Treatment of pediatric intracranial aneurysms: institutional case series and systematic literature review.

INTRODUCTION: Pediatric intracranial aneurysms (IAs) are rare and have distinct clinical profiles compared to adult IAs. They differ in location, size, morphology, presentation, and treatment strategies. We present our experience with pediatric IAs over an 18-year period using surgical and endovascular treatments and review the literature to identify commonalities in epidemiology, treatment, and outcomes. METHODS: We identified all patients < 20 years old who underwent treatment for IAs at our institution between 2005 and 2020. Medical records and imaging were examined for demographic, clinical, and operative data. A systematic review was performed to identify studies reporting primary outcomes of surgical and endovascular treatment of pediatric IAs. Demographic information, aneurysm characteristics, treatment strategies, and outcomes were collected. RESULTS: Thirty-three patients underwent treatment for 37 aneurysms over 18 years. The mean age was 11.4 years, ranging from one month to 19 years. There were 21 males (63.6%) and 12 females (36.4%), yielding a male: female ratio of 1.75:1. Twenty-six (70.3%) aneurysms arose from the anterior circulation and 11 (29.7%) arose from the posterior circulation. Aneurysmal rupture occurred in 19 (57.5%) patients, of which 8 (24.2%) were categorized as Hunt-Hess grades IV or V. Aneurysm recurrence or rerupture occurred in five (15.2%) patients, and 5 patients (15.2%) died due to sequelae of their aneurysms. Twenty-one patients (63.6%) had a good outcome (modified Rankin Scale score 0-2) on last follow up. The systematic literature review yielded 48 studies which included 1,482 total aneurysms (611 with endovascular treatment; 656 treated surgically; 215 treated conservatively). Mean aneurysm recurrence rates in the literature were 12.7% and 3.9% for endovascular and surgical treatment, respectively. CONCLUSIONS: Our study provides data on the natural history and longitudinal outcomes for children treated for IAs at a single institution, in addition to our treatment strategies for various aneurysmal morphologies. Despite the high proportion of patients presenting with rupture, good functional outcomes can be achieved for most patients.

Optimizing suction force in mechanical thrombectomy: Priming the aspiration tubing with air versus saline.

Objective: We sought to investigate how priming the tube between air versus air mixed with saline ex vivo influenced suction force. We examined how priming the tube influenced peak suction force and time to achieve peak suction force between both modalities. Methods: Using a Dwyer Instruments (Dwyer Instruments Inc., Michigan City, IN, USA), INC Digitial Pressure Gauge, we were able to connect a .072 inch aspiration catheter to a rotating hemostatic valve and to aspiration tubing. We recorded suction force measured in negative inches of Mercury (inHg) over 10 iterations between having the aspiration tube primed with air alone versus air mixed with saline. A test was used to compare results between both modalities. Results: Priming the tube with air alone compared to air mixed with saline was found to have an increased average max suction force (-28.60 versus -28.20 in HG, p<0.01). We also identified a logarithmic curve of suction force across time in which time to maximal suction force was more prompt with air compared with air mixed with saline (13.8 seconds versus 21.60 seconds, p<0.01). Conclusions: Priming the tube with air compared to air mixed with saline suggests that not only is increased maximal suction force achieved, but also the time required to achieve maximal suction force is less. This data suggests against priming the aspiration tubing with saline and suggests that the first pass aspiration primed with air may have the greatest suction force.

The use of robot-assisted surgery for the unstable traumatic spine: A retrospective cohort study.

