Thrombectomy using Zoom Reperfusion System in pediatric acute ischemic strokes: Case series and literature review.

INTRODUCTION: Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in adult mechanical thrombectomies (MTs) but has not been described in pediatrics. We present two cases of a 14-year-old with acute right middle cerebral artery (MCA) syndrome and a 10-year old with acute left MCA syndrome who underwent MT using Zoom Reperfusion System safely with TICI 2B and TICI 3 recanalization, respectively. METHOD: Case report and literature review. RESULTS: A 14-year-old healthy boy with right supraclinoid internal carotid artery (ICA) occlusion (case 1) and a 10-year-old boy with left hypoplastic heart syndrome and left ICA terminus occlusion (case 2) were taken for MT after receiving alteplase at our institution. Through femoral access, an 8-French sheath was introduced into the right femoral artery through which a Zoom 88 catheter was introduced and parked at the right petrous ICA segment in case 1 and left ophthalmic ICA segment in case 2. Angiogram demonstrated complete ICA occlusion just past the ophthalmic artery origin in case 1 and at the ICA terminus in case 2. Zoom system (88 and 71) was then navigated to the face of clot with vacuum manifold engaged with the clot. TICI 2B (with the help of Trevo stent retriever [Stryker]) and TICI 3 recanalization were achieved in cases 1 and 2, respectively. CONCLUSION: The use of Zoom reperfusion system could potentially be feasible for use in pediatric age group. Larger pediatric patient population is needed to establish its safety.

Cangrelor for neurointerventional procedures: A systematic review.

Thromboembolism is a complication of neurointerventional procedures that requires patients to be placed under antiplatelet therapy. Current options for antiplatelet therapies have a delayed onset of action that prevents a rapid door to puncture transition for patents presenting in acute settings. Cangrelor (Kengreal, Chiesi, USA) is an intravenous P2Y12 platelet inhibitor approved in percutaneous coronary interventions that has an immediate onset of action and half-life between 2 and 6 min. Thus, the goal of this study is to report on the safety, effectiveness, and indications for using Cangrelor in neurointerventional procedures. A systematic review of studies describing the use of Cangrelor in neurointervention was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was conducted on PubMed, Ovid Medline, and Embase databases through June 2023. Seventeen studies with 314 patients met inclusion criteria. The most common indication for Cangrelor use was acute ischemic strokes: 70% followed by aneurysms 27.4%. The Infusion protocol varied from 5 to 30 µg/kg bolus and 1 to 4 µg/kg/min infusion with 30 µg/kg bolus and 4 µg/kg/min infusion being reported in 64.7% of studies. Intra-operative platelet reacting unit levels were below 200 in all the studies that reported it, and the percentage of hemorrhagic, thromboembolic, and deaths occurrence in this patient cohort was respectively 11.1%, 4.8%, and 8.6%. Cangrelor appears to be a promising P2Y12 platelet inhibitor for neurointerventional procedures. However, large, randomized trials are needed to determine the full range of its effects in neurointerventional procedures.

Degenerative cervical myelopathy: establishing severity thresholds for neuromotor dysfunction in the aging spine using the NIH Toolbox Assessment Scale.

