Correlation Between Medically Diagnosed Anxiety and Depression Disorder and Self-Reported Breast Implant Illness.

BACKGROUND: Anxiety disorders, both with and without comorbid depression, are widespread globally. This study investigates the intersection of anxiety, depression, and self-reported Breast Implant Illness (BII) in women undergoing aesthetic breast surgery. OBJECTIVES: The objective of our research is to enhance understanding about mental health history, psychotropic medication use, and its relation to BII symptoms. METHODS: A cohort of 240 consecutive female patients undergoing elective breast surgery was studied. The study categorized patients into groups based on the presence of self-reported BII symptoms and the type of breast surgery performed. Mental health history, psychotropic medication use, and time spent in treatment for mental illness were scrutinized. Statistical analyses were conducted, including multiple regression analysis. RESULTS: Results reveal that patients with self-reported BII symptoms often have a pre-existing anxiety/depression disorder treated medically before obtaining breast implants, and this disorder predicts the occurrence of BII symptoms. These patients tend to be diagnosed with anxiety and depression at a younger age, initiate medication therapy earlier, take more medications for their condition, and spend more time in therapy compared to others undergoing elective breast surgery. CONCLUSIONS: Implications of this study highlight the need for comprehensive counseling between plastic surgeons and patients with self-reported BII symptoms. Understanding the role of anxiety/depression in the pathogenesis of self-reported BII is crucial, and collaboration with psychiatrists and other mental health professionals can ensure improved supportive care. The findings contribute to a better understanding of the psychological aspects surrounding breast implant surgery and self-reported BII and emphasize the importance of preoperative mental health assessments in appropriate patient selection for elective breast surgery.

Bioengineered recombinant vault nanoparticles coupled with NY-ESO-1 glioma-associated antigens induce maturation of native dendritic cells.

PURPOSE: Glioblastoma prognosis remains grim despite maximal, multimodal management. Recent literature has demonstrated an increase in research devoted to experimental treatments, particularly those relying on the foundations of active immunotherapy with promising results. We hypothesize that the utilization of bioengineered recombinant vault nanoparticles coupled with glioma-associated antigens, such as the NY-ESO-1 peptide, may be capable of stimulating native dendritic cell (DC) maturation and inducing an anti-tumor response. METHODS: Immature DCs were cultured from the bone marrow of 4-6-week-old C57BL/6 mice. The three treatment groups consisted of: (1) DC and media, (2) DC with mCherry vault, and (3) DC with NYESO and vault. DC maturity was assessed via flow cytometric evaluation of CD11c, CD86, and MHC-II. Increase in CD86 Median Fluorescence Intensity (MFI) was analyzed in the CD11c+CD86+MHC-II+ population to determine the extent of maturation RESULTS: Our findings suggest that CP-MVP-NY-ESO-1-INT recombinant vault nanoparticles are efficiently bioengineered with exceptional integrity, are quickly internalized by immature DCs for antigen processing, and result in DC maturation. CONCLUSION: This study reports our preliminary results, which demonstrate the feasibility and progress regarding our immunotherapeutic technique utilizing NY-ESO-1 packaged vault nanoparticles to prime DCs for subsequent anti-cancer therapies.

Intratumor injection of CCL21-coupled vault nanoparticles is associated with reduction in tumor volume in an in vivo model of glioma.

PURPOSE: Glioblastoma (GBM) is the most common and malignant primary adult brain tumor. Current care includes surgical resection, radiation, and chemotherapy. Recent clinical trials for GBM have demonstrated extended survival using interventions such as tumor vaccines or tumor-treating fields. However, prognosis generally remains poor, with expected survival of 20 months after randomization. Chemokine-based immunotherapy utilizing CCL21 locally recruits lymphocytes and dendritic cells to enhance host antitumor response. Here, we report a preliminary study utilizing CPZ-vault nanoparticles as a vehicle to package, protect, and steadily deliver therapy to optimize CCL21 therapy in a murine flank model of GBM. METHODS: GL261 cells were subcutaneously injected into the left flank of eight-week-old female C57BL/6 mice. Mice were treated with intratumoral injections of either: (1) CCL21-packaged vault nanoparticles (CPZ-CCL21), (2) free recombinant CCL21 chemokine empty vault nanoparticles, (3) empty vault nanoparticles, or 4) PBS. RESULTS: The results of this study showed that CCL21-packaged vault nanoparticle injections can decrease the tumor volume in vivo. Additionally, this study showed mice injected with CCL21-packaged vault nanoparticle had the smallest average tumor volume and remained the only treatment group with a negative percent change in tumor volume. CONCLUSIONS: This preliminary study establishes vault nanoparticles as a feasible vehicle to increase drug delivery and immune response in a flank murine model of GBM. Future animal studies involving an intracranial orthotopic tumor model are required to fully evaluate the potential for CCL21-packaged vault nanoparticles as a strategy to bypass the blood brain barrier, enhance intracranial immune activity, and improve intracranial tumor control and survival.

