Safety and Efficacy of Surgical Implantation of Intrathecal Drug Delivery Pumps in Patients With Cancer With Refractory Pain.

BACKGROUND AND OBJECTIVES: Pain management in patients with cancer is a critical issue in oncology palliative care as clinicians aim to enhance quality of life and mitigate suffering. Most patients with cancer experience cancer-related pain, and 30%-40% of patients experience intractable pain despite maximal medical therapy. Intrathecal pain pumps (ITPs) have emerged as an option for achieving pain control in patients with cancer. Owing to the potential benefits of ITPs, we sought to study the long-term outcomes of this form of pain management at a cancer center. METHODS: We retrospectively reviewed medical records of all adult patients with cancer who underwent ITP placement at a tertiary comprehensive cancer center between 2013 and 2021. Baseline characteristics, preoperative and postoperative pain control, and postoperative complication rate data were collected. RESULTS: A total of 193 patients were included. We found that the average Numerical Rating Scale (NRS) score decreased significantly by 4.08 points (SD = 2.13, P < .01), from an average NRS of 7.38 (SD = 1.64) to an average NRS of 3.27 (SD = 1.66). Of 185 patients with preoperative and follow-up NRS pain scores, all but 9 experienced a decrease in NRS (95.1%). The median overall survival from time of pump placement was 3.62 months (95% CI: 2.73-4.54). A total of 42 adverse events in 33 patients were reported during the study period. The 1-year cumulative incidence of any complication was 15.6% (95% CI: 10.9%-21.1%) and for severe complication was 5.7% (95% CI: 3.0%-9.7%). Eleven patients required reoperation during the study period, with a 1-year cumulative incidence of 4.2% (95% CI: 2.0%-7.7%). CONCLUSION: Our study demonstrates that ITP implantation for the treatment of cancer-related pain is a safe and effective method of pain palliation with a low complication rate. Future prospective studies are required to determine the optimal timing of ITP implantation.

A smartphone pupillometry tool for detection of acute large vessel occlusion.

OBJECTIVES: Pupillary light reflex (PLR) parameters can be used as quantitative biomarkers of neurological function. Since digital infrared pupillometry is expensive, we sought to examine alterations in PLR parameters using a smartphone quantitative pupillometry platform in subjects with acute ischemic stroke (AIS). MATERIALS AND METHODS: Patients were enrolled if they presented to the emergency department as a stroke code activation and had evidence of a large vessel occlusion (LVO) on computed tomography angiography. Controls were enrolled from hospital staff. A smartphone pupillometer was used in AIS patients with LVO pre-mechanical thrombectomy, immediately post-thrombectomy, and at 24 h post-thrombectomy. Clinical and demographic data were collected, along with the proprietary Neurological Pupil index (NPi) score from the NPi-200 digital infrared pupillometer. PLR parameters were compared using mean differences. The absolute and non-absolute inter-eye difference in each parameter for each subject were also analyzed by measuring 1 - (R:L) to determine alteration in the equilibrium between subject pupils. The NPi was analyzed for mean differences between cohorts. RESULTS: Healthy controls (n = 132) and AIS patients (n = 31) were enrolled. Significant differences were observed in PLR parameters for healthy subjects when compared to pre-thrombectomy subjects in both mean and absolute inter-eye differences after post hoc Bonferroni correction. The proprietary NPi score was not significantly different for all groups and comparisons. CONCLUSIONS: Significant alterations in the PLR were observed in AIS patients with LVO before thrombectomy, indicating the potential use of smartphone pupillometry for detection of LVO.

Implantation of Intracranial Electrodes Predicts Worse Outcome in Mesial Temporal Lobe Epilepsy.

