Long-term outcomes of hospitalized patients with SARS-CoV-2/COVID-19 with and without neurological involvement: 3-year follow-up assessment.

BACKGROUND: Acute neurological manifestation is a common complication of acute Coronavirus Disease 2019 (COVID-19) disease. This retrospective cohort study investigated the 3-year outcomes of patients with and without significant neurological manifestations during initial COVID-19 hospitalization. METHODS AND FINDINGS: Patients hospitalized for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection between 03/01/2020 and 4/16/2020 in the Montefiore Health System in the Bronx, an epicenter of the early pandemic, were included. Follow-up data was captured up to 01/23/2023 (3 years post-COVID-19). This cohort consisted of 414 patients with COVID-19 with significant neurological manifestations and 1,199 propensity-matched patients (for age and COVID-19 severity score) with COVID-19 without neurological manifestations. Neurological involvement during the acute phase included acute stroke, new or recrudescent seizures, anatomic brain lesions, presence of altered mentation with evidence for impaired cognition or arousal, and neuro-COVID-19 complex (headache, anosmia, ageusia, chemesthesis, vertigo, presyncope, paresthesias, cranial nerve abnormalities, ataxia, dysautonomia, and skeletal muscle injury with normal orientation and arousal signs). There were no significant group differences in female sex composition (44.93% versus 48.21%, p = 0.249), ICU and IMV status, white, not Hispanic (6.52% versus 7.84%, p = 0.380), and Hispanic (33.57% versus 38.20%, p = 0.093), except black non-Hispanic (42.51% versus 36.03%, p = 0.019). Primary outcomes were mortality, stroke, heart attack, major adverse cardiovascular events (MACE), reinfection, and hospital readmission post-discharge. Secondary outcomes were neuroimaging findings (hemorrhage, active and prior stroke, mass effect, microhemorrhages, white matter changes, microvascular disease (MVD), and volume loss). More patients in the neurological cohort were discharged to acute rehabilitation (10.39% versus 3.34%, p < 0.001) or skilled nursing facilities (35.75% versus 25.35%, p < 0.001) and fewer to home (50.24% versus 66.64%, p < 0.001) than matched controls. Incidence of readmission for any reason (65.70% versus 60.72%, p = 0.036), stroke (6.28% versus 2.34%, p < 0.001), and MACE (20.53% versus 16.51%, p = 0.032) was higher in the neurological cohort post-discharge. Per Kaplan-Meier univariate survival curve analysis, such patients in the neurological cohort were more likely to die post-discharge compared to controls (hazard ratio: 2.346, (95% confidence interval (CI) [1.586, 3.470]; p < 0.001)). Across both cohorts, the major causes of death post-discharge were heart disease (13.79% neurological, 15.38% control), sepsis (8.63%, 17.58%), influenza and pneumonia (13.79%, 9.89%), COVID-19 (10.34%, 7.69%), and acute respiratory distress syndrome (ARDS) (10.34%, 6.59%). Factors associated with mortality after leaving the hospital involved the neurological cohort (odds ratio (OR): 1.802 (95% CI [1.237, 2.608]; p = 0.002)), discharge disposition (OR: 1.508 (95% CI [1.276, 1.775]; p < 0.001)), congestive heart failure (OR: 2.281 (95% CI [1.429, 3.593]; p < 0.001)), higher COVID-19 severity score (OR: 1.177 (95% CI [1.062, 1.304]; p = 0.002)), and older age (OR: 1.027 (95% CI [1.010, 1.044]; p = 0.002)). There were no group differences in radiological findings, except that the neurological cohort showed significantly more age-adjusted brain volume loss (p = 0.045) than controls. The study's patient cohort was limited to patients infected with COVID-19 during the first wave of the pandemic, when hospitals were overburdened, vaccines were not yet available, and treatments were limited. Patient profiles might differ when interrogating subsequent waves. CONCLUSIONS: Patients with COVID-19 with neurological manifestations had worse long-term outcomes compared to matched controls. These findings raise awareness and the need for closer monitoring and timely interventions for patients with COVID-19 with neurological manifestations, as their disease course involving initial neurological manifestations is associated with enhanced morbidity and mortality.

Risk of adjacent level fracture after percutaneous vertebroplasty and kyphoplasty vs natural history for the management of osteoporotic vertebral compression fractures: a network meta-analysis of randomized controlled trials.

