Intrafacet Spacer Placement as a Mobility-Sparing Bailout Option in Atlantoaxial Fusion Construct Salvage.

Background: Salvage revisions of atlantoaxial (AA) joint complex posterior segmental instrumented fusion constructs require careful individualized planning to prevent occipital extension. In this case report, we describe the use of bilateral intrafacet spacer placement as a mobility-sparing bailout option for the revision surgery. Case Report: A 64-year-old male with a history of diffuse idiopathic skeletal hyperostosis, extremely limited baseline cervical mobility, and prior AA posterior segmental instrumented fusion presented with increasing pain at his 6-month follow-up. Imaging showed fusion and hardware failures and dynamic instability. To prevent occipitocervical fixation, AA intra-articular fusion via a DTRAX spinal system (Providence Medical Technology, Inc) was used as an adjunct to a navigated C1 lateral mass and C2 pars screw posterior segmental instrumented fusion construct. The patient had an uneventful postoperative course and was discharged with resolution of symptoms. Three-month postoperative follow-up confirmed persistent resolution of symptoms and absence of complaints, along with successful arthrodesis on imaging. Conclusion: AA posterior segmental instrumented fusion revision is technically challenging, particularly when partial preservation of craniovertebral junction mobility is required. Bilateral intra-articular cages may be used as an adjunct to hardware revision in construct salvage when sturdy arthrodesis is desired without occipital extension and may represent a major potential strength of intra-articular cages.

Training Cerebrovascular and Neuroendovascular Surgery Residents: A Systematic Literature Review and Recommendations.

Background: The rapid evolution of neuroendovascular intervention has resulted in the inclusion of endovascular techniques as a core competency in neurosurgical residency training. Methods: We conducted a literature review of studies involving the training of neurosurgical residents in cerebrovascular and endovascular neurosurgery. We reviewed the evolution of cerebrovascular neurosurgery and the effects of these changes on residency, and we propose interventions to supplement contemporary training. Results: A total of 48 studies were included for full review. Studies evaluated trainee education and competency (29.2%, 14/48), neuroendovascular training models (20.8%, 10/48), and open cerebrovascular training models (52.1%, 25/48), with some overlap. We used a qualitative analysis of reviewed reports to generate a series of suggested training supplements to optimize cerebrovascular education. Conclusion: Cerebrovascular neurosurgery is at a crossroads where trainees must develop disparate skill sets with inverse trends in volume. Continued longitudinal exposure to both endovascular and open cerebrovascular surgical fields should be mandated in general resident education, and blended learning tactics using adjunct simulation systems and models should be incorporated with didactics to both optimize learning and alleviate restraints placed by decreased volume and autonomy.

Neonatal high-flow anterior circulation dural arteriovenous fistulae successfully treated with subtotal endovascular embolization; A case report.

High-flow grade-III dural arteriovenous fistulae(dAVF) represent rare abnormal vascular connections with a high risk of rupture. Management involves obliteration of both the fistulous connection as well as the draining venous network with preservation of normal vasculature. We describe and multiple neonatal dAVFs inducing cardiomyopathy via high-flow grade III shunting in the anterior circulation successfully treated via transvenous and transarterial embolization.

Impact of SARS-CoV-2 pandemic on pancreatic cancer services and treatment pathways: United Kingdom experience.

INTRODUCTION: The SARS-CoV-2 pandemic presented healthcare providers with an extreme challenge to provide cancer services. The impact upon the diagnostic and treatment capacity to treat pancreatic cancer is unclear. This study aimed to identify national variation in treatment pathways during the pandemic. METHODS: A survey was distributed to all United Kingdom pancreatic specialist centres, to assess diagnostic, therapeutic and interventional services availability, and alterations in treatment pathways. A repeating methodology enabled assessment over time as the pandemic evolved. RESULTS: Responses were received from all 29 centres. Over the first six weeks of the pandemic, less than a quarter of centres had normal availability of diagnostic pathways and a fifth of centres had no capacity whatsoever to undertake surgery. As the pandemic progressed services have gradually improved though most centres remain constrained to some degree. One third of centres changed their standard resectable pathway from surgery-first to neoadjuvant chemotherapy. Elderly patients, and those with COPD were less likely to be offered treatment during the pandemic. CONCLUSION: The COVID-19 pandemic has affected the capacity of the NHS to provide diagnostic and staging investigations for pancreatic cancer. The impact of revised treatment pathways has yet to be realised.

COVID-19 and neurointerventional service worldwide: a survey of the European Society of Minimally Invasive Neurological Therapy (ESMINT), the Society of NeuroInterventional Surgery (SNIS), the Sociedad Iberolatinoamericana de Neuroradiologia Diagnostica y Terapeutica (SILAN), the Society of Vascular and Interventional Neurology (SVIN), and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN).

BACKGROUND: This survey was focused on the provision of neurointerventional services, the current practices of managing patients under COVID-19 conditions, and the expectations for the future. METHODS: Invitations for this survey were sent out as a collaborative effort of the European Society of Minimally Invasive Neurological Therapy (ESMINT), the Society of NeuroInterventional Surgery (SNIS), the Sociedad Iberolatinoamericana de Neuroradiologia Diagnostica y Terapeutica (SILAN), the Society of Vascular and Interventional Neurology (SVIN), and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN). RESULTS: Overall, 475 participants from 61 countries responded (six from Africa (1%), 81 from Asia (17%), 156 from Europe (33%), 53 from Latin America (11%), and 172 from North America (11%)). The majority of participants (96%) reported being able to provide emergency services, though 26% of these reported limited resources. A decrease in emergency procedures was reported by 69% of participants (52% in ischemic and hemorrhagic stroke, 11% ischemic, and 6% hemorrhagic stroke alone). Only 4% reported an increase in emergency cases. The emerging need for social distancing and the rapid adoption of remote communication was reflected in the interest in establishing case discussion forums (43%), general online forums (37%), and access to angio video streaming for live mentoring and support (33%). CONCLUSION: Neurointerventional emergency services are available in almost all centers, while the number of emergency patients is markedly decreased. Half of the participants have abandoned neurointerventions in non-emergent situations. There are considerable variations in the management of neurointerventions and in the expectations for the future.

