Risk of Neurological Decline in Patients With Temporal Lobe Brain Masses.

AIM: The objective of this study was to assess which clinical and radiographic findings may be associated with neurological decline in patients with temporal lobe mass lesions. PATIENTS AND METHODS: This represents a retrospective cohort study. Neurological decline was defined as a decline in Glasgow Coma Scale of 2 or more or new anisocoria. Adult patients aged 18 to 89 years with isolated temporal lobe, intra-axial, contrast-enhancing masses diagnosed between 1/1/2010 and 12/31/2020 were included. Clinical and radiographic findings were collected for each patient. Linear regression analysis was used to identify findings predictive of neurological decline. Patients with neurological decline were compared to stable patients to identify factors that may increase risk for neurological decline. RESULTS: A total of 71 patients met the inclusion criteria. Four out of the 71 patients experienced neurological decline, representing an incidence of 6%. Linear regression analysis identified only radiographic transtentorial herniation as a predictor of neurological decline (ß=0.26, p=0.03). A midline shift greater than 5 mm (100% vs. 40%; odds ratio=1.12, 95% confidence interval=1.00-1.32; p=0.05) and radiographic transtentorial herniation (75% vs. 18%; odds ratio=32.12, 95% confidence interval=3.91-264.18; p=0.03) were significantly more prevalent in patients with neurological decline and were associated with an increased risk of neurological decline. CONCLUSION: Radiographic transtentorial herniation and a midline shift greater than 5 mm may be useful findings to suggest an increased risk of neurological decline in patients with masses of the temporal lobe. This knowledge may be useful to neurosurgeons and physicians in other specialties to best care for this patient population.

Use of intravenous cangrelor in the treatment of ruptured and unruptured cerebral aneurysms: an updated single-center analysis and pooled analysis of current studies.

BACKGROUND: Intracranial stent placement for the treatment of cerebral aneurysms is increasingly utilized in both ruptured and unruptured scenarios. Intravenous (IV) cangrelor is a relatively new antiplatelet agent that was initially approved for coronary interventions. In addition to our institution, five other centers have published their results using IV cangrelor in neurointerventional procedures. This article combines the aneurysm treatment data from all prior studies to provide insight into the safety and efficacy of cangrelor for intracranial aneurysm treatment. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during aneurysm embolization. 20 additional patients were identified who had not been previously published. In addition, a literature search was performed to identify prior publications regarding cangrelor in neurointervention. The data from these were combined with our institutional results in a pooled-analysis. RESULTS: Overall, 85 patients who received IV cangrelor during aneurysm embolization were identified, including 46 ruptured and 39 unruptured cases. The asymptomatic and symptomatic intracranial hemorrhage rates were 4% (2/46) for ruptured cases and 2.6% (1/39) for unruptured cases. The rate of retroperitoneal hematoma and gastrointestinal bleeding was 0%. There were no incidents of intraprocedural thromboembolic complication or intraprocedural in-stent thrombosis in either cohort. One subject suffered an ischemic stroke at 24 hours secondary to in-stent thrombosis in a ruptured case. CONCLUSIONS: IV cangrelor during aneurysm embolization appears to be safe, with a symptomatic intracranial hemorrhage rate of 4% in ruptured cases and 2.6% in unruptured cases. More research is needed to determine the ideal dosing regimen.

Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques.

INTRODUCTION: As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. METHODS: Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. RESULTS: 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019-2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. DISCUSSION: Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. CONCLUSION: We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.

Long Segment Anterior Cervical Discectomy and Fusion, Including C2: Surgical Pearls and Review of Our Experience.

STUDY DESIGN: A retrospective study of thirteen patients undergoing 5-level anterior spinal surgery for cervical myelopathy. OBJECTIVE: While limited literature exists in reviewing the treatment of high cervical pathology extending caudally, we believe long segment surgery beginning at C2-3 can be accomplished with good success and is an option more patients may benefit from. We aim to describe the technique in accessing the C2-C3 disk space and efficacy of treating multilevel disease beginning at the C2 vertebral body. This includes an extensive technical report and surgical pearls. SUMMARY OF BACKGROUND DATA: Compression at the level of C2 can be daunting to access because of steep approach required. Few studies have described the technique in reaching the C2 level, with less information describing the efficacy of a 5-level anterior fusion starting at C2. METHODS: Patients who underwent surgery between 2000 and 2016 were identified utilizing the department billing database and ICD codes. Patients age, operative indications, levels treated, length of hospital stay, fusion outcome, and operative complications were explored. Independent analysis of fusion was performed. RESULTS: The average length of hospital stay was 3.9 days. Eight patients reported significant improvement of hand weakness, numbness, and/or gait at 6 months follow-up. The most frequent complication was dysphagia (23%). One patient experienced recurrent symptoms secondary to nonunion, and another patient suffered a postoperative neurological worsening because of anterior spinal artery syndrome. CONCLUSION: This retrospective review discusses the technique to visualize and fully decompress C2-C3 spinal segments. In addition, we explored the efficacy and perioperative risk in long segment anterior cervical discectomy and fusion.

