Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis.

Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.

United States regulatory approval of medical devices used for endovascular neurosurgery: A two-decade review of FDA regulatory files.

BACKGROUND: The evolution of neuroendovascular technologies has progressed substantially. Over the last two decades, the introduction of new endovascular devices has facilitated treatment for more patients, and as a result, the regulatory environment concerning neuroendovascular devices has evolved rapidly in response. OBJECTIVE: To examine trends in the approval of neuroendovascular devices by the United States Food and Drug Administration (FDA) over the last 20 years. METHODS: Open-access US FDA databases were queried between January 2000 and December 2022 for all devices approved by the Neurological Devices Advisory Committee. Neuroendovascular devices were manually classified and grouped by category. Device approval data, including approval times, approval pathway, and presence of predicate devices, were examined. RESULTS: A total of 3186 neurological devices were approved via various US FDA pathways during the study period. 320 (10.0%) corresponded to neuroendovascular devices, of which 301 (94.1%) were approved via the 510(k) pathway. The percentage of 510(k) pathway neuroendovascular devices increased from 6.9% to 14.3% of all neuro devices before and after 2015, respectively. There was an increase in approval times for neuroendovascular devices cleared after 2015. CONCLUSION: Over the last two decades, the neuroendovascular device armamentarium has rapidly expanded, especially after positive stroke trials in 2015. Regulatory approval times are significantly affected by device category, generation, company size, and company location, and a vast majority are approved by the 510(k) pathway. These results can guide further innovation in the endovascular device space and may act as a roadmap for future regulatory planning.

Case Volume Justification of 3D-Navigated Spinal Procedures: A Cost-Benefit Analysis.

3D image-guidance platforms have transformed spinal surgery by enhancing visualization, increasing precision, and improving patient outcomes. However, with high procurement, operational, and maintenance costs relative to the standard of care, the benefits of acquiring these platforms must be thoroughly assessed. This study aims to develop a model that weighs the cost of a typical 3D navigation platform against its clinical benefits to determine the facility case volume required to justify its purchase. Using Medtronic's StealthStation and O-Arm as a market example, we calculated the break-even case volume by dividing the cost of the platform by the difference in gross margins between 3D navigation and the standard of care. Total gross margins earned from first-time and revision surgeries were calculated based on each payer's reimbursement rate and covered case volume, as well as each technology's revision rate. Values reported in literature and by Centers for Medicare and Medicaid Services databases were plugged into the model to calculate variables. At a 0% reimbursement rate from private payers for revision surgeries, an annual case volume of 158 spinal surgeries would be required to justify the per-year 3D navigation cost; at 100% private payer reimbursement, 352 surgeries would be required. Given these volumes, 61% of all US inpatient facilities cannot justify 3D navigation at 0% reimbursement, and 86% cannot justify it at 100% reimbursement. Accordingly, greater pricing flexibility, such as per-procedure models, is required for 3D navigation systems to standardize clinical outcomes across medical centers.

Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. METHODS: We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. RESULTS: Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90). CONCLUSION: Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.

Augmented reality-assisted microsurgical resection of brain arteriovenous malformations: illustrative case.

BACKGROUND: Arteriovenous malformations (AVMs) of the brain are vessel conglomerates of feeding arteries and draining veins that carry a risk of spontaneous and intraoperative rupture. Augmented reality (AR)-assisted neuronavigation permits continuous, real-time, updated visualization of navigation information through a heads-up display, thereby potentially improving the safety of surgical resection of AVMs. OBSERVATIONS: The authors report a case of a 37-year-old female presenting with a 2-year history of recurrent falls due to intermittent right-sided weakness and increasing clumsiness in the right upper extremity. Magnetic resonance imaging, magnetic resonance angiography, and cerebral angiography of the brain revealed a left parietal Spetzler-Martin grade III AVM. After endovascular embolization of the AVM, microsurgical resection using an AR-assisted neuronavigation system was performed. Postoperative angiography confirmed complete obliteration of arteriovenous shunting. The postsurgical course was unremarkable, and the patient remains in excellent health. LESSONS: Our case describes the operative setup and intraoperative employment of AR-assisted neuronavigation for AVM resection. Application of this technology may improve workflow and enhance patient safety.

Racial and Ethnical Diversity Within the Neurosurgery Resident and Faculty Workforce in the United States.

