Delayed-Onset Idiopathic Intracranial Hypertension After Liposuction: A Case Report and Review.

ABSTRACT: Although systemic complications following liposuction are rare, visual impairment has been reported in a few cases and may occur for a variety of reasons. Here we present the case of a 31-year-old woman who underwent 360° liposuction and subsequently developed headaches and delayed partial visual disturbance 10 days after the procedure. She had symptoms suggestive of idiopathic intracranial hypertension, which was confirmed by lumbar puncture. A literature search revealed other case reports of visual changes or headaches following high-volume liposuction. Our case provides further evidence of a rare association between liposuction and idiopathic intracranial hypertension, emphasizing the need for thorough preoperative evaluations and the consideration of possible risks.

Triad of cluster-like headaches, hypertension and hypercoagulability a pointer to pheochromocytoma.

We report the case of a middle-aged hypertensive woman presenting to the neurology department with short-lasting episodic headaches for 4 years. She was initially diagnosed and treated with cluster headaches for one year. Following this, she presented with right lower limb arterial claudication. Arterial Doppler of lower limbs showed thrombosis of the bilateral common femoral arteries. Further computed tomography (CT) angiogram of the lower limbs confirmed extensive arterial thrombosis in bilateral lower limbs. The CT angiogram incidentally detected a left adrenal lesion. She had elevated urinary vanillylmandelic Acid and 24-hour metanephrines suggesting the presence of a pheochromocytoma. She was initially medically managed and later underwent left open adrenalectomy. Histopathology examination of the sections proved pheochromocytoma. Postsurgery, the patient's symptoms improved remarkably. This case highlights the importance of diagnosing pheochromocytoma when you encounter a patient with refractory short-lasting headaches, hypertension and hypercoagulability.

Are there characteristic indicators for increased pressure in chronic subdural hematoma?

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical disorders. However, no study has yet documented biomarkers indicating increased CSDH pressure. This study aimed to explore such indicators. A total of 50 patients underwent measurement for CSDH pressure during burr-hole irrigation. The mean hematoma pressure was 16.8 ± 7.6 cmH2O with no significant difference between new-onset and recurrent CSDHs. In 12 patients with a CSDH pressure ≥25 cmH2O, further analyses were carried out. Eight of them had bilateral CSDHs. All six patients with a CSDH pressure ≥28 cmH2O suffered headaches before surgery. Two out of three patients with a CSDH pressure ≥29 cmH2O felt nauseous. In statistical analyses, headache was positively correlated with a high CSDH pressure, whereas age and hematoma thickness were negatively correlated with it. Patients' sex, initial Glasgow coma scale score, motor weakness, midline shift on computed tomography scans, and administration of anticoagulants/antiplatelet agents, showed no significant correlation. When patients with bilateral CSDHs are not older adults and suffering headaches, an increased CSDH pressure should be assumed. For such patients, a prompt hematoma evacuation is indicated.

Granuloma formation as a late complication of burr-hole surgery for chronic subdural hematoma.

BACKGROUND: Surgical treatment remains the mainstream therapeutic regimen for chronic subdural hematoma (CSDH), and burr-hole craniostomy with subdural drainage is the preferable approach. Herein, we reported a case of intracranial granuloma formation as a late complication of burr-hole surgery for CSDH. CASE PRESENTATION: A 31-year-old man presented with a 1-month history of headache. Head computed tomography (CT) showed a subdural hematoma in the left frontal-temporal-parietal region with significant midline shifting. A burr-hole evacuation of the hematoma with closed-system drainage was performed. CT obtained immediately after the surgery demonstrated that the hematoma was mostly evacuated. Nine months later, he presented to us again due to intermittent headache in the left temporoparietal region. Brain magnetic resonance imaging revealed a space-occupying mass at the site of the original hematoma. A bone-flap craniotomy was performed for resecting the mass. Histopathological examination revealed a granuloma. The microbial cultivation of the resected specimen was negative. The postoperative course was uneventful, and the headache was relieved. CONCLUSION: Granuloma formation is an extremely rare late complication of burr-hole surgery for CSDH. Physicians involved in the perioperative management of CSDH should be aware of this condition, and bone-flap craniotomy may be warranted.

Surgical management of pseudotumor cerebri syndrome: A single center experience with endoscopic optic nerve decompression and CSF diversion procedures.