OBJECTIVE: Anteromesial resection is an effective method for treating seizures arising from the medial temporal lobe, as these cases are often the most straightforward and have the best outcomes. Nevertheless, some patients who go on to have a mesial resection are recommended to have an implantation of electrodes before surgery. Whether the need for such an implant alters the rate of seizure freedom is not well-studied in this particular subgroup of epilepsy patients. METHODS: We performed a retrospective review of consecutive anteromesial surgeries for medial temporal lobe epilepsy performed between 2005 and 2020. Of a total of 39 patients, 19 required electrode implantation (electrode group) and 20 did not (no-electrode group). The primary outcomes assessed were reduction in seizure frequency and Engel score. Complication rates were also compared. RESULTS: Postresection seizure frequency reduction was nonsignificantly higher in the no-electrode group (97.0 ± 10.3%) than in the electrode group (88.5 ± 23.7%, P = 0.15). The rate of Engel I outcome was nonsignificantly higher in the no-electrode group (84.2%) than in the electrode group (65.0%, P = 0.17). Major complication rates were nonsignificantly higher in the no-electrode group (15.8 ± 1.9%) than in the electrode group (5.0 ± 1.1%, P = 0.26). Power analysis revealed that 74 patients would need to be included in each group to reach statistical significance. CONCLUSIONS: Although not statistically significant, our study showed a trend for improved seizure control if a decision was made not to implant electrodes prior to potentially curative anteromesial resection. Engel I outcome in this group reached approximately 85%. A larger multi-instiutional study may be required to reach statistical significance.

Reevaluating Innovations in Medical Student Neurosurgery Education: Lessons Learned Today from Data Collected Before COVID-19.

OBJECTIVE: Virtual learning has made neurosurgery education more available to medical students (MSs) of all stages than ever before. We aimed to evaluate the impact of on-site learning in order to assess whether a return to this method of teaching, when safe, is warranted for MSs of all years. METHODS: Registrants of the 2019 MS Neurosurgery Training Camps were sent precourse and postcourse surveys to assess changes in self-assessed confidence in concrete neurosurgical skills. Data were analyzed using a 2-tailed paired Student's t-test for continuous variables. A P value <0.05 was considered significant. RESULTS: The 2019 Training Camp had 105 attendees, of whom 94 (89.5%) completed both surveys. Students reported statistically significant improvements in every surveyed skill area, except for understanding what is and is not sterile in an operating room. The cohort of MS 3/4 students indicated a postcourse decrease in confidence in their ability to understand what is and is not sterile in an operating room (93.69 ± 16.41 vs. 86.20 ± 21.18; P < 0.05). MS 3/4 students did not benefit in their ability to perform a neurologic examination or tie knots using a 1-handed technique. CONCLUSIONS: Neurosurgical education initiatives for MSs should continue to be developed. Hands-on neurosurgical training experiences for MSs serve as a valuable educational experience. Improvement in training models will lead to capitalizing on MS education to better improve readiness for neurosurgical residency without concern for patient safety.

Risk of tract recurrence with stereotactic biopsy of brain metastases: an 18-year cancer center experience.

OBJECTIVE: Stereotactic biopsy is increasingly performed on brain metastases (BrMs) as improving cancer outcomes drive aggressive multimodality treatment, including laser interstitial thermal therapy (LITT). However, the tract recurrence (TR) risk is poorly defined in an era defined by focused-irradiation paradigms. As such, the authors aimed to define indications and adjuvant therapies for this procedure and evaluate the BrM-biopsy TR rate. METHODS: In a single-center retrospective review, the authors identified stereotactic BrM biopsies performed from 2002 to 2020. Surgical indications, radiographic characteristics, stereotactic planning, dosimetry, pre- and postoperative CNS-directed and systemic treatments, and clinical courses were collected. Recurrence was evaluated using RANO-BM (Response Assessment in Neuro-Oncology Brain Metastases) criteria. RESULTS: In total, 499 patients underwent stereotactic intracranial biopsy for any diagnosis, of whom 25 patients (5.0%) underwent biopsy for pathologically confirmed viable BrM, a proportion that increased over the time period studied. Twelve of the 25 BrM patients had ≥ 3 months of radiographic follow-up, of whom 6 patients (50%) developed new metastatic growth along the tract at a median of 5.0 months post-biopsy (range 2.3-17.1 months). All of the TR cases had undergone pre- or early post-biopsy stereotactic radiosurgery (SRS), and 3 had also undergone LITT at the time of initial biopsy. TRs were treated with resection, reirradiation, or observation/systemic therapy. CONCLUSIONS: In this study the authors identified a nontrivial, higher than previously described rate of BrM-biopsy tract recurrence, which often required additional surgery or radiation and justified close radiographic surveillance. As BrMs are commonly treated with SRS limited to enhancing tumor margins, consideration should be made, in cases lacking CNS-active systemic treatments, to include biopsy tracts in adjuvant radiation plans where feasible.

Closed-loop vagal nerve stimulation for intractable epilepsy: A single-center experience.

