Endovascular Treatment for Complex Vascular Pathologies in the Pediatric Population: Experience from a Center with Dual-Trained Neurosurgeons.

OBJECTIVE: Endovascular treatment of complex vascular pathologies in the pediatric population is often performed by nonpediatric subspecialists with adaptation of equipment and techniques developed for adult patients. We aimed to report our center's experience with safety and outcomes of endovascular treatments for pediatric vascular pathologies. METHODS: We performed a retrospective review of our endovascular database. All patients ≤18 years who underwent endovascular treatment between January 1, 2004 and December 1, 2022 were included. RESULTS: During the study time frame, 118 cerebral angiograms were performed for interventional purposes in 55 patients. Of these patients, 8(14.5%) had intracranial aneurysms, 21(38.2%) had intracranial arteriovenous malformations, 6(10.9%) had tumors, 5(9.1%) had arterial occlusions (n = 3) or dissections (n = 2), 8(14.5%) had vein of Galen malformations, and 7(12.7%) had other cerebrovascular conditions. Of the total 118 procedures, access-site complications occurred in 2(1.7%), intraprocedural complications occurred in 3(2.5%), and transient neurological deficits were observed after 2(1.7%). Treatment-related mortality occurred in 1(1.8%) patient. CONCLUSIONS: Neurointervention in pediatric patients was safe and effective in our experience.

Efficacy of intra-arterial carboplatin and bevacizumab in the C6 rat glioma model of glioblastoma multiforme.

BACKGROUND: Utilizing an endovascular rat glioma model, this study aimed to analyze the efficacy of intra-arterial (IA) carboplatin and bevacizumab delivery with blood-brain barrier breakdown (BBBB) for glioblastoma treatment. METHODS: C6-glioma cells were stereotactically injected into the left frontal lobe of Wistar rats. Tumor growth was confirmed on day 8 via MRI. On day 9, a microcatheter was navigated under fluoroscopy from the left femoral artery to the left internal carotid artery. A volume of 2.25 mL of 25% mannitol was administered, followed by either 10 mg/kg of bevacizumab or 2.4 mg/kg of carboplatin. Serial MRI was obtained post-treatment to assess tumor response via analysis of tumor size and radiomics. Histology was analyzed after termination. RESULTS: Control tumor rats and IA mannitol treated tumor rats had fatal tumor growths, with survival until 19.75±2.21 and 36.3±15.1 days, respectively. Carboplatin and bevacizumab treated rats lived >40 days, after which they were euthanized. From serial MRI and histology, IA carboplatin treated rats exhibited tumor regression and resolution by day 35. In IA bevacizumab treated rats, there was tumor regression near the basal ganglia of the brain, closer to the IA chemotherapy injection site, which had reorganized growth patterns. From MRI, 29 unique radiomic features were significantly different between control and treated tumors (notably for total energy and skewness), and treatment responders had a distinct, early manifesting radiomic profile. CONCLUSION: IA carboplatin and bevacizumab treatment resulted in varying degrees of tumor suppression, validating the first endovascular C6 glioma model as a reliable method to assess new IA therapies.

The Effect of Diabetes on Complications after Spinal Fusion: A Systematic Review and Meta-Analysis.

OBJECTIVE: Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures. METHODS: Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed. RESULTS: Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12-1.58; P = 0.001), postoperative pulmonary complications (OR=2.01; 95%CI=1.31-3.08; P = 0.001), postoperative renal complications (OR=2.20; 95%CI=1.27-3.80; P = 0.005), surgical site infection (OR=2.65; 95%CI=2.19-3.20; P < 0.001), and prolonged hospital stay (OR=1.67; 95%CI=1.47-1.90; P < 0.001). CONCLUSIONS: Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.

Bevacizumab and gamma knife radiosurgery for first-recurrence glioblastoma.

