The Influence of Body Mass Index on Outcomes in Patients Undergoing Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion: Institutional Experience and Meta-analysis.

BACKGROUND: An obesity paradox, whereby patients with higher body mass index (BMI) experience improved outcomes, has been described for ischemic stroke. It is unclear whether this applies to patients undergoing mechanical thrombectomy (MT) for large vessel occlusion (LVO). METHODS: Mechanical thrombectomies for anterior circulation LVO between 2015 and 2021 at a single institution were reviewed. Multivariable logistic regressions were used to determine the association between BMI and favorable functional outcome (90-day modified Rankin Scale 0-2), intracranial hemorrhage, and malignant middle cerebral infarction. A systematic review was performed to identify studies reporting the effect of BMI on outcomes among patients receiving MT for LVO. The data from the systematic review were combined with the institutional data by using a random effects model. RESULTS: The institutional cohort comprised 390 patients with a median BMI of 27 kg/m2. Most patients were obese [36.7% (BMI ≥ 30 kg/m2)], followed by overweight [30.5% (BMI ≥ 25 and < 30 kg/m2)], normal [27.9% (BMI ≥ 18.5 and < 25 kg/m2)], and underweight [4.9% (BMI < 18.5 kg/m2)]. As a continuous variable, BMI was not associated with any of the outcomes. When analyzing BMI ordinally, obesity was associated with lower odds of favorable 90-day modified Rankin Scale (odds ratio 0.42, 95% confidence interval 0.20-0.86). The systematic review identified three eligible studies comprising 1,348 patients for a total of 1,738 patients. In the random effects model, there was no association between obesity and favorable outcome (odds ratio 0.89, 95% confidence interval 0.63-1.24). CONCLUSIONS: Obesity is not associated with favorable outcomes in patients undergoing MT for LVO.

Massive inferior wall aneurysm presenting with ventricular tachycardia and refractory cardiomyopathy requiring multiple interventions: A case report.

BACKGROUND: Inferior wall left ventricular aneurysms are rare, they develop after transmural myocardial infarction (MI) and may be associated with poorer prognosis. We present a unique case of a large aneurysm of the inferior wall complicated by ventricular tachycardia (VT) and requiring surgical resection and mitral valve replacement. CASE SUMMARY: A 59-year-old male was admitted for VT one month after he had a delayed presentation for an inferior ST-segment elevation MI and was discovered to have a large true inferior wall aneurysm on echocardiography and confirmed on coronary computed tomography (CT) angiography. Due to the sustained VT, concern for aneurysm expansion, and persistent heart failure symptoms, the patient was referred for surgical resection of the aneurysm with patch repair, mitral valve replacement, and automated implantable cardioverter defibrillator insertion with significant improvement in functional and clinical status. CONCLUSION: Inferior wall aneurysms are rare and require close monitoring to identify electrical or contractile sequelae. Coronary CT angiography can outline anatomic details and guide surgical intervention to ameliorate life-threatening complications and improve performance status.

Pseudogout mimicking cervical spine osteomyelitis and ventral epidural abscess: A case report and literature review.

Background: Calcium pyrophosphate deposition disease (CPPD), also known as "pseudogout," is a crystal deposition arthropathy involving the synovial and periarticular tissues. Pseudogout rarely presents in the axial spine. Here, we present the case of an 80-year-old female patient admitted after a mechanical fall, initially misdiagnosed on computed tomography (CT)/magnetic resonance studies with cervical osteodiscitis/ventral epidural abscess that proved to be pseudogout. Case Description: An 80-year-old female was admitted after a mechanical fall. The initial cervical CT scan showed multilevel degenerative changes with an acute C6 anterior wedge compression fracture, focal kyphosis, C5-6 disc space collapse, and endplate destruction. The magnetic resonance imaging showed marked contrast enhancement of the C5-6 vertebral bodies and disc space. An interventional radiology-guided biopsy of the C5-6 vertebral bodies and disc space was consistent with calcium pyrophosphate deposits, was diagnostic for pseudogout, and was negative for infection. She was managed conservatively with a rigid collar and seven days of oral prednisone. Conclusion: CPPD involvement in the axial spine is rare. Prompt pathologic diagnosis should be pursued to rule out an infectious process.

