Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus.

OBJECTIVE: The risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts. METHODS: We performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher's exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively. RESULTS: Five of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy. CONCLUSIONS: Earlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.

First Direct Observation of Collider Neutrinos with FASER at the LHC.

We report the first direct observation of neutrino interactions at a particle collider experiment. Neutrino candidate events are identified in a 13.6 TeV center-of-mass energy pp collision dataset of 35.4 fb^{-1} using the active electronic components of the FASER detector at the Large Hadron Collider. The candidates are required to have a track propagating through the entire length of the FASER detector and be consistent with a muon neutrino charged-current interaction. We infer 153_{-13}^{+12} neutrino interactions with a significance of 16 standard deviations above the background-only hypothesis. These events are consistent with the characteristics expected from neutrino interactions in terms of secondary particle production and spatial distribution, and they imply the observation of both neutrinos and anti-neutrinos with an incident neutrino energy of significantly above 200 GeV.

Stereotactic radiosurgery and resection for treatment of multiple brain metastases: a systematic review and analysis.

OBJECTIVE: Stereotactic radiosurgery (SRS) has recently emerged as a minimally invasive alternative to resection for treating multiple brain metastases. Given the lack of consensus regarding the application of SRS versus resection for multiple brain metastases, the authors aimed to conduct a systematic literature review of all published work on the topic. METHODS: The PubMed, OVID, Cochrane, Web of Science, and Scopus databases were used to identify studies that examined clinical outcomes after resection or SRS was performed in patients with multiple brain metastases. Radiological studies, case series with fewer than 3 patients, pediatric studies, or national database studies were excluded. Data extracted included patient demographics and mean overall survival (OS). Weighted t-tests and ANOVA were performed. RESULTS: A total of 1300 abstracts were screened, 450 articles underwent full-text review, and 129 studies met inclusion criteria, encompassing 20,177 patients (18,852 treated with SRS and 1325 who underwent resection). The OS for the SRS group was 10.2 ± 6 months, and for the resection group it was 6.5 ± 3.8 months. A weighted ANOVA test comparing OS with covariates of age, sex, and publication year revealed that the treatment group (p = 0.045), age (p = 0.034), and publication year (0.0078) were all independently associated with OS (with SRS, younger age, and later publication year being associated with longer survival), whereas sex (p = 0.95) was not. CONCLUSIONS: For patients with multiple brain metastases, SRS and resection are effective treatments to prolong OS, with published data suggesting that SRS may have a trend toward lengthened survival outcomes. The authors encourage additional work examining outcomes of treatments for multiple brain metastases.

Histologic Assessment of Lumbosacral Transitional Vertebrae Pseudoarticulation as a Source of Pain in Bertolotti Syndrome.

BACKGROUND: Bertolotti syndrome (BS) is characterized by chronic pain and functional impairment associated with lumbosacral transitional vertebrae (LSTVs). The study aimed to investigate the histologic characteristics of the pseudoarticulation between the enlarged transverse process and sacrum seen in Castellvi 2a LSTV and explore the involvement of nervous tissue in pain generation. METHODS: Immunohistochemical analysis using S100 protein staining was performed to assess the presence of nerve tissue. RESULTS: These changes included fibrillation, chondrocyte cloning, alterations in the proteoglycan matrix, and focal chondrocyte necrosis. Notably, no nerve tissue was observed in any of the specimens, as confirmed by negative S100 protein staining. CONCLUSIONS: The study findings suggest that nerve tissue is not involved in the nociceptive mechanisms underlying pain in BS. The histologic similarities between the pseudoarticulation and osteoarthritic joints indicate that pseudoarticulation itself may be a significant source of pain in BS. These insights contribute to our understanding of the pathophysiology of BS and support treatment paradigms prioritizing pain control with medications such as NSAIDs before considering surgical intervention. Future studies with larger sample sizes and in vivo models are needed to further validate these findings and explore the changes in joint histology under biomechanical forces in LSTVs.

Predictive factors of hydrocephalus development in pediatric patients undergoing hemispherectomy for intractable epilepsy.

OBJECTIVE: Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management. METHODS: A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale). RESULTS: Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors' institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus. CONCLUSIONS: Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.

Indication as a predictor for outcomes in anterior cervical discectomy and fusion: The impact of myelopathy on disposition.

BACKGROUND: While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy. METHODS: A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition. RESULTS: A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02). CONCLUSIONS: Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy.

