Trans-superior ophthalmic vein approach for treatment of carotid-cavernous fistula.

The authors present a case of a patient with a Barrow Type B carotid-cavernous fistula (CCF) who presented with severe symptoms of eye redness, diplopia, and proptosis. Due to the tortuosity and size of her angular vein and the lack of good flow/access via the inferior petrosal sinus, she was treated with a transvenous approach via a large, dilated superior ophthalmic vein for coil embolization of the CCF. The patient had a full angiographic and symptomatic cure. The authors present the treatment plan and strategy and the fluoroscopic recording of the treatment. Nuances of the technique are discussed.The video can be found here: https://youtu.be/ABkGm17-cBU.

Glioblastoma of the cerebellum in children: report of five cases and review of the literature.

PURPOSE: Cerebellar glioblastomas in children are rare. As a result, an optimal treatment strategy has not yet been identified. A review of the characteristics of the disease as well as the effectiveness of various therapeutic modalities would help in optimizing the treatment paradigm. METHODS: We performed a detailed clinical, radiographic, and pathologic retrospective review of five patients (three boys and two girls, average age at presentation 7.2 years (range, 3-14 years)) and surveyed the literature for an additional 55 cases. RESULTS: Computed tomography and magnetic resonance imaging usually revealed a large lesion with minimal edema, heterogeneous contrast enhancement, and a discrete border. Subtotal tumor resection was performed in two patients and gross total resection in three patients. Immunostaining of the tumor cells with antisera to glial fibrillary acidic protein and vimentin was variably positive. Adjuvant therapy included local radiation and chemotherapy in all followed patients. Tumor recurrence was seen in two patients. Patients were followed from 2 months to 3.5 years (mean, 12 months). Two patients were dead at last follow-up with a mean survival of 9.5 months. CONCLUSIONS: The prognosis for pediatric patients with cerebellar glioblastomas is dismal, even when compared to adult counterparts or other malignant posterior fossa tumors in children. Cerebellar glioblastomas have a tendency to recur and disseminate despite treatment with surgery, chemotherapy, and radiation. The poor outcomes seen with this tumor suggest that the optimal treatment strategy has yet to be elucidated and much work needs to be done.

Intracranial Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Case Report and Review of the Literature.

We describe a case of severe headaches, double vision, and progressive vision loss secondary to a ruptured intracranial cyst (IAC) in a 31-year-old woman with no relevant past medical history. The case is peculiar because drainage of the subdural hygroma led to a minimal improvement in vision with persistent elevated intracranial pressure (ICP). Further exploration revealed transverse sinus stenosis necessitating stenting. Evaluation post-stenting showed marked reduction of ICP and improvement in symptoms. This report underscores the importance of comprehensive work-up and suspicion of multiple underlying etiologies that may be crucial to complete resolution of presenting symptoms in some cases. We provide an overview of the clinical indications and evidence for venous sinus stenting in treating idiopathic intracranial hypertension (IIH).

Deep brain stimulation in the management of disorders of consciousness: a review of physiology, previous reports, and ethical considerations.

Patients suffering from disorders of consciousness constitute a population that exists largely outside of the daily practice patterns of neurosurgeons. Historically, treatment has focused on nursing and custodial issues with limited neurosurgical intervention. Recently, however, deep brain stimulation has been explored to restore cognitive and physical function to patients in minimally conscious states. In this article, the authors characterize the physiological mechanisms for the use of deep brain stimulation in persistently vegetative and minimally conscious patients, review published cases and associated ethical concerns, and discuss future directions of this technology.

Self Manipulated Cervical Spine Leads to Posterior Disc Herniation and Spinal Stenosis.

