Stenting for Traumatic Pseudoaneurysms of the Cervical Internal Carotid Artery: Case Report and Systematic Review.

BACKGROUND: The optimal stenting approach for traumatic pseudoaneurysms (PSA) of the extracranial internal carotid artery (ICA) remains underinvestigated. We present a case of a traumatic pseudoaneurysm of the extracranial ICA managed with stenting and review of prior published similar cases. METHODS: The systematic review followed PRISMA-S guidelines and included studies that investigated traumatic pseudoaneurysms of the extracranial ICA managed by stent placement. Statistical analysis assessed the association between the type of injury and stent type, dual antiplatelet therapy (DAPT) duration, and clinical presentation, and the association between stent type and DAPT duration. RESULTS: Our search yielded 82 publications with 135 patients with extracranial ICA PSA treated with stenting. The odds of neck hematoma presentation was 12.2 times greater for patients with penetrating rather than blunt injuries (P = 0.000002). Covered stents had 2.02 times higher odds of use for penetrating rather than blunt injuries compared to bare metal stents. (P = 0.0029). Shorter duration DAPT was seen with bare metal stents having 1.25 higher odds of DAPT duration less than one month compared to covered (P = 0.001). CONCLUSIONS: In traumatic extracranial ICA pseudoaneurysms, covered stents are used more commonly for penetrating injuries compared to blunt injuries. Penetrating injuries are more strongly associated with the presentation of a hematoma compared to blunt injuries. Stent type may influence the recommended DAPT duration. Surgeons should consider these findings when selecting stent type and DAPT duration with patients presenting with traumatic extracranial ICA pseudoaneurysm.

Vertebral Artery to Middle Cerebral Artery Bypass for Flow Augmentation.

BACKGROUND AND IMPORTANCE: Extracranial-intracranial bypass remains an enduring procedure for a select group of patients suffering from steno-occlusive cerebrovascular disease. Although the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is most familiar among neurosurgeons, particular circumstances preclude the use of an STA donor. In such cases, alternative revascularization strategies must be pursued. CLINICAL PRESENTATION: A 63-year-old female presented with symptoms of hemodynamic insufficiency and was found to have left common carotid artery occlusion at the origin. She experienced progressive watershed ischemia and pressure-dependent fluctuations in her neurological examination despite maximum medical therapy. The ipsilateral STA was unsuitable for use as a donor vessel. We performed an extracranial vertebral artery (VA) to MCA bypass with a radial artery interposition graft. CONCLUSION: This technical case description and accompanying surgical video review the relevant anatomy and surgical technique for a VA-MCA bypass. The patient was ultimately discharged home at her preoperative neurological baseline with patency of the bypass. The VA can serve as a useful donor vessel for cerebral revascularization procedures in pathologies ranging from malignancies of the head and neck to cerebral aneurysms and cerebrovascular steno-occlusive disease.

Racial disparities in incidence, treatment, and survival in adult brain metastases: a 10-year national database analysis.

OBJECTIVE: The aim of this study was to assess demographic and racial disparities in incidence, treatment, and survival of adults with metastatic malignancy to the brain. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) Program database, the authors identified adults with nonprimary brain metastases between 2010 and 2019. Incidence was calculated for all 10 years while data from 2010 to 2014 were used for survival analysis. The primary outcome measure was all-cause mortality within 5 years, assessed by 6-month, 1-year, 2-year, and 5-year survival rates. Chi-square tests of independence and one-way ANOVA were used to compare categorical and continuous measures, respectively, between non-Hispanic White (NHW), Hispanic White (HW), Black, and Asian/Pacific Islander (API) patients. A multivariable Cox proportional hazards model was developed to evaluate the risk of death within 5 years. RESULTS: A total of 64,690 patient records were identified and analyzed following exclusion based on age (patients > 84 years or < 18 years were excluded), missing race data, and missing survival data. Incidences are reported per 100,000 adults. The incidence of brain metastases increased from 2.59 in 2010 to 2.78 in 2019, with an average 10-year incidence of 2.72. API patients had the highest population-adjusted incidence (3.52), followed by NHW (2.99), Black (2.32), and HW (1.59) patients. Black patients were the most likely to have low income and single status, while API patients were the most likely to have high income and married status. Subsequently, Black patients had the shortest survival time (9.05 months vs 9.19 months for NHW vs 12.93 months for HW vs 15.89 months for API patients, p < 0.001). After controlling for the effect of socioeconomic factors on survival, the multivariable analysis showed that Black (HR 0.91, 95% CI 0.88-0.94), HW (HR 0.73, 95% CI 0.69-0.76), and API (HR 0.69, 95% CI 0.66-0.73) patients all had a survival advantage compared with NHW patients. Surgery also conferred a strong survival advantage (HR 0.47, 95% CI 0.44-0.49). CONCLUSIONS: The incidence of brain metastases has increased slightly between 2010 and 2019, with the highest rate in API patients. Black patients had the lowest survival, potentially due to poor socioeconomic status and lower rates of surgery and chemotherapy. Black patients were the most likely to not be recommended surgery, suggesting a discrepancy in services offered to these patients. More research is warranted to understand the underlying causes of these disparities.