Evaluating analgesic medications utilized in the treatment of aneurysmal subarachnoid hemorrhage and association with delayed cerebral ischemia.

BACKGROUND: Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) recovery may be hampered by delayed cerebral ischemia (DCI). Herein, we sought to identify whether frequently administered medications in the intensive care unit (ICU) are associated with DCI. METHODS: In this retrospective study, patients admitted to a tertiary care center neuro-ICU between 2012 and 2019 with aSAH who could verbalize pain intensity scores were included. Medication dosages and clinical characteristics were abstracted from the medical record. Both paired and unpaired analyses were utilized to measure individual DCI risk for a given patient in relation to drug dosages. RESULTS: 119 patients were included; average age was 61.7 ± 15.2 (SD) years, 89 (74.7%) were female, and 32 (26.9%) experienced DCI during admission. Patients with DCI had longer length of stay (19.3 ± 7.4 vs 12.7 ± 5.3 days, p < 0.0001). The combination medication of acetaminophen 325 mg/butalbital 50 mg/caffeine 40 mg (A/B/C) was associated with decreased DCI on paired (2.3 ± 2.0 vs 3.1 ± 1.9 tabs, p = 0.034) and unpaired analysis (1.84 ± 2.4 vs 2.6 ± 2.4 tabs, p < 0.001). No associations were found between DCI and opioids, dexamethasone, levetiracetam, or acetaminophen. Max and mean daily headache pain was not associated with DCI occurrence. CONCLUSION: We identified an association between a commonly administered analgesic and DCI. A/B/C is associated with decreased DCI in this study, while other medications are not associated with DCI risk.

Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis.

BACKGROUND: Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management. OBJECTIVE: To investigate inpatient mortality after conservative management of large aSDHs. METHODS: Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale. RESULTS: Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110). CONCLUSION: In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.

Examining degenerative disease adjacent to lumbosacral transitional vertebrae: a retrospective cohort study.

OBJECTIVE: Bertolotti syndrome is a clinical diagnosis given to patients with low-back pain arising from a lumbosacral transitional vertebra (LSTV). While biomechanical studies have demonstrated abnormal torques and range of motion occurring at and above this type of LSTV, the long-term effects of these biomechanical changes on the LSTV adjacent segments are not well understood. This study examined degenerative changes at segments superjacent to the LSTV in patients with Bertolotti syndrome. METHODS: This study involved a retrospective comparison of patients between 2010 and 2020 with an LSTV and chronic back pain (Bertolotti syndrome) and control patients with chronic back pain with no LSTV. The presence of an LSTV was confirmed on imaging, and the caudal-most mobile segment above the LSTV was assessed for degenerative changes. Degenerative changes were assessed by grading the intervertebral disc, facets, degree of spinal stenosis, and spondylolisthesis using well documented grading systems. All computations were performed in R, version 4.1.0. All tests were two-sided, and p values < 0.05 was considered statistically significant. Separate logistic regression analyses were run with the associated dependent variables for each aim, with age at MRI and sex included as covariates. Odds ratios and 95% confidence intervals were computed. RESULTS: A total of 172 patients were included, 101 with Bertolotti syndrome and 71 controls. Control patients consisted of patients with low-back pain but no diagnosis of Bertolotti syndrome or an LSTV. Fifty-six Bertolotti (55.4%) and 27 control (38.0%) patients were female, (p = 0.03). After adjusting for age at MRI and sex, Bertolotti patients had pelvic incidence (PI) that was 9.83° greater than control patients (95% CI 5.15°-14.50°, p < 0.001). Sacral slope was not significantly different between the Bertolotti and control groups (beta estimate 3.10°, 95% CI -1.07° to 7.27°; p = 0.14). Bertolotti patients had 2.69 times higher odds of having a high disc grade at L4-5 (3-4 vs 0-2), compared with control patients (OR 2.69, 95% CI 1.28-5.90; p = 0.01). There were no significant differences between Bertolotti patients and controls for spondylolisthesis, facet grade, or spinal stenosis grade. CONCLUSIONS: Patients with Bertolotti syndrome had a significantly higher PI and were more likely to have adjacent-segment disease (ASD; L4-5) compared with control patients. However, after controlling for age and sex, PI and ASD did not appear to have a significant association within the cohort of Bertolotti patients. The altered biomechanics and kinematics in this condition may be a causative factor in this degeneration, although proof of causation is not possible in this study. This association may warrant closer follow-up protocols for patients being treated for Bertolotti syndrome, but further prospective studies are needed to establish if radiographic parameters can serve as an indicator for biomechanical alterations in vivo.

