Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms.

BACKGROUND: Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost. METHODS: The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters. RESULTS: One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost. CONCLUSIONS: These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.

Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion.

OBJECTIVE With the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system. METHODS The authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient's cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed. RESULTS A total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001). CONCLUSIONS Facility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

Novel Approach to Securing Deep Brain Stimulation Leads: Technique and Analysis of Lead Migration, Breakage, and Surgical Infection.

BACKGROUND: Fixation of the electrode during deep brain stimulation (DBS) surgery is an important aspect of the procedure. We have developed an alternative method for securing leads that utilizes a titanium hemoclip and cement. This technique is described, and the rates of complications are compared to conventional methods of securing leads. METHODS: A total of 291 DBS operations performed by a single surgeon were retrospectively analyzed. We reviewed medical records to look for complications. We compared rates of complications based on the technique used. Re sults: 9 patients (3.1%) developed surgical site infections (SSIs), 4 (1.3%) with SSI of the internal pulse generator pocket. Of the 5 SSIs around the leads, none occurred with StimLoc and 5 (1.1%) with the novel technique. Eight patients (2.7%) required surgical readjustment of the DBS leads due to suboptimal clinical benefit; all 8 (1.8%) occurred with the novel technique. Four patients (1.4%) had lead fractures, 2 (2.2%) with StimLoc and 2 (0.5%) with the novel technique. CONCLUSIONS: We described a method for securing DBS leads and showed an acceptable incidence of hardware complications when compared to the conventional method. We feel this technique has improved cosmetic results and should be considered as a method for securing DBS leads.

Primary osseous tumors of the pediatric spinal column: review of pathology and surgical decision making.

Spinal column tumors are rare in children and young adults, accounting for only 1% of all spine and spinal cord tumors combined. They often present diagnostic and therapeutic challenges. In this article, the authors review the current management of primary osseous tumors of the pediatric spinal column and highlight diagnosis, management, and surgical decision making.

Differential accessibility of a rotavirus VP6 epitope in trimers comprising type I, II, or III channels as revealed by binding of a human rotavirus VP6-specific antibody.

Previous human antibody studies have shown that the human VH1-46 antibody variable gene segment encodes much of the naturally occurring human B cell response to rotavirus and is directed to virus protein 6 (VP6). It is currently unknown why some of the VH1-46-encoded human VP6 monoclonal antibodies inhibit viral transcription while others do not. In part, there are affinity differences between antibodies that likely affect inhibitory activity, but we also hypothesize that there are differing modes of binding to VP6 that affect the ability to block the transcriptional pore on double-layered particles. Here, we used a hybrid method approach for antibody epitope mapping, including single-particle cryo-electron microscopy (cryo-EM) and enhanced amide hydrogen-deuterium exchange mass spectrometry (DXMS) to determine the location and mode of binding of a VH1-46-encoded antibody, RV6-25. The structure of the RV6-25 antibody-double-layered particle (DLP) complex indicated a very complex binding pattern that revealed subtle differences in accessibility of the VP6 epitope depending on its position in the type I, II, or III channels. These subtle variations in the presentation or accessibility of the RV VP6 capsid layer led to position-specific differences in occupancy for binding of the RV6-25 antibody. The studies also showed that the location of binding of the noninhibitory antibody RV6-25 on the apical surface of RV VP6 head domain does not obstruct the transcription pore upon antibody binding, in contrast to binding of an inhibitory antibody, RV6-26, deeper in the transcriptional pore.

Dual Dural Patch Graft With AlloDerm and DuraGen Underlay for Duraplasty in Chiari Malformation Results in Significantly Decreased Cerebrospinal Fluid Leak Complications.