The authors report a case in which a 38-year-old male who presented himself to the emergency department with a chief complaint of cervical neck pain and paresthesia radiating from the right pectoral region down his distal right arm following self-manipulation of the patient's own cervical vertebrae. Initial emergency department imaging via cervical x-ray and magnetic resonance imaging (MRI) without contrast revealed no cervical fractures; however, there was evidence of an acute cervical disc herniation (C3-C7) with severe herniation and spinal stenosis located at C5-C6. Immediate discectomy at C5-C6 and anterior arthrodesis was conducted in order to decompress the cervical spinal cord. Acute traumatic cervical disc herniation is rare in comparison to disc herniation due to the chronic degradation of the posterior annulus fibrosus and nucleus pulposus. Traumatic cervical hernias usually arise due to a very large external force causing hyperflexion or hyperextension of the cervical vertebrae. However, there have been reports of cervical injury arising from cervical spinal manipulation therapy (SMT) where a licensed professional applies a rotary force component. This can be concerning, considering that 12 million Americans receive SMT annually (Powell, F.C.; Hanigan, W.C.; Olivero, W.C. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery 1993, 33, 73-79.). This case study involved an individual who was able to apply enough rotary force to his own cervical vertebrae, causing severe neurological damage requiring surgical intervention. Individuals with neck pain should be advised of the complications of SMT, and provided with alternative treatment methods, especially if one is willing to self manipulate.

Intraoperative Computed Tomography Angiography: A Novel Completion Imaging Modality for Carotid Endarterectomy.

BACKGROUND: Intraoperative computed tomography angiography (ICTA) is a novel completion imaging modality for carotid endarterectomy (CEA). No studies exist in the literature describing ICTA use in CEA. OBJECTIVE: To evaluate the feasibility and efficacy of ICTA as a method of immediately evaluating the technical results of CEA. METHODS: Twenty-three consecutive CEAs were performed by a single neurosurgeon over an 8-month period. Of this series, 12 utilized ICTA for completion imaging, 10 utilized duplex ultrasonography (US), and 1 utilized no intraoperative completion imaging. Electronic medical records were reviewed to assess demographics, CTA results, US results, and need for revisions. RESULTS: Patients included 13 men (62%) and 8 women (38%). All patients had symptomatic internal carotid artery stenosis. Polytetrafluoroethylene (PTFE) patch angioplasty was used in 16 cases (70%). Average operative times were comparable between cases that utilized CTA and US, 180 and 175 min, respectively. Major technical defects were identified in one of the 12 cases utilizing ICTA and none of the 10 cases utilizing intraoperative US. The technical defect was revised without subsequent neurological complication. One patient had a postoperative intracerebral hemorrhage requiring surgical evacuation. Fifteen patients were followed for up to 3 months with no postoperative stroke or transient ischemic attacks. CONCLUSION: ICTA is a potentially safe and effective completion imaging modality compared to traditional alternatives, enabling the identification of technical deficits intraoperatively. While no statistically significant difference in operative times were noted between intraoperative CTA and US use, numerous steps must be taken to maximize the efficiency of ICTA.

Occipital Artery Pseudoaneurysm After Posterior Fossa Craniotomy.

BACKGROUND: Pseudoaneurysms of scalp arteries have been reported in rare cases after iatrogenic injury; however, they are far more commonly seen after traumatic injuries. They are usually associated with the superficial temporal artery; however, there have been a few reports of psuedoaneurysms of the occipital artery (OA). CASE DESCRIPTION: We present a unique case of an OA pseudoaneurysm presenting with delayed postoperative hemorrhage after a retrosigmoid craniotomy. The pseudoaneurysm was treated by coil embolization. CONCLUSIONS: The patient recovered fully after endovascular embolization. Other treatment options for pseudoaneurysms of facial, temporal, and scalp arteries include surgical clipping/trapping with excision, Hunterian ligation, or direct compression. Pseudoaneurysms of extracranial scalp arteries are rare and most often caused by traumatic compression of the artery against a bony ridge. Despite their rarity, pseudoaneurysms secondary to iatrogenic injury to extracranial arteries should be considered in the differential diagnosis in patients presenting with delayed incisional pain, redness, and swelling.

Intraventricular Cavernomas of the Third Ventricle: Report of 2 Cases and a Systematic Review of the Literature.