PURPOSE: A new class of heart-rate sensing, closed-loop vagal nerve stimulator (VNS) devices for refractory epilepsy may improve seizure control by using pre-ictal autonomic changes as an indicator for stimulation. We compared our experience with closed- versus open-loop stimulator implantation at a single institution. METHODS: We conducted a retrospective chart review of consecutive VNS implantations performed from 2004 to 2018. Bivariate and multivariable analyses were performed to compare changes in seizure frequency and clinical outcomes (Engel score) with closed- versus open-loop devices. Covariates included age, duration of seizure history, prior epilepsy surgery, depression, Lennox Gastaut Syndrome (LGS), tonic seizures, multiple seizure types, genetic etiology, and VNS settings. We examined early (9-month) and late (24-month) outcomes. RESULTS: Seventy subjects received open-loop devices, and thirty-one received closed-loop devices. At a median of 8.5 months, there was a greater reduction of seizure frequency after use of closed-loop devices (median 75% [IQR 10-89%]) versus open-loop (50% [0-78%], p < 0.05), confirmed in multivariable analysis (odds ratio 2.72 [95% CI 1.02 - 7.4]). Similarly, Engel outcomes were better after closed-loop compared to open-loop confirmed in the multivariable analysis at the early timepoint (OR 0.26 [95% CI 0.09 - 0.69]). These differences did not persist at a median of 24.5 months. CONCLUSIONS: This retrospective single-center study suggests the use of closed-loop VNS devices is associated with greater seizure reduction and more favorable clinical outcomes than open-loop devices at 9-months though not at 24-months. Expansion of this study to other centers is warranted to increase the generalizability of our study.

Increases in female academic productivity and female mentorship highlight sustained progress in previously identified neurosurgical gender disparities.

OBJECTIVE: A meta-analysis was performed to understand disparities in the representation of female authorship within the neurosurgical literature and implications for career advancement of women in neurosurgery. METHODS: Author names for articles published in 16 of the top neurosurgical journals from 2002 to 2019 were obtained from MEDLINE. The gender of each author was determined using automated prediction methods. Publication trends were compared over time and across subdisciplines. Female authorship was also compared to the proportionate composition of women in the field over time. RESULTS: The metadata obtained from 16 major neurosurgical journals yielded 66,546 research articles. Gender was successfully determined for 96% (127,809/133,578) of first and senior authors, while the remainder (3.9%) were unable to be determined through prediction methods. Across all years, 13.3% (8826) of articles had female first authorship and 9.1% (6073) had female senior authorship. Female first authorship increased significantly over time from 5.8% in 2002 to 17.2% in 2019 (p < 0.001). Female senior authorship also increased significantly over time, from 5.5% in 2002 to 12.0% in 2019 (p < 0.001). The journals with the highest proportions of female first authors and senior authors were the Journal of Neurosurgery: Pediatrics (33.5%) and the Asian Journal of Neurosurgery (23.8%), respectively. Operative Neurosurgery had the lowest fraction of female first (12.4%) and senior (4.7%) authors. There was a significant difference between the year-by-year proportion of female neurosurgical trainees and the year-by-year proportion of female neurosurgical first (p < 0.001) and senior (p < 0.001) authors. Articles were also more likely to have a female first author if the senior author of the article was female (OR 2.69, CI 2.52-2.86; p < 0.001). From 1944 to 2019, the Journal of Neurosurgery showed a steady increase in female first and senior authorship, with a plateau beginning in the 1990s. CONCLUSIONS: Large meta-analysis techniques have the potential to effectively leverage large amounts of bibliometric data to quantify the representation of female authorship in the neurosurgical literature. The proportion of female authors in major neurosurgical journals has steadily increased. However, the rate of increase in female senior authorship has lagged behind the rate of increase in first authorship, indicating a disparity in academic advancement in women in neurosurgery.

Neurosurgery in COVID-19 Ground Zero: The Weill Cornell Medicine Experience.