Quantitative Blood Flow Reduction in Selective Embolization of Intranidal Fistula of Cerebral Arteriovenous Malformations: Case Series.

BACKGROUND AND OBJECTIVES: Arteriovenous malformations (AVMs) are often associated with high-flow intranidal fistulas (INFs). Although INF embolization has been suggested to provide higher reduction of total AVM flow compared with regular pedicle embolization, this effect has not previously been quantified. The aim of this study was to characterize the effect of AVM INF embolization on total AVM flow. METHODS: This study is an Institutional Review Board-approved, retrospective case series of patients from 2010 to 2022 with AVMs, both with and without INFs, who underwent quantitative magnetic resonance angiography and endovascular embolization. RESULTS: Twenty patients accounted for 35 separate embolization sessions: 13 patients with INFs underwent a total 21 embolizations and 12 patients without INFs had 14 embolizations. No significant differences were found between groups on age, sex, laterality, drainage pattern, and Spetzler-Martin grade. However, AVMs with INFs were larger than the control group (12.7 vs 8.37 cm 3 , P = .049). Baseline pre-embolization AVM flow significantly differed between AVM with INF vs control groups (522 vs 320 cc/min, P = .005). Similarly, postembolization AVM flow also differed between AVM with INF and control groups (392 vs 224 cc/min, P = .008), with a larger decrease in flow per vessel per embolization session within the AVM INF group compared with controls (101.5 vs 33.2 cc/min, P < .001). Repeated measure analysis of variance showed significant differences pre-embolization and postembolization AVM flow between those with INFs vs controls ( P < .001). CONCLUSION: This study represents the first to examine the effect of INF embolization on total AVM flow. AVMs with INFs showed higher baseline flow, and targeted embolization toward INFs significantly lowered AVM flow in comparison with controls without INFs. The results of this study emphasize the importance of recognizing the presence of INFs within AVMs and their embolization to reduce AVM flow as part of a multistep management paradigm.

Middle meningeal artery embolization in pediatric patient.

PURPOSE: There is paucity of data in management of recurrent and expanding subdural hematomas (SDH) within the pediatric population, who are otherwise not surgical candidates. Middle meningeal artery (MMA) embolization has been utilized minimally in this population and here, we explore the utility of this procedure in a 15-month-old-child, along with review of the literature. METHODS: A case report of a 15-month-old child who underwent MMA embolization for recurrent and expanding SDH in the setting of anticoagulation for cardiac condition. A literature review of MMA embolization in pediatric patients was conducted. RESULTS: Initially stabilization of SDH was noted on serial imaging; however, recurrent hemorrhages were noted with subsequent boluses of antiplatelet and anticoagulating agents. There are only 5 total reported cases, included ours, of MMA embolization in pediatrics with an overall success rate of 80%. CONCLUSION: Treatment of chronic or recurrent subdural hematoma by MMA embolization in the pediatric population is understudied. Our case notes limitation of this procedure and impact on long-term success, specifically in patients with systemic illness and ongoing anticoagulation.

Five-Year Outcomes After Decompression and Fusion Versus Decompression Alone in the Treatment of Lumbar Synovial Cysts.

BACKGROUND: Spinal synovial cysts are acquired, fluid-filled lesions of the facet joint that most commonly occur in the lumbar spine. They are thought to arise from degenerative changes and to result from segmental instability. Although the treatment of these lesions has been studied, the long-term implications and effects of the different strategies for surgical intervention (i.e., decompression and fusion vs. decompression alone) have not yet been elucidated or established. METHODS: Using an all-payer database with 53 million patient records (MARINER-53), patients with a diagnosis of lumbar synovial cysts were identified. Patients who had undergone lumbar fusion versus laminectomy were matched 1:1 using binomial and gaussian logistic regression models to evaluate the need for future lumbar surgery within 5 years after their index procedure. RESULTS: No statistically significant differences were noted between the 5-year rates of subsequent intervention, additional laminectomy, or fusion among patients who had undergone index decompression and fusion (n = 51; 10.5%) versus decompression alone (n = 43; 8.8%; P = 0.39). Furthermore, no significant differences were found in the odds of intervention type after index decompression and fusion versus decompression alone (subsequent laminectomy: odds ratio, 0.59; 95% confidence interval, 0.32-1.09; subsequent fusion: odds ratio, 1.14; 95% confidence interval, 0.64-2.02). CONCLUSIONS: Patient-specific factors and surgeon-patient-shared decision-making should be used when planning interventions for these lesions. However, synovial cysts might not require a fusion procedure for presumed instability. Further investigation is required, using randomized and prospective studies, to further evaluate the effective treatment of this entity.

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature.

Introduction For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation ( p = 0.047) . Conclusion Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

A Novel Instrumentation Approach in a Pediatric Patient with Atlanto-Occipital Dislocation and Cervical Fracture: Case Report.