BACKGROUND: Promoting workplace diversity leads to a variety of benefits related to a broader range of perspectives and insights. Underrepresented in medicine (URiM), including African Americans, Latinx, and Natives (Americans/Alaskan/Hawaiians/Pacific Islanders), are currently accounting for approximately 40% of the US population. OBJECTIVE: To establish a snapshot of current URiM representation within academic neurosurgery (NS) programs and trends within NS residency. METHODS: All 115 NS residencies and academic programs accredited by the Accreditation Council for Graduate Medical Education in 2020 were included in this study. The National Residency Matching Program database was reviewed from 2011 to 2020 to analyze URiM representation trends over time within the NS resident workforce. The academic rank, academic and clinical title(s), subspecialty, sex, and race of URiM NS faculty (NSF) were obtained from publicly available data. RESULTS: The Black and Latinx NS resident workforce currently accounts for 4.8% and 5.8% of the total workforce, respectively. URiM NSF are present in 71% of the Accreditation Council for Graduate Medical Education-accredited NS programs and account for 8% (148 of 1776) of the workforce. Black and Latinx women comprise 10% of URiM NSF. Latinx NSFs are the majority within the URiM cohort for both men and women. URiM comprise 5% of all department chairs. All are men. Spine (26%), tumor (26%), and trauma (17%) were the top 3 subspecialties among URiM NSF. CONCLUSION: NS has evolved, expanded, and diversified in numerous directions, including race and gender representation. Our data show that ample opportunities remain to improve URiM representation within NS.

Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow.

OBJECTIVE: To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times. METHODS: We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes. RESULTS: Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04). CONCLUSIONS: Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.

Endovascular therapy versus microsurgical clipping of unruptured wide-neck aneurysms: a prospective multicenter study with propensity score analysis.

OBJECTIVE: Numerous techniques have been developed to treat wide-neck aneurysms (WNAs), each with different safety and efficacy profiles. Few studies have compared endovascular therapy (EVT) with microsurgery (MS). The authors' objective was to perform a prospective multicenter study of a WNA registry using rigorous outcome assessments and to compare EVT and MS using propensity score analysis (PSA). METHODS: Unruptured, saccular, not previously treated WNAs were included. WNA was defined as an aneurysm with a neck width ≥ 4 mm or a dome-to-neck ratio (DTNR) < 2. The primary outcome was modified Rankin Scale (mRS) score at 1 year after treatment (good outcome was defined as mRS score 0-2), as assessed by blinded research nurses and compared with PSA. Angiographic outcome was assessed using the Raymond scale with core laboratory review (adequate occlusion was defined as Raymond scale score 1-2). RESULTS: The analysis included 224 unruptured aneurysms in the EVT cohort (n = 140) and MS cohort (n = 84). There were no differences in baseline demographic characteristics, such as proportion of patients with good baseline mRS score (94.3% of the EVT cohort vs 94.0% of the MS cohort, p = 0.941). WNA inclusion criteria were similar between cohorts, with the most common being both neck width ≥ 4 mm and DTNR < 2 (50.7% of the EVT cohort vs 50.0% of the MS cohort, p = 0.228). More paraclinoid (32.1% vs 9.5%) and basilar tip (7.1% vs 3.6%) aneurysms were treated with EVT, whereas more middle cerebral artery (13.6% vs 42.9%) and pericallosal (1.4% vs 4.8%) aneurysms were treated with MS (p < 0.001). EVT aneurysms were slightly larger (p = 0.040), and MS aneurysms had a slightly lower mean DTNR (1.4 for the EVT cohort vs 1.3 for the MS cohort, p = 0.010). Within the EVT cohort, 9.3% of patients underwent stand-alone coiling, 17.1% balloon-assisted coiling, 34.3% stent-assisted coiling, 37.1% flow diversion, and 2.1% PulseRider-assisted coiling. Neurological morbidity secondary to a procedural complication was more common in the MS cohort (10.3% vs 1.4%, p = 0.003). One-year mRS scores were assessed for 218 patients (97.3%), and no significantly increased risk of poor clinical outcome was found for the MS cohort (OR 2.17, 95% CI 0.84-5.60, p = 0.110). In an unadjusted direct comparison, more patients in the EVT cohort achieved a good clinical outcome at 1 year (93.4% vs 84.1%, p = 0.048). Final adequate angiographic outcome was superior in the MS cohort (97.6% of the MS cohort vs 86.5% of the EVT cohort, p = 0.007). CONCLUSIONS: Although the treatments for unruptured WNA had similar clinical outcomes according to PSA, there were fewer complications and superior clinical outcome in the EVT cohort and superior angiographic outcomes in the MS cohort according to the unadjusted analysis. These results may be considered when selecting treatment modalities for patients with unruptured WNAs.

