Metastatic malignant struma ovarii to the pituitary presenting as a sellar mass and responding to total thyroidectomy with adjuvant radioactive iodine therapy.

Malignant struma ovarii (MSO) is a rare ovarian teratoma composed primarily of thyroid tissue. Common sites of metastasis include peritoneum, bone, liver, lung, gastrointestinal tract and omentum. We present a woman in her 50s with a history of remote oophorectomy presenting with hypopituitarism and a 2.7 cm sellar mass. Trans-sphenoidal surgery for presumed pituitary macroadenoma achieved near total resection and resultant pathology surprisingly showed ectopic thyroid tissue. The patient acquired her ovarian pathology report from Southeast Asia which showed struma ovarii of the left ovary. The pituitary mass was thus determined to be a metastatic lesion from MSO. She underwent total thyroidectomy and radioactive iodine ablation therapy with good initial response and no regrowth of the tissue or emergence of distant metastases after 5 years of annual follow-up. To our knowledge, this is the first reported case of MSO to the pituitary.

Current Trends in Neurosurgical Management of Adult Diffuse Low-Grade Gliomas in Canada.

There is considerable variability in the management of diffuse low-grade gliomas (LGGs). To characterize treatment paradigms, a survey of Canadian neurosurgeons was performed with forty neurosurgeons responding. Their responses show that the management of patients with LGGs has evolved in the past decade and findings from the RTOG9802 trial have been integrated into the practice of Canadian neurosurgeons. Most respondents stated that the patient selection and treatment strategy advocated by the RTOG9802 trial needs further evaluation. Overall, there is a trend toward more aggressive surgical resections, and future investigations will have to more accurately stratify patient risk profiles.

The Unified Visual Function Scale Assessments Show Inter- and Intraobserver Agreement and Correlate with Patient Quality of Life in Skull Base Parasellar Tumors.

Introduction The authors have previously described the Unified Visual Function Scale (UVFS). Here, we assessed intra- and interobserver reliability of the scale, and investigated correlations with patient quality of life (QoL). Methods Eight healthcare practitioners independently applied the UVFS in 20 representative cases from our parasellar meningioma series. Scoring was compared with consensus grades assigned by lead authors. Inter- and intraobserver agreement was measured using intraclass correlation coefficient (ICC), Fleiss's κ, and Cohen's κ, respectively. Patient QoL was assessed Visual Function Questionnaire 25 (VFQ-25) or Activities of Daily Vision Scale (ADVS), and correlated with UVFS grades for each eye. Results The interobserver ICC was 0.734 (95% confidence interval [CI]: 0.652-0.811), with Fleiss's κ of 0.758, 0.691, and 0.899 for grades A, B, and C, respectively. The intraobserver ICC was 0.758 (95% CI: 0.638-0.872), and Fleiss's κ was 0.604, 0.268, and 0.910 for grades A, B, and C respectively. The Cohen's κ for agreement between UVFS category grades and consensus grades was 0.816 (95 CI: 0.698-0.934). Survey response rate was 51% (27/53). The UVFS demonstrated strong correlation with VFQ-25 subdivisions general vision ( r = 0.7712), near activities ( r = 0.7262), peripheral vision ( r = 0.6722), and driving ( r = 0.6608), and also demonstrated strong correlation with the overall ADVS score ( r = 0.5902). Conclusion This study shows that the UVFS is valid within a small subset of observers, and accurately reflects patient QoL. It is robust and practical, which make it suitable for broad implementation.

Survival and Recurrence Outcomes Following Adjuvant Radiotherapy for Grade 2 Intracranial Meningiomas: 13-Year Experience in a Tertiary-Care Center.