Metastatic choroid plexus papilloma presenting as a sellar mass: A case report and literature review.

Background: Choroid plexus papillomas (CPPs) are rare neoplasms arising from choroid plexus epithelium representing <1% of all intracranial tumors. Symptoms vary based on location and regional mass effect; however, hydrocephalus is common due to cerebrospinal fluid flow obstruction and/or overproduction. Distant site metastasis or de novo formation in extraventricular sites is rare. Case Description: A 57-year-old female with a history of a 4th ventricular CPP status post resection in 2004 and 2018 with subsequent gamma knife therapy in 2019 presented with increased thirst and urination. Since her initial surgery, she has experienced significant gait imbalance, diplopia, dysphagia, and right-sided hemiparesis and hemisensory loss. Magnetic resonance imaging revealed a new 1.5 × 1.8 cm suprasellar lesion. She underwent a left supraorbital craniotomy for tumor resection, with pathology revealing metastatic World Health Organization grade II CPP. Conclusion: Extraventricular manifestation of CPP is rare. De novo or metastatic involvement of the sella has seldom been reported. Treatment should target gross total surgical resection. Adjuvant chemotherapy and radiation may be useful in higher-grade lesions.

Opioid Overdose-Induced Diffusion Restriction in the Bilateral Basal Ganglia Revealed on Brain Imaging.

Opioid misuse and addiction have led to an opioid epidemic in the United States, with widespread effects on the healthcare system. Opioid-induced cardiovascular morbidity and mortality effects have been extensively described in past literature; however, neurological effects have been described less frequently.  Here, we describe a case of a female patient who presented to our center after being found unresponsive with magnetic resonance imaging (MRI), revealing bilateral basal ganglia diffuse restriction hyperintensities secondary to a diagnosis of opioid overdose.  Opioid overdose-induced bilateral basal ganglia diffusion restriction has only been described infrequently in the literature. Recognizing the associated imaging findings as a potential consequence of opioid overdose is important to avoid unnecessary workups for ischemic stroke.

C5 palsy following esophageal diverticulum resection.

Background: C5 palsy (C5P) is a recognized potential postoperative complication of cervical spine surgery but has rarely been reported following an open esophageal diverticulectomy. Methods: A 61-year-old underwent an open esophageal diverticulectomy for symptomatic Zencker's diverticulum. Results: Postoperatively, she presented with right upper extremity weakness and sensory deficits consistent with a C5P that was later confirmed by electromyography. Conclusion: The potential for C5P after esophageal diverticulectomy for symptomatic Zencker's diverticulum is rare. Postoperative recognition and appropriate management are critical to recovery.

Sarcopenia Predicts the Development of Early Adjacent Segment Disease After Transforaminal Lumbar Interbody Fusion.

BACKGROUND AND OBJECTIVES: Predicting the development of adjacent segment disease (ASD) after lumbar spine fusion would help guide preoperative and postoperative therapies to prevent reoperation. We sought to evaluate whether sarcopenia predicts the development of early ASD after transforaminal lumbar interbody fusion (TLIF). METHODS: Retrospective data were collected from 109 patients who underwent TLIF from 2013 to 2023. Patients older than 18 years who underwent elective posterior midline approach TLIF were included. Patients with prior lumbar instrumented fusions, cases of trauma, central nervous system infection, cancer, or long-construct thoracolumbar deformity corrections and those who lacked sufficient follow-up were excluded. The primary outcome was radiographic ASD development within 3 years of surgery. Psoas volumetric measurements were recorded from the most recent preoperative MRI. Odds ratios were calculated with logistic regression analyses. RESULTS: In 109 patients undergoing elective TLIF, 22 (20.2%) developed ASD within 3 years. Gender, body mass index, and extent of surgery were not associated with ASD development. Multivariate analysis showed left/right psoas cross-sectional area, and psoas:vertebral body ratio (P:VBR) predicted early ASD (P < .0001). Sarcopenia was further categorized as having bilateral P:VBR ≥1 SD below gender mean (T-score -1). Of 18 sarcopenic patients, 15 developed early ASD (83.33%) vs 7 of 91 nonsarcopenic patients (7.69%; P < .0001). Postoperative mismatch between pelvic incidence and lumbar lordosis was predictive of ASD on univariate (P = .0480) but not multivariate analysis. Pelvic tilt and lumbar lordosis postoperatively were not associated with early ASD. CONCLUSION: Sarcopenia, measured by decreased psoas area and P:VBR, predicts ASD formation within 3 years of surgery. Morphometric analysis of psoas size is a simple tool to identify patients at risk of developing ASD. This information can potentially guide preoperative and postoperative therapies, affect surgical decision making, and effectively counsel patients on risks of reoperation.