Endovascular Therapy Versus Microsurgical Clipping of Ruptured Wide Neck Aneurysms (EVERRUN Registry): a multicenter, prospective propensity score analysis.

OBJECTIVE: Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA). METHODS: Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0-2) and compared using PSA. RESULTS: The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13-1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04). CONCLUSIONS: EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT's previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.

Availability and Readability of Spinal Cord Injury Online Information Materials for Spanish Speaking Population in Neurosurgical Academic Programs: A Nationwide Study.

BACKGROUND: Recent publications have demonstrated that information has been transmitted inappropriately to the lay person in different pathologies. This limitation is also observed in Spanish language. We evaluate the availability and readability of online patient education material (PEM) on spinal cord injury (SCI) information for the Spanish-speaking population from academic neurosurgery residency programs in the United States. METHODS: This is a descriptive analysis of online SCI PEM from neurosurgical residency programs websites. We assess the availability of information in Spanish using a modification of a previously published classification. To assess accessibility, we calculated the time spent and the number of clicks to find the information in Spanish. We calculated the readability of the material using the "Indice Flesch-Szigriszt" (INFLESZ), which determines the difficulty of readability of health-related material in Spanish. RESULTS: A total of 116 accredited neurosurgery residency programs comprised our cohort. Ten (9%) programs had available "mirrored" information in Spanish from its original version in English, 9 (8.1%) used a translation software, 79 (71.2%) provide interpreter services, and 3 (2%) did not have written information or information about translation services. A mean of 72.9 seconds (SD +/- 71.2) were required to have access to the Spanish information or contact information for translation services. Twelve (57.1%) websites with written Spanish information had an INFLESZ score above 55.00, which translates as an appropriate readability level for the general population. CONCLUSIONS: More than half of the academic neurosurgery programs or affiliated hospital websites do not provide written informative material about SCI in Spanish. When available, the information is not always transmitted with a level of readability appropriate for the layperson. Most of the websites provide translation or interpreter services that are not directly related to SCI.

Student Survey Results of a Virtual Medical Student Course Developed as a Platform for Neurosurgical Education During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Before the coronavirus disease 2019 (COVID-19) pandemic, medical students training in neurosurgery relied on external subinternships at institutions nationwide for immersive educational experiences and to increase their odds of matching. However, external rotations for the 2020-2021 cycle were suspended given concerns of spreading COVID-19. Our objective was to provide foundational neurosurgical knowledge expected of interns, bootcamp-style instruction in basic procedures, and preinterview networking opportunities for students in an accessible, virtual format. METHODS: The virtual neurosurgery course consisted of 16 biweekly 1-hour seminars over a 2-month period. Participants completed comprehensive precourse and postcourse surveys assessing their backgrounds, confidence in diverse neurosurgical concepts, and opinions of the qualities of the seminars. Responses from students completing both precourse and postcourse surveys were included. RESULTS: An average of 82 students participated live in each weekly lecture (range, 41-150). Thirty-two participants completed both surveys. On a 1-10 scale self-assessing baseline confidence in neurosurgical concepts, participants were most confident in neuroendocrinology (6.79 ± 0.31) and least confident in spine oncology (4.24 ± 0.44), with an average of 5.05 ± 0.32 across all topics. Quality ratings for all seminars were favorable. The mean postcourse confidence was 7.79 ± 0.19, representing an improvement of 3.13 ± 0.38 (P < 0.0001). CONCLUSIONS: Feedback on seminar quality and improvements in confidence in neurosurgical topics suggest that an interactive virtual course may be an effective means of improving students' foundational neurosurgical knowledge and providing networking opportunities before application cycles. Comparison with in-person rotations when these are reestablished may help define roles for these tools.

Middle Meningeal Artery Embolization of a Pediatric Patient With Progressive Chronic Subdural Hematoma.