Characterization of antiplatelet response to low-dose cangrelor utilizing platelet function testing in neuroendovascular patients.

STUDY OBJECTIVES: The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT). DESIGN: A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy-two patients met inclusion criteria. An in-depth analysis of dose response to low dose cangrelor based on PFT was performed. PATIENTS: Neuroendovascular patients treated with cangrelor. SETTING: Albany Medical Center Hospital. INTERVENTION AND MAIN RESULTS: Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient's doses were titrated to achieve a platelet reactivity unit (PRU) between 50-150; three patient's doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10-180) and desired (50-150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50-150) and 88% of patients had PRUs in the desire range (10-180). CONCLUSIONS: Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.

Use of intravenous cangrelor and stenting in acute ischemic stroke interventions: a new single center analysis and pooled-analysis of current studies.

INTRODUCTION: Emergent stenting of both extra- and intracranial occlusions during acute ischemic stroke procedures is complicated by the need for immediate platelet inhibition to prevent thromboembolic complications. IV cangrelor is a relatively new antiplatelet that was initially approved for coronary interventions. Five prior case series have been published evaluating the results of IV cangrelor in neurointerventional procedures. We sought to combine the data from all prior studies and analyze only ischemic stroke interventions. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during acute ischemic stroke intervention. Nine additional patients were identified who have not been previously published. In addition, a literature search was performed to identify five prior publications of cangrelor in neurointervention. The data from these was combined with our institution in a pooled-analysis. RESULTS: Overall, 129 patients who received IV cangrelor during an acute ischemic stroke intervention were identified. The asymptomatic intracranial hemorrhage rate was 12.6%(11/87). The symptomatic intracranial hemorrhage rate was 6.2% (8/129). The rate of retroperitoneal hematoma and gastrointestinal bleeding were also low (1.5% and 0.8%, 2/129 and 1/129). There was one case of intraprocedural thromboembolic complication (0.8%) and no cases of intraprocedural in-stent thrombosis(0%). CONCLUSIONS: IV cangrelor during acute ischemic stroke intervention appears to be safe, with a symptomatic intracranial hemorrhage rate of 6.2%. More research is needed to determine the ideal dosing regimen.

Does One Week of Postoperative Antibiotic Prophylaxis Reduce the Rate of Infection After Vagus Nerve Stimulator Surgery?

OBJECTIVE: Vagus nerve stimulation (VNS) therapy is an increasingly popular treatment for medically intractable epilepsy. During a review of our cases, we noted that one of the senior authors give patients 1 week of antibiotic prophylaxis after VNS surgery while the other does not. We reviewed our experience with postoperative antibiotic prophylaxis after VNS surgery. METHODS: We retrospectively reviewed the records of patients from January 2009 to September 2018 who had undergone surgery for VNS therapy, including generator replacement. The office and operative notes were reviewed to obtain the indications and operative details for VNS placement. RESULTS: A total of 570 operations were reviewed, 232 of which were primary implantations and 338 were revisions. The indication was intractable epilepsy in all cases. A total of 5 infections occurred, 4 in the group with postoperative antibiotic prophylaxis and 1 in the group without. The difference was not statistically significant. CONCLUSION: Just as with any hardware implantation, infection of the hardware can lead to significant morbidity. However, the use of postoperative oral antibiotic prophylaxis did not show benefit in reducing the infection rate.

Neurosurgical management of vascular compression presenting as visual symptoms secondary to elongated styloid processes (Eagle syndrome).