OBJECTIVES: Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures. MATERIALS AND METHODS: A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the "netmeta" package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects. RESULTS: Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3-49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78-2.34, p = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62-2.14) p = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs. CONCLUSION: There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice. CLINICAL RELEVANCE STATEMENT: The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures. KEY POINTS: RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures. There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures. This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures.

Prediction of delayed cerebral ischemia followed aneurysmal subarachnoid hemorrhage. A machine-learning based study.

INTRODUCTION: Delayed Cerebral Ischemia (DCI) is a significant complication following aneurysmal subarachnoid hemorrhage (aSAH) that can lead to poor outcomes. Machine learning techniques have shown promise in predicting DCI and improving risk stratification. METHODS: In this study, we aimed to develop machine learning models to predict the occurrence of DCI in patients with aSAH. Patient data, including various clinical variables and co-factors, were collected. Six different machine learning models, including logistic regression, multilayer perceptron, decision tree, random forest, gradient boosting machine, and extreme gradient boosting (XGB), were trained and evaluated using performance metrics such as accuracy, area under the curve (AUC), precision, recall, and F1 score. RESULTS: After data augmentation, the random forest model demonstrated the best performance, with an AUC of 0.85. The multilayer perceptron neural network model achieved an accuracy of 0.93 and an F1 score of 0.85, making it the best performing model. The presence of positive clinical vasospasm was identified as the most important feature for predicting DCI. CONCLUSIONS: Our study highlights the potential of machine learning models in predicting the occurrence of DCI in patients with aSAH. The multilayer perceptron model showed excellent performance, indicating its utility in risk stratification and clinical decision-making. However, further validation and refinement of the models are necessary to ensure their generalizability and applicability in real-world settings. Machine learning techniques have the potential to enhance patient care and improve outcomes in aSAH, but their implementation should be accompanied by careful evaluation and validation.

Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage.

Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.

Natural history and management of posterior cerebral artery aneurysms: a systematic review and meta-analysis of individual patient data.

We conducted a comprehensive review and meta-analysis to investigate clinical, radiographic characteristics, and treatment outcomes of posterior cerebral artery aneurysms (PCAA). We systematically reviewed English-language articles investigating available treatments (parent artery occlusion (PAO), microsurgery, reconstructive endovascular (rEVT), and conservative treatments) for PCAA and analyzed the based on aneurysm morphology and rupture status. Six-hundred-eighty-five patients with 698 PCAA were identified from 59 studies. Overall, 371 (54.2%) aneurysms were ruptured, 325 (49%) were saccular, and 342 (51%) were non-saccular aneurysms. The mean age of the saccular was lower (40 years) than non-saccular aneurysm group (50 years) (P < .05). In ruptured PCAA, favorable clinical outcomes were comparable between the treatment groups except for patients treated conservatively, which had lower rates of favorable clinical outcomes (35.6%) and higher mortality (55.7%) (P < .0001). Ruptured aneurysms treated with rEVT (22.6%) had the highest recanalization rates compared to PAO (9.2%, P = 0.0001) and microsurgery (3.8%, P = 0.005). In unruptured PCAA, clinical outcomes were similar; higher complication rates were noted in microsurgery (40.4%, P = 0.026) and PAO (21.5%, P = 0.015) compared to rEVT (13.2%), which had higher recanalization rates (15.6%, P < .0001). The rates of subsequent stroke following PAO were 21.8% for unruptured and 32.3% for ruptured PCAA (P = 0.078). Ruptured PCAA portend worse prognosis and typically require an intervention to achieve better outcome whereas the benefit of an intervention in unruptured PCAA is much less clear. rEVT is promising for PCAA management with a good clinical and safety profile but more recurrence compared to PAO and microsurgery.

Surgical management outcomes of intracranial arteriovenous malformations after preoperative embolization: a systematic review and meta-analysis.