BACKGROUND: Grafts available for posterior fossa dural reconstruction after Chiari decompression surgery include synthetic, xenograft, allograft, and autograft materials. The reported rates of postoperative pseudomeningocele and cerebrospinal fluid leak vary, but so far, no dural patch material or technique has sufficiently eliminated these problems. OBJECTIVE: To compare the incidence of graft-related complications after posterior fossa surgery using AlloDerm alone vs AlloDerm with a DuraGen underlay. METHODS: We performed a retrospective single-center study of a cohort of 106 patients who underwent Chiari decompression surgery by a single surgeon from 2014 through 2021. Age, sex, body mass index, tonsillar descent, syrinx formation, type of dural graft, and follow-up data were analyzed using univariate and χ2 statistical tests. RESULTS: The AlloDerm-only group had a percutaneous cerebrospinal fluid (CSF) leak rate of 8.6% vs a 0% rate in the dual graft group (P = .037). At initial follow-up, there was a 15.5% combined rate of pseudomeningocele formation plus CSF leak in the AlloDerm-only group vs 18.8% in the AlloDerm + DuraGen group (P = .659). However, the pseudomeningoceles were larger in the AlloDerm-only cohort (45.5 vs 22.4 mm anteroposterior plane, P = .004), and 5 patients in this group required operative repair (56%). All pseudomeningoceles resolved without reoperation in the AlloDerm + DuraGen group (P = .003). CONCLUSION: The use of a DuraGen underlay with a sutured AlloDerm dural patch resulted in significantly fewer CSF-related complications and eliminated the need for reoperation compared with AlloDerm alone. This single-center study provides evidence that buttressing posterior fossa dural grafts with a DuraGen underlay may decrease the risk of postoperative complications.

Masseter-to-facial nerve transfer for facial nerve reanimation.

Smooth symmetric facial muscle function is important for social interactions. When lesions of the facial nerve occur, achieving complete restoration of balanced and spontaneous facial function can be challenging. In this video, the authors demonstrate the surgical details and long-term follow-up of a masseter-to-facial nerve transfer in a 3-year-old girl who had insidious onset of a left facial palsy due to a facial nerve schwannoma. After resection, she underwent distal nerve repair with a masseter-to-zygomatic branch transfer. She demonstrated decreased lagophthalmos and good activation and excursion on the left side with near symmetry to the right side, but lacked left frontalis function. The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID22107.

Minimally Invasive Surgery for Spinal Metastasis: A Review.

OBJECTIVE: Minimally invasive surgery (MIS) techniques have advanced the treatment of metastatic diseases to the spine. The objective of this review is to describe clinical outcomes, benefits, and complications of these techniques. METHODS: All relevant clinical studies describing the role of MIS, computer-assisted navigation (CAN), robot-assisted (RA) procedures, and laser interstitial thermal therapy (LITT) in the treatment of metastatic spine diseases were identified from PubMed, MEDLINE, and relevant article bibliographies. RESULTS: For MIS articles, we filtered 1480 results and identified 26 studies. For CAN, we searched 464 articles to identify 18 articles for review. For RA, we searched 321 results to identify 7 studies for review. For LITT, we identified 21 articles for review. CONCLUSIONS: MIS for the treatment of spine metastasis has significant potential benefits in reducing surgical site infections, hospital stay, and blood loss without compromising instrument accuracy or overall outcomes. Overall, MIS and its adjuncts have the potential to reduce the risks involved in the treatment of patients with metastatic disease to the spinal column without compromising the benefits of decompression and stabilization of the spine.

Age, body mass index, and osteoporosis are more predictive than imaging for adjacent-segment reoperation after lumbar fusion.

BACKGROUND: Adjacent-segment disease (ASD) is a well-described long-term complication after lumbar fusion. There is a lack of consensus about the risk factors for development of ASD, but identifying them could improve surgical outcomes. Our goal was to analyze the effect of patient characteristics and radiographic parameters on the development of symptomatic ASD requiring revision surgery after posterior lumbar fusion. METHODS: In this retrospective cohort study, we identified patients who underwent lumbar fusion surgery and revision surgery from May 2012 to November 2018 using an institutional lumbar fusion registry. Patients having both pre- and post-operative upright radiographs were included in the study. Revision surgeries for which the index operation was performed at an outside hospital were excluded from analysis. Univariate analysis was conducted on candidate variables, and variables with P< 0.2 were selected for multivariate logistic regression. RESULTS: Of the 106 patients identified, 21 required reoperation (29 months average follow-up). Age >65 years (OR 4.14, 95% CI 1.46-11.76, P= 0.008), body mass index (BMI) >34 (OR 1.13, 95% CI 1.04-1.23, P = 0.004), and osteoporosis (OR 14, 95% CI 1.38-142.42, P = 0.03) were independent predictors of reoperation in the multivariate analysis. Increased facet diastasis at fusion levels (OR 0.60, 95% CI 0.42-0.85, P = 0.004) was associated with reduced reoperation rates. Change in segmental LL at the index operation level, rostral and caudal facet diastasis, vacuum discs, and T2 hyperintensity in the facets were not predictors of reoperation. CONCLUSION: Age >65, BMI >34, and osteoporosis were independent predictors of adjacent-segment reoperation after lumbar spinal fusion.