Surgery versus stereotactic radiosurgery for the treatment of multiple meningiomas in neurofibromatosis type 2: illustrative case and systematic review.

Neurofibromatosis type 2 (NF2) is a genetic neoplastic disorder that presents with hallmark bilateral vestibular schwannomas and multiple meningiomas. Though the current standard of care for meningiomas includes surgery, the multiplicity of meningiomas in NF2 patients renders complete resection of all developing lesions infeasible. Stereotactic radiosurgery (SRS) may be a viable non-invasive therapeutic alternative to surgery. We describe a particularly challenging case in a 39-year-old male with over 120 lesions who underwent more than 30 surgical procedures, and review the literature. We also searched three popular databases and compared outcomes of SRS versus surgery for the treatment of multiple meningiomas in patients with NF2. A total of 50 patients (27 radiosurgical and 23 surgical) were identified. For patients treated with SRS, local tumor control was achieved in 22 patients (81.5%) and distal control was achieved in 14 patients (51.8%). No malignant inductions were observed at an average follow-up duration of 90 months. Complications in the SRS-treated cohort were reported in 9 patients (33%). Eight patients (29.6%) died due to disease progression. Six patients experienced treatment failure and required further management. For NF2 patients treated with surgery, 11 patients (48%) showed tumor recurrence and 10 patients (43.5%) died due to neurological complications. SRS may be a safe and effective alternative for NF2-associated meningiomas. Further studies are required to identify the ideal radiosurgical candidate.

Neuroglial ectopia of the vestibular nerve masquerading as a vestibular schwannoma: A case report.

Neuroglial ectopia is a rare entity of undetermined clinical significance. Here, we report a unique case of neuroglial ectopia of the vestibular nerve. A 27-year-old pharmacy student with a previous radiological diagnosis of vestibular schwannoma presented to our clinic for surgical evaluation. Magnetic resonance imaging (MRI) of the brain revealed a 17-mm T1 hypo- to isointense, T2 iso- to hyperintense, poorly enhancing left cerebellopontine angle mass extending into the left internal auditory canal compatible by imaging with a vestibular schwannoma. The lesion was resected under MRI guidance. The frozen specimen came back as a benign hypocellular lesion. Histological assessment revealed a peripheral nerve engulfed by glial fibrillary acidic protein-positive, S-100-negative cells, suggestive of neuroglial ectopia. There was no evidence of schwannoma. The main concerns were benign neoplasm with potential for progression or sampling artifact. The patient had an uncomplicated hospital course. This case report demonstrates an unusual case of neuroglial ectopia of the vestibular nerve. The differential diagnoses for a poorly enhancing cerebellopontine angle mass should include neuroglial ectopia.

Middle cranial fossa approach for the repair of superior semicircular canal dehiscence is associated with greater symptom resolution compared to transmastoid approach.

BACKGROUND: Superior semicircular canal dehiscence (SSCD) is a disorder of the skull base that is gaining increasing recognition among neurosurgeons. Traditionally, the middle cranial fossa (MCF) approach has been used for the surgical repair of SSCD. However, the transmastoid (TM) approach is an alternative strategy that has demonstrated promising results. METHODS: We performed independent searches of a popular database to identify studies that described outcomes following the surgical repair of SSCD through MCF and TM approaches. The primary outcome was symptom resolution. RESULTS: Our analysis included 24 studies that described 230 patients that underwent either an MCF (n = 148, 64%) approach or a TM (n = 82, 36%) approach for primary surgical repair of SSCD. A greater percentage of patients in the MCF group experienced resolution of auditory symptoms (72% vs 59%, p = 0.012), aural fullness (83% vs 55%, p = 0.049), hearing loss (57% vs 31%, p = 0.026), and disequilibrium (75% vs 44%, p = 0.001) when compared to the TM group. The MCF approach was also associated with higher odds of symptom resolution for auditory symptoms (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.14-2.82), aural fullness (OR 4.02, 95% CI 1.04-15.53), hearing loss (OR 2.91, 95% CI 1.14-7.42), and disequilibrium (OR 3.94, 95% CI 1.78-8.73). The mean follow-up was 9 months. CONCLUSIONS: The literature suggests that the MCF approach for the repair of SSCD is associated with greater symptom resolution when compared to the TM approach. This information could help facilitate patient discussions.