BACKGROUND AND IMPORTANCE: Evidence suggests middle meningeal artery (MMA) embolization benefits adult patients with chronic subdural hematoma (CSDH) at high risk for recurrence or hemorrhagic complications. Yet, there has not been any report discussing MMA embolization in the pediatric population. Thus, we present a case of an infant with CSDH successfully managed with MMA embolization without surgical management. CLINICAL PRESENTATION: A 5-mo-old girl with idiopathic dilated cardiomyopathy underwent surgical implantation of a left ventricular assist device for a bridge to heart transplantation. This was complicated by left ventricular thrombus causing stroke. She was placed on dual antiplatelet antithrombotic therapy on top of bivalirudin infusion. She sustained a left middle cerebral artery infarction, but did not have neurological deficits. Subsequent computed tomography scans of the head showed a progressively enlarging asymptomatic CSDH, and the heart transplant was repeatedly postponed. The decision was made to proceed with MMA embolization at the age of 7 mo. Bilateral modified MMA embolization, using warmed, low-concentration n-butyl-cyanoacrylate (n-BCA) from distal microcatheter positioning, allowed the embolic material to close the distal MMA and subdural membranous vasculature. The patient underwent successful heart transplant and the CSDH improved significantly. She remained neurologically asymptomatic and had normal neurological development after the MMA embolization. CONCLUSION: MMA embolization may represent a safe and effective minimally invasive option for pediatric CSDH, especially for patients at high risk for surgery or hematoma recurrence.

Making a match: trends in the application, interview, and ranking process for the neurological surgery residency programs.

OBJECTIVE: Neurosurgery is a highly competitive residency field with a match rate lower than that of other specialties. The aim of this study was to analyze trends associated with the residency match process from the applicants' and program directors' perspectives. METHODS: Between 2010 and 2020, the National Residency Matching Program (NRMP) Applicant and Program Director Surveys, the NRMP Charting Outcomes reports, and the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books were analyzed to identify the number of applicants interviewed and ranked in US programs, the applicants' ranking preferences, the program directors' preferential factors in offering interviews, and rank list order. Applicants were divided between US senior medical students and independent applicants. Each cohort was dichotomized for matched and unmatched applicants. RESULTS: Over the study period, 2935 applicants applied to neurosurgery residency, including 2135 US senior medical students and 800 independent applicants, with an overall match rate of 65%. Overall, matched applicants had a significantly higher number of publications (p < 0.05). Among US senior medical student applicants, the application-to-interview ratio more than doubled over the study period, yet the number of interview invitations received, interviews accepted, and programs ranked remained unchanged. In the US senior medical student cohort, the number of submitted applications, interview invitations, accepted interviews, and programs ranked did not significantly differ between matched and unmatched applicants. In both cohorts, applicants shifted ranking factors from a more academic focus in early years to more well-being in later years. Letters of recommendation and board scores were key factors for program directors while screening applicants for interviews and ranking. CONCLUSIONS: Neurosurgery residency continues to be a highly competitive field in medicine, with match rates of 65%. Recently, applicants have placed greater importance on ranking programs that value residents' well-being, as opposed to strictly academic factors. A data-driven understanding of factors important to applicants and program directors during the match process has the potential to improve resident candidate recruitment and overall resident-program fit, thereby improving well-being during residency, reducing the attrition rate, and overall enhancing the diversity of the neurosurgery resident workforce.

Bilateral middle cerebral artery occlusions treated with simultaneous bilateral thrombectomy: an approach to multivessel occlusions.

The scarcely described phenomenon of acute ischaemic stroke due to bilateral large vessel occlusions and limited reports of its treatment raises the question about the best method for revascularisation. We present a simultaneous bilateral thrombectomy method on a patient with acute bilateral middle cerebral artery occlusions. This technique resulted in successful vessel recanalisation within 35 min without haemorrhagic complications-deeming the method both safe and effective. Patient outcome was unfavourable, complicated by the patient's history of heart failure and other cardiac-related problems. Patient is residing at a skilled nursing facility with maximal assistance.

Early Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation.