The mobilization of subspecialty departments in reaction to the unique demands of the onset of the coronavirus disease 2019 (COVID-19) pandemic in New York City was swift and left little time for reflection and commemoration. The early days of the pandemic brought unprecedented stressors on the medical system that necessitated a restructuring of hospitals, reallocation of health care workers, and a shift in care and education paradigms to meet patient care demands and public health needs. As the number of cases, intensive care unit patients, and deaths skyrocketed in New York City, many struggled with a somewhat paradoxical difficulty in perceiving the human value of what these numbers mean. Easily lost in the statistics are the stories and experiences of the physicians and trainees who were counted on to halt their own clinical practices and adapt their skillsets to tackle the pandemic. In this article, we present 10 brief narratives from the student members of the Neurosurgery Publication Group at Weill Cornell Medical College and members of the Weill Cornell Medicine Neurological Surgery Residency Program and Department of Neurological Surgery faculty. Reflecting on these individual experiences gives us an opportunity to simultaneously contribute to a history of New York City's reaction to COVID-19 and commemorate the individuals who were impacted by or succumbed to this disease.

Risk of Acquiring Perioperative COVID-19 During the Initial Pandemic Peak: A Retrospective Cohort Study.

OBJECTIVE: To determine the risk of acquiring perioperative COVID-19 infection in previously COVID-19 negative patients. SUMMARY OF BACKGROUND DATA: During the initial peak of the COVID-19 pandemic, there was significant concern of hospital acquired COVID-19 infections. Medical centers rapidly implemented systems to minimize perioperative transmission, including routine preoperative testing, patient isolation, and enhanced cleaning. METHODS: In this retrospective cohort study, medical records of all adult patients who underwent surgery at our quaternary, acute care hospital between March 15 and May 15, 2020 were reviewed. The risk of preoperatively negative patients developing symptomatic COVID-19 within 2-14 days postoperatively was determined. Surgical characteristics, outcomes, and complications were compared between those with and without acquired perioperative COVID-19 infection. RESULTS: Among 501 negative patients undergoing index surgeries, 9 (1.8%) developed symptomatic COVID-19 in the postoperative period; all occurred before implementation of routine preoperative testing [9/243, 3.7% vs 0/258, 0%, odds ratio (OR): 0.048, P = 0.036]. No patient who was polymerase-chain-reaction negative on the day of surgery (n = 170) developed postoperative infection. Perioperative infection was associated with preoperative diabetes (OR: 3.70, P = 0.042), cardiovascular disease (OR: 3.69, P = 0.043), angiotensin receptor blocker use (OR: 6.58, P = 0.004), and transplant surgery (OR: 11.00, P = 0.002), and multiple complications, readmission (OR: 5.50, P = 0.029) and death (OR: 12.81, P = 0.001). CONCLUSIONS: During the initial peak of the COVID-19 pandemic, there was minimal risk of acquiring symptomatic perioperative COVID-19 infection, especially after the implementation of routine preoperative testing. However, perioperative COVID-19 infection was associated with poor postoperative outcome.

Missing diversity in brain tumor trials.

BACKGROUND: Clinical trials for brain tumors represent a significant opportunity for both patients and providers to understand and combat a disease with substantial morbidity. The aim of this study was to quantify and map ethnic and racial representation in brain tumor trials and examine the potential gaps in trial recruitment. We also show that these representation gaps persist even in large multicultural cities like New York City. METHODS: We analyzed brain tumor clinical trials registered on www.clinicaltrials.gov between July 1, 2005 and completed on or before November 11, 2017. We used a combination of PubMed/MEDLINE and Google Scholar to find associated publications and obtained trial information as well as patient demographic information (when available) including race or ancestry. RESULTS: Out of 471 trials, 27% had no published results. Only 28.4% of trials with results reported race or ethnicity of trial participants, with no observed upward trend by year. Whites were significantly overrepresented in trials for metastatic brain tumors (P < .001) and high-grade trials (P < .001). Blacks/African Americans (AAs), Hispanics, and Asians were significantly underrepresented (P < .001) in high-grade trials, while only Blacks/AAs were underrepresented in trials for metastatic brain tumors (P < .001). Representation gaps were not observed in pediatric trials. Despite being a multicultural hub, New York City displayed similar gaps in trial representation. CONCLUSIONS: Despite increasing representation in the American population, minorities are underrepresented in brain tumor trials. In addition, despite numerous legal requirements and ethical mandates, published results including race-based information are remarkably absent from 70% of brain tumor trials.