OBJECTIVES: Pseudotumor cerebri syndrome (PTC) is a chronic disorder, which is initially treated by conservative measures, yet surgery is inevitable in case of progressive worsening of vision or headache despite medical treatment. The surgical management is controversial including CSF diversion procedures and optic decompression. The purpose of this study was to evaluate the efficacy of different surgeries in PTC and to present surgical outcomes in a single center. METHODS: This retrospective study included the patients with PTC who were operated by endoscopic optic nerve decompression (EOND), ventriculoperitoneal (VP) and lumboperitoneal (LP) shunting. Surgical outcomes, i.e. visual acuity, visual field, papilledema and headache were compared according to type of surgery. Surgical complications were noted. RESULTS: Seventeen of 36 patients were treated with shunting, 14 with EOND and 5 patients with both EOND and shunting. No statistical significance was observed between CSF diversion procedures and EOND concerning clinical outcomes. The improvement rate of papilledema was higher with VPS (p = 0574) while more patients benefitted from LPS regarding visual field and acuity (p = 0471 and p = 0718, respectively). The best treatment response for headache was in shunt implemented patients (VPS and LPS) with a rate of 88.2% followed by EOND (78.6%) and both surgeries (60%)(p = 0.294). Gender and BMI were significant predictors of improved papilledema (p = 0.034). CONCLUSIONS: Our study demonstrated comparable results between shunting and EOND, regarding the efficacy on surgical outcomes. EOND is quite effective for headache besides its advantage on treatment-refractory visual loss. Shunting may offer sustained relief of symptoms when compared with EOND.

Surgical closure of spinal cerebrospinal fluid leaks improves symptoms in patients with superficial siderosis.

BACKGROUND AND PURPOSE: Spinal cerebrospinal fluid (CSF) leaks may cause a myriad of symptoms, most common being orthostatic headache. In addition, ventral spinal CSF leaks are a possible etiology of superficial siderosis (SS), a rare condition characterized by hemosiderin deposits in the central nervous system (CNS). The classical presentation of SS involves ataxia, bilateral hearing loss, and myelopathy. Unfortunately, treatment options are scarce. This study was undertaken to evaluate whether microsurgical closure of CSF leaks can prevent further clinical deterioration or improve symptoms of SS. METHODS: This cohort study was conducted using data from a prospectively maintained database in two large spontaneous intracranial hypotension (SIH) referral centers in Germany and Switzerland of patients who meet the modified International Classification of Headache Disorders, 3rd edition criteria for SIH. Patients with spinal CSF leaks were screened for the presence of idiopathic infratentorial symmetric SS of the CNS. RESULTS: Twelve patients were included. The median latency between the onset of orthostatic headaches and symptoms attributed to SS was 9.5 years. After surgical closure of the underlying spinal CSF leak, symptoms attributed to SS improved in seven patients and remained stable in three. Patients who presented within 1 year after the onset of SS symptoms improved, but those who presented in 8-12 years did not improve. We could show a significant association between patients with spinal longitudinal extrathecal collections and SS. CONCLUSIONS: Long-standing untreated ventral spinal CSF leaks can lead to SS of the CNS, and microsurgical sealing of spinal CSF leaks might stop progression and improve symptoms in patients with SS in a time-dependent manner.

Headache relief 10 years after cervical disc arthroplasty: multicenter randomized clinical trial post hoc analysis.

OBJECTIVE: Headache relief after anterior cervical spine surgery has been reported. No study, however, has followed patients out to 10 years to assess the durability of headache improvement. The authors analyzed a group of patients with a 10-year follow-up after one- or two-level cervical disc arthroplasty (CDA) from an FDA investigational device exemption (IDE) study. METHODS: The authors performed a post hoc analysis of 189 patients treated with CDA from the 9 highest enrolling sites in a prospective multicenter randomized US FDA IDE clinical trial. Patients had one- or two-level CDA at contiguous levels from C3 to C7 using the Mobi-C device. The authors evaluated headache scores from the headache section of the Neck Disability Index (NDI), along with associated demographic variables (age, sex, race, ethnicity, and BMI). Preoperative and 10-year postoperative headache scores were analyzed. Primary analysis was conducted via the Wilcoxon rank-sum test, followed by univariate and multivariable logistic regression. RESULTS: After accounting for age, BMI, race, ethnicity, and sex, there was sustained headache improvement 10 years after CDA (p = 0.04). Preoperatively, the median NDI score was 3.00 (IQR 1.00-4.00) and after 10 years it was 1.00 (IQR 0.00-2.00), with a decrease in the NDI score by 1.00 point (95% CI 0.00-2.00, p = 0.04). For one-level CDA, the median NDI score was 3.00 (IQR 1.00-4.00) preoperatively but 1.00 (IQR 0.00-2.00) at 10 years, with an estimated reduction in the NDI score of 1 point (95% CI 1.00-2.00, p < 0.0001). For two-level CDA, the median NDI score was 3.00 (IQR 1.75-4.00) preoperatively and 1.00 (IQR 0.00-2.00) at 10 years, with an estimated reduction in the NDI score of 1 point (95% CI 1.00-2.00, p < 0.0001). CONCLUSIONS: Headache relief provided by cervical CDA, for symptomatic C3-7 cervical spondylosis, was sustained even 10 years after surgery. There was no difference in headache improvement between the one- and two-level CDA groups, or among BMI, sex, race, and ethnicity strata.