OBJECTIVE: We sought to evaluate overall survival (OS) and local recurrence (LR) in patients with grade 2 meningiomas treated with adjuvant radiotherapy compared to surgery alone at time of diagnosis. METHODS: All patients at the authors' institution between 2007 and 2020 were retrospectively reviewed. OS, LR, and treatment toxicities were assessed. Sensitivity analyses were performed for patients with initial gross total resection (GTR) and subtotal resection (STR). Kaplan-Meier analyses and log-rank test for significance were used to compare surgery alone and adjuvant radiotherapy groups. RESULTS: We included 189 patients with mean age 57.4 ± 14.6 years. Patients were 64% female, and median follow-up was 64 (interquartile range: 20-96) months. At initial treatment, 21 patients received adjuvant radiotherapy and 168 received surgery alone. There was no significant difference for OS (hazard ratio = 1.3 [95% confidence interval 0.4-4.5], P = 0.92) overall or when limited to GTR (P = 0.38) or STR (P = 0.85). There was no significant difference in LR overall (P = 0.75) or when restricted to GTR (P = 0.77) or STR (P = 0.20). No patient had radiotherapy stopped or altered because of side effects; however, 71.4% reported tolerable side effects during the treatment period and 14.3% reported chronic side effects persisting longer than 12 months post treatment. CONCLUSIONS: In a large retrospective cohort, we found no survival or local recurrence benefit to adjuvant radiotherapy in treatment of grade 2 meningiomas. Sensitivity analysis limited to initial GTR and STR also failed to demonstrate any OS or LR benefit with adjuvant radiotherapy. In our experience, there is limited utility to upfront adjuvant radiotherapy following initial surgical resection in the treatment of grade 2 meningiomas.

The impact of brain invasion criteria on the incidence and distribution of WHO grade 1, 2, and 3 meningiomas.

BACKGROUND: In 2016 brain invasion was added as a standalone diagnostic criterion for Grade 2 meningiomas in the WHO Classification of Brain Tumors. The aim of this study was to compare the incidence and distribution of meningiomas, and agreement, between the 2007 and 2016 WHO criteria. METHODS: All cases of intracranial meningiomas diagnosed between 2007 and 2020 at a tertiary care academic hospital were identified. The incidence of each meningioma grade in the WHO 2007 and WHO 2016 cohorts were compared. Additionally, each case in the 2007 cohort was re-graded according to the WHO 2016 criteria to determine the intra-class correlation (ICC) between criteria. RESULTS: Of 814 cases, 532 (65.4%) were in the 2007 WHO cohort and 282 (34.6%) were in the 2016 WHO cohort. There were no differences in the distribution of meningioma grades between cohorts (P = .11). Incidence rates were: 75.0% vs. 75.2% for Grade 1, 22.7% vs. 24.5% for Grade 2, and 2.3% vs. 0.4% for Grade 3, for the 2007 and 2016 cohorts, respectively. Upon re-grading, 21 cases (3.9%) were changed. ICC between original and revised grade was 0.92 (95% CI: 0.91-0.93). Amongst Grade 2 meningiomas with brain invasion, 75.8% had three or more atypical histologic features or an elevated mitotic index. CONCLUSIONS: Including brain invasion as a standalone diagnostic criterion for Grade 2 meningiomas had minimal impact on the incidence of specific meningioma grade tumors. There is strong agreement between the 2007 and 2016 WHO criteria, likely due to cosegregation of grade elevating features.

Delayed coil migration into oropharynx following endovascular coiling of a traumatic carotid cavernous fistula: management considerations.

Carotid-cavernous fistulas (CCFs) are abnormal vascular shunts between the carotid artery and the cavernous sinus. A 37-year-old male presented with a traumatic CCF and basal skull fracture extending through the medial wall of the cavernous sinus and sphenoid sinus. The CCF was treated with endovascular coiling. Three months after this procedure, he was found to have coil migration through the traumatic sphenoid defect into the pharynx. He underwent urgent endonasal endoscopic surgery to disconnect and remove the extruded coil. Post-operative coil migration is a rare but serious complication following endovascular treatment of traumatic CCF.

Quantitative Optical Coherence Tomography Angiography in Patients with Moyamoya Vasculopathy: A Pilot Study.

Moyamoya (MM) disease is a chronic cerebrovascular disease that can lead to progressive stenosis of the terminal portions of the internal carotid arteries and their proximal branches. We sought to investigate and quantify retinal vascular changes in patients with MM vasculopathy (MMV) using optical coherence tomography angiography (OCTA) compared to healthy controls. Our findings reveal retinal microvascular changes in patients with MMV and highlights the potential of OCTA imaging for the detection of subclinical retinal pathology.

Functional Outcomes After Treatment of Posterior Inferior Cerebellar Artery Aneurysms.