Medical Student Concerns Relating to Neurosurgery Education During COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has created significant obstacles within medical education. For medical students interested in pursuing neurosurgery as a specialty, the educational policies surrounding COVID-19 have resulted in unique challenges. The present study used a nationwide survey to identify the concerns of medical students interested in pursuing neurosurgery during the COVID-19 pandemic. METHODS: Students who had previously registered for medical student neurosurgery training camps were sent an online Qualtrics survey requesting them to assess how the COVID-19 pandemic was affecting their neurosurgical education. The Pearson χ2 test and post hoc pairwise Fisher exact test were used for analysis of categorical variables, and the 2-tailed paired Student t test was used for continuous variables. RESULTS: The survey was distributed to 852 medical students, with 127 analyzed responses. Concerns regarding conferences and networking opportunities (63%), clinical experience (59%), and board examination scores (42%) were most frequently cited. Of the third-year medical students, 76% reported ≥1 cancelled or postponed neurosurgery rotation. On average, students were more likely to take 1 year off from medical school after than before the start of the COVID-19 pandemic, measured from 0 to 100 (25.3 ± 36.0 vs. 39.5 ± 37.5; P = 0.004). Virtual mentorship pairing was the highest rated educational intervention suggested by first- and second-year medical students. The third- and fourth-year medical students had cited virtual surgical skills workshops most frequently. CONCLUSIONS: The results from the present nationwide survey have highlighted the concerns of medical students regarding their neurosurgery education during the COVID-19 pandemic. With these findings, neurosurgery organizations can consider targeted plans for students of each year to continue their education and development.

Medical Students' Perceived Interests and Concerns for a Career in Neurosurgery.

OBJECTIVE: The factors that attract and concern medical students about a career in neurosurgery have never been clearly characterized or delineated in a large nationwide cohort of medical students intending to pursue a career in neurosurgery. The objective of the present study was to characterize the factors that influence medical student interest in neurosurgery and assess the effects of a formal neurosurgery training course on participants' perceptions of a career in neurosurgery. METHODS: Before the Medical Student Neurosurgery Training Camp for subinternship preparation, registered students were surveyed about their interest level in neurosurgery, factors that attracted or concerned them about a career in neurosurgery, attendance at a national neurosurgery conference or course, formal clinical neurosurgery exposure in medical school, and whether they had a resident or attending mentor in neurosurgery. At the end of the course, all the participants completed the surveyed again. P < 0.05 was considered significant on Pearson's χ2 and Fisher's exact tests for categorical variables and 2-tailed paired Student's t tests for continuous variables. RESULTS: Of the training camp attendees, >95% completed both pre- and postcourse surveys, including 41 first-year, 19 second-year, 30 third-year, and 5 fourth-year medical school students. The most common factors that concerned students about a career in neurosurgery were work-life balance (76%) and competitiveness (56%). All factors of concern were decreased in the postcourse survey, except for competitiveness. A small cohort (8.4%) of students had no concerns about a career in neurosurgery; this cohort had doubled to 17% after the course (P < 0.05). The students that indicated no concern had a greater postcourse interest level in neurosurgery (95.8 ± 8.7 vs. 86.7 ± 20.5; P < 0.05). Student reasons for an interest in neurosurgery included intellectually stimulating work (94%), interest in neurosciences (93%), effect on patients (84%), innovation and new technology (80%), research opportunities (77%), and prestige (24%). All reasons increased after the course, with the exception of prestige, which decreased to 22%. CONCLUSION: A training camp for students pursuing a neurosurgery subinternship was effective in providing transparency and positively influencing the factors that attract and concern students about a career in neurosurgery. Characterization of medical student perceptions of neurosurgery from a large, nationwide cohort of students pursuing a subinternship has provided novel data and could help identify factors protecting against burnout later in life.

Clinical Outcomes in Patients with Renal Cell Carcinoma Metastases to the Choroid Plexus.