Reconstitution of Helicobacter pylori VacA toxin from purified components.

Helicobacter pylori VacA is a pore-forming toxin that causes multiple alterations in human cells and contributes to the pathogenesis of peptic ulcer disease and gastric cancer. The toxin is secreted by H. pylori as an 88 kDa monomer (p88) consisting of two domains (p33 and p55). While an X-ray crystal structure for p55 exists and p88 oligomers have been visualized by cryo-electron microscopy, a detailed analysis of p33 has been hindered by an inability to purify this domain in an active form. In this study, we expressed and purified a recombinant form of p33 under denaturing conditions and optimized conditions for the refolding of the soluble protein. We show that refolded p33 can be added to purified p55 in trans to cause vacuolation of HeLa cells and inhibition of IL-2 production by Jurkat cells, effects identical to those produced by the p88 toxin from H. pylori. The p33 protein markedly enhances the cell binding properties of p55. Size exclusion chromatography experiments suggest that p33 and p55 assemble into a complex consistent with the size of a p88 monomer. Electron microscopy of these p33/p55 complexes reveals small rod-shaped structures that can convert to oligomeric flower-shaped structures in the presence of detergent. We propose that the oligomerization observed in these experiments mimics the process by which VacA oligomerizes when in contact with membranes of host cells.

Restabilization of the Occipitocervical Junction After a Complete Unilateral Condylectomy: A Biomechanical Comparison of Unilateral and Bilateral Fixation Techniques.

BACKGROUND: Occipitocervical instability may result from transcondylar resection of the occipital condyle. Initially, patients may be able to maintain a neutral alignment but severe occipitoatlantal subluxation may subsequently occur, with cranial settling, spinal cord kinking, and neurological injury. OBJECTIVE: To evaluate the ability of posterior fixation constructs to prevent progression to severe deformity after radical unilateral condylectomy. METHODS: Eight human cadaveric specimens (Oc-C2) underwent biomechanical testing to compare stiffness under physiological loads (1.5 N m). A complete unilateral condylectomy was performed to destabilize one Oc-C1 joint, and the contralateral joint was left intact. Unilateral Oc-C1 or Oc-C2 constructs on the resected side and bilateral Oc-C1 or Oc-C2 constructs were tested. RESULTS: The bilateral Oc-C2 construct provided the greatest stiffness, but the difference was only statistically significant in certain planes of motion. The unilateral constructs had similar stiffness in lateral bending, but the unilateral Oc-C1 construct was less stiff in axial rotation and flexion-extension than the unilateral Oc-C2 construct. The bilateral Oc-C2 construct was stiffer than the unilateral Oc-C2 construct in axial rotation and lateral bending, but there was no difference between these constructs in flexion-extension. CONCLUSION: Patients who undergo a complete unilateral condylectomy require close surveillance for occipitocervical instability. A bilateral Oc-C2 construct provides suitable biomechanical strength, which is superior to other constructs. A unilateral construct decreases abnormal motion but lacks the stiffness of a bilateral construct. However, given that most patients undergo a partial condylectomy and only a small proportion of patients develop instability, there may be scenarios in which a unilateral construct may be appropriate, such as for temporary internal stabilization.

Spine trauma and spinal cord injury in Utah: a geographic cohort study utilizing the National Inpatient Sample.