INTRODUCTION: Glioblastoma (GBM) is the most common central nervous system malignancy in adults. Despite decades of developments in surgical management, radiation treatment, chemotherapy, and tumor treating field therapy, GBM remains an ultimately fatal disease. There is currently no definitive standard of care for patients with recurrent glioblastoma (rGBM) following failure of initial management. OBJECTIVE: In this retrospective cohort study, we set out to examine the relative effects of bevacizumab and Gamma Knife radiosurgery on progression-free survival (PFS) and overall survival (OS) in patients with GBM at first-recurrence. METHODS: We conducted a retrospective review of all patients with rGBM who underwent treatment with bevacizumab and/or Gamma Knife radiosurgery at Roswell Park Comprehensive Cancer Center between 2012 and 2022. Mean PFS and OS were determined for each of our three treatment groups: Bevacizumab Only, Bevacizumab Plus Gamma Knife, and Gamma Knife Only. RESULTS: Patients in the combined treatment group demonstrated longer post-recurrence median PFS (7.7 months) and median OS (11.5 months) compared to glioblastoma patients previously reported in the literature, and showed improvements in total PFS (p=0.015), total OS (p=0.0050), post-recurrence PFS (p=0.018), and post-recurrence OS (p=0.0082) compared to patients who received either bevacizumab or Gamma Knife as monotherapy. CONCLUSION: This study demonstrates that the combined use of bevacizumab with concurrent stereotactic radiosurgery can have improve survival in patients with rGBM.

A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes.

BACKGROUND: Extensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting. OBJECTIVE: In view of this potential benefit, to investigate the safety and effectiveness of proximal flow arrest using a BGC during concurrent MT and carotid revascularization for tandem stroke treatment in a comparative, propensity score-matched (PSM) study. METHODS: Patients with a tandem stroke identified from our endovascular database were dichotomized into groups treated with BGCs versus conventional guide catheters. One-to-one PSM adjustment for baseline demographics and treatment selection bias using nearest-neighbor matching was performed. Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes assessed were final modified Thrombolysis in Cerebral Infarction (mTICI) grade, periprocedural symptomatic intracranial hemorrhage (sICH) rate, in-hospital mortality, and 90-day modified Rankin Scale (mRS) score. Mann-Whitney U test and multivariate logistic regression were performed to compare procedural parameters and clinical outcomes. RESULTS: Concurrent carotid revascularization (stenting with/without angioplasty) and MT was performed in 125 cases (BGC: 85; no BGC: 40). After PSM (40 patients/group), the BGC group had a significantly shorter procedure duration (77.9 vs 61.5 min; OR=0.996; P=0.006), lower discharge National Institutes of Health Stroke Scale score (8.0 vs 11.0; OR=0.987; P=0.042), and higher odds of 90-day mRS 0-2 score (52.3% vs 27.5%; OR=0.34; P=0.040). On multivariate regression, the BGC group had a significantly higher first pass effect rate (mTICI 2b or 3)(OR=1.115, 95% CI 1.015 to 1.432; P=0.013) and lower periprocedural sICH rate (OR=0.615, 95% CI 0.406 to 0.932; P=0.025). No difference in in-hospital mortality was observed (OR=1.591, 95% CI 0.976 to 2.593; P=0.067). CONCLUSION: BGCs used for concurrent MT-carotid revascularization with flow arrest were safe and resulted in superior clinical and angiographic outcomes in patients with a tandem stroke.

An online calculator using machine learning for predicting survival in pediatric patients with medulloblastoma.

OBJECTIVE: Medulloblastoma is the most common malignant intracranial tumor affecting the pediatric population. Despite advancements in multimodal treatment over the past 2 decades yielding a 5-year survival rate > 75%, children who survive often have substantial neurological and cognitive sequelae. The authors aimed to identify risk factors and develop a clinically friendly online calculator for prognostic estimation in pediatric patients with medulloblastoma. METHODS: Pediatric patients with a histopathologically confirmed medulloblastoma were extracted from the Surveillance, Epidemiology, and End Results database (2000-2018) and split into training and validation cohorts in an 80:20 ratio. The Cox proportional hazards model was used to identify the univariate and multivariate survival predictors. Subsequently, a calculator with those factors was developed to predict 2-, 5-, and 10-year overall survival as well as median survival months for pediatric patients with medulloblastoma. The performance of the calculator was determined by discrimination and calibration. RESULTS: One thousand seven hundred fifty-nine pediatric patients with medulloblastoma met the prespecified inclusion criteria. Age, sex, race, ethnicity, median household income, county attribute, laterality, anatomical location, tumor grade, tumor size, surgery status, radiotherapy, and chemotherapy were variables included in the calculator (https://spine.shinyapps.io/Peds_medullo/). The concordance index was 0.769 in the training cohort and 0.755 in the validation cohort, denoting clinically useful predictive accuracy. Good agreement between the predicted and observed outcomes was demonstrated by the calibration plots. CONCLUSIONS: An easy-to-use prognostic calculator for a large cohort of pediatric patients with medulloblastoma was established. Future efforts should focus on improving granularity of population-based registries and externally validating the proposed calculator.