Background: Robotic assistance has been shown to increase instrumentation placement accuracy in open and minimally invasive spinal fusion. These gains have been achieved without increases in operative times, blood loss, or hospitalization duration. However, most work has been done in the degenerative population and little is known of the utility of robotic assistance when applied to spinal trauma. This is largely due to the uncertainty stemming from the disruption of normal anatomy by the traumatic injury. Since the robot depends upon registration for instrumentation guidance according to the fiducials it uses, trauma can introduce unique challenges. The present study sought to evaluate the safety and efficacy of robotic assistance in a consecutive cohort of spine trauma patients. Methods: All patients with Thoracolumbar Injury Classification and Severity Scale (TLICS) >4 who underwent robot-assisted spinal fusion using the Globus ExcelsiusGPS at a single tertiary care center for trauma between 2020 and 2022 were identified. Demographic, clinical, and surgical data were collected and analyzed; the primary endpoints were operative time, fluoroscopy time, estimated blood loss, postoperative complications, admission time, and 90-day readmission rate. The paired t-test was used to compare differences between mean values when looking at the number of surgical levels. Results: Forty-two patients undergoing robot-assisted spinal surgery were included (mean age 61.3±17.1 year; 47% female. Patients were stratified by the number of operative levels, 2 (n = 10), 3-4 (n = 11), 5 to 6 (n = 13), or >6 (n = 8). There appeared to be a positive correlation between number of levels instrumented and odds of postoperative complications, admission duration, fluoroscopy time, and estimated blood loss. There were no instances of screw malposition or breach. Conclusions: This initial experience suggests robotic assistance can be safely employed in the spine trauma population. Additional experiences in larger patient populations are necessary to delineate those traumatic pathologies most amenable to robotic assistance.

Safety of middle meningeal artery embolization for treatment of subdural hematoma: A nationwide propensity score matched analysis.

OBJECTIVE: Middle meningeal artery embolization (MMAe) has burgeoned as a treatment for chronic subdural hematoma (cSDH). This study evaluates the safety and short-term outcomes of MMAe patients relative to traditional treatment approaches. METHODS: In this retrospective large database study, adult patients in the National Inpatient Sample from 2012-2019 with a diagnosis of cSDH were identified. Cost of admission, length of stay (LOS), discharge disposition, and complications were analyzed. Propensity score matching (PSM) was utilized. RESULTS: A total of 123,350 patients with cSDH were identified: 63,450 without intervention, 59,435 surgery only, 295 MMAe only, and 170 surgery plus MMAe. On PSM analysis, MMAe did not increase the risk of inpatient complications or prolong the length of stay compared to conservative management (p>0.05); MMAe had higher cost ($31,170 vs. $10,768, p<0.001) than conservative management, and a lower rate of nonroutine discharge (53.8% vs. 64.3%, p=0.024). Compared to surgery, MMAe had shorter LOS (5 vs. 7 days, p<0.001), and lower rates of neurological complications (2.7% vs. 7.1%, p=0.029) and nonroutine discharge (53.8% vs. 71.7%, p<0.001). There was no significant difference in cost (p>0.05). CONCLUSIONS: MMAe had similar LOS and decreased odds of adverse discharge with a modest cost increase compared to conservative management. There was no difference in inpatient complications. Compared to surgery, MMAe treatment was associated with decreased LOS and rates of neurological complications and nonroutine discharge. This nationwide analysis supports the safety of MMAe to treat cSDH.

Direct Transorbital Approach for Treatment of Carotid Cavernous Fistula: An Illustrative Case Series.