Degenerative cervical myelopathy (DCM) is a leading cause of age-related non-traumatic spinal cord disorders resulting from chronic degeneration of the cervical spine. While traditional clinical assessments rely on patient-reported measures, this study used the NIH Toolbox Motor Battery (NIHTBm) as an objective, quantitative measure to determine DCM severity. The objective is to define NIHTBm cutoff values that can accurately classify the severity of DCM neuromotor dysfunction. A case-controlled pilot study of patients with DCM and age-matched controls. The focus was an in-depth quantitative motor assessment using the NIHTBm to understand the severity of neuromotor deficits due to degenerative spine disease. Motor assessments, dexterity, grip strength, balance, and gait speed were measured in 45 DCM patients and 37 age-matched healthy subjects (HC). Receiver operating curve (ROC) analysis determined cutoff values for mild and moderate-to-severe myelopathy which were validated by comparing motor assessment scores with disability scores. The ROC curves identified thresholds for mild dexterity impairment (T-score range 38.4 - 33.5, AUC 0.77), moderate-to-severe dexterity impairment (< 33.5, AUC 0.70), mild grip strength impairment (47.4 - 32.0, AUC 0.80), moderate-to-severe grip strength impairment (< 32.0, AUC 0.75), mild balance impairment (36.4 - 33.0, AUC 0.61), and moderate-to-severe balance impairment (< 33.0, AUC 0.78). Mild gait speed impairment was defined as 0.78-0.6 m/sec (AUC 0.65), while moderate-to-severe gait speed impairment was < 0.6 m/sec (AUC 0.65). The NIHTB motor score cutoff points correlated negatively with the DCM neck disability index (NDI) and showed balance and dexterity measures as independent indicators of DCM dysfunction. The use of NIHTB allows for precise delineation of DCM severity by establishing cutoff values corresponding to mild and moderate-to-severe myelopathy. The use of NIHTB in DCM allows enhanced clinical precision, enabling clinicians to better pinpoint specific motor deficits in DCM and other neurological disorders with motor deficits, including stroke and traumatic brain injury (TBI). Furthermore, the utility of objective assessment, NIHTB, allows us to gain a better understanding of the heterogeneity of DCM, which will enhance treatment strategies. This study serves as a foundation for future research to facilitate the discovery of innovative treatment strategies for DCM and other neurological conditions.

Ruptured vertebrobasilar junction aneurysm supplied by reversed flow from the anterior spinal artery: Illustrative case report.

BACKGROUND AND IMPORTANCE: In patients with vertebral artery (VA) occlusion, spontaneous flow reversal may occur in the anterior spinal artery (ASA) as a source of compensatory supply to the posterior circulation. Turbulent flow and increased flux through these small arteries may predispose to luminal damage and intracranial aneurysm formation. We report a novel case of a ruptured ASA-VA junction aneurysm in a patient with chronic bilateral VA occlusion, successfully treated with endovascular embolization. CLINICAL PRESENTATION: A 62-year-old female with uncontrolled hypertension presented with acute-onset headache, emesis, neck stiffness, and decreased level of consciousness. Head computed tomography demonstrated diffuse cisternal subarachnoid hemorrhage with intraventricular extension and ventriculomegaly. Computed tomography angiography showed left VA atresia and chronic right VA occlusion just distal to the posterior inferior cerebellar artery origin, as well as a complex, bilobed aneurysm at the ASA-VA junction. Angiography demonstrated flow reversal from the ASA into the distal stump of the occluded right VA, which in turn filled the aneurysm. Of note, the patient's posterior circulation was predominantly supplied by the dilated ASA, and associated collaterals from ASA and right VA stump. The aneurysm was accessed and embolized using superselective microcatheterization over a soft microguidewire through the right cervical VA perforators supplying retrograde flow into and through the ASA. CONCLUSION: ASA-VA aneurysms are exceedingly rare, and generally associated with atypical flow dynamics. Dynamic treatment strategies may be needed, especially in the setting of subarachnoid hemorrhage.

Novel usage of everolimus-eluting coronary stent for intracranial atherosclerotic disease: a technical report and case series.

Objectives: This report describes the use of an Everolimus-eluting stent (Xience Skypoint stent) for the treatment of medically-refractory ICAD. Design: Retrospective, case-series. Setting: In-hospital patients. Participants: All patients in this report had a history of stroke secondary to ICAD. All patients failed aggressive medical treatments and had recurrence of symptoms despite anticoagulation or dual-antiplatelet therapy plus a statin. Diagnostic angiogram in each case showed severe vessel stenosis, therefore patients were recommended for intracranial artery stenting. Main outcome measures: Technical feasibility of deploying Xience Skypoint stent for treatmet of ICAD. Results: The Xience Skypoint stent was safely and effectively deployed in the vertebral artery (x1) and the internal carotid artery (x2) using trans-ulnar (x1), trans-radial (x1), and trans-femoral (x1) approaches without the use of an intermediate catheter. Conclusion: Second-generation EES such as Xience Skypoint may be utilized for treatment of medically-refractory ICAD. This technical report serves as a proof of concept for further studies analysing long-term safety and efficacy of such stents for treatment of ICAD.