Pediatric spondylolysis/spinal stenosis and disc herniation: national trends in decompression and discectomy surgery evaluated through the Kids' Inpatient Database.

PURPOSE: The purpose of this study is to describe national trends in spinal decompression without fusion and discectomy procedures in the US pediatric inpatient population. METHODS: The Kids' Inpatient Database (KID) was queried for pediatric patients with primary diagnoses of spinal spondylolysis/stenosis or disc herniation and having undergone spinal decompression without fusion or discectomy over more than a decade (2000 to 2012). The primary (indirect) outcomes of interest were in-hospital complication rates, length of stay (LOS), total costs, and discharge dispositions. RESULTS: A total of 7315 patients, comprised of pediatric spinal spondylolysis/stenosis (n = 287, 3.92%) and pediatric disc herniation (n = 7028, 96.1%) patients, were included in the study. During the years 2000 to 2012, diagnoses of pediatric spondylolysis/spinal stenosis increased from 61 to 90 diagnoses per 3-year period, while diagnoses of pediatric disc herniation decreased from 2133 to 1335 diagnoses per 3-year period. Spinal decompression was associated with higher in-hospital complication rates (18.1 vs 5.3%, p < 0.0001), longer hospital stays (5 vs 1.69 days, p < 0.0001), higher mean total charges ($49,186 vs $19,057, p < 0.0001), and higher non-routine discharge rates (12.3 vs 2.5%, p < 0.0001) versus discectomy. CONCLUSIONS: Spinal decompression is associated with longer hospital stays, more complications, higher costs, and more non-routine discharges when compared to discectomy. The data supports the disparate nature of these disease processes and elucidates basic clinical trends in uncommon spinal disorders affecting children.

Skull fracture with effacement of the superior sagittal sinus following drone impact: a case report.

BACKGROUND: The popularity of unmanned aerial vehicles, or drones, raises safety concerns as they become increasingly common for commercial, personal, and recreational use. Collisions between drones and people may result in serious injuries. CASE REPORT: A 13-year-old male presented with a comminuted depressed skull fracture causing effacement of the superior sagittal sinus secondary to a racing drone impact. The patient experienced a brief loss of consciousness and reported lower extremity numbness and weakness after the accident. Imaging studies revealed bone fragments crossing the superior sagittal sinus with a short, focal segment of blood flow interruption. Neurosurgical intervention was deferred given the patient's improving neurological deficits, and the patient was treated conservatively. He was discharged home in stable condition. CONCLUSION: Drones may represent a hazard when operated inappropriately due to their capacity to fly at high speeds and altitudes. Impacts from drones can carry enough force to cause skull fractures and significant head injuries. The rising popularity of drones likely translates to an increased incidence of drone-related injuries. Thus, clinicians should be aware of this growing trend.

National trends following decompression, discectomy, and fusion in octogenarians and nonagenarians.