BACKGROUND AND OBJECTIVES: Endovascular techniques have become the first-line treatment for carotid-cavernous fistulas (CCFs). Direct transorbital venous access may be used if anatomic constraints limit standard transarterial or transvenous access. We describe our institutional experience with the transorbital approach for Barrow Type A-D CCFs. METHODS: Patients with CCFs undergoing transorbital endovascular treatment at our institution between 2017 and 2019 were retrospectively reviewed. Demographic, treatment, and outcome data were collected. RESULTS: Eight patients met inclusion criteria, 4 female and 4 male patients. The mean age was 43 years, with 6 right-sided CCF and 2 left-sided CCFs. Symptoms were present for an average of 1.5 months before treatment. All patients presented with eye pain and subjective visual changes. Seven (87.5%) patients presented with proptosis, 6 (75%) patients had elevated intraocular pressure (IOP), and 3 (37.5%) patients had ophthalmoplegia. Six CCFs (75%) were spontaneous, and 2 CCFs (25%) were traumatic. Barrow types were A (n = 1), B (n = 1), C (n = 1), and D (n = 5). All patients underwent direct percutaneous transorbital embolization with coils followed by Onyx. Three patients had undergone prior transarterial and/or transvenous treatment. A radiographic cure was obtained in all patients after direct transorbital embolization. After CCF cure, cranial nerve palsies resolved in 66.7% of patients, visual acuity in the affected eye was improved or stable in 75% of patients, and IOP had normalized in 85.7% of patients. Proptosis improved in all patients, with complete resolution in 75%. CONCLUSION: Direct transorbital embolization is a safe and potentially curative treatment for all 4 Barrow types of CCFs.

Characterizing the frequency, morbidity, and types of traumatic brain injuries after the Mexico-San Diego border wall extension: a retrospective cohort review.

OBJECTIVE: The aim of this study was to investigate the impact of the US-Mexico border wall height extension on traumatic brain injuries (TBIs) and related costs. METHODS: In this retrospective cohort study, patients who presented to the UC San Diego Health Trauma Center for injuries from falling at the border wall between 2016 and 2021 were considered. Patients in the pre-height extension period (January 2016-May 2018) were compared with those in the post-height extension period (January 2020-December 2021). Demographic characteristics, clinical data, and hospital charges were analyzed. RESULTS: A total of 383 patients were identified: 51 (0 TBIs, 68.6% male) in the pre-height extension cohort and 332 (14 TBIs, 77.1% male) in the post-height extension cohort, with mean ages of 33.5 and 31.5 years, respectively. There was an increase in the average number of TBIs per month (0.0 to 0.34) and operative TBIs per month (0.0 to 0.12). TBIs were associated with increased Injury Severity Score (8.8 vs 24.2, p < 0.001), median (IQR) hospital length of stay (5.0 [2-11] vs 8.5 [4-45] days, p = 0.03), and median (IQR) hospital charges ($163,490 [$86,369-$277,918] vs $243,658 [$136,769-$1,127,920], p = 0.04). TBIs were normalized for changing migration rates on the basis of Customs and Border Protection apprehensions. CONCLUSIONS: This heightened risk of intracranial injury among vulnerable immigrant populations poses ethical and economic concerns to be addressed regarding border wall infrastructure.

Helical coils augment embolization of the middle meningeal artery for treatment of chronic subdural hematoma: A technical note.

Embolization of the middle meningeal artery (MMA) is a safe and effective adjunct in the treatment of chronic subdural hematoma. While prior authors describe the use of coils to assist embolization by preventing reflux through eloquent collaterals, we de- scribe the use of coils to further open the MMA, allowing the administration of greater amounts of embolisate for a more robust embolization. The objective of this study was to demonstrate that helical coils can safely open the MMA following the administration of polyvinyl alcohol (PVA) particles. This allows for more embolisate to be administered into the MMA for more effective treatment. A retrospective review was conducted at our institution including intraoperative images and postoperative clinical and radiographic follow up. Failure rates using MMA embolization with PVA and helical coil augmentation were compared to failure rates in the literature of MMA embolization with PVA or ethylene vinyl-alcohol copolymer alone. A total of 8 cases were reviewed in which this technique was implemented. There were no immediate complications after treatment. All patients that underwent helical coil embolization following the administration of PVA had increased amount of embolisate delivered into the MMA. All patients at follow up had resolution of the subdural hematoma on outpatient imaging. Helical coil embolization allows for more embolisate administration into the MMA and provides a technical advantage for patients that fail traditional techniques of embolization. Case series are taking place to further test this hypothesis and identify the ideal patient population that may gain maximal yield from this novel technique.