Objective Aneurysms of the posterior inferior cerebellar artery (PICA) are a rare cause of subarachnoid hemorrhage. Treatment for this type of aneurysm may be microsurgical clipping or endovascular. This decision is based on patient characteristics, aneurysm location and dimensions, along with surgeon and institutional experience. In this study we aim to assess the outcomes of surgical and endovascular treatment of PICA aneurysms. Methods We retrospectively reviewed the charts of 52 patients who were admitted to Vancouver General Hospital for ruptured or symptomatic PICA aneurysms between 2005 and 2015. Modified Rankin scores were assigned at the time of discharge and at two subsequent follow-up time points. The mean short-term follow-up period post-operatively was 11.1 months and the mean long-term follow-up period was 19.3 months. Clinical and radiological characteristics were collected for all patients. Results Of the 52 patients, two died prior to obtaining treatment. Of the 50 patients who were treated for their PICA aneurysm, 39 presented with subarachnoid hemorrhage while 11 had symptomatic unruptured PICA aneurysms. Overall, 11 patients had endovascular treatment (coil embolization) while 39 patients underwent microsurgical clipping/trapping of the aneurysm. At the time of hospital discharge, patients in the microsurgical group trended towards a better the modified Rankin Scale score (2.3) compared to the endovascular group, though this did not reach significance (3.0) (p=0.20). The long-term score in the endovascular group (1.6) was also comparable to the microsurgical group (1.9) (p=0.55). Conclusion While the early outcomes in patients treated endovascularly appear better, there is no statistically significant difference in outcomes between the microsurgical and endovascular treatment groups at short- and long-term follow-up.

Functional Outcomes After Revascularization Procedures in Patients With Hemorrhagic Moyamoya Disease.

BACKGROUND: Poor natural history of hemorrhagic Moyamoya disease (MMD) is related to high rehemorrhage rates between 32% and 61%. Postrevascularization, rehemorrhage rates reportedly decrease to 12% to 17%. OBJECTIVE: To evaluate long-term functional outcomes and rehemorrhage rates of hemorrhagic MMD patients treated with surgical revascularization and examine these in relation to clinical and radiological factors. METHODS: Patients treated surgically for hemorrhagic MMD over a 26-yr period were identified. Modified Rankin scale (mRS) was used to assess clinical status at presentation and functional outcomes. Multivariable regression analyses were performed to evaluate the risk factors associated with rehemorrhage rates and functional outcomes. RESULTS: A total of 104 patients (mean age: 38.04 yr) were identified. The mean mRS score at baseline was 1.3. Of 172 revascularized hemispheres, 157 (91.3%) were direct superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses and the rest indirect. Over the mean follow-up of 61.4 mo, 8 of 104 patients (7.7%) experienced rehemorrhage with rehemorrhage rate per person-years of 1.9%. A total of 4 patients died with 1 related to rehemorrhage. At the last follow-up, mean mRS score improved to 1.1. No significant risk factors were identified in relation to the rehemorrhage rates (P < .05). The patients' initial mRS score was positively associated with mRS scores at the final follow-up (P < .001). STA-MCA direct bypass was associated with better performance status (P = .033). CONCLUSION: Rehemorrhage rate following surgical revascularization of the hemorrhagic MMD patients at 7.7% is lower compared with much higher natural history rates. Surgical revascularization improved patients' performance status. These outcomes support performing revascularization procedure with a preference for direct STA-MCA bypasses.

Immediate Use of Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea Following Transsphenoidal Pituitary Surgery: A Case Series.

BACKGROUND: Patients who undergo transsphenoidal pituitary resection have an elevated risk of obstructive sleep apnea (OSA) yet their outcomes and the safety of continuous positive airway pressure (CPAP) remains unclear. Our study objective was to determine the incidence of complications related to the use of early positive airway pressure following pituitary resection. METHODS: We retrospectively identified all patients who underwent endoscopic transsphenoidal pituitary tumor resection between January 1, 2005 and March 24, 2016 at our institution, including those with diagnosed or suspected OSA. We compared characteristics and postoperative complications of OSA patients who did and did not receive CPAP postoperatively. RESULTS: In total, 427 patients underwent transsphenoidal pituitary resection. Of these, 64 (15%) had OSA. Acromegaly was more common in patients with OSA (42% vs. 10%; P<0.001) but not Cushing Disease (19% vs. 16%; P=0.54). Hypoxia was more common in patients with OSA as compared to those without (14% vs. 5%; P<0.001) and one patient with OSA was reintubated compared with none in the control group (P=0.017). Eight patients had CPAP applied in the immediate postoperative period and the incidence of postoperative cerebrospinal fluid (CSF) leak, infection, and pneumocephalus was similar between OSA patients with and without CPAP. DISCUSSION: Our case series of patients with OSA who received CPAP immediately following transsphenoidal pituitary resection resulted in similar rates of surgical complications. Our results support further investigation to establish the safety of CPAP in this population.