BACKGROUND: Intraventricular cavernous malformations are relatively rare benign vascular malformations. Patients may be asymptomatic or present with headache, seizure, hemorrhage, or neurologic deficits. We report 2 cases of patients with cavernomas in the third ventricle and at the foramen of Monro. We also performed a systematic review of the literature to examine the clinical features and efficacy of the current standard of care for these lesions. METHODS: We performed the systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple databases were queried; the title/abstract and MeSH keywords used included "cavernous malformation," "cavernoma," "cavernous hemangioma," "cavernous angioma," "foramen of Monro," "third ventricle," and "intraventricular," along with "AND" and "OR" operators. Patient demographic and clinical data were collected for qualitative synthesis. RESULTS: Patients presented at a median age of 38 years; the most common symptom was headaches. Gross total resection was performed in 84.6% of patients, and 81.8% had clinical improvement with intervention. The incidence of intraventricular hemorrhage and hydrocephalus was 15.4% and 59%, respectively. CONCLUSIONS: The specific location of the cavernoma determines clinical features seen and approach used in surgical resection. Ventriculoperitoneal shunting was not required in most cases, as hydrocephalus improved with removal of the obstruction at the foramen of Monro. Gross total resection appears to be the optimal management strategy in symptomatic patients and leads to a good outcome in most cases.

Clinical application of near-infrared spectroscopy in patients with traumatic brain injury: a review of the progress of the field.

Near-infrared spectroscopy (NIRS) is a technique by which the interaction between light in the near-infrared spectrum and matter can be quantitatively measured to provide information about the particular chromophore. Study into the clinical application of NIRS for traumatic brain injury (TBI) began in the 1990s with early reports of the ability to detect intracranial hematomas using NIRS. We highlight the advances in clinical applications of NIRS over the past two decades as they relate to TBI. We discuss recent studies evaluating NIRS techniques for intracranial hematoma detection, followed by the clinical application of NIRS in intracranial pressure and brain oxygenation measurement, and conclude with a summary of potential future uses of NIRS in TBI patient management.

Intracranial Hypertension Caused by Occipital Calvarial Hemangioma: Case Report.

BACKGROUND: Primary intraosseous calvarial hemangiomas (PICHs) are generally rare and predominate (3:1) in women. Occurrence in the frontal and parietal bones is most common, but involvement of the occipital bone is exceedingly rare, representing 3 of 125 cases in a series of PICHs studied by Heckl et al. in 2000. Histopathology establishes the diagnosis of cavernous hemangioma, which represents the most common subtype of intraosseous hemangiomas. Others include sclerosing, cellular, and capillary. When they do occur in the calvarium, they are most often asymptomatic and discovered incidentally or due to a palpable defect in the skull. CASE DESCRIPTION: In this case, a calvarial hemangioma was found to be the cause of elevated intracranial pressure in a 35-year-old woman. Resection of the hemangioma and reconstruction of the calvarium provided a complete cure for her symptoms. CONCLUSIONS: Primary intraosseous hemangiomas are rarely symptomatic but must be considered in the differential for calvarial lesions as part of safe surgical planning. Formulating an accurate differential diagnosis by acquiring proper imaging studies and specifically recognizing the classical "starburst" appearance, as well as considering the highly vascular pathology to avoid excess blood loss, is important. This unique case of a hemangioma-induced venous sinus compression and subsequent elevated intracranial pressure illustrates that hemangiomas can arise from any part of the calvarium and cause a wide variety of clinical symptoms.

Spatial distribution of nonlinear interactions in subthalamic nucleus local field potentials in Parkinson'S disease.

Abnormally synchronized neural oscillations within the subthalamic nucleus have been proposed as a contributor to the pathophysiology of Parkinson's disease. Recent studies have demonstrated phase-amplitude coupling between beta rhythms and high frequency oscillations in the subthalamic nucleus in unmedicated Parkinsonian patients. However, the nature of this coupling remains unclear. In this study, we first show the presence of nonlinear interactions between different frequency bands of oscillations. Then, we demonstrate that the amplitude of spatially localized high frequency activity is phase coupled with widespread beta oscillations within the subthalamic nucleus.

The efficacy of routine use of recombinant human bone morphogenetic protein-2 in occipitocervical and atlantoaxial fusions of the pediatric spine: a minimum of 12 months' follow-up with computed tomography.