Racial and ethnic disparities in brain tumour survival by age group and tumour type.

PURPOSE: The extent to which racial/ethnic brain tumour survival disparities vary by age is not very clear. In this study, we assess racial/ethnic brain tumour survival disparities overall by age group and type. METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) 18 registries for US-based individuals diagnosed with a first primary malignant tumour from 2007 through 2016. Cox proportional hazards regression was used to compute adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between race/ethnicity and brain tumour survival, stratified by age group and tumour type. RESULTS: After adjusting for sex, socioeconomic status, insurance status, and tumour type, non-Hispanic (NH) Blacks (HR: 1.26; 95% CI: 1.02-1.55), NH Asian or Pacific Islanders (HR: 1.29; 95% CI: 1.01-1.66), and Hispanics (any race) (HR: 1.28; 95% CI: 1.09-1.51) all showed a survival disadvantage compared with NH Whites for the youngest age group studied (0-9 years). Furthermore, NH Blacks (HR: 0.88; 95% CI: 0.91-0.97), NH Asian or Pacific Islanders (HR: 0.84; 95% CI: 0.77-0.92), and Hispanics (any race) (HR: 0.91; 95% CI: 0.85-0.97) all showed a survival advantage compared with NH Whites for the 60-79 age group. Tests for interactions showed significant trends, indicating that racial/ethnic survival disparities disappear and even reverse for older age groups (P < 0.001). This reversal appears to be driven by poor glioblastoma survival among NH Whites (P < 0.001). CONCLUSION: Disparities in brain tumour survival among minorities exist primarily among children and adolescents. NH White adults show worse survival than their minority counterparts, which is possibly driven by poor glioblastoma biology.

Microsurgical Resection of a Giant Posterior Fossa Aneurysmal Malformation in a 21-Month-Old.

Pediatric aneurysms commonly occur in the vertebrobasilar circulation with complex morphologies.1 "Aneurysmal malformations," or fistulous vessel dilations without a nidus, have also been described.2 Vessel friability and sensitivity to blood loss can complicate surgery. A 21-month-old male with motor and speech delay was found to have a giant posterior fossa aneurysmal malformation. He was lethargic, with minimal speech, and moved all extremities with mild hypotonia. Imaging demonstrated a 6.9 × 5.1 × 4.6 cm aneurysm arising from a fenestrated right V4 segment. This communicated via a single connection with the deep venous system, draining through the superior vermian cistern veins, posterior mesencephalic vein, basal vein of Galen, and inferior sagittal sinus, consistent with an arteriovenous fistula with secondary aneurysmal dilatation. Endovascular sacrifice was not feasible, in addition to concern for swelling after embolization. Three-dimensional modeling confirmed close proximity of the single inflow and outflow tracts. A suboccipital and left far lateral craniotomy for clip trapping and excision of the aneurysmal arteriovenous malformation was performed in a lateral position to completely decompress the brainstem (Video 1). Angiography before closure and postoperative vascular imaging demonstrated complete aneurysmal resection and fistula disconnection, with patency of normal vasculature. The postoperative course was notable for transient swallowing difficulties likely from lower cranial nerve irritation and refractory hydrocephalus requiring a shunt. The patient was meeting all developmental milestones at 2-year follow-up. This case highlights the complex vascular pathology often seen in pediatric patients, as well as the importance of presurgical planning and careful microsurgical technique in achieving a successful outcome.

Application of Antibiotic-Impregnated Polymethyl-Methacrylate Bone Cement for the Treatment of Infected Cranioplasties: Initial Experience.