Machine learning for clinical outcome prediction in cerebrovascular and endovascular neurosurgery: systematic review and meta-analysis.

BACKGROUND: Machine learning (ML) may be superior to traditional methods for clinical outcome prediction. We sought to systematically review the literature on ML for clinical outcome prediction in cerebrovascular and endovascular neurosurgery. METHODS: A comprehensive literature search was performed, and original studies of patients undergoing cerebrovascular surgeries or endovascular procedures that developed a supervised ML model to predict a postoperative outcome or complication were included. RESULTS: A total of 60 studies predicting 71 outcomes were included. Most cohorts were derived from single institutions (66.7%). The studies included stroke (32), subarachnoid hemorrhage ((SAH) 16), unruptured aneurysm (7), arteriovenous malformation (4), and cavernous malformation (1). Random forest was the best performing model in 12 studies (20%) followed by XGBoost (13.3%). Among 42 studies in which the ML model was compared with a standard statistical model, ML was superior in 33 (78.6%). Of 10 studies in which the ML model was compared with a non-ML clinical prediction model, ML was superior in nine (90%). External validation was performed in 10 studies (16.7%). In studies predicting functional outcome after mechanical thrombectomy the pooled area under the receiver operator characteristics curve (AUROC) of the test set performances was 0.84 (95% CI 0.79 to 0.88). For studies predicting outcomes after SAH, the pooled AUROCs for functional outcomes and delayed cerebral ischemia were 0.89 (95% CI 0.76 to 0.95) and 0.90 (95% CI 0.66 to 0.98), respectively. CONCLUSION: ML performs favorably for clinical outcome prediction in cerebrovascular and endovascular neurosurgery. However, multicenter studies with external validation are needed to ensure the generalizability of these findings.

Comparison of Retroauricular and Reverse Question Mark Incisions for Decompressive Hemicraniectomy.

BACKGROUND: The retroauricular (RA) incision has several theoretical benefits compared with the reverse question mark (RQM) incision for decompressive hemicraniectomy (DHC), but limited data comparing the 2 exist. METHODS: Consecutive patients who underwent DHC between 2016 and 2022 and survived ≥30 days at a single institution were included. The primary outcome was wound complication within 30 days (30dWC) requiring reoperation. Secondary outcomes included 90-day wound complication (90dWC), craniectomy size in anterior-posterior (AP) and superior-inferior dimensions, distance from the inferior craniectomy margin to the middle cranial fossa (MCF), estimated blood loss (EBL), and operative duration. Multivariate analyses were performed for each outcome. RESULTS: A total of 110 patients (RA group: 27, RQM group: 83) were included. The incidence of 30dWC was 1.2% and 0 in the RQM and RA groups, respectively. The incidence of 90dWC was 2.4% and 3.7% in the RQM and RA groups, respectively. There was no difference in mean AP size (RQM: 15 cm, RA: 14.4 cm; P = 0.18), superior-inferior size (RQM: 11.8 cm, RA: 11.9 cm; P = 0.92), and distance from MCF (RQM: 15.4 mm, RA: 18 mm; P = 0.18). Mean EBL (RQM: 418 mL, RA: 314 mL; P = 0.36) and operative duration (RQM: 103 min, RA: 89 min; P = 0.14) were similar. There was no difference in cranioplasty wound complications, EBL, or operative duration. CONCLUSIONS: Wound complications are comparable between the RQM and RA incisions. The RA incision does not compromise craniectomy size or temporal bone removal.