OBJECTIVE: Preoperative embolization for brain arteriovenous malformations (AVMs) has been shown to mitigate morbidity for high-risk AVMs, chiefly by reducing lesional blood flow before resection. However, associated risks include postembolization AVM rupture, and the effect of preoperative embolization on outcome remains uncertain. We performed a meta-analysis of the literature on preoperative embolization for microsurgically treated AVMs. METHODS: A systematic review and meta-analysis were conducted of all English-language publications reporting clinical outcomes after combined embolization and surgical resection for AVMs. Single- and 2-arm analyses were performed using random-effects modeling. RESULTS: Thirty-six studies with 2108 patients were included in this analysis. Most patients (90.6%) who underwent embolization had at least a 50% obliteration of AVMs on posttreatment preoperative angiography, with a mean rate of obliteration of approximately 80% (range 28.8-100%). Among patients who had combined treatment, 3.4% (95% confidence interval [CI] 2.1-4.6%) experienced embolization-related hemorrhagic complications before surgery. Both treatment groups achieved excellent postsurgical complete resection rates (odds ratio [OR] 1.05; 95% CI 0.60-1.85). Neither the clinical outcome (OR 1.42; 95% CI 0.84-2.40) nor the total number of hemorrhagic complications (OR 1.84; 95% CI 0.88-3.85) was significantly different between the treatment groups. CONCLUSIONS: In this meta-analysis, preoperative embolization appears to have substantially reduced the lesional volume with active AV shunting before AVM resection. Anecdotally, preoperative embolization facilitates safe and efficient resection; however, differences in outcomes were not significant. The decision to pursue preoperative embolization remains a nuanced decision based on individual lesion anatomy and treatment team experience.

WEB for recurrent aneurysms: a case series to review technical nuances.

Recurrent intracranial aneurysms (IAs) often present with more complex morphology such as irregular shape, shallow height, and wide neck, which can make for challenging endovascular treatments.1 Initial rupture and interventions are associated with fibrotic changes and considerable alteration in the aneurysm configuration, which limits retreatment options and increases the risk of complications during retreatment.2 The Woven Endobridge (WEB) embolization device has demonstrated high efficacy, flexibility, and safety for the treatment of wide-neck bifurcation IAs, including ruptured and recurrent IAs, as shown in multiple retrospective studies and meta-analyses.3-8 Due to its optimal barrel shape, the WEB device is useful in the setting of previously treated aneurysms, particularly with wide-neck previously coiled aneurysms.1 9 10 In this technical video of four cases (video 1), we describe the technical nuances of WEB embolization for recurrent IAs, which were initially either coiled or clipped and demonstrated progressive growth with a wide-neck presentation on follow-up. neurintsurg;16/3/226/V1F1V1Video 1Management of recurrent intracranial aneurysms via WEB: This video describes four recurrent intracranial aneurysms, which were initially either coiled or clipped but demonstrated progressive growth with a wide-neck presentation on follow-up. All cases were successfully treated via WEB.

Balloon-assisted U-turn Technique to Access Cortical Vein for Transvenous Embolization of Mixed Dural-pial Arteriovenous Malformation.

Cerebral arteriovenous malformations can be classified into pure pial, mixed dural-pial, and pure dural types. Mixed pial-dural AVMs (DPAVM) are rare and often receive blood supply from dural meningeal arteries, including branches of the internal carotid, external carotid, and vertebral arteries.1- 6 DPAVMs, which are usually large and complex, require delicate endovascular and surgical treatment methods. The cure rate is low, and recurrence is very common, leading to high morbidity and mortality. In this case video, we present a case of PDAVM that recurred after initial endovascular onyx embolization, requiring additional endovascular coiling which resulted in obliteration of the DPAVM.

Exploring the Validity and Reliability of Neurosurgery Residency Program Rankings: A Quantitative Analysis.

OBJECTIVE: To evaluate the relationships between Doximity rankings (Doximity, Inc.) of residency programs and 2 new ranking systems based on publication rates and academic pursuits. METHODS: We collected data on 550 neurosurgery graduates over 3 years. We analyzed the median number of published manuscripts per resident and the percentage of residents pursuing academic careers and compared them across the Doximity Research Productivity and Reputation Rankings. We used logistic regression to evaluate the relationships among the rankings, publication rates, and academic pursuits. RESULTS: Neurosurgery residents published a median of 10 manuscripts per person (IQR: 6-17), and 50% (IQR: 33%-67%) of residents in a given program pursued an academic career. The distributions of the median number of published manuscripts across the Doximity Research Productivity Ranking and the Doximity Reputation Ranking tiers differed significantly (all P < 0.001). Similarly, the distribution of the percentage of residents pursuing an academic career across both published Doximity ranking systems' tiers differed significantly (all P = 0.02). Moreover, we found moderate agreement between the 2 Doximity rankings, fair agreement between the publication and the other 3 rankings, and slight agreement between the academic pursuit and the Doximity rankings. CONCLUSIONS: We introduced 2 new methods to rank residency programs based on the number of graduates pursuing an academic position and the median number of published manuscripts per resident. By taking a comprehensive approach, neurosurgery applicants can ensure that they select a residency program that meets their needs and offers them the best opportunity for success.

Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial. METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data. RESULTS: A total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others. CONCLUSION: VSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.

Metal allergy and neurovascular stenting: A systematic review.

BACKGROUND: Intracranial stents and flow diverters contain significant amounts of metals, notably nickel, which can cause allergic reactions in a considerable portion of the population. These allergic responses may lead to complications like in-stent stenosis (ISS) and TIA/Stroke in patients receiving stents or flow diverters for intracranial aneurysms. METHODS: We conducted a systematic review of studies from inception until July 2023, which reported outcomes of patients with metal allergy undergoing neurovascular stenting. The skin patch test was used to group patients into those with positive, negative, or absent patch test results but with a known history of metal allergy. RESULTS: Our review included seven studies with a total of 39 patients. Among them, 87% had a history of metal allergy before treatment. Most aneurysms (89%) were in the anterior circulation and the rest (11%) were in the posterior circulation. Skin patch tests were performed in 59% of patients, with 24% showing positive results and 33% negative. Incidental ISS was observed in 18% of patients, and the rate of TIA/Stroke was reported in 21%. The pooled rates of ISS and TIA/Stroke were higher in the first group (43% and 38%) compared to the second (18% and 9%) and third groups (15% and 15%), but these differences were not statistically significant. CONCLUSIONS: The current neurosurgical literature does not provide a conclusive association between metal allergy and increased complications among patients undergoing neurovascular stenting. Further studies are necessary to gain a more comprehensive understanding of this topic.

Multicenter early United States feasibility study and periprocedural safety of LVIS EVO for the treatment of unruptured intracranial aneurysms.

BACKGROUND: Stent development has focused recently on low-profile, self-expandable stents compatible with 0.0165 inch microcatheters. The LVIS EVO is the second-generation version of the Low-Profile Visualized Intraluminal Support (LVIS) with improved visibility and resheathability. The LVIS EVO underwent a limited premarket release (PMR) in December 2023. This study aims to report the early safety and feasibility experience with the LVIS EVO stent for the treatment of intracranial aneurysms in the United States (US). METHODS: This was a multicenter, retrospective, observational study evaluating patients who underwent treatment of an intracranial aneurysm with an LVIS EVO stent after the limited PMR. All physicians who had placed an LVIS EVO stent were asked to input their cases after institutional review board approval was obtained. The data were then sent to a single center for analysis. Any patient aged 18 years or older who underwent treatment of an intracranial aneurysm with a LVIS EVO stent in the US was included from the initial PMR in December 2023 until April 2024. Patient age (or ≤90 years old), sex, preoperative modified Rankin Scale (mRS), aneurysm location, aneurysm measurements, and information about preoperative antiplatelet management were all collected. Data on periprocedural complications, 30-day mortality, discharge mRS, and length of stay were also collected. RESULTS: Some 53 patients with 55 aneurysms underwent treatment with the LVIS EVO stent at 15 institutions. All aneurysms were unruptured. The most common location was the anterior communicating artery (35%) followed by the middle cerebral artery bifurcation (31%). All patients were on dual antiplatelet therapy. The average aneurysm size was 5.2 mm with a neck size of 3.7 mm. The smallest distal parent vessel size was 1.2 mm and 36% of stents were deployed in distal parent vessels <2 mm. All (100%) cases had successful deployment and the stent was repositioned in 10% of cases. A single stent was utilized in 91% of cases. Coils were placed in 48 cases (87.2%) and a microcatheter was jailed in 98% of those cases. Immediate Raymond Roy (RR) Class I occlusion was obtained in 33%, Class II in 22%, Class IIIa in 37%, and Class IIIb in 8% of cases. There were no delayed thromboembolic or hemorrhagic complications. CONCLUSIONS: The LVIS EVO is a braided, self-expanding, retrievable stent with enhanced visibility and smaller cell size. The drawn filled tube (DFT) technology results in improved visibility of the stent, allowing for more controlled stent positioning and visualization of vessel wall apposition. All cases in our series had complete neck coverage and good wall apposition. There were no thromboembolic or hemorrhagic complications.