OBJECTIVE: The objective of this study was to investigate the effect of hospital type and patient transfer during the treatment of patients with vertebral fracture and/or spinal cord injury (SCI). METHODS: The National Inpatient Sample (NIS) database was queried to identify patients treated in Utah from 2001 to 2011 for vertebral column fracture and/or SCI (ICD-9-CM codes 805, 806, and 952). Variables related to patient transfer into and out of the index hospital were evaluated in relation to patient disposition, hospital length of stay, mortality, and cost. RESULTS: A total of 53,644 patients were seen (mean [± SEM] age 55.3 ± 0.1 years, 46.0% females, 90.2% white), of which 10,620 patients were transferred from another institution rather than directly admitted. Directly admitted (vs transferred) patients showed a greater likelihood of routine disposition (54.4% vs 26.0%) and a lower likelihood of skilled nursing facility disposition (28.2% vs 49.2%) (p < 0.0001). Directly admitted patients also had a significantly shorter length of stay (5.6 ± 6.7 vs 7.8 ± 9.5 days, p < 0.0001) and lower total charges ($26,882 ± $37,348 vs $42,965 ± $52,118, p < 0.0001). A multivariable analysis showed that major operative procedures (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.4-2.0, p < 0.0001) and SCI (HR 2.1, 95% CI 1.6-2.8, p < 0.0001) were associated with reduced survival whereas patient transfer was associated with better survival rates (HR 0.4, 95% CI 0.3-0.5, p < 0.0001). A multivariable analysis of cost showed that disposition (ß = 0.1), length of stay (ß = 0.6), and major operative procedure (ß = 0.3) (p < 0.0001) affected cost the most. CONCLUSIONS: Overall, transferred patients had lower mortality but greater likelihood for poor outcomes, longer length of stay, and higher cost compared with directly admitted patients. These results suggest some significant benefits to transferring patients with acute injury to facilities capable of providing appropriate treatment, but also support the need to further improve coordinated care of transferred patients, including surgical treatment and rehabilitation.

A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits.

OBJECTIVE: Large experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors' intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits. METHODS: The authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living. RESULTS: Overall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up. CONCLUSIONS: Pediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.

Acute Compartment Syndrome as a Complication of the Use of Intraoperative Neuromonitoring Needle Electrodes.

BACKGROUND: The use of intraoperative neurophysiologic monitoring (IOM) has become commonplace in many neurosurgical procedures as a tool to reduce the risk of complications through the early identification of reversible neurologic compromise. Although complications related to IOM itself are exceedingly rare, recognizing their clinical presentation in the postoperative neurosurgical patient is essential for the early identification and implementation of appropriate treatment. CASE DESCRIPTION: The authors present a case report of a patient who developed postoperative acute compartment syndrome in the right arm after placement of neuromonitoring needles for routine IOM during endovascular treatment of a left internal carotid artery aneurysm. Before the procedure, the patient received dual antiplatelet therapy and was noted to have a P2Y12 reaction unit value within therapeutic range. The patient had not received other anticoagulation therapy and had no family or personal history of hematologic or coagulopathic disorders. Immediately after an uncomplicated endovascular intervention, the patient began to develop symptoms of forearm swelling, tightness, and tenderness to palpation; pain with wrist flexion and extension; and paresthesias of the distal digits of the hand. She had eventual loss of a palpable radial pulse. The patient underwent emergent fasciotomies of multiple forearm compartments and had immediate return of a palpable radial pulse. CONCLUSIONS: This case represents the first report of post-procedural compartment syndrome resulting from placement of neuromonitoring needles for routine IOM. Although it is a particularly rare complication of IOM, compartment syndrome represents a surgical emergency that carries significant morbidity if not immediately recognized and treated.

Postoperative Posterior Ischemic Optic Neuropathy After Left Far-Lateral Craniectomy for Resection of Craniocervical Meningioma.

BACKGROUND: Postoperative posterior ischemic optic neuropathy (PION) is a rare cause of postoperative vision loss, most often seen when surgical patients are placed in the prone position for a prolonged period of time. We report a case of bilateral PION after far-lateral craniectomy in the lateral position. CASE DESCRIPTION: A 36-year-old man presented with a history of right extremity numbness, weakness, and muscle atrophy, and a craniocervical meningioma was diagnosed. Surgery in the lateral position lasted 9 hours, 52 minutes; the patient had 2 L of blood loss. On postoperative day 1, the patient had bilateral vision loss, which prompted further work-up. Diffusion-weighted imaging of the orbits demonstrated restricted diffusion within the bilateral optic nerves. The clinical presentation of painless vision loss after surgery with these imaging findings led to a diagnosis of PION. At the time of discharge, he had not recovered any visual function. CONCLUSIONS: This case suggests that PION can occur in the lateral position where there is no direct pressure on the orbits. PION is often not discussed as a potential complication during the preoperative consent process. This case suggests it may be prudent to discuss PION in similar neurosurgical cases. Intraoperative blood transfusion should be considered in prolonged surgeries in the lateral position, where slow blood loss over a long period could be a contributing factor to development of PION.