Illustrative resection of mixed intra- and extramedullary thoracic spinal cord capillary hemangioma.

Background: Capillary hemangiomas are typically superficial benign tumors of the cutaneous and mucosal tissues of the face and neck in pediatric patients. In adults, they typically occur in middle-aged males who present with pain, myelopathy, radiculopathy, paresthesias, and bowel/bladder dysfunction. The optimal treatment for intramedullary spinal cord capillary hemangiomas is gross total/en bloc resection. Methods: Here, we present a 63-year-old male with increasing right greater than left lower extremity numbness/ weakness, attributed to a T8-9 mixed intra- and extramedullary capillary hemangioma. Results: One year following complete lesion resection, the patient used an assistive device to ambulate and continued to improve neurologically. Conclusion: We presented a 63-year-old male whose paraparesis was attributed to a T8-9 mixed intra- and extramedullary capillary hemangioma who did well following total en bloc lesion resection. In addition to this case study/technical note, we provide a 2-D intraoperative video detailing the resection technique.

Rare Sighting of Posterior Communicating Artery Infundibulum With Posterior Cerebral Artery Origin.

Infundibula are funnel-shaped lesions that develop at the intersections of major intracranial arteries. These lesions are prone to being misdiagnosed as intracranial aneurysms. The most common arterial infundibula have been noted in the posterior communicating artery (PCoA) branch of the internal carotid artery (ICA). Digitally subtracted angiography performed included catheter angiography of the vertebral artery and ipsilateral carotid to evaluate the suspected lesion. Right vertebral angiography demonstrated an infundibulum seen at the right PCoA/posterior cerebral artery (PCA) junction, with noted posterior-to-anterior circulation dominance of the Circle of Willis collateral flow. We report a case of posterior communicating artery infundibulum arising from the posterior cerebral artery origin in a 38-year-old man.

Association of ADHD symptoms with type 2 diabetes and cardiovascular comorbidities in adults receiving outpatient diabetes care.

Background: The relationship between attention-deficit/hyperactivity disorder (ADHD) symptoms and type 2 diabetes mellitus (T2D) and its cardiovascular outcomes have not been sufficiently studied. Methods: 2,986 adults with T2D from the Joslin Diabetes Center at Upstate Medical University were assessed for ADHD-like symptoms, executive dysfunction, and emotional control using the Adult Self-Report Scale V1.1 (ASRS) expanded version. Surveys were sent electronically, and clinical data were obtained from the electronic medical record. Pearson chi-square test was used for categorical variables association. When ASRS scores were the dependent variable, negative binomial regression correcting for demographic variables that were associated with the ASRS scores was used. Results: 155 (49.2%) of respondents met DSM-5 criteria for ADHD using the ASRS scores; Only ten (3.6%) of respondents had an ICD10 diagnosis of ADHD in their medical record; Forty-three (13.7%) had either a diagnosis of ADHD in the medical history or were taking medications used by people with ADHD. Higher levels of ADHD-like symptoms were found in patients with T2D compared with population norms. There was a modest association of the ASRS executive dysfunction subscale with overall cardiovascular comorbidities (p = 0.03). However, the p-value did not survive the multiple testing correction. Both ADHD-like symptoms and symptoms associated with emotional control, however, were not associated with specific cardiovascular diseases, hypertension, or with HbA1c, LDL-cholesterol, triglycerides, ALT, creatinine, or eGFR. Conclusion: Our results suggest that adults with T2D attending a tertiary care diabetes clinic are at risk for having ADHD-like symptoms, highlighting the importance of screening for ADHD symptoms in this specialty setting and referring undiagnosed adult patients for further assessment and treatment of ADHD. Larger studies are needed to clarify the relationship between ADHD-like symptoms, executive dysfunction, and emotional control with diabetic control and comorbidities.