BACKGROUND: The National Inpatient Sample (NIS) database is used to evaluate a wide variety of surgical procedures across a range of specialties. The authors of this study assess national trends of the three commonest spine procedures performed (decompression, fusion, and discectomy) in patients between the ages of 80 and 100 years (octogenarians and nonagenarians). METHODS: The NIS database was queried to identify patients between the ages of 80 and 100 with a primary diagnosis of spinal stenosis, disk herniation without myelopathy, or protrusion due to degeneration of spine/disk disorders and who have undergone spinal decompression, fusion, or discectomy between the years 1998 and 2011. Variables of concern included length-of-stay (LOS), non-routine discharge, average total charges, in-hospital complications, and mortality rate. RESULTS: Decompression was the most common procedure performed (n = 113,267, 50.5%). Fusion (n = 60,345, 26.9%) was associated with the longest LOS (5.1 days), highest in-hospital complication and mortality rates (n = 13,170, 21.8% and n = 449, 0.7%, respectively), most non-routine discharges (n = 42,662, 70.7%), and highest mean for average total charges ($69,295) (p < 0.001). Discectomy (n = 50,740, 22.6%), had the shortest LOS (3.7 days), lowest complication and mortality rates (n = 6823, 13.4% and n = 102, 0.2%, respectively), fewest non-routine discharges (n = 22,861, 45.1%), and lowest mean for average total charges ($22,787) (p < 0.001). CONCLUSIONS: Decompression was most common. Fusion had the longest LOS, highest complication and mortality rates, most non-routine discharges, and was most expensive. Discectomy was least commonly performed, had the shortest LOS, lowest complication and mortality rates, fewest non-routine discharges, and was least expensive.

Teratomas of the cranial vault: a systematic analysis of clinical outcomes stratified by histopathological subtypes.

BACKGROUND: Teratomas of the cranial vault are divided into histopathological subtypes and grouped by prognoses: mature (good prognosis), mixed/malignant and immature teratomas (intermediate prognosis). This schema also includes non-teratomatous tumors. The authors of this study sought to elucidate histologically dependent predictors of survival and further clarify the classification system of intracranial teratomas. METHODS: We performed a systematic analysis of the published literature to identify studies describing patients with intracranial teratomas diagnosed with magnetic resonance imaging (MRI) and presenting definite information on histologies, therapies, and outcomes at a minimum follow-up of 2 years. Disease-free (DFS) and overall survival (OS) were evaluated. RESULTS: A total of 18 articles comprised of 134 patients were included. On univariate analysis, male sex and gross-total resection (GTR) were associated with high mean DFS (p = 0.0362 and p < 0.0001, respectively). On multivariate analysis, mature teratomas located in the pineal, and those having undergone subtotal resection (STR) demonstrated high mean OS (p = 0.0023 and p = 0.0044, respectively). Mature and mixed/malignant suprasellar teratomas had equally higher mean OS versus immature suprasellar teratomas (p < 0.0001). Mature and immature teratomas treated with adjuvant therapy had significantly higher mean OS compared to those managed with surgery alone (p = 0.0421 and p = 0.0423, respectively). Males with immature teratomas had the highest mean OS (p < 0.0001). Immature teratomas managed with surgery alone had higher mean DFS, but lower mean OS, compared to those treated with adjuvant therapy (p = 0.0176 and p = 0.0423, respectively). CONCLUSIONS: Our data highlight the divergent nature of the different histopathological subtypes of teratomas, and suggest that survival outcomes are multifactorial. Specifically, male sex, pineal, suprasellar, GTR, and STR were dependent predictors of OS, while histopathology was an independent predictor of OS.

Evaluating the utility of a scoring system for lipomas of the cerebellopontine angle.

BACKGROUND: Cerebellopontine angle (CPA) lipomas are rare, benign, slow-growing masses. Resections are considered in symptomatic patients who are refractory to targeted medical therapies, but at those stages the lipomas have often reached considerable sizes and encompass critical neurovascular structures. The objective of this study is to develop and to evaluate the utility of a scoring system for CPA lipomas. The hypothesis is that CPA lipomas with lower scores are probably best managed with early surgery. METHODS: The PubMed database was searched using relevant terms. Data on patient and lipoma characteristics were extracted and used to design a scoring system. CPA lipomas were stratified by scores with corresponding managements and outcomes analyzed. RESULTS: One hundred and seventeen patients with CPA lipomas were identified and 40 CPA lipomas were scored. The remaining CPA lipomas were deficient in data and not scored. No lipomas were scored as 1. Score 2 lipomas (n = 12; 30%) most often underwent serial surveillances (n = 5; 41.6%), with the majority of symptoms remaining unimproved (n = 2; 40%). Patients with score 2 CPA lipomas treated with medical therapies (n = 3; 25%) often experienced symptom resolution (n = 2; 66.6%) (p = 0.0499). Patients with score 2 CPA lipomas undergoing surgical resections (n = 3; 25%) all experienced symptom resolution (n = 3; 100%) (p = 0.0499). Score 3 was most common (n = 16; 40%) and these lipomas were often surgically resected (n = 10; 62.5%). The majority of patients with score 3 CPA lipomas having undergone surgical resections (n = 10; 62.5%) experienced symptom improvement (n = 1; 10%) or resolution (n = 4; 40%). CONCLUSIONS: Score 2 CPA lipomas are smaller and would be deemed non-surgical in general practice. However, our data suggest that these lipomas may benefit from either medical therapies or early surgical resections. The advantages of early surgery are maximal resection, decreased surgical morbidity, and improved symptom relief.

