Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension. CASE PRESENTATION: We report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient's symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up. CONCLUSIONS: The absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.

Successful coil embolization of a ruptured pseudoaneurysm of the superior gluteal artery after a percutaneous awake robot-assisted sacroiliac joint fusion: illustrative case.

BACKGROUND: Robot-assisted sacroiliac joint (SIJ) fusion has gained popularity, but it carries the risk of complications such as injury to the superior gluteal artery (SGA). The authors present the case of an awake percutaneous robot-assisted SIJ fusion leading to an SGA pseudoaneurysm. OBSERVATIONS: An 80-year-old male, who had undergone an awake percutaneous robot-assisted SIJ fusion, experienced postoperative left hip pain and bruising. Subsequent arteriography demonstrated an SGA branch pseudoaneurysm requiring coil embolization. LESSONS: An SGA injury, although uncommon (1.2% incidence), can arise from percutaneous screw placement, aberrant anatomy, or hardware contact. Thorough preoperative imaging, precise robot-assisted screw insertion, and soft tissue protection are crucial to mitigate risks. Immediate angiography aids in prompt diagnosis and effective intervention. Comprehensive knowledge of anatomical variants is essential for managing complications and optimizing preventative measures in robot-assisted SIJ fusion.

Percutaneous lumbar interbody fusion results in less perioperative opioid usage compared to minimally invasive transforaminal lumbar interbody fusion: a single institution, multi-surgeon retrospective study.

Background: Ultra-minimally invasive percutaneous lumbar interbody fusion (percLIF) has been demonstrated to further minimize tissue trauma and has been associated with improved clinical outcomes including decreased blood loss, post-operative pain and length of stay when compared to minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery. A single-institution retrospective study was conducted to investigate whether 1-level percLIF is associated with decreased narcotic consumption compared to 1-level MIS-TLIF in the first 24-hour following surgery. Methods: A retrospective study of patients undergoing either single-level percLIF or MIS-TLIF from January 2018 to December 2021. Opioid consumption in the 24-hour following surgery was converted into total morphine milligram equivalents (MME). The primary outcome used univariate and multivariate regression analysis to compare MME consumption between the MIS-TLIF and percLIF groups. Secondary outcome variables included, estimated blood loss, total intraoperative MME, MME at discharge, MME at 30 days post-op, exiting nerve root injury, post-anesthesia care unit (PACU) visual analogue scale (VAS) score at handoff, time to first ambulation, distance ambulated post-operative day one and hospital length of stay. Results: A total of 51 patients (21 percLIF vs. 30 MIS-TLIF) were included in the study. Univariate regression analysis revealed that on average patients who underwent percLIF had a 24-hour postoperative MME -50.8 mg (95% CI: -91.6, -10) lower than those who had MIS-TLIF (P=0.02). On multivariable analysis, after adjusting for sex and age, 24-hour postoperative MME closely failed to meet statistical significance (P=0.06) with an average of -40.8 mg (95% CI: -83.2, 1.6) MME in percLIF patients compared to MIS-TLIF. There was no statistically significant difference in MME between MIS-TLIF and percLIF at the time of discharge and at 30 days post-op. Conclusions: In the setting of the current opioid epidemic in the United States and increased numbers of patients undergoing lumbar interbody fusion, spine surgeons must continue to do their part helping reduce the need for opioid prescriptions for postoperative pain management. New "ultra-MIS" techniques such as percLIF allow surgeons to further decrease tissue trauma, which should lead to reduced need for post-operative narcotic requirements.

Woven Endobridge device for treatment of dissection-related PICA aneurysm.

Ruptured vertebrobasilar dissecting aneurysms require urgent, often challenging treatment as they have with a high re-hemorrhage rate within the first 24 hours. The patient is a 57-year-old woman who presented with severe-sudden onset headache. Further work up showed a ruptured dissecting aneurysm of the caudal loop of the posterior inferior cerebellar artery (PICA) with associated narrowing distally, in the ascending limb. The aneurysm was immediately occluded with a Woven Endobridge (WEB) device (MicroVention, Tustin, CA, USA) while flow diversion treatment of the diseased ascending limb was postponed. Follow-up angiography three months later showed complete occlusion of the aneurysm, as well as healing of the diseased distal vessel, obviating the need for further intervention. WEB embolization of a ruptured dissecting posterior circulation aneurysm provided an excellent outcome for this patient.

Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases.

BACKGROUND: Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time. OBJECTIVE: To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study. METHODS: We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018. RESULTS: The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3). CONCLUSION: Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

Inverse National Trends in Decompressive Craniectomy versus Endovascular Thrombectomy for Stroke.