OBJECT The purpose of this study focusing on fusion rate was to determine the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) use in posterior instrumented fusions of the craniocervical junction in the pediatric population. The authors previously reported the short-term (mean follow-up 11 months) safety and efficacy of rhBMP-2 use in the pediatric age group. The present study reports on their long-term results (minimum of 12 months' follow-up) and focuses on efficacy. METHODS The authors performed a retrospective review of 83 consecutive pediatric patients who had undergone posterior occipitocervical or atlantoaxial spine fusion at Texas Children's Hospital or Riley Children's Hospital during the period from October 2007 to October 2012. Forty-nine patients were excluded from further analysis because of death, loss to follow-up, or lack of CT evaluation of fusion at 12 or more months after surgery. Fusion was determined by postoperative CT scan at a minimum of 12 months after surgery. The fusion was graded and classified by a board-certified fellowship-trained pediatric neuroradiologist. Other factors, such as patient age, diagnosis, number of vertebral levels fused, use of allograft or autograft, dosage of bone morphogenetic protein (BMP), and use of postoperative orthosis, were recorded. RESULTS Thirty-four patients had a CT scan at least 12 months after surgery. The average age of the patients at surgery was 8 years, 1 month (range 10 months-17 years). The mean follow-up was 27.7 months (range 12-81 months). There were 37 fusion procedures in 34 patients. Solid fusion (CT Grade 4 or 4-) was achieved in 89.2% of attempts (33 of 37), while incomplete fusion or failure of fusion was seen in 10.8%. Based on logistic regression analysis, there was no significant association between solid fusion and age, sex, BMP dose, type of graft material, use of postoperative orthosis, or number of levels fused. Three of 34 patients (8.8%) required revision surgery. CONCLUSIONS Despite the large number of adult studies reporting positive effects of BMP on bone fusion, our long-term outcomes using rhBMP-2 in the pediatric population suggest that rates of fusion failure are higher than observed in contemporary adult and pediatric reports of occipitocervical and atlantoaxial spine fusions.

A standardized protocol to reduce pediatric spine surgery infection: a quality improvement initiative.

OBJECT: Quality improvement methods are being implemented in various areas of medicine. In an effort to reduce the complex (instrumented) spine infection rate in pediatric patients, a standardized protocol was developed and implemented at an institution with a high case volume of instrumented spine fusion procedures in the pediatric age group. METHODS: Members of the Texas Children's Hospital Spine Study Group developed the protocol incrementally by using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied to all children undergoing complex spine surgery starting August 21, 2012. Acute infections were defined as positive wound cultures within 12 weeks of surgery, defined in alignment with current hospital infection control criteria. Procedures and infections were measured before and after protocol implementation. This protocol received full review and approval of the Baylor College of Medicine institutional review board. RESULTS: Nine spine surgeons performed 267 procedures between August 21, 2012, and September 30, 2013. The minimum follow-up was 12 weeks. The annual institutional infection rate prior to the protocol (2007-2011) ranged from 3.4% to 8.9%, with an average of 5.8%. After introducing the protocol, the infection rate decreased to 2.2% (6 infections of 267 cases) (p = 0.0362; absolute risk reduction 3.6%; relative risk 0.41 [95% CI 0.18-0.94]). Overall compliance with data form completion was 63.7%. In 4 of the 6 cases of infection, noncompliance with completion of the data collection form was documented; moreover, 2 of the 4 spine surgeons whose patients experienced infections had the lowest compliance rates in the study group. CONCLUSIONS: The standardized protocol for complex spine surgery significantly reduced surgical site infection at the authors' institution. The overall compliance with entry into the protocol was good. Identification of factors associated with post-spine surgery wound infection will allow further protocol refinement in the future.

Fixation with C-2 laminar screws in occipitocervical or C1-2 constructs in children 5 years of age or younger: a series of 18 patients.