Influence of thrombectomy volume on non-physician staff burnout and attrition in neurointerventional teams.

BACKGROUND: Burnout takes a heavy toll on healthcare providers. We sought to assess the prevalence and risk factors for burnout among neurointerventional (NI) non-physician procedural staff (nurses and technologists) given increasing thrombectomy demands. METHODS: A 41-question online survey containing questions including the Maslach Burnout Inventory-Human Services Survey for Medical Personnel was distributed to NI nurses and radiology technologists at 20 US endovascular capable stroke centers. RESULTS: 244 responses were received (64% response rate). Median (IQR) composite scores for emotional exhaustion were 25 (15-35), depersonalization 6 (2-11), and personal accomplishment 39 (35-43). Fifty-one percent of respondents met established criteria for burnout. There was no significant relationship between hospital thrombectomy volume, call frequency, call cases covered, or length of commute. On multiple logistic regression analysis, feeling under-appreciated by hospital leadership (OR 4.1; P<0.001) and working with difficult/unpleasant physicians (OR 1.2; P=0.05) were strongly associated with burnout. At participating centers, nurse and technologist attrition was 25% over the previous year. Over 50% of respondents indicated they had strongly considered leaving their position over the last 2 years. CONCLUSIONS: This survey of US NI non-physician procedural staff demonstrates a self-reported burnout prevalence of 51%. This was driven more by interaction with leadership and physician staff than by thrombectomy procedural volume and stroke call. Attrition among NI non-physician procedural staff is high.

Survey of Current Management Practices for Carotid Webs.

Background: Carotid webs are thick, fibrous intimal bands that appear as intraluminal shelf-like defects at the carotid bifurcation on vascular imaging. These lesions are a potential underrecognized cause of cryptogenic ischemic stroke. Although the recognition of carotid webs has increased, no evidence-based treatment guidelines are available. We surveyed subspecialists across multiple neurologic disciplines to assess the state of current clinical practice. Methods: An 8-question multiple-choice style survey of neurologists and radiologists assessed familiarity with this disease entity, preferred imaging modalities, and management strategies for asymptomatic and symptomatic (producing stroke) carotid webs. Responses were collected through SurveyMonkey software via anonymous responses to a posted survey link on the Society of Neurointerventional Surgery website in addition to invitation emails sent to colleagues in corresponding fields. Results: Of the 74 total respondents, 64% identified as neurointerventionalists. Respondents identified computed tomography angiography as the most commonly used imaging modality to place carotid webs in the differential diagnosis (57% of respondents' preference), while conventional digital subtraction angiogram was the preferred modality to confirm a web (54% of respondents' preference). Respondents preferred single and dual antiplatelet therapy to manage asymptomatic and acute stroke-producing carotid webs, while invasive treatment was most commonly sought for webs producing recurrent strokes. Conclusion: Familiarity with carotid webs varied across subspecialties. We found some consensus among respondents on the imaging modality preferred to identify webs, on asymptomatic carotid web management, and on recurrently symptomatic (multiple strokes) carotid web management. Less consistency was seen regarding preferences for confirmatory imaging and management of acutely symptomatic (initial stroke) carotid webs.

Clinical and biochemical characteristics of patients presenting with pituitary apoplexy.

PURPOSE: To review the clinical and biochemical characteristics and clinical outcome of patients presenting with pituitary apoplexy to a tertiary centre. METHODS: We retrospectively reviewed the clinical features, predisposing factors, biochemistry and clinical outcome of patients presenting with pituitary apoplexy to Imperial College Healthcare NHS Trust between 1991 to 2015. RESULTS: We identified 64 patients with pituitary apoplexy (more complete clinical records were available in 52 patients). The median age at presentation was 46.7 years (IQR 31.5-57.0 years). Pituitary apoplexy was the first presentation of pituitary disease in 38/52 of patients and predisposing factors were identified in 28/52. Pituitary apoplexy predominantly occurred in patients with non-functioning pituitary adenomas (47/52). Headache was most commonly described as sudden-onset, severe, lateralising to the frontal or temporal regions. Symptoms of meningeal irritation were reported in 7/18 and visual abnormalities in 22/35. A pre-treatment serum cortisol <100nmol/l was recorded in 12/31 of patients. All patients with visual disturbance had some resolution of their visual symptoms whether managed surgically (14/14) or conservatively (5/5), although pituitary endocrine function did not fully recover in any patient. CONCLUSIONS: In conclusion, these data describe the clinical features of pituitary apoplexy to aid the clinician in diagnosing this rare emergency presentation of pituitary disease. Prospective multicentre studies of the presentation of pituitary apoplexy are required to further characterise presentation and outcomes.

Endoscopic management of duodeno-ileal fistula secondary to diffuse B-cell lymphoma.

Lymphoma arising in the gastrointestinal tract is relatively common and can affect multiple sites. The development of a gastrointestinal fistula secondary to lymphoma is very rare and has not previously been reported between the duodenum and ileum. This is the first reported care where a fistula secondary to lymphoma has been treated by an endoscopic covered duodenal stent occluding the defect rather than surgical intervention. This strategy permitted early commencement of curative intent chemotherapy which led to tumour shrinkage and fistula closure.