Stenting for Venous Sinus Stenosis in Patients With Idiopathic Intracranial Hypertension: An Updated Systematic Review and Meta-Analysis of the Literature.

BACKGROUND AND OBJECTIVES: Although venous sinus stenting (VSS) improves cerebrospinal fluid reabsorption and decreases intracranial pressure in patients with idiopathic intracranial hypertension (IIH), the underlying pathophysiology of IIH is not well understood. We present a review and meta-analysis of the literature on VSS for IIH treatment, focusing on the rates of restenosis and symptom recurrence. METHODS: We performed a systematic review of PubMed and Embase databases between January 1, 2011, and December 31, 2021. Articles including ≥5 patients with IIH and venous sinus stenosis treated with VSS and post-treatment rates of restenosis (de novo stenosis at a different anatomic location along the dural sinuses or restenosis within or adjacent to the stent) were selected. Demographic, procedural, and outcomes data were collected and analyzed. Mean values for variables collected were pooled, and a mean value was calculated with a 95% CI. RESULTS: Twenty-four articles were included, comprising 694 patients and 781 VSS cases. The mean age was 33.9 (CI, 31.5-36.2) years. The mean body mass index was 35.3 (CI, 32.9-37.7) kg/m 2 . Before VSS, 98.8% (CI, 96.8%-100.0%) of patients experienced headaches, 87.7% (CI, 80.6%-95.5%) had visual acuity issues, 78.7% (CI, 69.9%-88.5%) had papilledema, 58.3% (CI, 46.0%-73.9%) had tinnitus, and 98.8% (96.4%-100.0%) had symptoms refractory to previous therapies. After VSS, 77.7% (CI, 71.1%-84.95%) experienced symptom improvement and 22.3% (CI, 15.1%-29.0%) had persistent or worsened symptoms. Pooled restenosis rate was 17.7% (CI, 14.9%-20.9%). CONCLUSION: VSS is effective in alleviating IIH signs and symptoms, but the associated high rates of restenosis and persistent symptoms highlight the need for further investigation of this procedure and other adjunctive treatments for IIH.

Association of area deprivation index (ADI) with demographics and postoperative outcomes in pediatric brain tumor patients.

PURPOSE: Although social determinants of health (SDOH) have been associated with adverse surgical outcomes, cumulative effects of multiple SDOH have never been studied. The area deprivation index (ADI) assesses cumulative impact of SDOH factors on outcomes. We analyzed the relationship between ADI percentile and postoperative outcomes in pediatric patients diagnosed with brain tumors. METHODS: A retrospective, observational study was conducted on our consecutive series of pediatric brain tumor patients presenting between January 1, 1999, and May 31, 2022. Demographics and outcomes were collected, identifying SDOH factors influencing outcomes found in the literature. ADI percentiles were identified based on patient addresses, and patients were stratified into more (ADI 0-72%) and less (ADI 73-100%) disadvantaged cohorts. Univariate and multivariate logistic regression analyses were completed for demographics and outcomes. RESULTS: A total of 272 patients were included. Demographics occurring frequently in the more disadvantaged group were Black race (13.1% vs. 2.8%; P = .003), public insurance (51.5% vs. 27.5%; P < .001), lower median household income ($64,689 ± $19,254 vs. $46,976 ± $13,751; P < .001), and higher WHO grade lesions (15[11.5%] grade III and 8[6.2%] grade IV vs. 8[5.6%] grade III and 5[3.5%] grade IV; P = .11). The more disadvantaged group required adjunctive chemotherapy (25.4% vs. 12.05%; P = .007) or radiation therapy (23.9% vs. 12.7%; P = .03) more frequently and had significantly greater odds of needing adjunctive chemotherapy (odds ratio [OR], 1.11; confidence interval [CI], 1.01-1.22; P = .03) in a multivariate model, which also identified higher WHO tumor grades at presentation (OR, 1.20; CI, 1.14-1.27; P < .001). CONCLUSION: These findings are promising for use of ADI to represent potential SDOH disadvantages that pediatric patients may face throughout treatment. Future studies should pursue large multicenter collaborations to validate these findings.

Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors.

BACKGROUND AND OBJECTIVES: Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children. METHODS: The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes. RESULTS: A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02). CONCLUSION: The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.

Comparative Analysis of the 3 Cervical Vertebral Bone Quality (C-VBQ) Score Methodologies and Their Correlations to the Lumbar Vertebral Bone Quality (VBQ) Score.

OBJECTIVE: Common complications after spinal fusion, such as pseudoarthrosis, cage subsidence, or instrumentation failure, are affected by patients' bone quality. The cervical-vertebral bone quality (C-VBQ) score, a magnetic resonance imaging (MRI)-based adaption of the lumbar vertebral bone quality (VBQ) score, was developed by 3 separate research groups simultaneously to evaluate bone quality in cervical spinal fusion patients. We present the first analysis comparing these scoring methods to the well-validated VBQ score. METHODS: A retrospective analysis of data for consecutive patients who underwent spine surgery at a single institution was completed. The VBQ score was calculated using the Ehresman et al. METHOD: The C-VBQ scores, named according to placement of the region of interest within the cerebral spinal fluid, were calculated separately using the methods of Soliman et al. (C2-VBQ), Razzouk et al. (C5-VBQ), and Huang et al. (T1-VBQ). Linear regression models were utilized to evaluate correlations to the VBQ score. RESULTS: A total of 105 patients were identified (mean age, 57.0 ± 11.9 years; women, 50.5%). Mean scores were C2-VBQ, 2.37 ± 0.55; C5-VBQ, 2.36 ± 0.61; and T1-VBQ, 2.64 ± 0.68. The C-VBQ scores for the C2 level were significantly higher than those for the C3-C6 levels (3.18 ± 0.96 vs. 2.63 ± 0.77, P < 0.001), whereas the C7 level was found to have significantly lower C-VBQ scores (2.42 ± 0.78 vs. 2.63 ± 0.77, P = 0.04). The C2-VBQ (r = 0.63) score had the strongest correlation to the VBQ score, compared to C5-VBQ (r = 0.41) and T1-VBQ (r = 0.43) (P < 0.001). CONCLUSIONS: This study demonstrates that the C2-VBQ had the strongest correlation to the lumbar VBQ score among all C-VBQ scores.

Non-dermatologic isolated intracranial necrobiotic xanthogranuloma.

Necrobiotic xanthogranuloma is a condition that was first identified in 1980 based on its characteristic histological identity, and it has been known since then as a dermatologic manifestation of an underlying systemic dysproteinemia. Intracranial manifestation is a rare presentation of this condition and has been reported only once in its more than 40 years of existence. Herein and to our knowledge, we report the second observation of an intracranial manifestation and, surprisingly, the first case without the expected dermatologic and systemic dysproteinemia associations. This case identifies an existing knowledge gap in our understanding of necrobiotic xanthogranuloma and emphasises the need for further research into understanding the presentation, comorbidities and management of this condition.