The Safety of Abdominal Contouring in the Presence of a Gastric Band.

Background: Gastric bands, specifically the Lap-Band, have been widely used for weight loss. However, little is known about the complications associated with abdominal contouring procedures in patients with Lap-Bands. This study aimed to determine the complication rates and consent processes for these procedures. Methods: We conducted a survey study of 300 members of the American Society of Aesthetic Plastic Surgery. Commonly performed abdominal contouring procedures included abdominal liposuction, abdominoplasty, and combined abdominoplasty with abdominal liposuction. Results: The overall infection rate was low (1%) and did not significantly differ between the procedural groups. Abdominoplasty and combined liposuction with abdominoplasty had significantly higher complication rates (4.7% and 10.5%, respectively) than liposuction alone (1%, P = 0.0004). Abdominoplasty procedures also had higher rates of port/tubing malposition (2.3%, P = 0.04) and system leaks (1.6%, P = 0.003). Approximately 59% of plastic surgeons provided written or dictated consent as part of the standard procedural consent to address the presence of the Lap-Band, whereas 8% of plastic surgeons provided a separate written or printed signed consent specifically related to the procedure in the presence of a Lap-Band. Conclusions: Our study supports the relative safety of aesthetic abdominal contouring procedures in patients with gastric bands but highlights the increased risk of complications in the presence of a Lap-Band. Surgeons should use careful dissection techniques to minimize complications and consider involving a bariatric surgeon, especially with abdominoplasty procedures. Surgical consent should explicitly outline the risks identified in this study to ensure that patients are fully informed.

En Plaque Meningiomas: A Narrative Review.

Background En plaque meningiomas are a rare subtype of meningiomas that are frequently encountered in the spheno-orbital region. Characterized by a hyperostotic and dural invasive architecture, these tumors present unique diagnostic and treatment considerations. Objective The authors conduct a narrative literature review of clinical reports of en plaque meningiomas to summarize the epidemiology, clinical presentation, diagnostic criteria, and treatment considerations in treating en plaque meningiomas. Additionally, the authors present a case from their own experience to illustrate its complexity and unique features. Methods A literature search was conducted using the MEDLINE database using the following terminology in various combinations: meningioma , meningeal neoplasms, en plaque , skull base , spheno-orbital, and sphenoid wing . Only literature published in English between 1938 and 2018 was reviewed. All case series were specifically reviewed for sufficient data on treatment outcomes, and all literature was analyzed for reports of misdiagnosed cases. Conclusion En plaque meningiomas may present with a variety of symptoms according to their location and degree of bone invasion, requiring a careful diagnostic and treatment approach. While early and aggressive surgical resection is generally accepted as the optimal goal of treatment, these lesions require an individualized approach, with further investigation needed regarding the role of new therapies.

Analysis of academic publishing output among 1634 successful applicants in the 2011-2018 neurosurgery residency match.

BACKGROUND: Research productivity is a key criterion for applicant selection reported by residency program directors. Research volume reported on neurosurgery residency applications has risen steadily over the past decade. OBJECTIVE: Perform retrospective bibliographic searches of successful applicants who matched into U.S. neurosurgery residency programs from 2011 to 2018, and assess the relationship between academic publishing and residency placement. METHODS: Gender, MD/PhD status, U.S. News research ranking of medical school, and international medical graduate status (IMG) were determined for 1634 successful applicants from 2011 to 2018. Indexed publications before and after the start of residency were tabulated by Scopus®. Publication counts were stratified by first author, basic/clinical science, case reports, reviews, or other research. We then compared publishing trends across demographic variables and match cohorts. RESULTS: Average pre-residency publications increased from 2.6 [1.7, 3.4] in 2011 to 6.5 [5.1, 7.9] in 2018. Men, PhD-holders, Top 20 and Top 40 U.S. medical school graduates, and IMGs had higher pre-residency publication counts overall. After stratifying by match cohort, however, there was no significant effect of gender on pre-residency publications. Applicants matching into residency programs with highly ranked affiliated hospitals had significantly higher pre-residency publications. CONCLUSION: Publishing volume of successful neurosurgery applicants in the U.S. has risen recently and is associated with the stature of matched residency programs. Given the gap between verifiable and claimed research on residency applications, attention is needed to objectively evaluate research credentials in the selection process. The impending phase out of USMLE step 1 scores may increase emphasis on academic productivity.