Isolating Neurologic Deficits in Cervical Spondylotic Myelopathy: A Case-Controlled Study, Using the NIH Toolbox Motor Battery.

Background and Objectives: Patients with cervical spondylotic myelopathy (CSM) have motor impairments, including weakness, imbalance, and loss of dexterity. The reliable assessment of these symptoms is critical for treatment decisions. This study aimed to determine, for the first time, the use of the NIH Toolbox motor battery (NIHTBm) in the objective assessment of motor deficits in patients with CSM. Methods: Patients with symptoms and MRI evidence of CSM and age-matched healthy controls (HC), with no evidence of spinal disorder or surgery were included in this case-control study based on our inclusion and exclusion criteria. We performed motor tests, dexterity, gait speed, grip strength, and balance tests, using the NIHTBm in patients with CSM and HCs. Motor impairment rates were determined in patients with CSM based on the NIHTBm scores. We determined the association between NIHTBm scores and patient-reported outcome scores; patient-reported outcome measures (the modified Japanese Orthopedic Association [mJOA] and Nurick grade) to determine the association. One-way analysis of variance was used to analyze group differences and the Spearman rank correlation to determine the relationship between assessment scores. Results: We enrolled 24 patients with CSM with a mean age (SD) of 57.96 (10.61) years and 24 age-matched HCs with a mean age (SD) of 53.17 (6.04) years in this study. Overall, we observed a significant decrease in the motor function T-scores mean (SD): dexterity 31.54 (14.82) vs 51.54 (9.72), grip strength 32.00 (17.47) vs 56.79 (8.46), balance 27.58 (16.65) vs 40.21 (6.35), and gait speed 0.64 (0.18) vs 0.99 (0.17) m/s, in patients with CSM compared with that in HCs. The lower extremity dysfunction scores on the NIHTBm, balance (ρ = -0.67) and gait speed (ρ = -0.62), were associated with higher Nurick grades. We observed a similar but weaker association with the Nurick grades and NIHTBm tests: dexterity (ρ = -0.49) and grip strength (ρ = -0.31) scores. The total motor mJOA showed a positive but weak association with NIHTBm scores, gait speed (ρ = 0.38), balance (ρ = 0.49), grip strength (ρ = 0.41), and dexterity (ρ = 0.45). Discussion: Patients with CSM had significantly lower NIHTBm scores compared with HCs. The results from the NIHTBm are consistent with the clinical presentation of CSM showing patients have motor impairments in both upper and lower extremities. As a neurologic-specific scale, NIHTBm should be used in the evaluation and clinical management of patients with CSM.

Platelet-Rich Plasma Injections: Pharmacological and Clinical Considerations in Pain Management.

PURPOSE OF REVIEW: Regenerative medicine through interventional pain procedures is evolving with data demonstrating efficacy for a number of pain states in recent years. Platelet-rich plasma (PRP), defined as a sample of plasma with a platelet concentration 3 to 5 times greater than the physiologic platelet concentration found in healthy whole blood, releases bioactive proteins which can restore anatomical function in degenerative states. PRP is dense in growth factors, such as platelet-derived growth factor, transforming growth factor-beta1, basic fibroblastic growth factor, vascular endothelial growth factor, and epidermal growth factors. RECENT FINDINGS: To date, well-designed case-control or cohort studies for the use of PRP have demonstrated efficacy in lumbar facet joint, lumbar epidural, and sacroiliac joint injections. At present, there is only level IV evidence indicating the need for larger and more carefully controlled prospective studies. PRP is utilized autogenously in order to facilitate healing and injection and has been studied in the long-term management of discogenic low back pain. In this regard, numerous studies have evaluated PRP to steroid injections in chronic pain states with favorable results. PRP represents an opportunity for a new strategy in the therapeutic treatment of degenerative states of spines, joints, and other locations throughout the body with evolving data demonstrating both safety and long-term efficacy.

Social Media Use Among Neurosurgery Trainees: A Survey of North American Training Programs.