The impact of skull thickness on pediatric stereoencephalography electrode implantation and technical considerations.

OBJECTIVE: One consideration in pediatric stereoencephalography (SEEG) is decreased skull thicknesses compared with adults, which may limit traditional bolt-based anchoring of electrodes. The authors aimed to investigate the safety profile, complication rates, and technical adaptations of placing SEEG electrodes in pediatric patients. METHODS: The authors retrospectively reviewed all patients aged 12 years or younger at the time of SEEG implantation at their institution. Postimplantation CT scans were used to measure skull thickness at the entry point of each SEEG lead. Postimplantation lead accuracy was also assessed. RESULTS: Fifty-three patients were reviewed. The median skull thickness was 4.1 (interquartile range [IQR] 3.15-5.2) mm. There were 5 total complications: 1 retained bolt fragment, 3 asymptomatic subdural hematomas, and 1 asymptomatic intracranial hemorrhage. Median radial error from the lead target was 3.5 (IQR 2.24-5.25) mm. Linear regression analysis revealed that increasing skull thickness decreased the deviation from the intended target, implying an improved accuracy to target at thicker skull entry points; this trended towards improved accuracy, but did not achieve statistical significance (p = 0.54). CONCLUSIONS: This study found a 1.9% hardware complication rate and a 9.4% asymptomatic hemorrhage rate. Suturing electrodes to the scalp may represent a reasonable option if there are concerns of young age or a thin skull. These data indicate that invasive SEEG evaluation is safe among patients 12 years old or younger.

Determinants of epileptogenic zone identification and seizure outcome in children with refractory epilepsy undergoing stereoelectroencephalography.

OBJECTIVE: The objective of this paper was to investigate the factors associated with successful epileptogenic zone (EZ) identification and postsurgical seizure freedom in pediatric patients with drug-resistant epilepsy who underwent first-time stereoelectroencephalography (SEEG). METHODS: The authors conducted a retrospective cohort study of all consecutive patients younger than 18 years of age at the time of recommendation for invasive evaluation with SEEG who were treated from July 2009 to June 2020. The authors excluded patients who had undergone failed prior resective epilepsy surgery or prior intracranial electrode evaluation for seizure localization. For their primary outcome, the authors evaluated the relationship between clinical and radiographic factors and successful identification of a putative EZ. For their secondary outcome, the authors investigated whether these factors had a significant relationship with seizure freedom (according to the Engel classification) at last follow-up. RESULTS: The authors included 101 patients in this study. SEEG was safe, with no major morbidity or mortality experienced. The population was complex, with an MRI lesion present in less than 40% of patients and patients as young as 2.9 years included. A proposed EZ was identified in 88 (87%) patients. Patients with an older onset of epilepsy (OR 1.20/year, p = 0.04) or epilepsy etiology suspected to be due to a developmental lesion (OR 8.38, p = 0.02) were more likely to have proposed EZ identification. Patients with a preimplantation bilateral seizure-onset hypothesis (OR 0.29, p = 0.047) and those who underwent longer periods of monitoring (OR 0.86/day, p = 0.006) were somewhat less likely to have proposed EZ identification. The presence of an MRI lesion was a positive factor on secondary analyses (OR 4.18, p = 0.049; 1-tailed test). Fifty percent of patients who underwent surgical treatment with resection or laser ablation achieved Engel class I outcomes, in contrast to 0% of patients who underwent neuromodulation. Patients with a preimplantation hypothesis in the frontal/parietal lobes had increased odds of seizure freedom compared with patients with a hypothesis in other locations (OR 3.64, p = 0.01). CONCLUSIONS: Pediatric SEEG is safe and often identifies a proposed resectable EZ. These results suggest that SEEG is effective in patients with frontal/parietal preimplantation hypothesis, with or without identified lesions on MRI.

Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study.