Outcomes of mechanical thrombectomy in anticoagulated patients with acute distal and medium vessel stroke.

BACKGROUND: Stroke remains a major health concern globally, with oral anticoagulants widely prescribed for stroke prevention. The efficacy and safety of mechanical thrombectomy (MT) in anticoagulated patients with distal medium vessel occlusions (DMVO) are not well understood. METHODS: This retrospective analysis involved 1282 acute ischemic stroke (AIS) patients who underwent MT in 37 centers across North America, Asia, and Europe from September 2017 to July 2023. Data on demographics, clinical presentation, treatment specifics, and outcomes were collected. The primary outcomes were functional outcomes at 90 days post-MT, measured by modified Rankin Scale (mRS) scores. Secondary outcomes included reperfusion rates, mortality, and hemorrhagic complications. RESULTS: Of the patients, 223 (34%) were on anticoagulation therapy. Anticoagulated patients were older (median age 78 vs 74 years; p < 0.001) and had a higher prevalence of atrial fibrillation (77% vs 26%; p < 0.001). Their baseline National Institutes of Health Stroke Scale (NIHSS) scores were also higher (median 12 vs 9; p = 0.002). Before propensity score matching (PSM), anticoagulated patients had similar rates of favorable 90-day outcomes (mRS 0-1: 30% vs 37%, p = 0.1; mRS 0-2: 47% vs 50%, p = 0.41) but higher mortality (26% vs 17%, p = 0.008). After PSM, there were no significant differences in outcomes between the two groups. CONCLUSION: Anticoagulated patients undergoing MT for AIS due to DMVO did not show significant differences in 90-day mRS outcomes, reperfusion, or hemorrhage compared to non-anticoagulated patients after adjustment for covariates.

Traumatic posterior cerebral artery dissection and dissecting aneurysms: A systematic review with an illustrative case report.

BACKGROUND: Traumatic posterior cerebral artery (tPCA) dissection and dissecting aneurysms are rare and constitute a challenging clinical entity. OBJECTIVE: We analyze existing literature on tPCA dissection and present our institutional experience. METHODS: We retrospectively queried our database for tPCA isolated dissection or dissecting aneurysms from 2008 until now and conducted a systematic literature review of published cases. We analyzed the clinical and radiographic characteristics and treatment outcomes of tPCA dissection. RESULTS: Including our case, a total of 11 cases with either isolated dissection (n = 2) or dissecting aneurysms (n = 9) were included. The median age was 27 years, and 45% were females. The median interval between trauma and tPCA dissection diagnosis was nine days. Mental status declined in four (36%) patients. Half of the patients demonstrated tentorial subdural hematoma on head CT. Ischemic stroke was detected in three (43%) patients. Four (36%) patients were conservatively managed, one (9.1%) patient was treated with surgical clipping of the proximal PCA, and six patients underwent endovascular treatments. The complication rate was 20%. Immediate total occlusion was demonstrated in five patients (100%), and the conservatively managed case showed immediate, spontaneous thrombosis of the aneurysm. Glasgow Coma Scale scores were 15 in eight (89%) and 14 in one (11%) patients at the last clinical follow-up with a median of six months. The mortality and retreatment rates were null. CONCLUSIONS: tPCA dissection is diagnosed late and commonly affects the young population. The clinical outcome for this condition is typically favorable. Current endovascular techniques showed considerable efficacy and safety.

Current Understanding of Moyamoya Disease (MMD) and Associated Neuropsychiatric Outcomes.

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by the progressive narrowing and occlusion of the intracranial internal carotid arteries, leading to the formation of abnormal collateral vessels. MMD primarily affects the cerebrovascular system, and evidence suggests it is associated with various neuropsychiatric outcomes. This manuscript aims to provide an overview of the current understanding of MMD, including its epidemiology, pathophysiology, clinical manifestations, and diagnosis. Furthermore, it explores the emerging research on the neuropsychiatric sequelae of MMD, such as cognitive impairment, psychiatric disorders, and quality of life. The manuscript concludes with the challenges in managing MMD-related neuropsychiatric outcomes and potential avenues for future research.