Standalone versus Anterior Cervical Plating for One-To-Two Level Anterior Cervical Discectomy and Fusion: A Propensity Score-Matched Comparative Study.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) can be performed with and without supportive anterior cervical plating. Fusion rates, incidence of dysphagia, and repeat surgery are concerns when performing ACDF with or without plating. We aimed to compare procedural success and outcomes between patients treated with and without cervical plating for 1-2 level ACDF. METHODS: A prospectively maintained database was retrospectively searched for patients who underwent 1-2 level ACDF surgery. Patients were divided into cohorts treated with plating and without (standalone). Propensity score matching (PSM) was performed to eliminate selection bias and control for baseline comorbidities and disease severity. Patient demographics (including age, body mass index, smoking status, diabetes mellitus, osteoporosis), disease presentation (cervical stenosis, degenerative disc disease), and operative details (number of operative levels, cage type used, intraoperative, and postoperative complications) were recorded. Outcomes assessed were fusion observed at 3, 6, and 12 months, patient-reported postoperative pain, and any repeat surgeries. Univariate analysis was performed according to data normality and variables for PSM cohorts. RESULTS: A total of 365 patients were identified (plating=289, standalone=76). After PSM, 130 patients (65 in each group) were included for final analysis. Similar mean operative times (101.3 ± 26.5-standalone; 104.8 ± 32.2-plating; P = 0.5) and mean hospital stays (1.2 ± 1.8-standalone; 0.7 ± 0.7-plating; P = 0.1) were noted. Twelve-month fusion rates were also similar (84.6%-standalone; 89.2%-plating; P = 0.6). Repeat surgery rates were equivalent (13.8%-standalone; 12.3%-plating; P = 0.8). CONCLUSIONS: In this propensity score-matched case-control study, we report comparable effectiveness and outcomes of performing 1-2 level ACDF with and without cervical plating.

Expansion and Subsequent Rupture of Carotid Pseudoaneurysm After Tandem Carotid and Middle Cerebral Artery Occlusion Treated With Mechanical Thrombectomy and Carotid Stenting.

BACKGROUND AND IMPORTANCE: Extracranial carotid artery pseudoaneurysm is a rare entity with potential etiologies including infection, blunt trauma, postsurgical atherosclerotic disease, and invasive neoplasia. Although the natural history of carotid pseudoaneurysm is difficult to determine because of its rarity, complications such as stroke, rupture, and local mass effect may occur at staggering rates. CLINICAL PRESENTATION: In this case, a middle-aged man presented with a tandem carotid, middle cerebral artery occlusion that was treated with a carotid stent and mechanical thrombectomy. He returned 3 weeks later with a ruptured carotid pseudoaneurysm that was then treated with a covered stent. He made a full recovery and was neurologically intact on follow-up. CONCLUSION: This case illustrates a rare potential complication of carotid occlusion and stenting with possible catastrophic consequences. The goal of this report was to educate other clinicians in remaining vigilant in awareness of this complication and provide a framework for potential treatment if and when it occurs.

The first endovascular rat glioma model for pre-clinical evaluation of intra-arterial therapeutics.

BACKGROUND: Several translational animal models have been described assessing intra-arterial (IA) treatments for malignant gliomas. We describe the first endovascular animal model that allows testing of IA drug delivery as a first-line treatment, which is difficult to do in actual patients. We report a unique protocol for vascular access and IA delivery in the rat model that, unlike prior reports, does not require direct puncture and opening of proximal cerebrovasculature which carries risk of ischemia in the animal brain post-delivery. METHODS: Wistar rats underwent left femoral artery catherization with a Balt Magic 1.2F catheter or Marathon Flow directed 1.5F Microcatheter with an Asahi Chikai 0.008 micro-guidewire which was navigated to the left internal carotid artery under x-ray. 25% mannitol was administered to test blood brain barrier breakdown (BBBB). Additional rats were implanted with C6 glioma cells in the left frontal lobe. C6 Glioma-Implanted Rats (C6GRs) were monitored for overall survival and tumor growth. Tumor volumes from MRI images were calculated utilizing 3D slicer. Additional rats underwent femoral artery catheterization with Bevacizumab, carboplatin, or irinotecan injected into the left internal carotid artery to test feasibility and safety. RESULTS: A successful endovascular access and BBBB protocol was established. BBBB was confirmed with positive Evans blue staining. 10 rats were successfully implanted with C6 gliomas with confirmed growths on MRI. Overall survival was 19.75 ± 2.21 days. 5 rats were utilized for the development of our femoral catheterization protocol and BBBB testing. With regards to IA chemotherapy dosage testing, control rats tolerated targeted 10 mg/kg of bevascizumab, 2.4 mg/kg of carboplatin, and 15 mg/kg of irinotecan IA ICA injections without any complications. CONCLUSIONS: We present the first endovascular IA rat glioma model that allows selective catheterization of the intracranial vasculature and assessment of IA therapies for gliomas without need for access and sacrifice of proximal cerebrovasculature.

