The correlation between intracranial pressure and venous sinus pressures changes after venous sinus stenting.

BACKGROUND: The pathophysiology of idiopathic intracranial hypertension (IIH) and other cerebral venous outflow disorders (CVD) has largely been unexplored. While a correlation between venous sinus pressure and opening pressure (OP) has been previously noted, there are limited data on this relationship in patients with prior venous sinus stenting (VSS). METHODS: A single center retrospective chart review was conducted on CVD patients who underwent diagnostic cerebral venography with manometry followed immediately by lateral decubitus lumbar puncture, from 2016 to 2024. RESULTS: 206 patients underwent 216 total procedures and were included. Among all patients, there was a moderate nearly one-to-one correlation between OP and torcular or superior sagittal sinus (SSS) pressures. Thirty-two patients underwent testing after having undergone VSS. Patients with previous VSS showed a significantly altered relationship between venous pressures and OP, whereby as venous sinus pressures increased, OP increased more gradually in previously stented patients compared with non-stented patients. For example, when OP was fixed at 21 mm Hg and body mass index at 30 kg/m2, predicted mean SSS pressure was 19.47 mm Hg in non-stented patients versus 16.91 mm Hg in stented patients. CONCLUSION: This study confirmed a strong relationship between OP and venous sinus pressure in CVD patients. However, patients with previous VSS demonstrated an altered relationship with higher CSF pressures relative to venous pressures compared with naïve patients. This finding may have important clinical implications in the management of IIH patients.

Medical malpractice claims and state medical board complaints among United States neurointerventionalists.

BACKGROUND: Surgeons are at high risk for malpractice claims, which can significantly impact physician quality of life and risk of burnout. There are few published data reporting the incidence, outcomes, and repercussions of malpractice lawsuits on neurointerventionalists. METHODS: A survey of senior members of the United States Society of Neurointerventional Surgery (SNIS) was performed to study malpractice litigation and medical board complaints. RESULTS: In total, 173 responses were obtained. Of the total sample, 66 respondents (38.2%) reported being subject to a total of 84 malpractice claims during independent practice over the last 10 years, amounting to a malpractice claim annual incidence of 5.9% (84 cases per 1423 years of practice). The majority of claims involved either brain aneurysms (34.5%) or arteriovenous malformations (23.8%), with most alleging either intra-procedural (38.1%) or post-procedural (27.3%) complications. Only three of the 58 claims that had concluded ended in court settlements (5.2%). The majority (78.3%) of claims resulted in no consequences to physician practice. Fourteen respondents (8.1%) reported being subject to a total of 16 state medical board complaints over the previous decade, with most resulting in no significant repercussions. CONCLUSION: Malpractice claims are common among neurointerventionalists and often cause significant physician distress, yet most result in claims being dropped or no paid damages, and the majority conclude without practice repercussions for the named physicians.

Intensive care unit admission is not necessary after venous sinus stenting.

BACKGROUND: Venous sinus stenting (VSS) has emerged as a safe and effective treatment option for idiopathic intracranial hypertension. Many physicians routinely admit patients to the intensive care unit (ICU) for close monitoring, but little data exists on whether this is necessary. METHODS: Electronic medical records of consecutive patients who underwent VSS by the senior author from 2016 to 2022 at a single center were reviewed. RESULTS: 214 patients were included. The mean (SD) age was 35.5 (11.6) and 196 (91.6%) patients were female. A total of 166 (77.6%) patients underwent transverse sinus stenting alone; 9 (4.2%) underwent superior sagittal sinus (SSS) stenting alone, 37 (17.3) concomitant transverse and SSS stenting, and 2 (0.9%) underwent stenting at alternate sites. All patients were planned admission to the regular ward (27.6%) or day hospital (72.4%). Twenty (9.3%) patients were discharged to home the same day as the procedure and 182 (85%) patients were discharged the following day. Major periprocedural complications were identified in 2 (0.93%) patients and minor complications were identified in 16 (7.4%). Only one patient with a subdural hematoma identified in the post-anesthesia care unit (PACU) had care escalated to the ICU. No severe complications were identified after the PACU stay. During the next 48 hours after discharge, 4 (1.9%) patients returned to any emergency room to be evaluated without requiring readmission. CONCLUSION: Routine ICU admission following uncomplicated VSS is unnecessary. Overnight admission to a low-acuity ward, or even same-day discharge in select patients, appears to be a safe and cost-effective strategy.

Coil embolization alone appears sufficient for middle meningeal artery embolization.