BACKGROUND: Eagle syndrome (ES) was first described in 1937, to characterize elongation of the styloid process. It is rarely encountered by neurosurgeons but does present the potential for vascular sequelae and neurological complications. DEMONSTRATIVE CASES: We discuss three patients with uncommon presentations of neurovascular compromise with uncommon symptomatology, secondary to ES. Their management ranged from retrospective diagnoses following self-limited events, antiplatelet therapy, and endovascular and surgical interventions. DISCUSSION: While traumatic fractures, chiropractic manipulation, and history of prior neck surgery have been implicated as the etiologies for ES, congenital cases are common. The styloid process intimately interplays with adjacent neurovascular and nervous structures; its elongation can cause symptoms in 10% of patients. CONCLUSION: Awareness of this potentially dangerous but rare disease - more commonly seen by our otolaryngology colleagues - may help reduce diagnostic delays when an elongated styloid process is the cause, as surgery may be required.

Cangrelor dose titration using platelet function testing during cerebrovascular stent placement.

BACKGROUND: Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS: A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS: All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION: Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION: Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.

Pediatric cervical spine injury in the United States: Defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers.

BACKGROUND: Pediatric cervical spine injury (PCSI) in children is rare. Incidence of PCSI requiring intervention is not known, and imaging practices for screening in United States trauma centers are not well described. METHODS: The 2016 NTDB was queried for patients younger than 15 years with PCSI. Incidence of PCSI, operative interventions, and imaging rates were analyzed by age and ACS accreditation status. RESULTS: Of 84,554 children, 873 (1.03%) had PCSI. Patients <4 years were less likely to have PCSI (0.68% vs. 1.1%, RR 0.59, p < 0.001). 165 children (0.20%) required an intervention for PCSI. 12.8% of all children were screened for PCSI with imaging, 9.3% with CT, and 3.2% with plain X-rays. In spite of similar injury and intervention rates, stand-alone pediatric trauma centers were less likely than others to image patients without PCSI (11% vs. 13% p < 0.001), less likely to utilize CT scan (5.8% vs. 10.6% p < 0.001) and more likely to utilize plain films (5.2% vs. 2.4% p < 0.001). CONCLUSION: Despite exceedingly low rates of PSCI requiring intervention (0.2%), imaging rates for screening are significant. Stand-alone pediatric trauma centers outperform others in limiting unnecessary imaging. LEVEL OF EVIDENCE: IV.

High lead impedances requiring revision during vagal nerve stimulator generator replacement.

OBJECTIVE: Vagal nerve stimulation (VNS) therapy is among the growing options in the treatment of intractable epilepsy. The phenomenon of surprise lead impedance issues found at the time of surgery resulting in unplanned lead revision is a challenge with this type of device. We reviewed our experience with VNS revisions. MATERIAL AND METHODS: We retrospectively reviewed the records of all adult and pediatric patients between January 2009 and September 2018 who underwent surgery for VNS therapy, including revision surgery. Office and operative notes were reviewed to obtain the indications and operative details for VNS placement. RESULTS: A total of 570 operations were reviewed. The indication was intractable epilepsy in all cases. Primary implantation was performed in 232 patients, while the remaining 338 cases were revision cases of various natures. Surprise high lead impedance was found in 10 (3%) of these cases, resulting in a significantly increased complexity of surgery in those instances. CONCLUSION: Lead impedance issues can be caused by disconnection, electrode fracture, hardware failure, or tissue scarring but ultimately require a more extended surgery than may be initially planned. Anticipating the potential for a more extensive operation than a simple generator replacement may prevent perioperative frustrations on both sides.

Vegetation of Ventriculoatrial Shunt Managed via Multidisciplinary Surgical Approach.

INTRODUCTION: The popularity of the ventriculoatrial shunt as a means for cerebrospinal fluid diversion was temporally limited, overcome by the success of the peritoneum as a site for distal drainage. Nevertheless, it remains an important tool for patients for whom ventriculoperitoneal shunting is not an option. CLINICAL PRESENTATION: We present the case of a 9-year-old girl with a ventriculoatrial shunt, who had undergone multiple revisions. Ultimately, she suffered a wound dehiscence, resulting in infectious seeding of the bloodstream and formation of a thrombus, presumed granuloma, at the tip of the distal catheter in the right atrium. She underwent successful removal of the lesion via an open approach by our cardiothoracic colleagues. DISCUSSION: Previous authors have noted a high number of mortalities as a result of these lesions. A collaborative approach resulted in a successful outcome for our patient. Although limited in utility today, the ventriculoatrial shunt remains a common procedure for neurosurgeons today. CONCLUSION: Recognizing the potential for atrial thrombus formation and using a team approach can help avoid a poor outcome.

The effect of minimally invasive dorsal cervical decompression for myelopathy on spinal alignment and range of motion.