BACKGROUND AND PURPOSE: Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center. METHODS: We conducted a retrospective review of adult aneurysmal subarachnoid hemorrhage cases from 2013 to 2019 at a single large tertiary medical center. Data extracted from the medical record included sex, age, race, insurance status, aneurysm location, aneurysm treatment, initial systolic and diastolic blood pressure, Hunt Hess grade, modified Fisher score, time to blood pressure control (defined as time in minutes from first blood pressure measurement to the first of three consecutive systolic blood pressure measurements under 140mmHg), hospital length of stay, and final discharge disposition. RESULTS: 194 patients met inclusion criteria; 140 (72%) White and 54 (28%) Black. While White patients were more likely than Black patients to be privately insured (62.1% versus 33.3%, p < 0.001), Black patients were more likely than White patients to have Medicaid (55.6% versus 15.0%, p < 0.001). Compared to White patients, Black patients presented with a higher median systolic (165 mmHg versus 148 mmHg, p = 0.004) and diastolic (93 mmHg versus 84 mmHg, p = 0.02) blood pressure. Black patients had a longer median time to blood pressure control than White patients (200 minutes versus 90 minutes, p = 0.001). Black patients had a shorter median hospital length of stay than White patients (15 days versus 18 days, p < 0.031). There was a small but statistically significant difference in modified Fisher score between black and white patients (3.48 versus 3.17, p = 0.04).There were no significant racial differences present in sex, Hunt Hess grade, discharge disposition, complications, or need for further interventions. CONCLUSION: Black race was associated with higher blood pressure at presentation, longer time to blood pressure control, but shorter hospital length of stay. No racial differences were present in aneurysmal subarachnoid hemorrhage associated complications or interventions.

Impact of anemia on acute ischemic stroke outcomes: A systematic review of the literature.

INTRODUCTION: Anemia has been reported in nearly 40% of acute ischemic stroke (AIS) patients and is linked to significant morbidity and disability. The presence of anemia is associated with worse outcomes in AIS, specifically in the presence of large vessel occlusion (LVO). An optimal hemoglobin (Hb) target specific to this pathology has not yet been established. The goal of this review is to systematically review literature that observes the association that exists between AIS outcomes and hemoglobin (Hb) levels. METHODS: A systematic review was performed in accordance with guidelines for the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to identify studies from 2008-2022. The following inclusion and exclusion criteria were used: studies of adult patients with AIS; must describe outcomes with regard to Hb levels in AIS (not limited to LVO); must be written in English. The clinical variables extracted included Length of Stay (LOS), modified rankin score (mRS), Hb levels, and mortality. RESULTS: A total of 1,154 studies were gathered, with 116 undergoing full text review. 31 studies were included in this review. The age of patients ranged from 61.4 to 77.8. The presence of anemia in AIS increased LOS by 1.7 days on average and these patients also have a 15.2% higher rate of mortality at one year, on average. DISCUSSION: This data suggests that the contemporary thresholds for treating anemia in AIS patients may be inadequate because anemia is strongly associated with poor outcomes (e.g., mRS>2 or mortality) and increased LOS in AIS patients. The current generalized Hb threshold for transfusion (7 g/dL) is also used in AIS patients, however, a more aggressive transfusion parameter should be further explored based on these findings. Further studies are required to confirm these findings and to determine if a more liberal RBCT threshold will result in clinical benefits.

Cervical arterial dissection and traumatic myelopathy following yoga: surgical case report.

INTRODUCTION: Cervical spondylosis can predispose patients to central canal stenosis. In this setting, myelopathy through further flattening of the cord from extrinsic compression can be precipitated by relatively minor traumas. Arterial dissection is similarly considered a result of high velocity or momentum during trauma, commonly associated with fractures, cervical hyperflexion, or direct blunt force to the neck. Overall, precautions for both arterial dissection and myelopathy are rarely considered in low-velocity, static activities such as yoga. CASE PRESENTATION: The authors report the case of a 63-year-old man who suffered concurrent cervical myelopathy from multilevel spondylopathy, right vertebral artery dissection, and left cervical carotid artery dissection following a yoga session. Symptomatology consisted of acute onset neck pain, upper extremity sensory paresthesia, worsening gait and balance, and impaired dexterity for several weeks. Cervical MRI was obtained given myelopathic symptoms and revealed spondylosis with compression and T2 signal change at C3-C4. CT angiography of the neck revealed aforementioned dissections without flow limiting stenosis or occlusion. A therapeutic heparin infusion was started preoperatively until the patient underwent C3-C4 anterior cervical discectomy and fusion. Aspirin and Plavix were then started without incidence and the patient had significant but gradual improvement in myelopathic symptoms at 6-week follow-up. DISCUSSION: The static yet intensive poses associated with yoga present a rare etiology for arterial dissection and myelopathy, but patients with persistent and progressive symptoms should be screened with the appropriate imaging modality. Cervical decompression should be expedited before initiating an antiplatelet medication.