OBJECTIVE: Intraventricular metastatic brain tumors account for a small, but challenging, fraction of metastatic brain tumors (0.9%-4.5%). Metastases from renal cell carcinoma (RCC) account for a large portion of these intraventricular tumors. Although patient outcomes have been assumed to be poor, these have not been reported in a modern series with a multimodality treatment paradigm of radiotherapy (RT), resection, and cerebrospinal fluid (CSF) diversion. We have presented the first case series of patients with intraventricular metastatic tumors from RCC. METHODS: We performed a single-institution retrospective review of patients with intraventricular RCC metastases treated from January 2003 to January 2019. Volumetric analysis was used to delineate the tumor size and the Kaplan-Meier method to evaluate the survival data. RESULTS: A total of 22 intraventricular RCC metastases were identified in 19 patients with 61.3 patient-years of follow-up. The median patient age was 64 years, and the median tumor volume was 2.2 cm3. Overall, 19 metastases had been treated initially with RT. Of these, 16 had received stereotactic body RT and 3 had received whole brain RT. Three tumors were surgically excised and had received adjuvant stereotactic body RT in the upfront setting. Although 5 patients had presented with obstructive hydrocephalus, none had required CSF diversion. After treatment, 5 metastases had progressed, resulting in 1- and 3-year progression-free survival rates of 81.6% and 68%, respectively. The median overall survival was 2.8 years, with 1- and 5-year overall survival rates of 76.7% and 28.3%, respectively. Leptomeningeal carcinomatosis was not observed. CONCLUSIONS: Despite the relatively limited overall survival for this population with metastatic cancer, comparable to contemporary parenchymal brain metastasis cohorts, reasonable local central nervous system control was achieved in most patients using a paradigm of focal RT and resection, where indicated. Finally, CSF diversion was not required even in patients presenting with hydrocephalus.

A Multidisciplinary Team Approach to Brain and Spine Stereotactic Radiosurgery Conferences: A Unique Institutional Model.

OBJECTIVE: The use of multidisciplinary teams (MDTs) comprised of all members of the patient care team is becoming increasingly popular in the field of oncology. We present a single-center experience exploring the utility and uniqueness of an MDT in the care of patients undergoing brain and spine stereotactic radiosurgery (SRS). METHODS: The weekly SRS conference brought together neurosurgeons, radiation oncologists, neuroradiologists, physicists, dosimetrists, therapists, advanced practice providers, and trainees in these fields as well as researchers from a variety of disciplines with a goal of optimizing patient care. A survey of 20 conference attendees from 7 different facets of the MDT was conducted for feedback. RESULTS: The survey results revealed that most respondents believed the SRS conference increased educational opportunities, provided opportunities for research and collaborations, helped streamline patient care, and was beneficial to their practice. CONCLUSIONS: We present our institutional MDT model, a framework and workflow that can be incorporated at other large academic centers. We believe that the SRS conference has educational, academic, and patient care value.

Neurosurgery Training Camp for Sub-Internship Preparation: Lessons From the Inaugural Course.

OBJECTIVE: Historically, medical student education in neurological surgery has generally limited student involvement to assisting in research projects with minimal formal clinical exposure before starting sub-internships and application for the neurosurgery match. Consequently, students have generally had little opportunity to acquire exposure to clinical neurosurgery and attain minimal proficiency. A medical student training camp was created to improve the preparation of medical students for the involvement in neurological surgery activities and sub-internships. METHODS: A 1-day course was held at Weill Cornell Medicine, which consisted of a series of morning lectures, an interactive resident lunch panel, and afternoon hands-on laboratory sessions. Students completed self-assessment questionnaires regarding their confidence in several areas of clinical neurosurgery before the start of the course and again at its end. RESULTS: A significant increase in self-assessed confidence was observed in all skill areas surveyed. Overall, rising fourth year students who were starting sub-internships in the subsequent weeks reported a substantial increase in their preparedness for the elective rotations in neurosurgery. CONCLUSIONS: The preparation of medical students for clinical neurosurgery can be improved. Single-day courses such as the described training camp are an effective method for improving knowledge and skill gaps in medical students entering neurosurgical careers. Initiatives should be developed, in addition to this annual program, to increase the clinical and research skills throughout medical student education.

The Intracranial and Intracanalicular Optic Nerve as Seen Through Different Surgical Windows: Endoscopic Versus Transcranial.