United States Medical Licensing Examination step 2 scores do not predict American Board of Neurological Surgery scores: A single-institution experience.

OBJECTIVES: The neurosurgery residency match is becoming increasingly competitive, with numerous factors being considered as part of the application. We aim to determine whether USMLE Step 2 scores were a significant predictor of neurosurgery board performance. PATIENTS AND METHODS: Residents who entered a neurological surgery residency program at a single academic institution during 2000-2017 provided scores for all ABNS attempts, USMLE Step 1 and Step 2 scores. Data were deidentified and analyzed for correlation and regression. Pearson's correlation coefficients were determined. RESULTS: USMLE Step 1, Step 2, and maximum ABNS scores were all normally distributed. Step 1 and Step 2 scores were less variable than ABNS scores. USMLE Step 2 and residents' best ABNS written examination scores were not correlated (Pearson Correlation of 0.228 with a 2-tailed significance of 0.272). No outliers were present. When comparing USMLE Step 2 scores with year in residency at which residents scored over 300 on the ABNS written examination, Pearson correlation was -0.500 (p = .015). A simple linear regression was calculated using Step 2 scores to predict the passing year of ABNS written examination (F(1,14) = 6.984, p = .015, R2 = 0.25). CONCLUSION: Although other studies have found correlations between USMLE Step 2 scores and performance before graduating medical school and during residency for other specialties, this is the first study comparing USMLE Step 2 scores with the ABNS written examination scores of neurosurgical residents. Our data showed that USMLE Step 2 was not a reliable predictor of ABNS written examination scores.

Patient Safety Analysis in Radiation Burden of Head Computed Tomography Imaging in 1185 Neurosurgical Inpatients.

OBJECTIVE: We performed a retrospective analysis in a cohort of 1185 patients at our institution who were identified as undergoing ≥1 head computed tomography (CT) examinations during their inpatient stay on the neurosurgery service, to quantify the number, type, and associated radiation burden of head CT procedures performed by the neurosurgery service. METHODS: CT procedure records and radiology reports were obtained via database search and directly validated against records retrieved from manual chart review. Next, dosimetry data from the head CT procedures were extracted via automated text mining of electronic radiology reports. RESULTS: Among 4510 identified adult head CT procedures, 88% were standard head CT examinations. A total of 3.65 ± 3.60 head CT scans were performed during an average adult admission. The most common primary diagnoses were neoplasms, trauma, and other hemorrhage. The median cumulative effective dose per admission was 5.66 mSv (range, 1.06-84.5 mSv; mean, 8.56 ± 8.95 mSv). The median cumulative effective dose per patient was 6.4 mSv (range, 1.1-127 mSv; mean, 9.26 ± 10.0 mSv). CONCLUSIONS: The median cumulative radiation burden from head CT imaging in our cohort equates approximately to a single chest CT scan, well within accepted limits for safe CT imaging in adults. Refined methods are needed to characterize the safety profile of the few pediatric patients identified in our study.

Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases.

BACKGROUND: External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. OBJECTIVE: To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. METHODS: We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. RESULTS: Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. CONCLUSION: Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

Relationship between middle cerebral parent artery asymmetry and middle cerebral artery aneurysm rupture risk factors.