OBJECTIVE: Endovascular thrombectomy (ET) for acute large vessel occlusion reduces infarct size, and it should hypothetically decrease the incidence of major ischemic strokes requiring decompressive craniectomy (DC). The aim of this retrospective cohort study is to determine trends in the utilization of ET versus DC for stroke in the United States over a 10-year span. METHODS: We extracted data from the Nationwide Inpatient Sample using International Classification of Diseases-9/10 codes from 2006-2016. Patients with a primary diagnosis of stroke were included. Baseline demographics, outcomes, and hospital charges were analyzed. RESULTS: The study cohort comprised 14,578,654 patients diagnosed with stroke. During the study period, DC and ET were performed in 124,718 and 62,637 patients, respectively. The number of stroke patients who underwent either ET or DC increased by 266% from 2006 to 2016. During that time period, the ET utilization rate increased (0.19% in 2006 to 14.07% in 2016, P < 0.0004), whereas the DC utilization rate decreased (7.07% in 2006 to 6.43% in 2016, P < 0.0001). In 2015, the utilization rate of ET (9.73%) exceeded that of DC (9.67%). ET-treated patients had shorter hospitalization durations (mean 8.8 vs. 16.8 days, P < 0.0001), lower mortality (16.2% vs. 19.3%), higher likelihood of discharge home (27.1% vs. 24.1%, P < 0.0001), and reduced hospital charges (mean $189,724 vs. $261,314, P < 0.0001). CONCLUSIONS: We identified an inverse relationship between national trends in rising ET and diminishing DC utilization for stroke treatment over a recent decade. Although direct causation cannot be inferred, our findings suggest that ET curtails the necessity for DC.

Impact of Surgical Timing and Approaches to Health Care Utilization in Patients Undergoing Surgery for Acute Traumatic Cervical Spinal Cord Injury.

Objective Acute traumatic cervical spinal cord injury (AcSCI) causes significant morbidity and has an impact on health care utilization. The aim of our study was to analyze health care utilization in patients undergoing surgical decompression and fusion for AcSCI based on timing and type of surgical approaches.  Patient and methods Data were extracted using ICD9/10 and CPT codes from MarketScan (IBM Corp. Armonk, New York [v. 2000-2015]). We defined the comparative groups based on the timing of surgery (early <24 hours and late >24 hours) and surgical approaches: anterior, posterior and circumferential. Outcomes of interest were: length of hospital stay, discharge disposition and health care utilization in the index hospitalization, within 30 days after discharge and 12 months following injury. Results Of 1604 patients, 80.9% had early procedures and 55.7% of these had anterior-only procedures. Overall, the median age was 46 years in the early surgery group and 47 years in the late surgery group. Patients in the early surgical group incurred higher outpatient services and there was no difference in cumulative median payments (index + 12 months) across the cohorts (early: $127,379, late: $121,049). The incidence of repeat surgery at the index level did not differ based on the timing of surgery (early 5% vs. late 7%). Complications were higher in the circumferential surgery cohort irrespective of the timing of surgery. Overall, combined median payment (index hospitalization + 12 months) was significantly higher for early circumferential cohorts compared to the anterior or posterior-only cohort ($195,990 and $109,977 vs. $121,236 respectively). Conclusion Late (>24 hours) surgeries were associated with a higher likelihood to be discharged home, lower utilization of outpatient services, higher hospital readmissions and no differences in payments (index and cumulative) compared to early surgeries. Circumferential approaches were associated with higher complication rates, lesser likelihood to be discharged home, higher utilization of outpatient services compared to anterior-only approaches.

Traumatic Ventral Cervical Spinal Cord Herniation: A Case Report.

Spinal cord herniation (SCH) is an uncommon traumatic event that should be considered in patients with vertebral fractures who develop an unusual constellation of autonomic and motor deficits. Herein, we describe a case of rapidly deteriorating neurological function following cervical spine fracture including sequelae such as bilateral lower-extremity weakness, loss of upper extremity motor function, and priapism. Decompression of the spinal cord allowed for the identification of the unusual herniation of the spinal cord and prevention of any further worsening of the neurological injury. Hyperflexion of the cervical spine upon traumatic impact provided the impetus for vertebral retropulsion and subsequent incarceration of the spinal cord. This phenomenon should be considered in the setting of acute traumatic injury to the cervical spinal cord. Surgical intervention is likely to allow the preservation of the remaining neurological function.

Republished: MRI SPACE sequence confirmation of occluded MCA M2 dissection stump masquerading as a ruptured MCA aneurysm.

Intracranial vascular pathologies often have overlapping clinical presentations. Dissected vessel occlusions and bifurcation aneurysms can appear similar on pretherapeutic imaging. The medical management of these two entities is drastically different. The patient is a 51-year-old man who presented with severe, sudden-onset headache. Initial presentation was consistent with a ruptured middle cerebral artery (MCA) aneurysm and surgical clipping was recommended. However, further review of radiographic findings could not definitively differentiate an aneurysmal origin of the symptoms as opposed to intracranial dissection followed by occlusion of the M2 branch of the MCA. MRI sampling perfection with application optimised contrasts using different flip angle evolution (SPACE) was performed and showed thin flow signalling distal to the dissected vessel stump confirming the diagnosis. Accurate diagnosis is a crucial step in directing treatment for intracranial vascular lesions. MRI SPACE is a simple tool in the diagnostic armamentarium to adequately direct treatment and avoid the potential for unnecessary interventions.