BACKGROUND: Surgically manageable lesions involving the intracranial or intracanalicular portions of the optic nerve (cranial nerve II) can be approached through several different operative windows. Given the complex anatomy of the optic nerve and its surrounding neurovascular structures, it is essential to understand the conventional and topographic anatomy of the optic nerve from different surgical perspectives as well as its relationship with surrounding structures. We describe the intracranial and intracanalicular course of the optic nerve and present an analytical evaluation of the degree of exposure provided by several different transcranial and endoscopic surgical approaches. METHODS: Using 12 cadaveric specimens (24 sides), pterional, frontotemporal-orbital, supraorbital, unilateral subfrontal, and extended endonasal approaches were performed. The transcranial approaches were extended by removing the anterior clinoid process, unroofing the optic canal, and/or cutting the falciform ligament. The endonasal approach was extended using the transplanum transtuberculum, transmedial optic carotid recess, and transcanalicular modifications. The optic nerve was divided into proximal intracranial, distal intracranial, and intracanalicular segments, which were each divided coronally into quadrants and subquadrants, to evaluate their degree of exposure in each approach. RESULTS: The pterional approach provided 135° of exposure along the superolateral aspects of the entire intracranial optic nerve, and 225° of exposure of the intracanalicular optic nerve. The supraorbital and subfrontal approaches provided similar degrees of exposure, with 225°-270° of superolateral and superomedial exposure of the nerve along its intracranial and intracanalicular segments, depending on the approach extension used, with the subfrontal approach allowing for more medial control of the nerve. The endoscopic endonasal approach provided access to the inferior and medial quadrants of the optic nerve, allowing for 180° of exposure. CONCLUSIONS: Although the pterional approach provides the widest degree of surgical exposure of all optic nerve segments, the inferior and medial quadrants of the nerve can be adequately exposed only through an endoscopic endonasal approach. Optimal approach selection based on the intended target quadrant is essential for safe surgical exposure of the optic nerve.

Impact of imaging modality, age, and gender on craniocervical junction angles in adults without structural pathology.

CONTEXT: Multiple angles of the craniocervical junction (CCJ) are associated with pathological conditions and surgical outcomes, including the clivo-axial angle (CXA), clival slope (CS), and sagittal axis (XS). However, there are varying normative ranges reported and a paucity of data analyzing the effects of imaging modality, age, and gender on these angles. SETTING AND DESIGN: A retrospective review of computed tomographic (CT) and magnetic resonance imaging (MRI) scans in fifty adults without CCJ pathology from 2014 to 2019. METHODS: Age, gender, indication, and hours between scans were recorded. Two-blinded observers measured all angles. Analysis between angles from the same patient was performed using the Wilcoxon signed-rank test. Multivariable linear regression was used to test for associations between average angles and age or gender. RESULTS: Average age and time between scans were 41.3 and 14.3 h, respectively, with 94% performed due to trauma. On CT, average CXA, CS, and XS were 162.1°, 118.4°, and 81.3°, respectively. On MRI, they were 159.8°, 117.2°, 85.3°, respectively. There were statistically significant differences between CXA and XS (P < 0.01) based on imaging modality. On CT, there was a significant increase in XS by 1.93°° and decrease in CS by 1.88°° and on MRI, there was a significant increase in CXA by 1.93°° and decrease in CS by 2.75°° corresponding with a 10-year advancement of age. Gender did not have an effect. CONCLUSION: There are significant differences in angular measurements of the CCJ between CT and MRI from the same patient, as well as changes in normative values based on age.

Treatment of Unruptured Brain Arteriovenous Malformations: A Single-Center Experience of 86 Patients and a Critique of the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) Trial.

OBJECTIVE: The A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial has received fierce criticism, including considerable selection bias, poor generalizability, questionable clinical practices (only 15.8% underwent surgical resection, the gold standard for arteriovenous malformation [AVM] treatment), and short follow-up (33 months) for a disease process that carries a life-long risk. In this study, we sought to present our own experience treating unruptured brain AVMs to provide supporting evidence of the ARUBA trial criticism. METHODS: All cases of treated brain AVMs from 2004 to 2017 at our institution were retrospectively reviewed and included in the analysis if they met ARUBA trial inclusion criteria. The primary outcome was symptomatic stroke or death. Secondary outcomes included AVM obliteration, long-term clinical impairment (modified Rankin Scale score >1), and new major or minor postoperative deficit. RESULTS: Of the 245 reviewed cases, 86 met the ARUBA trial criteria. Treatment included microsurgical resection alone (2.3%), preoperative embolization followed by microsurgical resection (62.8%), stereotactic radiosurgery alone (10.5%), embolization followed by stereotactic radiosurgery (15.1%), and embolization alone (9.3%). The primary outcome was met in 8.3%, new perioperative major and minor complications occurred in 5.8% and 12.8%, and long-term clinical impairment in 4.5%. AVM obliteration was observed in 92.4% overall and in 100% of patients who underwent surgical resection. CONCLUSIONS: The criticism of the ARUBA trial is warranted, as our study found that treatment of unruptured brain AVMs has an acceptable safety profile when approached in a multidisciplinary manner at an experienced institution, using surgical resection as the primary treatment modality when applicable.