Early ambulation versus prolonged bed rest for incidental durotomies in spine procedures: a systematic review and meta-analysis.

Incidental durotomies are frequent complications of spine surgery associated with cerebrospinal fluid (CSF) leak-related symptoms. Management typically involves prolonged bed rest to reduce CSF pressure at the durotomy site. However, early ambulation may be a safer, effective alternative. PubMed, Web of Science, Embase, Cochrane, and Scopus were systematically searched for studies comparing early ambulation (bed rest ≤ 24 h) with prolonged bed rest (> 24 h) for patients with incidental durotomies in spine surgeries. The outcomes of interest were CSF leak, hypotensive headache, additional surgical repair, pseudomeningocele, and pulmonary complications. Systematic reviews and meta-analysis were performed following the Cochrane Handbook for Systematic Reviews of Interventions. We included a total of 704 patients from 6 studies. There was a significant reduction in the incidence of pulmonary complications (RR 0.23; 95% CI 0.08-0.67; p = 0.007) in the early mobilization group. The incidence of CSF leak (RR 1.34; 95% CI 0.83-2.14; p = 0.23), hypotensive headache (RR 0.72; 95% CI 0.27-1.90; p = 0.50), additional repair surgery (RR 1.29; 95% CI 0.76-2.2; p = 0.35), and pseudomeningocele (RR 1.29; 95% CI 0.20-8.48; p = 0.79) did not differ significantly. In patients with incidental durotomy following spinal surgery, early mobilization was associated with a lower incidence of pulmonary complications as compared with prolonged bed rest. There was no significant difference between groups in terms of CSF leak, need for additional repair, pseudomeningocele, and hypotensive headache.

Calcifying Pseudoneoplasm of the Neuraxis: An Institutional Series of Ten Cases and Review of the Literature to Date.

BACKGROUND: Calcified pseudoneoplasms of the neuraxis (CAPNONs) are rare, fibro-osseous lesions with an unknown cause that may present anywhere along the neuroaxis. Little is known about how intracranial CAPNONs present and about patients' long-term outcomes. METHODS: A retrospective institutional review of intracranial pathology-confirmed CAPNONs was performed. Presenting clinical features, management, and clinical outcomes are highlighted. A literature review of intracranial CAPNON lesions was also performed to build on our series. RESULTS: Ten patients were identified who met the inclusion criteria. Most patients presented with headaches (n = 6; 60%), seizures (n = 5; 50.0%), and neck and facial pain (n = 3; 30.0%). Most lesions were supratentorial (n = 7; 70.0%), with 3 infratentorial origins. Surgical resection was the most common initial management undertaken (n = 7; 70.0%). No new permanent postoperative neurologic deficits were identified. The median clinical and/or radiographic follow-up for all patients was 6.8 years (range, 0.7-23.3 years), with no recurrence of disease for 5 patients who underwent gross total resection. Four of 5 patients with residual or nonresectable lesions showed no interval growth on radiographic follow-up; 1 patient showed progression and worsening of presenting symptoms 2 months after resection. Resection substantially improved seizures and headaches in patients presenting with these symptoms (80% and 83.3%, respectively). CONCLUSIONS: Intracranial CAPNONs may present with a wide variety of symptoms characteristic of the site of origin. The outcomes of these symptoms regarding survival and disease control are generally favorable, although resection does not always yield complete resolution of presenting deficits in certain patients, particularly those presenting with headaches or neck/facial pain.

