after initial resection. Transformation time in the no-surgery group was statistically significantly shorter as compared to the surgery only and surgery + adjuvant therapy groups. Overall survival was statistically significantly higher in the surgery + adjuvant therapy group as compared to the surgery only and no surgery groups.

Thrombosed orbital varix of the inferior ophthalmic vein: A rare cause of acute unilateral proptosis.

Background: Orbital varices are rare, accounting for only 0-1.3% of orbital masses. They can be found incidentally or cause mild to serious sequelae, including hemorrhage and optic nerve compression. Case Description: We report a case of a 74-year-old male with progressively painful unilateral proptosis. Imaging revealed the presence of an orbital mass compatible with a thrombosed orbital varix of the inferior ophthalmic vein in the left inferior intraconal space. The patient was medically managed. On a follow-up outpatient clinic visit, he demonstrated remarkable clinical recovery and denied experiencing any symptoms. Follow-up computed tomography scan showed a stable mass with decreased proptosis in the left orbit consistent with the previously diagnosed orbital varix. One-year follow-up orbital magnetic resonance imaging without contrast showed slight increase in the intraconal mass. Conclusion: An orbital varix may present with mild to severe symptoms and management, depending on case severity, ranges from medical treatment to escalated surgical innervation. Our case is one of few progressive unilateral proptosis caused by a thrombosed varix of the inferior ophthalmic vein described in the literature. We encourage further investigation into the causes and epidemiology of orbital varices.

Intracranial Hypertension After Primary Decompressive Craniectomy for Head Trauma.

BACKGROUND: Primary decompressive craniectomy (DC) is commonly performed for patients with traumatic brain injury (TBI). Some, but not all patients, will benefit from invasive monitoring of intracranial pressure (ICP) after surgery. We intended to identify risk factors for elevated ICP after primary DC to treat TBI. METHODS: A retrospective chart review study identified all patients at our institution who underwent primary DC for TBI during the study period and who had ICP monitors placed at the time of surgery. Various preoperative and intraoperative variables were assessed for correlation with the presence of postoperative elevated ICP. RESULTS: Postoperative elevated ICP occurred in 36% of patients after DC. In univariate analysis, Glasgow Coma Scale <8, abnormal pupillary examination, and intraoperative brain swelling were all associated with elevated postoperative ICP. However, in multivariate analysis only intraoperative brain swelling was associated with elevated postoperative ICP (incidence 56% vs. 5%, P = 0.0043). CONCLUSIONS: Placement of an ICP monitor at the time of primary DC for patients with TBI should be considered if there is intraoperative brain swelling.

Anterior petrosal (Kawase) approach to petroclival meningioma: 2-dimensional operative video.

Petroclival meningiomas are challenging lesions that can be treated with several surgical approaches. The authors present a 66-year-old woman with a 1.6-cm left petroclival meningioma that was initially observed and then radiated after it grew 8 years later. Despite radiation, the tumor continued to grow to 4 cm; therefore, the patient was referred to the authors' institution. A left anterior petrosal (Kawase) approach was performed. Postoperatively, the patient had transient cranial nerve IV and VI palsy that improved. The case presentation, surgical anatomy, operative technique, postoperative course, and different surgical approaches are reviewed. The patient gave verbal consent for participating in the surgical video. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21259.