Headache Outcomes After Treatment of Unruptured Intracranial Aneurysm: A Systematic Review and Meta-Analysis.

Background and Purpose- While unruptured intracranial aneurysms may be discovered incidentally in the workup of chronic headache, it remains unclear whether their treatment ultimately impacts headache severity. We aim to conduct a systematic review and meta-analysis assessing headache severity after treatment of unruptured intracranial aneurysm. Methods- MEDLINE and EMBASE were systematically reviewed. Results- Data from 7 studies met inclusion criteria (309 nonduplicated patients). The standard mean difference in pre- and post-intervention headache severity was estimated at -0.448 (95% CI, -0.566 to -0.329) under a random effects model. No significant heterogeneity was noted nor was any significant publication bias demonstrated. Conclusions- This is the first systematic review assessing postoperative headache severity following treatment of unruptured intracranial aneurysm. While a significant reduction in headache severity was observed, further investigation into this phenomenon is recommended before it influences clinical practice. Future study should stratify headache outcomes by aneurysm size, location, and treatment modality.

Impact of work hours and sleep on well-being and burnout for physicians-in-training: the Resident Activity Tracker Evaluation Study.

OBJECTIVE: The Resident Activity Tracker Evaluation (RATE) is a prospective observational study evaluating the impact of work hours, sleep and physical activity on resident well-being, burnout and job satisfaction. BACKGROUND: Physician burnout is common and its incidence is increasing. The impact of work hours and sleep on resident well-being and burnout remains elusive. Activity trackers are an innovative tool for measuring sleep and physical activity. METHODS: Residents were recruited from (i) general surgery and orthopaedics (SURG), (ii) internal medicine and neurology (MED) and (iii) anaesthesia and radiology (RCD). Groups 1 and 2 do not enforce restrictions on the duration of being on-call, and group 3 had restricted the duration of being on-call to 12 hours. Participants wore FitBit trackers for 14 days. Total hours worked, daily sleep, sleep on-call and daily steps were recorded. Participants completed validated surveys assessing self-reported well-being (Short-Form Health Survey), burnout (Maslach Burnout Inventory), and satisfaction with medicine. RESULTS: Surgical residents worked the most hours per week, followed by medical and RCD residents (SURG, 84.3 hours, 95% CI, 80.2-88.5; MED, 69.2 hours, 95% CI, 65.3-73.2; RCD, 52.2 hours, 95% CI, 48.2-56.1; p < 0.001). Surgical residents obtained fewer hours of sleep per day (SURG, 5.9 hours, 95% CI, 5.5-6.3; MED, 6.9 hours, 95% CI, 6.5-7.3; RCD, 6.8 hours, 95% CI, 5.6-7.2; p < 0.001). Nearly two-thirds of participants (61%) scored high burnout on the Maslach depersonalisation subscore. Total steps per day and well-being, burnout and job satisfaction were comparable between groups. Total hours worked, daily sleep and steps per day did not predict burnout or well-being. CONCLUSIONS: Work hours and average daily sleep did not affect burnout. Physical activity did not prevent burnout. Work hour restrictions may lead to increased sleep but may not affect resident burnout or well-being.

Anemia After Aneurysmal Subarachnoid Hemorrhage Is Associated With Poor Outcome and Death.

Background and Purpose- Anemia after aneurysmal subarachnoid hemorrhage is common and potentially modifiable. Here, we first evaluate the effect of anemia on neurological outcome and death and second, study the effects of packed red blood cell transfusion on outcome. Methods- A secondary analysis on 413 subjects in the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage). Multivariable logistic regression identified independent risk factors for anemia and determined the effect of anemia on neurological outcome and death, while adjusting for selected covariates. Optimal predictive thresholds for hemoglobin levels were determined using receiver operating characteristic curve analysis. Finally, patients were pseudorandomized to transfusion using propensity score matching to study the effect of transfusions on outcome. Results- Anemia, defined as hemoglobin <10 g/dL, was present in 5% of patients at presentation, in 29% of patients after aneurysm securing (days 1-3), and in 32% of patients during the peak delayed cerebral ischemia risk period (days 5-9). Anemia after aneurysm securing (odds ratio, 1.96; 95% confidence interval, 1.07-3.59; P=0.03) and during the delayed cerebral ischemia window (odds ratio, 2.63; 95% confidence interval, 1.46-4.76; P=0.0014) was independently associated with poor neurological outcome. Anemia postaneurysm securing (odds ratio, 3.50; 95% confidence interval, 1.15-10.62; P=0.027) but not during the delayed cerebral ischemia window was associated with death. Using propensity score-matched cohorts, we found that transfusion of anemic patients did not improve long-term outcome (P=0.8) or mortality rates (P=0.9). Transfusion of patients with a hemoglobin concentration >10 g/dL was associated with improved neurological outcomes (odds ratio, 0.09; 95% confidence interval, 0.002-0.72; P=0.015), with no differences in mortality. Conclusions- Anemia after aneurysmal subarachnoid hemorrhage is associated with poor long-term neurological outcome and death. Transfusion of packed red blood cells is beneficial for patients who are not considerably anemic beforehand, suggesting further work needs to define the threshold but also the time period of anemia that is sufficient and necessary to contribute to poor outcomes. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00111085.