BACKGROUND: Middle meningeal artery embolization (MMAE) has shown promise as an alternative treatment for chronic subdural hematoma (cSDH); however, the most effective procedural technique is debated. We sought to assess the safety and efficacy of coil embolization as a stand-alone technique for MMAE in cSDH. METHODS: A single-center retrospective analysis was performed of patients who underwent MMAE for chronic SDH with coil embolization alone. RESULTS: Forty-five patients were included in the study. All underwent successful stand-alone coil MMAE, of which 51.1% were bilateral. Indications for MMAE were varied, but 13.3% of patients required ongoing anticoagulation and another 11.1% had severe thrombocytopenia. Conscious sedation or no sedation was used in 73.2% of patients; 10 patients (22.2%) were scheduled electively and discharged same day. There were no severe or minor procedural complications identified. Of the 45 patients, only 3 (6.6%) underwent unplanned repeat surgical intervention: one patient developed a large recurrence at eight weeks after MMAE and underwent burr hole drainage; the second patient received burr hole drainage prior to MMAE but needed repeat burr hole drainage two weeks later due to residual; the third patient received two burr hole drainages at two and three weeks post MMAE due to persistent disease. CONCLUSION: Stand-alone MMAE with coiling can be performed under conscious sedation as an outpatient procedure and may be sufficient to prevent cSDH recurrence in most cases without the need for particle penetration of cSDH microvascular beds. Larger confirmatory studies are necessary.

A descriptive study of venous pressures and gradients while awake and both pre- and post-stent under anesthesia in patients with idiopathic intracranial hypertension.

BACKGROUND: This study aims to explore factors that affect venous sinus pressures and associated gradients while awake and under general anesthesia (GA) both before and after venous sinus stenting (VSS) in patients with idiopathic intracranial hypertension (IIH). METHODS: A retrospective analysis was performed examining pressures and gradients in patients with IIH having undergone awake venography followed by VSS under GA. RESULTS: 174 patients were included. Compared with awake, GA superior sagittal sinus (SSS) pressures were 2.6 mmHg lower (p=0.01) resulting in a total cranial gradient reduction of 2.5 mmHg (p=0.002). The transverse-sigmoid gradient, the most commonly stented segment, did not differ under the two conditions (p=0.30). Regression analyses demonstrated that body mass index, gender, blood pressure, and end-tidal carbon dioxide content significantly affected venous pressures (all p<0.05). After stenting, mean total cranial gradients decreased by 13.2 mmHg while skull base gradients increased by 0.8 mmHg. Stenting resulted in an 84% mean reduction in the target gradient and a mean decrease in SSS pressures by 78% of the target gradient. When cardiopulmonary and anesthetic factors were optimized, GA had a limited effect on the target gradient in most patients (p=0.88). CONCLUSIONS: This study is the largest series to date to report on cerebral venous pressure measurements and gradients recorded while awake and under GA both before and after VSS for IIH. In a well-controlled cardiorespiratory and anesthetic setting, GA venography may provide information that is not substantially inequivalent to that obtained while awake.

Applying to residency: survey of neurosurgical residency applicants on virtual recruitment during COVID-19.

OBJECTIVE: The COVID-19 pandemic caused a significant disruption to residency recruitment, including a sudden, comprehensive transition to virtual interviews. The authors sought to characterize applicant experiences and perceptions concerning the change in the application, interview, and match process for neurological surgery residency during the 2020-2021 recruitment cycle. METHODS: A national survey of neurosurgical residency applicants from the 2020-2021 application cycle was performed. This survey was developed in cooperation with the Society of Neurological Surgeons (SNS) and the American Association of Neurological Surgeons Young Neurosurgeons Committee (YNC) and sent to all applicants (n = 280) who included academic video submissions to the SNS repository as part of their application package. These 280 applicants accounted for 69.6% of the total 402 neurosurgical applicants this year. RESULTS: Nearly half of the applicants responded to the survey (44.3%, 124 of 280). Applicants favored additional reform of the interview scheduling process, including a centralized scheduling method, a set of standardized release dates for interview invitations, and interview caps for applicants. Less than 8% of students desired a virtual-only platform in the future, though the majority of applicants supported incorporating virtual interviews as part of the process to contain applicant costs and combining them with traditional in-person interview opportunities. Program culture and fit, as well as clinical and research opportunities in subspecialty areas, were the most important factors applicants used to rank programs. However, subjective program "fit" was deemed challenging to assess during virtual-only interviews. CONCLUSIONS: Neurosurgery resident applicants identified standardized interview invitation release dates, centralized interview scheduling methods, caps on the number of interviews available to each candidate, and regulated opportunities for both virtual and in-person recruitment as measures that could significantly improve the applicant experience during and effectiveness of future neurosurgery residency application cycles. Applicants prioritized program culture and "fit" during recruitment, and a majority were open to incorporating virtual elements into future cycles to reduce costs while retaining in-person opportunities to gauge programs and their locations.

Genome Sequences of Gordonia Phages Bowser and Schwabeltier.

Gordonia phages Bowser and Schwabeltier are newly isolated phages infecting Gordonia terrae 3612. Bowser and Schwabeltier have similar siphoviral morphologies and their genomes are related to each other, but not to other phages. Their lysis cassettes are atypically situated among virion tail genes, and Bowser encodes two tyrosine integrases.