Intracerebral hemorrhage (ICH) is the most deadly form of stroke with a 40% mortality rate and bleak functional outcomes.1 There is currently no effective treatment of the condition, but preliminary trials focusing on endoscopic minimally invasive evacuation have suggested a potential benefit.2-4 The "SCUBA" technique (Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration) builds on prior strategies by permitting effective clot removal with visualization and cauterization of active arterial bleeding.5-7 The patient was a male in his '50s who presented with left-sided numbness after loss of consciousness and was found to have a right basal ganglia 5 mL ICH with a spot sign on computed tomography angiography CTA (Video 1). The hematoma then expanded to 28 mL and his examination worsened significantly for a National Institutes of Health Stroke Scale score of 15, a Glasgow Coma Scale score of 14, and an ICH score of 1. Approximately 8 hours after the patient was last known to be well, he was taken to the angiography suite for a diagnostic cerebral angiogram and right frontal minimally invasive endoscopic ICH evacuation with the Artemis system. The hematoma was evacuated using the stereotactic ICH underwater blood aspiration technique. After significant debulking of the clot, suction strength was decreased to 25% and irrigation was maintained on high. Sites of active bleeding were cauterized with the endoscopic bipolar cautery. The patient improved neurologically and was discharged from the hospital neurologically intact on postbleed day 4 with a National Institutes of Health Stroke Scale score of 0.

Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations.

BACKGROUND: Daunomycin is a chemotherapeutic agent of the anthracycline family that is administered intravenously, most commonly in combination therapy. The authors report the first known adult case of inadvertently administered daunomycin directly into the human central nervous system and the neurologic manifestations and therapeutic interventions that followed. CLINICAL DESCRIPTION: A 53-year-old male presenting to the hospital for his second cycle of consolidation therapy for acute promyelocytic leukemia t(15;17) was accidentally administered 93 mg of intrathecal (IT) daunomycin. Within several hours of injection, the patient subsequently developed bilateral lower extremity pain, ascending paresthesias, headache, and left cranial nerve (CN) III palsy. Immediately following these neurologic sequalae, a subarachnoid lumbar drain was placed at the L4-5 interspace for the initial irrigation and drainage of cerebrospinal fluid (CSF). By hospital day 2, the patient's mental status significantly declined requiring an external ventricular drain (EVD) for hydrocephalus. Despite therapeutic interventions, the patient developed an ascending radiculomyeloencephalopathy with deterioration in clinical status. Eighteen days after the inadvertent injection of IT daunomycin, the patient became comatose and lost all cranial nerve function. CONCLUSIONS: Accidental IT injection of daunomycin is a neurosurgical emergency and warrants prompt intervention. Symptoms can mimic other medical conditions, making it imperative an accurate diagnosis is made so that appropriate therapies are implemented. At this time, therapies include rapid removal of the chemotherapeutic agent from the IT compartment by aspiration and irrigation; however, it is unclear if neuroprotective agents may provide added benefit.

Minimally invasive surgiscopic evacuation of intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is a devastating form of stroke associated with a 40% mortality rate at 30 days and a 75% functional dependence rate at 6 months. The role of surgery to treat ICH remains controversial. Preclinical studies suggest minimally invasive clot evacuation following ICH may benefit patients by mitigating primary and secondary brain injury.1 2 In this video, we report the operative technique used in minimally invasive surgicsopic evacuation following ICH (video 1). We demonstrate our presurgical approach using preoperative volumetric imaging loaded onto a stereotactic guidance system. Evacuation of intraparenchymal and intraventricular components of a hemorrhage are shown under direct surgiscopic vision using the Aurora System (Integra LifeSciences, Princeton, NJ, USA). Hemostasis is achieved when actively bleeding vessels are directly cauterized and irrigation of the clot cavity yields no fresh blood. Pre- and postevacuation radiographic differences illustrate the mitigation of clot burden in an elderly patient. neurintsurg;13/4/400/V1F1V1Video 1.

A technical comparison of thrombectomy vacuum aspiration systems.