Demographic Analysis of Financial Hardships Faced by Brain Tumor Survivors.

OBJECTIVE: Quantitative analysis of the financial hardship faced by patients with brain tumors is lacking. The present study sought to conduct a longitudinal analysis of responses to the National Health Interview Survey by patients diagnosed with brain tumors and characterize the impact of demographic factors on financial hardship indices. METHODS: National Health Interview Survey respondents between 1997 and 2018 who reported previous diagnosis with cancer of the brain and who responded to 4 survey questions that assessed financial stress were included. Sociodemographic exposures included age, ethnicity/race, marriage status, insurance status, and degree of highest educational attainment. RESULTS: Educational attainment, marital status, and insurance status were the most significant risk factors for temporary or indefinite delays to necessary medical care. Those with only a high-school diploma had 9.6 times higher odds (adjusted odds ratio, 9.68; 95% confidence interval, 2.96-31.70; P < 0.001) of reporting that, in the past 12 months, one of their family members had to limit their medical care in an effort to save money. Similarly, patients with brain tumors who were not married had 3.94 times greater odds (adjusted odds ratio, 3.94; 95% confidence interval, 1.49-10.44; P = 0.009) of avoiding necessary medical care because of an inability to afford it. CONCLUSIONS: Given this variation in self-reported financial burden, demographics clearly have an impact on a patient's holistic experience after a brain cancer diagnosis. Therefore, by using the comparisons in this study, we hope that medical institutions and neurosurgical societies can more accurately predict which patients are most susceptible to significant financial stress and distribute resources accordingly.

Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review.

BACKGROUND: Most vertebral compression fractures (VCFs) are successfully managed conservatively; however, some patients fail conservative management and require further surgical treatment. We sought to identify significant variables that contribute to progressive vertebral collapse in nonoperative treatment of traumatic VCFs. METHODS: A systematic review identified original research articles of conservatively managed VCFs secondary to trauma from inception to September 2021. Articles with patients treated with initial nonoperative therapy, AO type A0, A1, and A2 fractures, risk factor analysis, >10 patients, and vertebral fracture secondary to trauma were included. Articles with pediatric patients, burst fractures or AO type A3 and A4 fractures, vertebral fractures secondary to neoplasm or infectious disease, and operative versus nonoperative treatment comparations were excluded. Failure of nonoperative treatment was defined as salvage surgery/vertebral augmentation, progressive kyphosis, chronic pain, or functional disability. RESULTS: Of 3877 articles identified, 6 articles were included with 582 patients with conservatively managed thoracolumbar VCFs. Treatment failure was reported in 102 (17.5%) patients. Of 102 treatment failures, 37 (36.3%) were due to subsequent VCF, 33 (32.4%) were due to back pain or functional disability at follow-up, and 32 (31.4%) were due to increased compression rate or kyphotic deformity at follow-up. Prior VCF was a significant variable in 2 (33.3%) of 6 studies. Age, lumbar bone mineral density, segmental Cobb angle, and vertebral height loss were each described as a significant factor in 1 (16.7%) of the 6 studies. CONCLUSIONS: Identifying patients who are at risk for treatment failure may help select patients who would benefit from close clinical follow-up or early surgical/procedural intervention.

Comparative effectiveness of stent-assisted coiling and Woven EndoBridge embolization for the treatment of unruptured wide-neck bifurcation intracranial aneurysms.

OBJECTIVE: Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs. METHODS: Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices. RESULTS: Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202-834] days vs 228 [177-494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8-3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630. CONCLUSIONS: Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.

Spine centers of excellence: a systematic review and single-institution description of a spine center of excellence.