Mechanical thrombectomy with a balloon-guide catheter: sheathless transradial versus transfemoral approach.

BACKGROUND: The transradial approach (TRA) for mechanical thrombectomy (MT) for acute ischemic stroke has been limited by the size of catheters usable in the radial artery, with the smaller access site precluding balloon-guide catheter (BGC) use. However, promising results have been reported for a TRA with a sheathless BGC (sTRA). We sought to perform a comparative study of MT with a BGC via the sTRA versus the transfemoral approach (TFA). METHODS: A retrospective review of our MT database was conducted. Baseline, procedure-related, and outcome data were compared for patients aged ≥18 years with anterior circulation large vessel occlusion, Alberta Stroke Program Early CT Score ≥6, and prestroke modified Rankin Scale score ≤2 treated with either approach. RESULTS: Ninety-three consecutive patients (34 sTRA and 59 TFA) were included. Both groups had similar demographics, comorbidities, stroke severity, intravenous alteplase use, and occlusion location. Mean time from puncture to final recanalization was faster in the sTRA group (29 vs 36 min, p=0.059) despite a higher access site crossover rate in the sTRA group (11.8% vs 0%, p=0.016). There were no differences between groups regarding last modified Thombolysis in Cerebral Infarction score; first-pass or modified first-pass effect; time from last known well to puncture; use of stent-retriever, aspiration, or combination first approach; number of passes; symptomatic intracranial hemorrhage; hospital stay; 90-day functional independence; and mortality. National Institutes of Health Scale score and modified first-pass effect were the only independent predictors of poor outcomes. CONCLUSIONS: Comparable patients treated with MT via the sTRA or TFA had similar angiographic and clinical outcomes.

Left Ophthalmic Segment Internal Carotid Artery Aneurysm Treated with Flow Diversion in a Child with Apert Syndrome: Technical Note.

INTRODUCTION: Prevalence of intracranial aneurysms in children with Apert syndrome has not been described, and development of an aneurysm as a complication secondary to craniofacial surgery has never been reported. CASE PRESENTATION: We report the rare case of a 10-year-old boy with Apert syndrome who underwent craniofacial reconstruction surgery consisting of subcranial Le Fort III osteotomies, bilateral lateral canthopexies, and nasal nares dilations for midfacial hypoplasia and resultant obstructive sleep apnea, and on routine follow-up magnetic resonance imaging (MRI) 1 year later, he was found to have a large left ophthalmic internal carotid artery (ICA) aneurysm that was not seen on MRI obtained 2 years prior. Immediately after the craniofacial surgery, the patient experienced a severe headache behind his left eye and extraocular movement abnormalities that subsided over the next days to months. Given the new and rapid growth of the aneurysm on follow-up MRI, the patient underwent a diagnostic cerebral angiogram followed by successful flow diversion treatment of the aneurysm with the pipeline embolization device (Medtronic, Dublin, Ireland). CONCLUSION: Post-procedurally, over the next year, the patient developed word-finding difficulty and stuttering speech. He was found to have in-stent ICA stenosis and middle cerebral artery (MCA) stenosis at the first follow-up and underwent an initial angioplasty. After several weeks, ICA, MCA, and anterior cerebral artery stenoses were identified, and the patient underwent angioplasties for the ICA and MCA stenoses. On follow-up examination after the second procedure, the patient had tremendous improvement in his speech difficulties and was doing well clinically.

Meta-analysis of overall survival and postoperative neurologic deficits after resection or biopsy of butterfly glioblastoma.