BACKGROUND: Management of infected cranioplasty implants remains a surgical challenge. Surgical debridement, removal of the infected implant, and prolonged antibiotic therapy are part of the acute management. In addition, cranioplasty removal poses the risk of dural tear. Reconstruction of the cranial defect is usually delayed for several months to years, increasing the difficulty due to soft tissue contraction and scarring. OBJECTIVE: The aim of the study was to propose an alternative to delayed reconstruction in the face of infection with a dual purpose: treat the infection with a material which delivers antibiotic to the area (polymethyl-methacrylate antibiotic) and which functions as a temporary or permanent cranioplasty. METHODS: We reviewed the records of 3 consecutive patients who underwent single-stage polymethyl-methacrylate antibiotic salvage cranioplasty. RESULTS: All patients underwent debridement of infected tissue. Titanium mesh was placed over the bony defect. Polymethyl methacrylate impregnated with vancomycin and tobramycin was then spread over the plate and defect before closure. Patients also received extended treatment with systemic antimicrobials. Early outcomes have been encouraging for both cosmesis and treatment of infection. CONCLUSIONS: Benefits of this treatment strategy include immediate reconstruction rather than staged procedures and delivery of high concentrations of antibiotics directly to the affected area in addition to systemic antibiotics.

Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis.

OBJECTIVE: Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. METHODS: A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. RESULTS: The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. CONCLUSIONS: Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Impact of COVID-19 on a Neurosurgical Service: Lessons from the University of California San Diego.

BACKGROUND: The institution-wide response of the University of California San Diego Health system to the 2019 novel coronavirus disease (COVID-19) pandemic was founded on rapid development of in-house testing capacity, optimization of personal protective equipment usage, expansion of intensive care unit capacity, development of analytic dashboards for monitoring of institutional status, and implementation of an operating room (OR) triage plan that postponed nonessential/elective procedures. We analyzed the impact of this triage plan on the only academic neurosurgery center in San Diego County, California, USA. METHODS: We conducted a de-identified retrospective review of all operative cases and procedures performed by the Department of Neurosurgery from November 24, 2019, through July 6, 2020, a 226-day period. Statistical analysis involved 2-sample z tests assessing daily case totals over the 113-day periods before and after implementation of the OR triage plan on March 16, 2020. RESULTS: The neurosurgical service performed 1429 surgical and interventional radiologic procedures over the study period. There was no statistically significant difference in mean number of daily total cases in the pre-versus post-OR triage plan periods (6.9 vs. 5.8 mean daily cases; 1-tail P = 0.050, 2-tail P = 0.101), a trend reflected by nearly every category of neurosurgical cases. CONCLUSIONS: During the COVID-19 pandemic, the University of California San Diego Department of Neurosurgery maintained an operative volume that was only modestly diminished and continued to meet the essential neurosurgical needs of a large population. Lessons from our experience can guide other departments as they triage neurosurgical cases to meet community needs.

Site of Occlusion May Influence Decision to Perform Thrombectomy Under General Anesthesia or Conscious Sedation.

BACKGROUND: Although mechanical thrombectomy has become the standard of care for large-vessel occlusion, the role of conscious sedation versus general anesthesia (GA) with intubation during thrombectomy remains controversial. Aphasia may increase patient agitation or apparent uncooperativeness/confusion and thereby lead to higher use of GA. The purpose of this study was to identify risk factors for GA and determine if the side of vessel occlusion potentially impacts GA rates. MATERIALS AND METHODS: Patients who underwent mechanical thrombectomy of the middle cerebral artery (MCA) for acute ischemic stroke at our institution between April 2014 and July 2017 were retrospectively reviewed. Patient characteristics, procedural factors, and outcomes were assessed using multivariate regression analyses. Mediation analysis was utilized to investigate whether aphasia lies on the causal pathway between left-sided MCA stroke and GA. RESULTS: Overall, 112 patients were included: 62 with left-sided and 50 with right-sided MCA occlusion. Patients with left-sided MCA occlusion presented with aphasia significantly more often those with right-sided occlusion (90.3% vs. 32.0%; P<0.001). GA rates were significantly higher for patients with left-sided compared with right-sided MCA occlusion (45.2% vs. 20.0%; P=0.028). Aphasia mediated 91.3% of the effect of MCA stroke laterality on GA (P=0.02). GA was associated with increased door-to-groin-puncture time (106.4% increase; 95% confidence interval, 24.1%-243.4%; P=0.006) and adverse discharge outcome (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P=0.019). CONCLUSIONS: Patients who had a stroke with left-sided MCA occlusion are more likely to undergo GA for mechanical thrombectomy than those with right-sided MCA occlusion. Aphasia may mediate this effect and understanding this relationship may decrease GA rates through modification of management protocols, potentially leading to improved clinical outcomes. Our study suggests that GA should preferentially be considered for the subset of patients with acute ischemic stroke undergoing mechanical thrombectomy for left-sided MCA occlusion.