UNLABELLED: OBJECT.: There are rare indications for upper cervical spine fusion in young children. Compared with nonrigid constructs, rigid instrumentation with screw fixation increases the fusion rate and reduces the need for halo fixation. Instrumentation may be technically challenging in younger children. A number of screw placement techniques have been described. Use of C-2 translaminar screws has been shown to be anatomically feasible, even in the youngest of children. However, there are few data detailing the clinical outcome. In this study, the authors describe the clinical and radiographic follow-up of 18 children 5 years of age or younger who had at least one C-2 translaminar screw as part of an occipitocervical or C1-2 fusion construct. METHODS: A retrospective review of all children treated with instrumented occipitocervical or C1-2 fusion between July 1, 2007, and June 30, 2013, at Riley Children's Hospital and Texas Children's Hospital was performed. All children 5 years of age or younger with incorporation of at least one C-2 translaminar screw were identified. RESULTS: Eighteen children were studied (7 boys and 11 girls). The mean age at surgery was 38.1 months (range 10-68 months). Indications for surgery included traumatic instability (6), os odontoideum (3), destructive processes (2), and congenital instability (7). A total of 24 C-2 translaminar screws were placed; 23 (95.8%) of 24 were satisfactorily placed (completely contained within the cortical walls). There was one medial cortex breach without neurological impingement. There were no complications with screw placement. Three patients required wound revisions. Two patients died as a result of their original condition (trauma, malignant tumor). The mean follow-up duration for the surviving patients was 17.5 months (range 3-60 months). Eleven (91.7%) of the 12 patients followed for 6 months or longer showed radiographic stability or completed fusion. CONCLUSIONS: Use of C-2 translaminar screws provides an effective anchor for internal fixation of the upper cervical spine. In this study of children 5 years of age or younger, the authors found a high rate of radiographic fusion with a low rate of complications.

Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group.

OBJECT: Upper cervical spine injuries in the pediatric age group have been recognized as extremely unstable from ligamentous disruption and as potentially lethal. Few measurement norms have been published for the pediatric upper cervical spine to help diagnose this pathological state. Instead, adult measurement techniques and results are usually applied inappropriately to children. The authors propose using high-resolution reconstructed CT scans to define a range of normal for a collection of selected upper cervical spine measurements in the pediatric age group. METHODS: Sagittal and coronal reformatted images were obtained from thin axial CT scans obtained in 42 children (< 18 years) in a 2-month period. There were 25 boys and 17 girls. The mean age was 100.9 months (range 1-214 months). Six CT scans were obtained for nontrauma indications, and 36 were obtained as part of a trauma protocol and later cleared for cervical spine injury. Six straightforward and direct linear distances-basion-dental interval (BDI); atlantodental interval (ADI); posterior atlantodental interval (PADI); right and left lateral mass interval (LMI); right and left craniocervical interval (CCI); and prevertebral soft-tissue thickness at C-2-that minimized logistical and technical distortions were measured and recorded. Statistical analysis including interobserver agreement, age stratification, and sex differences was performed for each of the 6 measurements. RESULTS: The mean ADI was 2.25 ± 0.24 mm (± SD), the mean PADI was 18.3 ± 0.07 mm, the mean BDI was 7.28 ± 0.10 mm, and the mean prevertebral soft tissue width at C-2 was 4.45 ± 0.43 mm. The overall mean CCI was 2.38 ± 0.44 mm, and the overall mean LMI was 2.91 ± 0.49 mm. Linear regression analysis demonstrated statistically significant age effects for PADI (increased 0.02 mm/month), BDI (decreased 0.02 mm/month), and CCI (decreased 0.01 mm/month). Similarly significant effects were found for sex; females demonstrated on average a smaller CCI by 0.26 mm and a smaller PADI by 2.12 mm. Moderate to high interrater reliability was demonstrated across all parameters. CONCLUSIONS: Age-dependent and age-independent normal CT measurements of the upper cervical spine will help to differentiate physiological and pathological states in children. The BDI appears to change significantly with age but not sex; on the other hand, the LMI and ADI appear to be age-independent measures. This preliminary study suggests acceptable levels of interrater reliability, and further expanded study will aim to validate these measurements to produce a profile of normal upper cervical spine measurements in children.

Emergency reversal of clopidogrel in the setting of spontaneous intracerebral hemorrhage.