OBJECTIVE: Minimally invasive dorsal cervical decompression (miDCD) has been reported as a novel alternative to open dorsal decompression techniques such as laminectomy, laminoplasty, or laminectomy and fusion. Only limited data have been presented regarding the effects of a minimally invasive approach on cervical motion and alignment. The object of the current study is to provide a more comprehensive analysis of radiographic outcomes following miDCD. PATIENTS AND METHODS: Thirty-five patients who had undergone miDCD for myelopathy were included. Exclusion criteria included prior cervical spine surgery, prior cervical spine fracture, fusion of the cervical spine during miDCD, and/or acute spinal cord injury. Analysis of x-rays included the following data elements: degrees of flexion, degrees of extension, and total range of motion; C2-C7 angle as a measure of cervical lordosis; C2-C7 sagittal vertical axis; effective lordosis; and C7 slope. Patient reported outcome measures included neck Visual Analog Score (VAS), Neck Disability Index (NDI), SF-12 Physical Component Score (PCS), SF-12 Mental Component Score (MCS), Nurick score, and modified Japanese Orthopedic Association Myelopathy scale (mJOA). RESULTS: Pre-operative to post-operative comparisons of all radiographic parameters - including total range of motion, C2-C7 Cobb angle, C2-C7 sagittal vertical axis, effective lordosis, and C7 slope angle - remained stable. Several clinical outcomes demonstrated statistical improvement, namely neck VAS, Nurick score, mJOA, NDI, and SF-12 PCS. CONCLUSIONS: miDCD can maintain cervical range of motion and alignment better than traditional laminectomy or laminoplasty techniques.

Debility Among Spinal Surgeons.

BACKGROUND: As the climate of medical care continually shifts, more is expected of surgical specialists than ever before. The rate of burnout among providers appears to be increasing, whereas the career longevity of the modern physician continues to rise to meet the growing demands of our patient population. Spinal surgery is a demanding field, requiring significant amounts of mental and physical fortitude. We intend to highlight issues that cause debility in this cohort of providers. METHODS: This study surveyed the members of the North American Spine Society to better ascertain the issues that plague our profession in relation to physical and mental debility. The survey included multiple-choice questions regarding demographics, burnout, and health status, among other physical and mental health concerns. RESULTS: We achieved a 19% response rate. Eighty percent of responders highlighted physical debility, and psychological, social, and/or behavioral debility (e.g., burnout) was reported by 39% of respondents. CONCLUSIONS: This study highlights the need to improve the work environment and maintain physician health. Although this report sheds light on the problems affecting our colleagues, there is much work that is needed to improve on them. Often the medical philosophy is to ignore one's own personal discomfort in the quest to help patients. In an era in which physician career longevity is needed, these issues must be identified and addressed.

Endovascular stenting of the superior sagittal sinus to alleviate venous compression caused by a parasagittal meningioma.

Idiopathic intracranial hypertension (IIH) is a challenging disease with unclear pathophysiology. Recognition of venous sinus stenting to improve intracranial pressure is increasing.We present a 56-year-old man diagnosed with IIH. A parasagittal meningioma abutting the sagittal sinus causing venous compression was found. Venous sinus stenting via endovascular approach using a WALLSTENT was performed. Intravascular pressures recorded after stenting demonstrated resolution of the pressure gradient.The patient had no complications from the procedure and reported substantial symptomatic improvement. Subsequent ophthalmologic exam demonstrated resolution of the bilateral papilledema noted prior to stenting. Endovascular treatment of venous sinus stenosis in the treatment of IIH is an emerging technique. Treatment of venous compromise due to a mass lesion with stenting is a rarely described concept. For our patient, endovascular stenting was the primary treatment modality, allowing the tumour to be followed with serial imaging.

Spontaneous Subdural Hematoma in Patient with Polycythemia Vera.

BACKGROUND: Polycythemia vera (PV) is a myeloproliferative disorder usually characterized by an increase tendency toward thromboembolic events. Spontaneous hemorrhage/bleeding in PV patients is seldom reported in neurosurgical literature. CASE DESCRIPTION: We report the case of a 76-year-old male with PV who developed a spontaneous subdural hematoma requiring surgical evacuation. He improved significantly after the resolution of brain compression and mass effect caused by the hematoma. CONCLUSIONS: Sporadic reports of hemorrhage within the central nervous system in the setting of PV exist and are attributed to microvascular thrombotic events with hemorrhagic conversion. Though rare, spontaneous central nervous system hemorrhage in the absence of vascular malformation or an inciting event such as trauma can occur in the setting of myeloproliferative disorders like PV.