Survival and quality of life after CSF diversion in adult patients with leptomeningeal metastasis-associated hydrocephalus: a systematic review and meta-analysis.

OBJECTIVE: Leptomeningeal metastasis (LM) is associated with altered CSF flow dynamics in 50%-70% of patients. Approximately 1%-5% of patients develop symptomatic LM-associated hydrocephalus (LM-H), which adversely impacts quality of life (QOL), functional status, and overall survival (OS). There is equipoise for CSF diversion procedures in LM-H. This systematic review and meta-analysis aimed to assess the effect of CSF diversion on OS and QOL in this context. METHODS: This systematic review was conducted according to the PRISMA guidelines. PubMed/Medline, Embase, Web of Science, and Scopus were searched for articles that evaluated the role of CSF diversion for LM-H due to systemic cancer in adult patients. A meta-analysis was conducted using random effects models, with mean differences and 95% CIs reported. Bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. RESULTS: Ten eligible studies with a total of 494 patients were included. Two studies reported multivariate HRs for median OS, suggesting no significant effect of shunting on OS (pooled HR 0.42, 95% CI 0.09-1.94, p = 0.27). A difference between preoperative and postoperative Karnofsky Performance Status of mean 17.6 points (95% CI 10.44-24.68, p < 0.0001) was calculated from 4 studies. Across all studies, a symptomatic improvement rate of 67%-100% was observed, with high rates of improvement for headaches and nausea and lower rates for cranial nerve palsies. Complication rates across 9 studies ranged from 0% to 21.1%. CONCLUSIONS: Based on the present findings, shunting does not improve OS but does relieve symptoms, suggesting that individuals who exhibit certain symptoms should be considered for CSF diversion. The present findings prompt the generation of a standardized decision-making tool and a critical analysis of the individual patient risk-benefit ratio. Implementation of these will optimize surgical management of LM-H patients.

Recovery and long-term outcome after neurosurgical closure of spinal CSF leaks in patients with spontaneous intracranial hypotension.

INTRODUCTION: Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid leak causes orthostatic headaches and impacts quality of life. Successful closure rates are often reported, whereas data on long-term outcome are still scarce. METHODS: Between April 2020 and December 2022 surgically treated patients completed the Headache Impact Test-6 prior to surgery and at 14 days, three months, six months, and 12 months postoperatively. In addition to the Headache Impact Test-6 score, we extracted data related to orthostatic symptoms. RESULTS: Eighty patients were included. Median Headache Impact Test-6 score preoperatively was 65 (IQR 61-69), indicating severe and disabling impact of headaches. At three months headache impact significantly improved to 49 (IQR 44-58) (p < 0.001) and remained stable up to 12 months (48, IQR 40-56), indicating little to no impact of headaches on quality of life. The need to lie down "always" or "very often" was reduced from 79% to 23% three months postoperatively (p < 0.001). CONCLUSIONS: Surgical closure of spinal CSF leaks significantly improves the impact of headaches in the long term. At least three months should be expected for recovery. Despite permanent closure of the CSF-leak, a quarter of patients still have relevant long-term impairment, indicating the need for further research on its cause and possible treatment.

Evaluation of Miethke M.scio Device Implantation for Intracranial Pressure Monitoring in Patients with Cerebrospinal Fluid Disorders.

BACKGROUND: Patients with complex shunt-related problems and varying diagnoses of cerebrospinal fluid (CSF) disturbance can present with headache and clinical symptoms that may be difficult to relate to underdrainage or overdrainage. Telemetric intracranial pressure (ICP) monitoring may assist in evaluating individual patients and assessing shunt function and adjustment. We report a case series of patients receiving a Miethke M.scio sensor. METHODS: Between June 2016 and August 2021, 14 patients older than 18 years with different diagnoses underwent ventriculoperitoneal shunt surgery and received a Miethke M.scio sensor. RESULTS: Patients had idiopathic intracranial hypertension (n = 3), obstructive hydrocephalus caused by tumors (n = 4), and malformations (n = 5). Headaches (71%) and visual impairment (50%) were the most common symptoms before surgery and 65% of the symptoms were improved after surgery. In total, 25 measurements were made and 11 of these led to changes in the shunt settings. Postoperative measurements were taken in 8 patients and the most common indication of ICP measurement was headache and/or control of the shunt settings. CONCLUSIONS: The Miethke M.scio is a safe and valuable device to use in shunt-treated patients, in particular those expected to need assessment of ICP monitoring postoperatively. Repeated ICP measurements can also assist in personalized adjustment of the shunt setting to optimize CSF flow in this diverse patient group. Future studies should include a standardized protocol with ICP measurements correlated to the symptoms and cause of CSF disturbances to provide better understanding of the dynamics of the ICP in each patient.