Case of Primary Central Nervous System Lymphoma Arising at Site of Remote Herpes Encephalitis.

BACKGROUND: Primary central nervous system lymphoma (PCNSL) is a rare malignancy that usually arises in the context of severe immunosuppression but has incompletely understood etiology, limiting effective treatments. CASE DESCRIPTION: We present the case of an 81-year-old immunocompetent man who developed a PCNSL in the right temporal lobe, at the site of a remote episode of herpes simplex virus (HSV) encephalitis 8 years prior. There are numerous viruses with known oncogenic associations; however, to our knowledge, this is the first reported case of PCNSL with an antecedent HSV infection. CONCLUSIONS: We discuss this case in the context of our current understandings of the pathogenesis of HSV encephalitis and PCNSL and postulate mechanisms through which the 2 could be associated.

A novel scale for describing visual outcomes in patients following resection of lesions affecting the optic apparatus: the Unified Visual Function Scale.

OBJECTIVEHistorically, descriptions of visual acuity and visual field change following intracranial procedures have been very rudimentary. Clinicians and researchers have often used basic descriptions, such as "improved," "worsened," and "unchanged," to describe outcomes following resections of tumors affecting the optic apparatus. These descriptors are vague, difficult to quantify, and challenging to apply in a clinical perspective. Several groups have attempted to combine visual acuity and visual fields into a single assessment score, but these are not user-friendly. The authors present a novel way to describe a patient's visual function as a combination of visual acuity and visual field assessment that is simple to use and can be used by surgeons and researchers to gauge visual outcomes following tumor resection.METHODSVisual acuity and visual fields were combined into 3 categories designed around the definitions of legal blindness and fitness to drive in Canada. The authors then applied the scale (the Unified Visual Function Scale, or UVFS) to their previously published case series of perisellar meningiomas to document and test overall visual outcomes for patients undergoing tumor resection. The results were compared with previously documented visual loss scales in the literature.RESULTSUsing the UVFS the authors were able to capture the overall visual change; the scale was sensitive enough to define the overall visual improvement or worsening quantitatively, using categories that are clinically relevant and understandable.CONCLUSIONSThe UVFS is a robust way to assess a patient's vision, combining visual fields and acuity. The implementation of pre- and postoperative assessment is sensitive enough to assess overall change while also providing clinically relevant information for surgeons, and allows for comparisons between treatment groups.

Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Systematic Review and Meta-Analysis.

BACKGROUND: Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of this systematic review and meta-analysis is to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts. METHODS: A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes. RESULTS: Eleven studies (with 283 patients) met our inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%). Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features. CONCLUSIONS: The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes.

Prevention and Treatment of Hyponatremia in Patients with Subarachnoid Hemorrhage: A Systematic Review.