Background: Centers of excellence (COEs) are interdisciplinary healthcare organizations created with the goal of improving health/economic outcomes in medical treatment for both individuals and health systems, compared to traditionally structured counterparts. Multiple studies have highlighted both societal/individual burdens associated with back pain, underscoring the importance of identifying new avenues for improving both cost/clinical outcomes for this patient population. Here, we utilize available literature to better characterize the features of a spine COE at a tertiary care center and determine the impact of COEs on patient satisfaction and outcomes. Methods: A systematic review describing spine COEs was performed. PubMed, OVID, Cochrane, Web of Science, and Scopus were utilized for electronic literature search. Data including institution, department, pathologies treated, patient satisfaction scores, patient outcomes, and descriptions of the COE, were extracted and analyzed by two reviewers per full-text article. Inclusion criteria consisted of literature describing the organization, purpose, or outcomes of a spine COE, all publication types (except technical/operative report), adult or pediatric patients, publication from inception through September 2021. Exclusion criteria consisted of articles that do not discuss spinal COEs, technical/operative reports, studies unavailable in English language, unavailable full text, or non-human subjects. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the included studies. Results: Five hundred and sixty-seven unique publications were obtained from the literature search. Of these articles, 20 were included and 547 were excluded based on inclusion and exclusion criteria. Following full-text review of the 20 publications, 6 contained pertinent data. Quantitative data comparing COE versus non-COE was contradictory in comparing complication rates and episodic costs. Qualitative data included descriptions of spine COE features and cited improved patient care, technical advancements, and individualized care paths as positive aspects of the COE model. Mean risk of bias assessment was 3.67. Discussion: There is little evidence regarding if spine COEs provide an advantage over traditionally organized facilities. The current number and heterogeneity of publications, and lack of standardized metrics used to define a spinal COE are limiting factors. Spinal COE may offer higher value care, reduced complication rates and advancements in knowledge and technical skill.

Glioma stem cells activate platelets by plasma-independent thrombin production to promote glioblastoma tumorigenesis.

Background: The interaction between platelets and cancer cells has been underexplored in solid tumor models that do not metastasize, for example, glioblastoma (GBM) where metastasis is rare. Histologically, it is known that glioma stem cells (GSCs) are found in perivascular and pseudsopalisading regions of GBM, which are also areas of platelet localization. High platelet counts have been associated with poor clinical outcomes in many cancers. While platelets are known to promote the progression of other tumors, mechanisms by which platelets influence GBM oncogenesis are unknown. Here, we aimed to understand how the bidirectional interaction between platelets and GSCs drives GBM oncogenesis. Methods: Male and female NSG mice were transplanted with GSC lines and treated with antiplatelet and anti-thrombin inhibitors. Immunofluorescence, qPCR, and Western blots were used to determine expression of coagulation mechanism in GBM tissue and subsequent GSC lines. Results: We show that GSCs activate platelets by endogenous production of all the factors of the intrinsic and extrinsic coagulation cascades in a plasma-independent manner. Therefore, GSCs produce thrombin resulting in platelet activation. We further demonstrate that the endogenous coagulation cascades of these cancer stem cells are tumorigenic: they activate platelets to promote stemness and proliferation in vitro and pharmacological inhibition delays tumor growth in vivo. Conclusions: Our findings uncover a specific preferential relationship between platelets and GSCs that drive GBM malignancies and identify a therapeutically targetable novel interaction.

Post-Medicare Access and CHIP Reauthorization Act of 2015 Trends in Lumbar Magnetic Resonance Imaging Use for Patients with Low Back Pain at 1373 Hospitals.

BACKGROUND: Lumbar Spine MRI Use for Low Back Pain (OP-8) is calculated by dividing the number of patients who received lumbar magnetic resonance imaging (MRI-L) before receiving alternative treatments (e.g., physical therapy) by the total number of patients receiving MRI-L in the outpatient setting at a given institution. Since the passage of the Post-Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), OP-8 scores became tied to hospital finances. This study aims to determine how MACRA has impacted OP-8 scores since its implementation. We also aim to investigate how regional designation, profit status (for-profit, government, and nonprofit), and hospital setting (critical access, non-critical access) affect OP-8 scores. METHODS: Data from the Centers for Medicare and Medicaid Services Hospital Compare database were used to extract information on the national trends in OP-8 scores from 2014 to 2020. A multivariable linear regression model was fit to isolate the impact of hospital characteristics on OP-8 scores. RESULTS: After a decrease from 2015 to 2016, the mean national OP-8 score plateaued, staying around 40% from 2017 through 2020. A critical access setting increased OP-8 scores by 5.41 (95% confidence interval, 3.51-6.77; P ≤ 0.001), compared with a non-critical access setting. Governmental status increased scores by 1.27 (95% confidence interval, 0.28-2.27; P = 0.012), compared with a nonprofit status. CONCLUSIONS: The implementation of MACRA seems to have been unsuccessful in altering practice patterns, given the minimal change in OP-8 scores over the last 4 years. Furthermore, institutional factors are clearly correlated with a lack of adherence to magnetic resonance imaging guidelines. Given these findings, there is a need to modify health policies.