Prone-transpsoas as single-position, circumferential access to the lumbar spine: A brief survey of index cases.

BACKGROUND CASE DESCRIPTION: Prone transposoas (PTP) is a novel approach to the lateral lumbar interbody fusion that harnesses the advantages of minimally invasive surgery with circumferential access to the lumbar spine in a single position. We present the peri-operative course of four index cases of patients having undergone PTP at a single institution. OUTCOME: Pre and post-operative spinal imaging with alignment parameters, operative approach, and patient outcome are reviewed for each index case. CONCLUSION: As advances in neuromonitoring and minimally invasive technology continue to evolve, new lumbar interbody fusion approaches are becoming operatively feasible.

Robot-assisted stereotactic biopsy of pediatric brainstem and thalamic lesions.

OBJECTIVE: Biopsies of tumors located in deep midline structures require highly accurate stereotaxy to safely obtain lesional tissue suitable for molecular and histological analysis. Versatile platforms are needed to meet a broad range of technical requirements and surgeon preferences. The authors present their institutional experience with the robotic stereotactic assistance (ROSA) system in a series of robot-assisted biopsies of pediatric brainstem and thalamic tumors. METHODS: A retrospective analysis was performed of 22 consecutive patients who underwent 23 stereotactic biopsies of brainstem or thalamic lesions using the ROSA platform at Rady Children's Hospital in San Diego between December 2015 and January 2020. RESULTS: The ROSA platform enabled rapid acquisition of lesional tissue across various combinations of approaches, registration techniques, and positioning. No permanent deficits, major adverse outcomes, or deaths were encountered. One patient experienced temporary cranial neuropathy, and 3 developed small asymptomatic hematomas. The diagnostic success rate of the ROSA system was 91.3%. CONCLUSIONS: Robot-assisted stereotactic biopsy of these lesions may be safely performed using the ROSA platform. This experience comprises the largest clinical series to date dedicated to robot-assisted biopsies of brainstem and diencephalic tumors.

Prone Transpsoas Technique for Simultaneous Single-Position Access to the Anterior and Posterior Lumbar Spine.

BACKGROUND: Effective decompression, arthrodesis, and correction of spinal conditions frequently utilize operative approaches that expose both the anterior and posterior spinal column. Until now, circumferential spinal column access often requires the surgeon to reposition and drape the patient multiple times or utilize a posterior only approach that has limited anterior correction capability or to utilize a lateral-only approach that complicates otherwise traditional posterior surgical maneuvers. OBJECTIVE: To describe a technique utilizing a single surgical position that enables minimally disruptive anterior column correction with simultaneous access to the posterior spinal column. METHODS: The operative technique for accessing the lateral lumbar interbody space from a prone transpsoas (PTP) approach is described. The rationale for this approach and a representative case example are reviewed. RESULTS: The PTP approach was used to perform an L3-4 and L4-5 interbody fusion in a 71-yr-old female with spondylolisthesis, severe stenosis, and locked facets. The PTP approach enabled efficient completion of an anterior column correction, direct posterior decompression, multi-segment pedicle fixation, and maintenance of alignment, all while in a single prone position. There were no intraoperative or postoperative complications. CONCLUSION: The authors' early experience with the described PTP technique suggests it is not only feasible but offers some advantages, as it allows for single-position surgery maximizing both anterior and posterior column access and corrective techniques. Further follow-up studies of this technique are ongoing.