Minimally Invasive Surgery for Spontaneous Cerebellar Hemorrhage: A Multicenter Study.

BACKGROUND: Spontaneous intracranial hemorrhage (ICH) of the cerebellum can be life threatening because of mass effect on the brainstem and fourth ventricle. Suboccipital craniectomy is currently the treatment of choice for cerebellar ICH evacuation. Minimally invasive surgery (MIS) is currently being investigated for the treatment of supratentorial ICH. However, its utility for cerebellar ICH is unknown. The aim of this multicenter, retrospective cohort study is to evaluate the outcomes of MIS for cerebellar ICH. METHODS: We retrospectively reviewed the records of all patients with cerebellar ICH who underwent MIS using either the Apollo or Artemis Neuro Evacuation Device (Penumbra Inc., Alameda, California, USA) at 3 institutions from May 2015 to July 2018. Data from each contributing center were deidentified and pooled for analysis. RESULTS: The study cohort comprised 6 patients with a median age of 62.5 years. The median pre- and postoperative Glasgow Coma Scale scores were 10.5 and 15, respectively. The median degree of hematoma evacuation was 97.5% (range, 79%-100%). There were no procedural complications, but 1 patient required subsequent craniectomy (retreatment rate 17%). The median discharge modified Rankin scale score was 4, including 3 patients who improved to functional independence at follow-up durations of 3 months. Two patients died from medical complications (mortality rate 33%). CONCLUSIONS: MIS could represent a reasonable alternative to conventional surgery for the treatment of appropriately selected patients with cerebellar ICH. However, further studies are needed to clarify the perioperative and long-term risk to benefit profiles of this technique.

MRI SPACE sequence confirmation of occluded MCA M2 dissection stump masquerading as a ruptured MCA aneurysm.

Intracranial vascular pathologies often have overlapping clinical presentations. Dissected vessel occlusions and bifurcation aneurysms can appear similar on pretherapeutic imaging. The medical management of these two entities is drastically different. The patient is a 51-year-old man who presented with severe, sudden-onset headache. Initial presentation was consistent with a ruptured middle cerebral artery (MCA) aneurysm and surgical clipping was recommended. However, further review of radiographic findings could not definitively differentiate an aneurysmal origin of the symptoms as opposed to intracranial dissection followed by occlusion of the M2 branch of the MCA. MRI sampling perfection with application optimised contrasts using different flip angle evolution (SPACE) was performed and showed thin flow signalling distal to the dissected vessel stump confirming the diagnosis. Accurate diagnosis is a crucial step in directing treatment for intracranial vascular lesions. MRI SPACE is a simple tool in the diagnostic armamentarium to adequately direct treatment and avoid the potential for unnecessary interventions.

Novel Treatments in Neuroprotection for Aneurysmal Subarachnoid Hemorrhage.

OPINION STATEMENT: New neuroprotective treatments aimed at preventing or minimizing "delayed brain injury" are attractive areas of investigation and hold the potential to have substantial beneficial effects on aneurysmal subarachnoid hemorrhage (aSAH) survivors. The underlying mechanisms for this "delayed brain injury" are multi-factorial and not fully understood. The most ideal treatment strategies would have the potential for a pleotropic effect positively modulating multiple implicated pathophysiological mechanisms at once. My personal management (RFJ) of patients with aneurysmal subarachnoid hemorrhage closely follows those treatment recommendations contained in modern published guidelines. However, over the last 5 years, I have also utilized a novel treatment strategy, originally developed at the University of Maryland, which consists of a 14-day continuous low-dose intravenous heparin infusion (LDIVH) beginning 12 h after securing the ruptured aneurysm. In addition to its well-known anti-coagulant properties, unfractionated heparin has potent anti-inflammatory effects and through multiple mechanisms may favorably modulate the neurotoxic and neuroinflammatory processes prominent in aneurysmal subarachnoid hemorrhage. In my personal series of patients treated with LDIVH, I have found significant preservation of neurocognitive function as measured by the Montreal Cognitive Assessment (MoCA) compared to a control cohort of my patients treated without LDIVH (RFJ unpublished data presented at the 2015 AHA/ASA International Stroke Conference symposium on neuroinflammation in aSAH and in abstract format at the 2015 AANS/CNS Joint Cerebrovascular Section Annual Meeting). It is important for academic physicians involved in the management of these complex patients to continue to explore new treatment options that may be protective against the potentially devastating "delayed brain injury" following cerebral aneurysm rupture. Several of the treatment options included in this review show promise and could be carefully adopted as the level of evidence for each improves. Other proposed neuroprotective treatments like statins and magnesium sulfate were previously thought to be very promising and to varying degrees were adopted at numerous institutions based on somewhat limited human evidence. Recent clinical trials and meta-analysis have shown no benefit for these treatments, and I currently no longer utilize either treatment as prophylaxis in my practice.