INTRODUCTION: Improved functional outcomes after mechanical thrombectomy for emergent large vessel occlusion depend on expedient reperfusion after clinical presentation. Device technology has improved substantially over the years, and several commercial options exist for both large-bore aspiration catheters and suction pump systems. OBJECTIVE: To compare various vacuum pumps and examine the aspiration forces they generate as well as the force of catheter tip detachment from an artificial thrombus. METHODS: Using an artificial thrombus made from polyvinyl alcohol gel, we tested various mechanical characteristics of commercially available suction pumps, including the Penumbra Jet Engine, Penumbra Max, Stryker Medela AXS, Microvention Gomco, and a 60 cc syringe. Both aspiration pressure and tip force generated were analyzed. Subsequently, a cohort of thrombectomy catheters were assessed using the Penumbra Jet Engine to determine tip forces generated on an artificial thrombus. One-way analysis of variance was used to assess statistical significance. RESULTS: The Penumbra Jet Engine system generated both the highest maximum aspiration pressures (28.8 inches Hg) and the highest tip force (23.68 grams force (gf)) on an artificial thrombus, with statistical significance compared with the other pump systems. Using the Jet Engine, the largest-bore catheter was associated with the highest tip force (32.12 gf). The overall correlation coefficient between catheter inner diameter and tip force was 0.98. CONCLUSIONS: The Penumbra Jet Engine pump generates significantly higher vacuum pressures and tip forces than the other commercially available aspiration pump systems. Furthermore, catheters with a larger inner diameter generate higher tip suction forces on aspiration. Whether these mechanical features lead to improved clinical outcomes is yet to be determined.

Mortality reduction after thrombectomy for acute intracranial large vessel occlusion: meta-analysis of randomized trials.

BACKGROUND: Thrombectomy for patients with emergent large vessel occlusion (ELVO) is currently recognized as the standard of care for appropriately selected patients. As proven in several randomized clinical trials and meta-analyses, treatment with thrombectomy lowers rates of poor functional outcomes after ELVO, compared with standard medical management. However, combined mortality rates of the most recent, high-quality clinical trials have not been collectively assessed. OBJECTIVE: The goal of this study was to assess the combined mortality rates of patients with ELVO following thrombectomy using data from the most recent, high-quality clinical trials. METHODS: Meta-analysis was performed in clinical trials comparing thrombectomy and medical management for patients with anterior circulation ELVO. Cumulative rates of mortality (mRS 6) as well as mortality or severe disability (mRS 5-6) were calculated. RESULTS: Ten clinical trials fit the inclusion criteria, including PISTE, REVASCAT, DAWN, THRACE, SWIFT PRIME, ESCAPE, DEFUSE 3, THERAPY, EXTEND-IA, and MR CLEAN, with 2233 patients assessed for mortality alone and 2229 for mortality or severe disability. There was a significantly reduced risk of death with thrombectomy compared with standard medical care (14.9% vs 18.3%, P=0.03; RR 0.81, 95% CI 0.67 to 0.98), as well as a reduced risk of mortality or severe disability (mRS 5-6) in ELVO patients treated with thrombectomy (21.1% vs 30.5%, P<0.0001; RR 0.69, 95% CI 0.60 to 0.80). CONCLUSIONS: Overall, these results suggest a lower risk of death, as well as death or severe disability, in patients with ELVO treated with thrombectomy compared with medical management alone.

Clinical impact of intraoperative hyperlactatemia during craniotomy.

OBJECT: Patients often develop markedly elevated serum lactate levels during craniotomy although the reason for this is not entirely understood. Elevated lactate levels have been associated with poor outcomes in critically ill septic shock patients, as well as patients undergoing abdominal and cardiac surgeries. We investigated whether elevated lactate in craniotomy patients is associated with neurologic complications (new neurological deficits) as well as systemic complications. METHODS: We performed a cohort study of elective craniotomy patients. Demographic and intraoperative data were collected, as well as three timed intraoperative arterial lactate values. Additional lactate, creatinine and troponin values were collected immediately postoperatively as well as 12 and 24 hours postoperatively. Assessment for neurologic deficit was performed at 6 hours and 2 weeks postoperatively. Hospital length-of-stay and 30-day mortality were collected. RESULTS: Interim analysis of 81 patients showed that no patient had postoperative myocardial infarction, renal failure, or mortality within 30 days of surgery. There was no difference in the incidence of new neurologic deficit in patients with or without elevated lactate (10/26, 38.5% vs. 15/55 27.3%, p = 0.31). Median length of stay was significantly longer in patients with elevated lactate (6.5 vs. 3 days, p = 0.003). Study enrollment was terminated early due to futility (futility index 0.16). CONCLUSION: Elevated intraoperative serum lactate was not associated with new postoperative neurologic deficits, other end organ events, or 30 day mortality. Serum lactate was related to longer hospital stay.