The impact of interaction between verteporfin and yes-associated protein 1/transcriptional coactivator with PDZ-binding motif-TEA domain pathway on the progression of isocitrate dehydrogenase wild-type glioblastoma.

Verteporfin and 5-ALA are used for visualizing malignant tissue components in different body tumors and as photodynamic therapy in treating isocitrate dehydrogenase (IDH) wild-type glioblastoma (GBM). Additionally, verteporfin interferes with Yes-associated protein 1 (YAP)/Transcriptional coactivator with PDZ-binding motif - TEA domain (TAZ-TEAD) pathway, thus inhibiting the downstream effect of these oncogenes and reducing the malignant properties of GBM. Animal studies have shown verteporfin to be successful in increasing survival rates, which have led to the conduction of phase 1 and 2 clinical trials to further investigate its efficacy in treating GBM. In this article, we aimed to review the novel mechanism of verteporfin's action, the impact of its interaction with YAP/TAZ-TEAD, its effect on glioblastoma stem cells, and its role in inducing ferroptosis.

Spinal Dorsal Intradural Arteriovenous Fistulas: Natural History, Imaging, and Management.

In this review, we describe the pathophysiology, diagnosis, and treatment of spinal dorsal intradural arteriovenous fistulas (DI-AVFs), focusing on novel research areas. DI-AVFs compose the most common subgroup of spinal arteriovenous lesions and most commonly involve the thoracic spine, followed by lumbar and sacral segments. The pathogenesis underlying DI-AVFs is an area of emerging understanding, thought to be attributable to venous congestion and hypertension that precipitate ascending myelopathy. Patients with DI-AVFs typically present with motor, sensory, or urinary dysfunction, although a wide swath of other less common symptoms has been reported. DI-AVFs can be subdivided by spinal region, which in turn is associated with 4 distinct clinical phenotypes: craniocervical junction (CCJ), subaxial cervical, thoracic, and lumbosacral. Patients with CCJ and lumbosacral DI-AVFs have particularly interesting presentations and treatment considerations. High-value diagnostic findings on MRI include flow voids, missing-piece sign, and T2-weighted intramedullary hyperintensity. However, digital subtraction angiography is the gold standard for diagnosis and localization of DI-AVFs and for definitive treatment planning. Surgical disconnection of DI-AVFs is almost universally curative and frontline treatment, especially for CCJ and lumbosacral DI-AVFs. Endovascular techniques evolve in promising ways, such as improved visualization, distal access, and liquid embolic techniques. The pathophysiology of DI-AVFs is better understood using newly identified radiologic diagnostic markers. Despite new techniques and devices introduced in the endovascular field, surgery remains the gold-standard treatment for DI-AVFs.

Frameless Hypofractionated Gamma Knife Radiosurgery for Residual or Recurrent Craniopharyngioma.

BACKGROUND: The management of craniopharyngiomas is challenging, usually requiring multidisciplinary care. Gamma Knife radiosurgery (GKRS) is an essential technique for residual/recurrent craniopharyngiomas. OBJECTIVE: To evaluate the efficacy of frameless hypofractionated GKRS (hfGKRS) for craniopharyngioma and factors which affect tumor control and complications. METHODS: This retrospective study involved 24 patients managed with hfGKRS. Clinical and radiological data, tumor characteristics, and procedural details were analyzed. RESULTS: There were 15 (62.5%) female patients. The median age was 38.5 years (range, 3-66 years). The mean tumor volume was 2.4 (1.93) cm 3 , with a mean solid volume of 1.6 (1.75) cm 3 . The median marginal dose was 20 Gy (range, 18-25 Gy) delivered in a median of 5 fractions (range, 3-5). During a median radiological follow-up of 23.5 months (range, 12-50 months), tumor progression was noted in 5 (20.8%) patients. The 2-year and 4-year progression-free survival were 81.8% and 61.4%, respectively. No deaths were identified at a median clinical follow-up of 31.3 months (range, 12-54 months). Visual deficits attributable to progression were noted in 3 (12.5%) patients with pre-GKRS visual field defects. An additional 4 (16.7%) patients with pre-GKRS visual deficit developed new minor visual field defects. Four (16.7%) patients showed improvement of vision after GKRS. There were no new-onset post-GKRS hormonal deficits. CONCLUSION: The management of craniopharyngioma requires a multidisciplinary approach, and irradiation represents effective treatment option for residual/recurrent tumors after surgery. To the best of our knowledge, this is the first study that addresses the efficacy of frameless hfGKRS in managing craniopharyngiomas over sufficient follow-up.