Relative Pain Reduction and Duration of Nerve Block Response Predict Outcomes in Headache Surgery: A Prospective Cohort Study.

BACKGROUND: Experts agree that nerve block (NB) response is an important tool in headache surgery screening. However, the predictive value of NBs remains to be proven in a prospective fashion. METHODS: Pre-NB and post-NB visual analogue pain scores (0 to 10) and duration of NB response were recorded prospectively. Surgical outcomes were recorded prospectively by calculating the Migraine Headache Index (MHI) preoperatively and postoperatively at 3 months, 12 months, and every year thereafter. RESULTS: The study population included 115 patients. The chance of achieving MHI percentage improvement of 80% or higher was significantly higher in subjects who reported relative pain reduction of greater than 60% following NB versus less than or equal to 60% [63 of 92 (68.5%) versus 10 of 23 (43.5%); P = 0.03]. Patients were more likely to improve their MHI 50% or more with relative pain reduction of greater than 40% versus 40% or less [82 of 104 (78.8%) versus five of 11 (45.5%); P = 0.01]. In subjects with NB response of greater than 15 days, 10 of 13 patients (77.0%) experienced MHI improvement of 80% or greater. Notably, all of these patients (100%) reported MHI improvement of 50% or greater, with mean MHI improvement of 88%. Subjects with a NB response of 24 hours or more achieved significantly better outcomes than patients with a shorter response (72.7% ± 37.0% versus 46.1% ± 39.7%; P = 0.02). However, of 14 patients reporting NB response of less than 24 hours, four patients had MHI improvement of 80% or greater, and seven, of 50% or greater. CONCLUSIONS: Relative pain reduction and duration of NB response are predictors of MHI improvement after headache surgery. NBs are a valuable tool to identify patients who will benefit from surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT). OBJECTIVE: To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward. METHODS: Review of the medical files of three patients and description of clinical and surgical outcomes. RESULTS: Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up. CONCLUSION: The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

ANTECEDENTES: Hipotensão intracraniana espontânea (HIE) é uma causa secundária de cefaleia e uma doença subdiagnosticada. A apresentação clínica pode ser muito variável. Tipicamente, se apresenta com queixas isoladas de cefaleia ortostática clássica, porém pode evoluir com complicações significativas como trombose venosa cerebral (TVC). OBJETIVO: Relatar 3 casos de diagnóstico de hipotensão intracraniana espontânea manejados em uma enfermaria de neurologia de nível terciário. MéTODOS: Revisão dos prontuários de três pacientes e descrição dos resultados clínicos e cirúrgicos. RESULTADOS: Três pacientes do sexo feminino com média de idade de 25.6 ± 10.0 anos. As pacientes apresentavam cefaleia ortostática e uma delas apresentou sonolência e diplopia devido a TVC. A ressonância magnética (RM) do encéfalo varia de achados normais até achados clássicos de HIE como realce paquimeníngeo e deslocamento inferior das tonsilas cerebelares. A RM da coluna mostrou coleções anormais de líquido epidural em todos os casos e a mielografia por tomografia computadorizada (TC) foi capaz de determinar fístula liquórica identificável em apenas uma paciente. Uma paciente recebeu abordagem conservadora e as outras duas foram submetidas a cirurgia aberta com laminoplastia. Ambas tiveram recuperação e remissão sem intercorrências no seguimento cirúrgico. CONCLUSãO: O diagnóstico e manejo da hipotensão intracraniana ainda são desafios na prática neurológica. Destacamos no presente estudo casos graves, complicação com TVC e bons resultados com tratamento neurocirúrgico.

Late-Presenting Sagittal Craniosynostosis: An Update to a Standardized Treatment Protocol.