Vitamin D status and 3-month Glasgow Outcome Scale scores in patients in neurocritical care: prospective analysis of 497 patients.

OBJECTIVE Vitamin D deficiency has been associated with a variety of negative outcomes in critically ill patients, but little focused study on the effects of hypovitaminosis D has been performed in the neurocritical care population. In this study, the authors examined the effect of vitamin D deficiency on 3-month outcomes after discharge from a neurocritical care unit (NCCU). METHODS The authors prospectively analyzed 25-hydroxy vitamin D levels in patients admitted to the NCCU of a quaternary care center over a 6-month period. Glasgow Outcome Scale (GOS) scores were used to evaluate their 3-month outcome, and univariate and multivariate logistic regression was used to evaluate the effects of vitamin D deficiency. RESULTS Four hundred ninety-seven patients met the inclusion criteria. In the binomial logistic regression model, patients without vitamin D deficiency (> 20 ng/dl) were significantly more likely to have a 3-month GOS score of 4 or 5 than those who were vitamin D deficient (OR 1.768 [95% CI 1.095-2.852]). Patients with a higher Simplified Acute Physiology Score (SAPS II) (OR 0.925 [95% CI 0.910-0.940]) and those admitted for stroke (OR 0.409 [95% CI 0.209-0.803]) or those with an "other" diagnosis (OR 0.409 [95% CI 0.217-0.772]) were significantly more likely to have a 3-month GOS score of 3 or less. CONCLUSIONS Vitamin D deficiency is associated with worse 3-month postdischarge GOS scores in patients admitted to an NCCU. Additional study is needed to determine the role of vitamin D supplementation in the NCCU population.

A prospective analysis of hypovitaminosis D and mortality in 400 patients in the neurocritical care setting.

OBJECTIVE Hypovitaminosis D is highly prevalent among the general population. Studies have shown an association between hypovitaminosis D and multiple negative outcomes in critical care patients, but there has been no prospective evaluation of vitamin D in the neurological critical care population. The authors examined the impact of vitamin D deficiency on in-hospital mortality and a variety of secondary outcomes. METHODS The authors prospectively collected 25-hydroxy vitamin D levels of all patients admitted to the neurocritical care unit (NCCU) of a quaternary-care center over a 3-month period. Demographic data, illness acuity, in-hospital mortality, infection, and length of hospitalization were collected. Univariate and multivariable logistic regression were used to examine the effects of vitamin D deficiency. RESULTS Four hundred fifteen patients met the inclusion criteria. In-hospital mortality was slightly worse (9.3% vs 4.5%; p = 0.059) among patients with deficient vitamin D (≤ 20 ng/dl). There was also a higher rate of urinary tract infection in patients with vitamin D deficiency (12.4% vs 4.2%; p = 0.002). For patients admitted to the NCCU on an emergency basis (n = 285), higher Simplified Acute Physiology Score II (OR 13.8, 95% CI 1.7-110.8; p = 0.014), and vitamin D deficiency (OR 3.0, 95% CI 1.0-8.6; p = 0.042) were significantly associated with increased in-hospital mortality after adjusting for other factors. CONCLUSIONS In the subset of patients admitted to the NCCU on an emergency basis, vitamin D deficiency is significantly associated with higher in-hospital mortality. Larger studies are needed to confirm these findings and to investigate the role of vitamin D supplementation in these patients.

Sellar Wegener Granulomatosis Masquerading as Cabergoline-Resistant Prolactinoma.