Is perioperative blood transfusion associated with postoperative thromboembolism or infection after metastatic spinal tumor surgery?

STUDY DESIGN: Retrospective cohort. SUMMARY OF BACKGROUND DATA: Patients with metastatic spine disease who undergo surgical intervention have a high risk of requiring red blood cell (RBC) transfusion. Perioperative transfusion has been independently associated with increased risk of venous thromboembolic (VTE) and infectious complications following orthopedic procedures and degenerative spinal intervention; however, literature within spine oncology is limited. OBJECTIVE: To determine the association between perioperative RBC transfusion and postoperative VTE or infection following spinal tumor surgery. METHODS: A total of 153 patients who underwent surgery for spinal metastases between April 2012 and April 2022 were included. Medical records were reviewed to identify RBC transfusion administered either intraoperatively or within 96 h following surgery. The primary endpoints were: 1) development of any VTE or 2) development of any infection within 30 days following surgery. Any VTE was defined as deep vein thrombosis or pulmonary embolism, and any infection was defined as pneumonia, meningitis, Clostridium difficile infection, urinary tract infection, surgical site infection, or sepsis. Logistic regression analyses were performed. RESULTS: Of the 153 patients included in the study, 43 % received a perioperative RBC transfusion. The overall incidence of postoperative VTE and infection was 15 % and 22 %, respectively. In univariate analysis, perioperative transfusion was not associated with postoperative VTE (odds ratio [OR] 2.41; 95 % confidence interval [CI] 0.97-6.00; p = 0.058) but was associated with infection (OR 3.02; 95 % CI 1.36-6.73; p = 0.007). After adjusting for confounders such as performance status, operative time, and surgical extent, transfusion was not associated with both VTE (OR 1.25; 95 % CI 0.36-4.32; p = 0.727) or infection (OR 1.86; 95 % CI 0.70-4.92; p = 0.210). While not statistically significant, sub-analyses demonstrated a trend towards increased VTE incidence in patients requiring transfusion earlier (within 24 h) as opposed to later postoperatively. CONCLUSIONS: We found that perioperative transfusion was not an independent predictor of 30-day postoperative VTE or infection in patients undergoing metastatic spinal surgery. Further exploration of time-dependent transfusion outcomes is warranted.

Academically Inclined: Predictors of Early Career Trajectory and Avenues for Early Intervention Among Neurosurgery Trainees.

BACKGROUND: The relationship of academic activities before and during neurosurgery residency with fellowship or career outcomes has not been studied completely. OBJECTIVE: To assess possible predictors of fellowship and career outcomes among neurosurgery residents. METHODS: US neurosurgery graduates (2018-2020) were assessed retrospectively for peer-reviewed citations of preresidency vs intraresidency publications, author order, and article type. Additional parameters included medical school, residency program, degree (MD vs DO; PhD), postgraduate fellowship, and academic employment. RESULTS: Of 547 neurosurgeons, 334 (61.1%) entered fellowships. Fellowship training was significantly associated with medical school rank and first-author publications. Individuals from medical schools ranked 1 to 50 were 1.6 times more likely to become postgraduate fellows than individuals from medical schools ranked 51 to 92 (odds ratio [OR], 1.63 [95% CI 1.04-2.56]; P = .03). Residents with ≥2 first-author publications were almost twice as likely to complete a fellowship as individuals with <2 first-author publications (OR, 1.91 [95% CI 1.21-3.03]; P = .006). Among 522 graduates with employment data available, academic employment obtained by 257 (49.2%) was significantly associated with fellowship training and all publication-specific variables. Fellowship-trained graduates were twice as likely to pursue academic careers (OR, 1.99 [95% CI 1.34-2.96]; P < .001) as were individuals with ≥3 first-author publications ( P < .001), ≥2 laboratory publications ( P = .04), or ≥9 clinical publications ( P < .001). CONCLUSION: Research productivity, medical school rank, and fellowships are independently associated with academic career outcomes of neurosurgeons. Academically inclined residents may benefit from early access to mentorship, sponsorship, and publishing opportunities.