OBJECTIVE: The exact pathophysiological mechanisms underlying cerebral aneurysm formation remain unclear. Asymmetrical local vascular geometry may play a role in aneurysm formation and progression. The object of this study was to investigate the association between the geometric asymmetry of the middle cerebral artery (MCA) and the presence of MCA aneurysms and associated high-risk features. METHODS: Using a retrospective case-control study design, the authors examined MCA anatomy in all patients who had been diagnosed with an MCA aneurysm in the period from 2008 to 2017 at the University Hospitals Cleveland Medical Center. Geometric features of the MCA ipsilateral to MCA aneurysms were compared with those of the unaffected contralateral side (secondary control group). Then, MCA geometry was compared between patients with MCA aneurysms and patients who had undergone CTA for suspected vascular pathology but were ultimately found to have normal intracranial vasculature (primary control group). Parent vessel and aneurysm morphological parameters were measured, calculated, and compared between case and control groups. Associations between geometric parameters and high-risk aneurysm features were identified. RESULTS: The authors included 247 patients (158 cases and 89 controls) in the study. The aneurysm study group consisted of significantly more women and smokers than the primary control group. Patients with MCA bifurcation aneurysms had lower parent artery inflow angles (p = 0.01), lower parent artery tortuosity (p < 0.01), longer parent artery total length (p = 0.03), and a significantly greater length difference between ipsilateral and contralateral prebifurcation MCAs (p < 0.01) than those in primary controls. Type 2 MCA aneurysms (n = 89) were more likely to be associated with dome irregularity or a daughter sac and were more likely to have a higher cumulative total of high-risk features than type 1 MCA aneurysms (n = 69). CONCLUSIONS: Data in this study demonstrated that a greater degree of parent artery asymmetry for MCA aneurysms is associated with high-risk features. The authors also found that the presence of a long and less tortuous parent artery upstream of an MCA aneurysm is a common phenotype that is associated with a higher risk profile. The aneurysm parameters are easily measurable and are novel radiographic biomarkers for aneurysm risk assessment.

Racial Differences in Hospital Stays among Patients Undergoing Craniotomy for Tumour Resection at a Single Academic Hospital.

BACKGROUND: Racial differences in American patients undergoing brain tumour surgery remain poorly characterized within urban medical centres. Our objective was to assess racial differences in operative brain tumour patients at a single academic hospital in Los Angeles, California. METHODS: We reviewed medical records of adult patients undergoing craniotomy for tumour resection from March 2013 to January 2017 at UCLA Medical Centre. Patients were categorized as Asian, Hispanic, Black, or White. Racial cohorts were matched on demographic variables for comparisons. Our primary outcome was post-operative length of stay (LOS). Secondary outcomes included hospital mortality and discharge disposition. RESULTS: In this study, 462 patients identified as Asian (15.1%), Hispanic (8.7%), Black (3.9%), or White (72.3%). After cohort matching, non-White patients had elevated risk of prolonged LOS [odds ratio (OR)=2.62 (1.44, 4.76)]. No differences were observed in hospital mortality or non-routine discharge. Longer LOS was positively correlated with non-routine discharge [rpb (458)=0.41, p<0.001]. Black patients with government insurance had average LOS 2.84 days shorter than Black patients with private insurance (p=0.04). Among Hispanics, government insurance was associated with non-routine discharge [OR=4.93 (1.03, 24.00)]. CONCLUSION: Racial differences manifested as extended LOS for non-White patients, with comparable rates of hospital mortality and non-routine discharge across races. Prolonged LOS loosely reflected complicated clinical course with greater risk of adverse discharge disposition. Private insurance coverage predicted markedly lower risk of non-routine discharge for Hispanic patients, and LOS of three additional days among Black patients. Further research is needed to elucidate the basis of these differences.

Stereotactic Radiosurgery for Neurosurgical Patients: A Historical Review and Current Perspectives.

Today, stereotactic radiosurgery is an effective therapy for a variety of intracranial pathology that were treated solely with open neurosurgery in the past. The technique was developed from the combination of therapeutic radiation and stereotactic devices for the precise localization of intracranial targets. Although stereotactic radiosurgery was originally performed as a partnership between neurosurgeons and radiation oncologists, this partnership has weakened in recent years, with some procedures being performed without neurosurgeons. At the same time, neurosurgeons across the United States and Canada have found their stereotactic radiosurgery training during residency inadequate. Although neurosurgeons, residency directors, and department chairs agree that stereotactic radiosurgery education and exposure during neurosurgery training could be improved, a limited number of resources exist for this kind of education. This review describes the history of stereotactic radiosurgery, assesses the state of its use and education today, and provides recommendations for the improvement of neurosurgical education in stereotactic radiosurgery for the future.