Antiplatelet therapy within 24 hours of tPA: lessons learned from patients requiring combined thrombectomy and stenting for acute ischemic stroke.

OBJECTIVE: Although stroke guidelines recommend antiplatelets be started 24 hours after tissue plasminogen activator (tPA), select mechanical thrombectomy (MT) patients with luminal irregularities or underlying intracranial atherosclerotic disease may benefit from earlier antiplatelet administration. METHODS: We explore the safety of early (<24 hours) post-tPA antiplatelet use by retrospectively reviewing patients who underwent MT and stent placement for acute ischemic stroke from June 2015 to April 2018 at our institution. RESULTS: Six patients met inclusion criteria. Median presenting and pre-operative National Institutes of Health Stroke Scale scores were 14 (Interquartile Range [IQR] 5.5-17.3) and 16 (IQR 13.7-18.7), respectively. Five patients received standard intravenous (IV) tPA and one patient received intra-arterial tPA. Median time from symptom onset to IV tPA was 120 min (IQR 78-204 min). Median time between tPA and antiplatelet administration was 4.9 hours (IQR 3.0-6.7 hours). Clots were successfully removed from the internal carotid artery (ICA) or middle cerebral artery (MCA) in 5 patients, the anterior cerebral artery (ACA) in one patient, and the vertebrobasilar junction in one patient. All patients underwent MT before stenting and achieved thrombolysis in cerebral infarction 2B recanalization. Stents were placed in the ICA (n=4), common carotid artery (n=1), and basilar artery (n=1). The median time from stroke onset to endovascular access was 185 min (IQR 136-417 min). No patients experienced symptomatic post-procedure intracranial hemorrhage (ICH). Median modified Rankin Scale score on discharge was 3.5. CONCLUSIONS: Antiplatelets within 24 hours of tPA did not result in symptomatic ICH in this series. The safety and efficacy of early antiplatelet administration after tPA in select patients following mechanical thrombectomy warrants further study.

Simulator Training for Endovascular Neurosurgery.

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

Clinical and genetic characterization of patients with Pierre Robin sequence and spinal disease: review of the literature and novel terminal 10q deletion.

INTRODUCTION: The Pierre-Robin sequence (PRS) is a pattern of congenital facial abnormalities comprising micrognathia, glossoptosis, and airway obstruction. Associated spinal pathologies have rarely been reported with PRS. METHODS: We explore the molecular genetic basis of this association through a systematic review of spinal disease in patients with PRS. We also present an illustrative case of a PRS patient with tethered cord in the setting of chromosome 10q terminal deletion. RESULTS: Our systematic literature review of spinal disease in patients with PRS revealed several patterns in the underlying genetic syndromes causing these conditions to co-occur. These principles are illustrated in the case of a 6-month-old female with PRS and a 14.34-Mb terminal deletion of chromosome 10q, who was found to have a sacral dimple during a routine outpatient checkup. Magnetic resonance imaging of the spine revealed a lumbar syrinx associated with tethered spinal cord. Surgical de-tethering was undertaken, with subsequent improvement in motor function and decrease in the size of the syrinx. The deletion of chromosome 10q in our patient had not previously been described in association with tethered cord or PRS. CONCLUSION: Spinal pathologies are understudied contributors to disease burden in patients with PRS. The range of predisposing syndromes and mutations in patients with both PRS and spinal disorders remains poorly characterized but may be more defined than previously conceived. Clinical screening is most critical during neonatal and adolescent developmental periods with continued neurological assessment. This study emphasizes the need for early genetic testing and counseling in this patient population, in parallel with research efforts to develop molecular classifications to guide clinical management.