BACKGROUND: Pituitary manifestation of Wegener granulomatosis (WG) is extremely rare. When there is pituitary involvement, the granulomatous inflammatory lesions involving the pituitary gland may appear several months to years after the primary diagnosis. CASE DESCRIPTION: We present a case of a 32-year-old woman who presented with galactorrhea, amenorrhea, and elevated serum prolactin levels. Imaging demonstrated a sellar lesion with characteristics of a pituitary macroadenoma. Treatment with cabergoline was initiated, but the tumor continued to grow during a 6-month period. Subsequent surgical exploration revealed a chronic inflammatory lesion; the patient subsequently was diagnosed with WG based on laboratory evaluation and further systemic manifestations. She had a favorable clinical and radiologic response with immunosuppressive doses of glucocorticoids and rituximab. CONCLUSIONS: This case appears to be the first reported of a patient with unknown WG in whom the diagnosis was established after she presented with a sellar lesion mimicking a prolactin-secreting pituitary adenoma on initial presentation requiring surgical resection. The only endocrine abnormality discovered was moderate hyperprolactinemia. Sellar lesions with only moderate elevations in serum prolactin, particularly those that are refractory to medical management with a dopamine agonist, should prompt further investigation to confirm the diagnosis. WG should be part of the differential diagnosis of inflammatory lesions in the sella, the identification of which can facilitate early diagnosis and treatment of this systemic disease for optimal outcome.

Primary Intracranial Epidermoid Carcinoma with Diffuse Leptomeningeal Carcinomatosis: Report of Two Cases.

BACKGROUND: Malignant degeneration of epidermoid cyst (EC) with accompanying leptomeningeal carcinomatosis (LC) at presentation is extremely rare. We add two cases to the literature, including the first case of primary brainstem involvement with simultaneous diffuse LC, and discuss clinical and radiological cues to differentiate benign and malignant epidermoid tumors for early diagnosis. CASE DESCRIPTION: The first patient in this report was a 54-year-old woman with recurrent aseptic meningitis and hydrocephalus. Imaging revealed a prepontine and parapontine extra-axial EC with an intra-axial brainstem ring-enhancing cystic lesion, diffuse leptomeningeal enhancement, and intradural extramedullary nodular deposits throughout the spine. Surgical decompression of the cysts confirmed the diagnosis of invasive primary squamous cell carcinoma of the brainstem and benign epidermoid tumor of the cerebellopontine cistern. The second patient was a 37-year-old woman with extensive left-sided cranial neuropathies. Imaging revealed prepontine and parapontine enhancing and nonenhancing deposits along multiple cranial nerves and diffuse leptomeningeal nodular enhancement in the thoracolumbar spine. A biopsy confirmed the diagnosis of infiltrative, poorly differentiated carcinoma adjacent to a benign EC. Both patients underwent systemic screening to rule out metastatic disease. CONCLUSIONS: These cases illustrate that a high index of clinical suspicion is necessary for early diagnosis of disseminated disease in cases of recurrent episodes of aseptic meningitis. In cases of primary benign EC, aggressive resection should be attempted to reduce the risk of malignant degeneration. A separate biopsy specimen from the enhancing portion of the tumor is used to rule out an underlying coexisting malignancy. Multimodal management carries the best prognosis for primary intracranial squamous cell carcinoma with LC.

Giant Spontaneous Epidural Pneumatocele: Case Report and Review of the Literature.

BACKGROUND: Pneumocephalus is a commonly encountered finding in neurosurgery in which air displaces intracranial cerebrospinal fluid after cranial surgery or a cerebrospinal fluid leak into paranasal or mastoid sinuses. When an intracranial air collection becomes chronically established in a fixed loculation causing mass effect, pneumatocele is a more appropriate term. We present an unusual case of a spontaneous giant frontotemporal epidural pneumatocele that persisted for more than 1 year before the patient presented for neurological treatment. CASE DESCRIPTION: A 40-year-old man with a remote history of minor head trauma presented with symptoms of headaches, dizziness, and vertigo. Imaging revealed a right giant epidural pneumocephalus secondary to bony dehiscence of the intracranial wall of the mastoid bone. A subtemporal middle fossa approach was performed to repair the mastoid defect with hydroxyapatite, fat graft, and temporalis fascia. The patient was discharged on postoperative day 2 with improvement in his headaches. One month after discharge operative imaging demonstrated complete resolution of his epidural pneumatocele and improvement in his headaches. CONCLUSIONS: This unique case represents the first reported case in the neurosurgical literature of a giant spontaneous epidural pneumatocele occurring in an adult treated with a middle fossa approach with resolution on follow-up imaging.