BACKGROUND: Current guidelines for the management of hyponatremia in patients with subarachnoid hemorrhage (SAH) are not based on a systematic assessment of the literature. We evaluated published studies on the efficacy and safety of current preventative and treatment strategies for hyponatremia in patients with SAH. METHODS: We searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PubMed for relevant studies. Primary outcomes of interest included neurologic functional outcomes, symptomatic vasospasm, and others. Secondary outcomes included measures of sodium and volume status. RESULTS: We included 5 out of 117 identified studies: 1 before-and-after observational trial (using fludrocortisone) and 4 randomized controlled trials (2 using fludrocortisone; 2 using hydrocortisone). All 5 trials had a high risk of bias in at least 1 domain. We could not perform a meta-analysis of functional outcomes; however, individual studies did not demonstrate statistically significant differences. Mineralocorticoid use did not statistically significantly reduce the incidence of symptomatic vasospasm (relative risk, 0.60; 95% confidence interval, 0.35-1.03; I2 = 0%). The studies did not report other primary outcomes. In the 4 RCTs, mineralocorticoid use reduced natriuresis and volume contraction. CONCLUSIONS: Current evidence does not demonstrate a benefit of preventative treatment with mineralocorticoids in clinically important outcomes, although a difference cannot be ruled out due to imprecision. Larger well-designed trials are needed to establish the impact of mineralocorticoids and fluid and sodium supplementation strategies on clinically relevant outcomes in the prevention and treatment of hyponatremia in patients with SAH.

Effects of an alveolar recruitment maneuver on subdural pressure, brain swelling, and mean arterial pressure in patients undergoing supratentorial tumour resection: a randomized crossover study.

PURPOSE: Although recruitment maneuvers have been advocated as part of a lung protective ventilation strategy, their effects on cerebral physiology during elective neurosurgery are unknown. Our objectives were to determine the effects of an alveolar recruitment maneuver on subdural pressure (SDP), brain relaxation score (BRS), and cerebral perfusion pressure among patients undergoing supratentorial tumour resection. METHODS: In this prospective crossover study, patients scheduled for resection of a supratentorial brain tumour were randomized to undergo either a recruitment maneuver (30 cm of water for 30 sec) or a "sham" maneuver (5 cm of water for 30 sec), followed by the alternative intervention after a 90-sec equilibration period. Subdural pressure was measured through a dural perforation following opening of the cranium. Subdural pressure and mean arterial pressure (MAP) were recorded continuously. The blinded neurosurgeon provided a BRS at baseline and at the end of each intervention. During each treatment, the changes in SDP, BRS, and MAP were compared. RESULTS: Twenty-one patients underwent the study procedure. The increase in SDP was higher during the recruitment maneuver than during the sham maneuver (difference, 3.9 mmHg; 95% confidence interval [CI], 2.2 to 5.6; P < 0.001). Mean arterial pressure decreased further in the recruitment maneuver than in the sham maneuver (difference, -9.0 mmHg; 95% CI, -12.5 to -5.6; P < 0.001). Cerebral perfusion pressure decreased 14 mmHg (95% CI, 4 to 24) during the recruitment maneuver. The BRS did not change with either maneuver. CONCLUSION: Our results suggest that recruitment maneuvers increase subdural pressure and reduce cerebral perfusion pressure, although the clinical importance of these findings is thus far unknown. This trial was registered with ClinicalTrials.gov, NCT02093117.

Nicotine replacement therapy in patients with aneurysmal subarachnoid hemorrhage: Systematic review of the literature, and survey of Canadian practice.

Tobacco smoke increases the risk of aneurysmal subarachnoid hemorrhage (SAH), as well as complications such as vasospasm. Most patients presenting with aneurysmal SAH smoke, and many survivors continue to smoke after discharge. Neurosurgeons often hesitate to use nicotine replacement therapy (NRT) during hospitalization of patients with SAH due to concerns of inducing vasospasm. We aimed to evaluate the safety and efficacy, and patterns of use of NRT in smokers hospitalized for SAH. We performed a systematic review of MEDLINE, CENTRAL, Embase, and unpublished sources of literature to October 2016 for randomized and observational studies comparing exposure to non-exposure of smoking cessation products in the acute phase of aneurysmal SAH. Additionally, we surveyed 50 Canadian vascular neurosurgeons to evaluate patterns of NRT use in SAH. Four cohort studies (n=1210) met our eligibility criteria. Three studies enrolled patients with aneurysmal SAH, and one study enrolled all neurocritically ill patients. We rated the quality of evidence as very low using the GRADE approach. We could not meta-analyze studies due to methodological heterogeneity. Individual studies reported beneficial or neutral effects of NRT on functional outcome, death, and clinical or radiographic vasospasm. None of the studies assessed long-term abstinence from tobacco. Of the 14 vascular neurosurgeons responding to our survey, most never used NRT in patients hospitalized with SAH, often citing training or standard of practice as the reason. Current evidence suggests that NRT does not induce vasospasm, and is associated with improved outcomes in smokers hospitalized for SAH. Protocol registered in PROSPERO, available at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016037200.