BACKGROUND: The authors previously published their protocol to treat patients who present with sagittal craniosynostosis after the age of 1 year. The purpose of this article is to present a follow-up and update of this cohort to evaluate outcomes of their treatment protocol. METHODS: Patients with isolated sagittal craniosynostosis who presented after the age of 1 year between July of 2013 and April of 2021 were included. RESULTS: A total of 108 patients met inclusion criteria. The average age at presentation was 5.2 ± 3.4 years, and 79 patients (73.1%) were male. The indications for imaging were head shape (54.6%), headache (14.8%), trauma (9.3%), seizure (4.6%), papilledema (2.8%), and other (13.9%). Of the 108 patients, 12 (11.1%) underwent surgery following their initial consultation: five for papilledema, four for elevated intracranial pressure, two for severely scaphocephalic head shapes, and one for abnormal funduscopic findings. Two of these patients underwent additional reconstructive surgery, one for the recurrence of papilledema and headache and the other for progressive scaphocephaly. The average length of time between operations was 4.9 years. Of the 96 patients who were managed conservatively, four (4.2%) underwent surgery at an average of 1.2 ± 0.5 years later (average age, 4.4 ± 1.5 years) for brain growth restriction ( n = 2), aesthetic concerns ( n = 1), and refractory headaches ( n = 1). The average follow-up of all patients with craniofacial surgery was 2.7 ± 2.3 years (median, 2.1 years; interquartile range, 3.7 years). CONCLUSIONS: Patients with late-presenting sagittal craniosynostosis require surgical correction less often than younger patients, likely because of milder phenotype. Few patients in the conservative treatment arm ultimately required surgery (4%). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evidence-Based Patient Selection in Headache Surgery: Impact of Preoperative Radiofrequency Ablation on Surgical Outcomes.

BACKGROUND: Radiofrequency ablation (RFA) of the greater occipital nerve (GON) is a minimally invasive treatment option commonly used in patients with occipital neuralgia. Patients who undergo occipital surgery for headaches after failed RFA treatment present a unique opportunity to evaluate RFA-treated occipital nerves and determine the impact on headache surgery outcomes. METHODS: Of 115 patients who underwent headache surgery at the occipital site, 29 had a history of RFA treatment. Migraine Headache Index, Pain Self- Efficacy Questionnaire, and Pain Health Questionnaire-2 outcome scores were recorded preoperatively and at follow-up visits. Intraoperative macroscopic nerve damage and surgical outcomes were compared between RFA-treated and non-RFA-treated patients. RESULTS: RFA-treated patients had a higher rate of macroscopic nerve damage (45%) than non-RFA-treated patients (24%) ( P = 0.03), and they were significantly more likely to require a second operation at the site of primary decompression (27.6% versus 5.8%; P = 0.001) and GON transection (13.8% versus 3.5%; P = 0.04). Outcome scores at the last follow-up visit showed no statistically significant difference between RFA-treated and non-RFA-treated patients ( P = 0.96). CONCLUSIONS: RFA-treated patients can ultimately achieve outcomes that are not significantly different from non-RFA-treated patients in occipital headache surgery. However, a higher number of secondary operations at the site of primary decompression and nerve transection are required to treat refractory symptoms. RFA-treated patients should be counseled about an increased risk of same-site surgery and possible GON transection to achieve acceptable outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Scratching and Stretching the Shrunken Cranial Dura for Primary Closure.

BACKGROUND: At craniotomy, the dura shrinks due to the drying effect of illumination and air exposure, rendering its primary closure difficult. When the opening is narrow, it can be patched with autologous grafts. However, tissue harvesting and meticulous suturing take time. As the cost-effectiveness of using dural substitutes is poor, we developed a new technique that involves dural scratching for the primary closure of dural openings. METHODS: We applied our technique because in 53 adults who underwent supratentorial craniotomy we encountered difficulties with the primary closure of a dural opening 5 mm or less in width. With a scalpel, we placed several fine scratches parallel to the edge of the opening on the surface of the dura, taking care not to perforate the deep layer. This relieved dural tension and the tissue was stretched enough to permit closing with sutures. RESULTS: Our technique achieved primary dural closure in 46 of 53 patients (87%) who primarily had undergone narrow supratentorial craniotomies. The other 7 additionally required small autologous grafts to patch narrow residual openings at the intersection of the durotomy. There were no procedure-related complications such as cerebrospinal fluid leakage and persistent headache due to tension of the closed dura. CONCLUSIONS: Dural scratching is simple, safe, requires no special instrumentation, facilitates primary closure of the shrunken dura by stretching, and reduces the need for patch grafting.

Artificial Intelligence-Enabled Evaluation of Pain Sketches to Predict Outcomes in Headache Surgery.