OBJECTIVE: To compare outcomes in the setting of spontaneous intracerebral hemorrhage (ICH) in patients taking aspirin (acetylsalicylic acid [ASA]) versus patients taking clopidogrel before hospitalization. METHODS: Patients admitted to the neurosurgical service with a spontaneous ICH while taking an antiplatelet agent were prospectively identified and retrospectively reviewed. Two groups of 28 consecutive patients taking ASA or clopidogrel on admission were ultimately evaluated. RESULTS: Patients in the clopidogrel group had a mean age of 72.6 years, and patients in the ASA group had a mean age of 65.8 years (P=0.04). Patients taking clopidogrel before hospitalization were significantly more likely than patients taking ASA to experience an increase in hematoma volume (P=0.05). Patients in the ASA group trended toward being discharged to home more frequently than other destinations (P=0.07). The in-hospital mortality rates in this series were 14.3% for the ASA group and 28.6% for the clopidogrel group. However, this association did not reach statistical significance (P=0.19). CONCLUSIONS: In this study, patients taking clopidogrel showed more hematoma expansion, higher in-hospital mortality rates, and a decreased likelihood of a home discharge compared with patients taking ASA alone.

Increased SRF transcriptional activity in human and mouse skeletal muscle is a signature of insulin resistance.

Insulin resistance in skeletal muscle is a key phenotype associated with type 2 diabetes (T2D) for which the molecular mediators remain unclear. We therefore conducted an expression analysis of human muscle biopsies from patients with T2D; normoglycemic but insulin-resistant subjects with a parental family history (FH(+)) of T2D; and family history-negative control individuals (FH(­)). Actin cytoskeleton genes regulated by serum response factor (SRF) and its coactivator megakaryoblastic leukemia 1 (MKL1) had increased expression in T2D and FH(+) groups. Furthermore, striated muscle activator of Rho signaling (STARS), an activator of SRF, was upregulated in T2D and FH(+) and was inversely correlated with insulin sensitivity. Skeletal muscle from insulin-resistant mice recapitulated this gene expression pattern and showed reduced G-actin and increased nuclear localization of MKL1, each of which regulates SRF activity. Overexpression of MKL1 or reduction in G-actin decreased insulin-stimulated Akt phosphorylation, whereas reduction of STARS expression increased insulin signaling and glucose uptake. Pharmacological SRF inhibition by CCG-1423 reduced nuclear MKL1 and improved glucose uptake and tolerance in insulin-resistant mice in vivo. Thus, SRF pathway alterations are linked to insulin resistance, may contribute to T2D pathogenesis, and could represent therapeutic targets.

Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: a clinical review.

OBJECTIVE: Prehospital use of antiplatelet agents has been associated with an increased risk for intracranial hemorrhage (ICH) as well as a secondary increase in ICH volume after the initial hemorrhage. Strategies to reestablish platelet aggregation are used in clinical practice, but without any established guidelines or recommendations. This article serves to evaluate the literature regarding "reversal" of antiplatelet agents in neurosurgical populations. METHODS: PubMed and MEDLINE databases were searched for publications from 1966 to 2009 relating to intracranial hemorrhage and antiplatelet agents. The reference sections of recent articles, guidelines, and reviews were reviewed and pertinent articles identified. Studies were classified by two broad subsets: those describing intracranial hemorrhage relatable to a traumatic mechanism and those with a spontaneous intracranial hemorrhage. Two independent auditors recorded and analyzed study design and the reported outcome measures. RESULTS: For the spontaneous intracranial hemorrhage group, nine reports assessing antiplatelet effects on various outcome measures were identified. Eleven studies evaluating the use of prehospital antiplatelets before a traumatic intracranial hemorrhage were examined. CONCLUSION: The data assessing the relationship between outcome and prehospital antiplatelet agents in the setting of ICH is conflicting in both the trauma and the stroke literature. Only one retrospective review specifically addressed outcomes after attempted reversal with platelet transfusion. Further study is needed to determine whether platelet transfusion ameliorates hematoma enlargement and/or improves outcome in the setting of acute ICH.