Butterfly glioblastoma (bGBM) is a grade 4 glioma with a poor prognosis. Surgical treatment of these cancers has been reviewed in the literature with some recent studies supporting resection as a safe and effective treatment instead of biopsy and adjuvant therapy. This meta-analysis was designed to determine whether there are significant differences in overall survival (OS) and postoperative neurologic deficits (motor, speech, and cranial nerve) following intervention in patients who underwent tumor resection as part of their treatment, compared to patients who underwent biopsy without surgical resection. A literature search was conducted using PubMed (National Library of Medicine) and Embase (Elsevier) to identify articles from each database's earliest records to May 25, 2021, that directly compared the outcomes of biopsy and resection in bGBM patients and met predetermined inclusion criteria. A meta-analysis was conducted to compare the effects of the two management strategies on OS and postoperative neurologic deficits. Six articles met our study inclusion criteria. OS was found to be significantly longer for the resection group at 6 months (odds ratio [OR] 2.94, 95% confidence interval [CI] 1.23-7.05) and 12 months (OR 3.75, 95% CI 1.10-12.76) than for the biopsy group. No statistically significant differences were found in OS at 18 and 24 months. Resection was associated with an increased rate of postoperative neurologic deficit (OR 2.05, 95% CI 1.02-4.09). Resection offers greater OS up to 1 year postintervention than biopsy alone; however, this comes at the cost of higher rates of postoperative neurologic deficits.

Minimally Invasive Resection of Intraventricular Pilocytic Astrocytoma Using the Aurora Surgiscope in an Adult Patient: Technical Note.

BACKGROUND: Pilocytic astrocytomas account for approximately 5%-6% of all gliomas and are most commonly diagnosed between the ages of 8 and 13 years. Although they may occur throughout the neuraxis, approximately two thirds arise from the cerebellum and optic pathway. Other locations of origin include midline structures such as thalamus, hypothalamus, and periventricular regions. Surgical approaches to lateral or third ventricular tumors include anterior transcallosal, subfrontal translamina terminalis, and anterior transcortical approaches. The Aurora Surgiscope is a single-use, disposable minimally invasive neurological endoscope designed for intraparenchymal hemorrhage evacuation. We present the successful use of this system to aid resection of a large intraventricular pilocytic astrocytoma. METHODS: A 29-year-old man presented with signs of developing hydrocephalus and was found to have a large intraventricular tumor, which was later identified to be a rare intraventricular pilocytic astrocytoma. A ventriculostomy was performed as a temporizing measure, and he was transferred to our tertiary care facility for surgical management. Sulcal dissection was performed, and the endoscope was inserted to create a minimally invasive corridor to the lateral ventricle. Using the endoscope, bimanual surgery using multiple instruments simultaneously was possible and enabled gross total resection of the tumor. RESULTS: The patient tolerated the procedure well and was discharged at his neurological baseline level. CONCLUSIONS: Extensive sulcal dissection preceding placement of the endoscope allowed access to the intraventricular space with minimal passage of parenchymal tissue. High-definition visualization was provided and allowed the operating surgeon to freely use both hands during surgery.

Preoperative Embolization of Fisch Grades II-IVa Juvenile Nasopharyngeal Angiofibromas: Transarterial Embolization in the Age of Onyx.

Objective The current mainstay treatment for juvenile nasopharyngeal angiofibromas (JNAs) is surgical resection, but embolization of primary feeding arteries through endovascular transarterial and direct tumoral puncture embolizations with various agents has been described. We describe a single institutional experience with JNA embolization utilizing Onyx (Medtronic, Dublin, Ireland). Methods A retrospective records review was performed to identify patients who underwent embolization for devascularization of Fisch grades II-IVa JNA (tumor extension beyond the sphenopalatine region) before surgical resection between 2010 and 2019. Fluoroscopy time, grade, intraoperative blood loss, and clinical follow-up data were compiled. Tumor devascularization percentage was calculated using ImageJ software (public domain, BSD-2) by measuring the ratio of preoperative and postoperative embolization tracing. Results Five consecutive patients (ages 12-16 years [average 14 years]; all male) with JNAs underwent preoperative transarterial embolizations performed under general anesthesia. All patients presented with epistaxis; two also presented with headaches. Fisch grades were II in two patients, IIIa in two, and IVa in one. The patient with the grade IVa lesion underwent direct transtumoral puncture and Onyx embolization. The mean percentage of all tumor devascularizations postembolization was 86.0±9.7%.Complete resection 24-48 hours postembolization was obtained for grades II and IIIa lesions with <700 mL blood loss. No embolization-related complications and no clinical sequelae were present in the five cases after embolization. Conclusion In our experience, Onyx embolization of JNAs was safely conducted with adequate tumor penetration beyond the sphenopalatine region through transarterial routes.