BACKGROUND: Recent evidence has shown that patient drawings of pain can predict poor outcomes in headache surgery. Given that interpretation of pain drawings requires some clinical experience, the authors developed a machine learning framework capable of automatically interpreting pain drawings to predict surgical outcomes. This platform will allow surgeons with less clinical experience, neurologists, primary care practitioners, and even patients to better understand candidacy for headache surgery. METHODS: A random forest machine learning algorithm was trained on 131 pain drawings provided prospectively by headache surgery patients before undergoing trigger-site deactivation surgery. Twenty-four features were used to describe the anatomical distribution of pain on each drawing for interpretation by the machine learning algorithm. Surgical outcome was measured by calculating percentage improvement in Migraine Headache Index at least 3 months after surgery. Artificial intelligence predictions were compared with clinician predictions of surgical outcome to determine artificial intelligence performance. RESULTS: Evaluation of the data test set demonstrated that the algorithm was consistently more accurate (94%) than trained clinical evaluators. Artificial intelligence weighted diffuse pain, facial pain, and pain at the vertex as strong predictors of poor surgical outcome. CONCLUSIONS: This study indicates that structured algorithmic analysis is able to correlate pain patterns drawn by patients to Migraine Headache Index percentage improvement with good accuracy (94%). Further studies on larger data sets and inclusion of other significant clinical screening variables are required to improve outcome predictions in headache surgery and apply this tool to clinical practice.

Foramen Magnum Decompression for Chiari Malformation Type 1: Is There a Superior Surgical Technique?

BACKGROUND: Foramen magnum decompression is a common operation used to treat Chiari malformation. There are different surgical techniques; however, some are anecdotally more effective than others. Our aim was to determine whether there is a superior technique in relation to revision rates, presence of persistent postoperative headache and nausea, and syrinx reduction. METHODS: This was a retrospective analysis of foramen magnum decompressions performed between 2012 and 2017 for Chiari 1 in a single institution. Three types of operations were performed: 1) bony decompression alone; 2) bony decompression with durotomy and dura left open; 3) bony decompression with opening of dura and duraplasty. We compared postoperative symptoms and revision rates between these 3 operations. RESULTS: In 168 patients, 185 foramen magnum decompressions were performed. Among the 168 primary operations, in 66 the dura was not opened, in 86 the dura was opened without a duraplasty, and in 16 a duraplasty was performed. Of 185 operations, 17 were revision surgery. For primary procedures, the revision rates were 12 (18%) where the dura was not opened, 4 (5%) where the dura was left open, and 1 (6%) when duraplasty was performed. Severe postoperative headache and nausea occurred in 2 (3%) patients where the dura was not opened, 4 (25%) patients after primary duraplasty, and 64 (74%) patients after primary durotomy. CONCLUSIONS: In this study, rate of revision surgery was highest in patients who had bony decompression without dural opening. Rate of postoperative headache and nausea was highest in the durotomy group. Overall duraplasty had the best results.

Idiopathic membranous occlusion of the foramen of Monro: an unusual cause of hydrocephalus and headache in adults.

Occlusion of foramen of Monro is an uncommon clinical entity that usually presents in children. Common causes are obstructing mass, infectious etiologies or vascular malformation. Rarely, it may be an idiopathic stricture or membrane. We report a case of idiopathic membranous obstruction of the foramen of Monro in a 45-year-old male with no past medical or surgical history. He presented with new intermittent dull and burning bifrontal severe headache for 2 d, which was alleviated slightly by non-steroidal anti-inflammatory medication. Imaging showed marked dilation of the lateral ventricles with normal third and fourth ventricles. The patient was discharged initially with conservative medical management and close follows up; however, the headache continued to progress and neurosurgical intervention was offered. The patient underwent endoscopic exploration, fenestration of the septum pellucidum, and right ventriculoperitoneal shunt placement. Bilateral membranous obstruction of foramina of Monro and an auto-fenestrated cavum septum pellucidum were identified intraoperatively. The patient reported resolution of headache post-operatively without recurrence on 1-month follow up. This case is unusual in that the patient presented without any known neurologic history or prior intracranial infections. It became apparent at the time of surgery that chronic obstruction of the bilateral foramina with collapse of the third ventricle had developed, and the safest durable treatment for him was septostomy and cerebrospinal fluid (CSF) shunt placement.