BACKGROUND: Although instrumented stabilization of pediatric atlanto-occipital dislocation (AOD) has been described in the literature, there is little evidence regarding instrumentation techniques in pediatric patients presenting with both AOD and a cervical fracture. We present a case of a 2-year-old male involved in a motor vehicle collision with an unstable C2 fracture and AOD, treated with an occiput-C4 posterior arthrodesis using a rod, crosslink, and cable construct. CASE DESCRIPTION: This patient suffered a type III C2 fracture and AOD with 4 mm craniocaudal and 3 mm anterior displacement. In the operating room, 2 cobalt chrome connecting rods (3.5 mm) were connected to 1 another with crosslinks at C2 and C4. These were affixed with suboccipital and sublaminar cables at C1, C2, and C4. At 14 months postoperatively, his spine is clinically and radiographically stable. He has spontaneous movement in all 4 extremities, and remains in a persistent vegetative state because of his underlying central nervous system injury. CONCLUSIONS: Although there is a breadth of literature investigating instrumentation approaches to pediatric AOD, there is minimal evidence on outcomes of patients presenting with both AOD and cervical fracture. The technique we describe has proven safe and effective for this patient.

Extracranial-to-Intracranial Bypass for Pressor Dependent Cerebrovascular Insufficiency: Modified Classification and Representative Case.

BACKGROUND: While some randomized clinical trials have reduced the indications for cerebral revascularization in the secondary prevention of ischemic stroke, a distinct subset of patients with blood pressure augmentation dependent cerebrovascular insufficiency due to large vessel occlusions remains unaddressed. With the recent paradigm shifts in acute ischemic stroke care, the role of extracranial to intracranial (EC-IC) bypass must be re-addressed when endovascular intervention is not a feasible option. We submit a refined classification of cerebrovascular insufficiency with a category called Pressor-Dependent Cerebrovascular Insufficiency (PD-CVI) for whom EC-IC bypass may be indicated. CLINICAL PRESENTATION: A 61-year-old female former smoker presented with one day of intermittent left faciobrachial weakness and was found to have middle cerebral artery and cervical internal carotid artery occlusions. On admission to the intensive care unit, she was found to have PD-CVI with an intravenous pressor dependent blood pressure threshold over which she had near resolution of her neurological deficits. With endovascular intervention precluded given the ICA occlusion, she underwent an urgent right sided EC-IC bypass. The procedure was without complication, with careful attention to maintaining hypertension perioperatively. She required no pressors postoperatively and was neurologically intact at three months post-operatively. CONCLUSION: With recent advances in acute ischemic stroke care, there remains a need for careful consideration of cerebral revascularization surgery in patients with evidence of PD-CVI who may be precluded from or failed endovascular intervention.

Surgical Results of Common Peroneal Nerve Neuroplasty at Lateral Fibular Neck.

BACKGROUND: Common peroneal nerve (CPN) compressive neuropathy is the most common lower-extremity entrapment neuropathy. MATERIALS AND METHODS: A retrospective review of a prospectively maintained single-institution database of all patients with CPN palsy who underwent decompression and neuroplasty over a 5-year period was performed. RESULTS: Thirty patients underwent a neuroplasty of the CPN over a 5-year period (2010-2015) at our institution. The median age was 45 years, and there was a male preponderance. The average time between first onset of symptoms to surgery was 122.9 weeks and between first clinic visit and surgery was 21 weeks. The etiology of the CPN neuropathy was as follows: in 12 patients, it followed a surgical procedure and in 14 patients, it occurred after a trauma to the lower extremity. In 2 patients, it occurred as a result of a mass lesion compromising the nerve and in 1 patient, a local infection predisposed to CPN palsy. Right and left lower extremities were equally involved. The median body mass index was 28.6. The most common presentation was weakness of the tibialis anterior (TA) and extensor hallucis longus (EHL) and loss of sensation in the distribution of the CPN or one of its major branches. Pain was a presenting symptom in 16 patients. Only 12 of the 30 patients had a positive Tinel's sign at the site of compression over the lateral fibular neck. Preoperative electrophysiologic confirmation of CPN neuropathy was available in all patients. Mean follow-up was 52 weeks. Prone positioning and selective use of the operating microscope provided excellent visualization and surgical exposure of the CPN from the lower popliteal region to the peroneal tunnel. Average operating room time was 170 minutes and average skin-to-skin time 91 minutes. Clinical improvement after surgery in terms of motor function was noted in 24 of the 26 patients who presented with a motor deficit. The most consistent improvement was noted in the TA and EHL; a trend toward greater improvement with shorter time to surgery was noted. No complications related to the surgical site or CPN were encountered, and no patient had a decline in their neurologic examination as a consequence of the surgery. One patient developed a positioning-related right upper-extremity brachial plexus neuropraxic injury after surgery that recovered completely. CONCLUSIONS: Common peroneal neuropathy usually presents with weakness of the TA and EHL and decreased sensation or pain in the distribution of the CPN. Microscope-assisted surgical neuroplasty of the CPN at the lateral fibular neck with the patient in a prone position allows decompression of the nerve from the lower popliteal region to the peroneal tunnel. Significant improvement in motor strength after surgery, particularly of the TA and EHL, was observed in this series.