BACKGROUND: Social media have revolutionized access to educational content. Given the extensive presence of social media, these platforms have the potential to influence neurosurgical training and education of residents and fellows. We explored the attitudes of neurosurgical trainees (postgraduate years 1-9) toward social media and their perceived influence on training and education. METHODS: This study was a survey of trainees at North American neurosurgery residency programs. A 22-item survey, including 2 free-text questions, was distributed through the Congress of Neurological Surgeons listserv. The survey consisted of questions regarding demographics, social media platform use, and trainee views on social media; their perceived impact on education and job performance was gauged using a 5-point Likert scale. Descriptive analysis was performed. RESULTS: The survey was disseminated to 1160 neurosurgery trainees, with a response rate of 15.3%. Of 178 respondents, 132 (74.2%) were men; 142 (79.8%) were 25-34 years old. All respondents used social media. The most commonly used platforms were Facebook (87.1%), followed by YouTube (84.3%), Instagram (81.5%), and Twitter (74.7%). The most common reasons for social media use were personal social (89.8%), networking (65.5%), and academic resources (65.0%); 113 respondents (63.5%) reported spending <25% of their time on social media for academics. The Neurosurgical Atlas (63.3%), Congress of Neurological Surgeons (11.2%), and American Association of Neurological Surgeons (10.1%) social media accounts were the most commonly used academic platforms. CONCLUSIONS: Social media use was ubiquitous among trainees. Although most used social media for personal social communication, most also used it for academic purposes.

Versatile use of catheter systems for deployment of the Pipeline embolization device: a comparison of biaxial and triaxial catheter systems.

BACKGROUND: A Pipeline embolization device (PED; Medtronic, Dublin, Ireland) can be deployed using either a biaxial or a triaxial catheter delivery system. OBJECTIVE: To compare the use of these two catheter delivery systems for intracranial aneurysm treatment with the PED. METHODS: A retrospective study of patients undergoing PED deployment with biaxial or triaxial catheter systems between 2014 and 2016 was conducted. Experienced neurointerventionalists performed the procedures. Patients who received multiple PEDs or adjunctive coils were excluded. The two groups were compared for PED deployment time, total fluoroscopy time, patient radiation exposure, complications, and cost. RESULTS: Eighty-two patients with 89 intracranial aneurysms were treated with one PED each. In 49 cases, PEDs were deployed using biaxial access; triaxial access was used in 33 cases. Time (min) from guide catheter run to PED deployment was significantly shorter in the biaxial group (24.0±18.7 vs 38.4±31.1, P=0.006) as was fluoroscopy time (28.8±23.0 vs 50.3±27.1, P=0.001). Peak radiation skin exposure (mGy) in the biaxial group was less than in the triaxial group (1243.7±808.2 vs 2074.6±1505.6, P=0.003). No statistically significant differences were observed in transient and permanent complication rates or modified Rankin Scale scores at 30 days. The triaxial access system cost more than the biaxial access system (average $3285 vs $1790, respectively). Occlusion rates at last follow-up (mean 6 months) were similar between the two systems (average 88.1%: biaxial, 89.2%: triaxial). CONCLUSION: Our results indicate near-equivalent safety and effectiveness between biaxial and triaxial approaches. Some reductions in cost and procedure time were noted with the biaxial system.

The Pipeline Embolization Device: Changes in Practice and Reduction of Complications in the Treatment of Anterior Circulation Aneurysms in a Multicenter Cohort.

BACKGROUND: The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. OBJECTIVE: To assess aneurysm occlusion and complication rates over time. METHODS: Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. RESULTS: A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P = .14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P = .1). CONCLUSION: We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.

Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.

OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.

Relationship of Grit and Resilience to Burnout Among U.S. Neurosurgery Residents.

INTRODUCTION: Studies have begun investigating grit (continued fortitude in the face of hardship) and resilience (ability to recover from a setback) and their relationship to burnout (emotional exhaustion [EE] caused by prolonged stress or frustration) within medicine. We investigated the prevalence of burnout among neurosurgery residents and aimed to determine the relationship among burnout, grit, and resilience. METHODS: We surveyed U.S. neurosurgical residents to perform a discretional analysis of prevalence of burnout. Multivariate analysis was performed to determine which variables were associated with higher and lower levels of EE, depersonalization (DP), personal accomplishment (PA), burnout, grit, and resilience. RESULTS: Of 1385 U.S. neurosurgery residents, 427 (30.8%) responded to our survey. Burnout prevalence was 33.0% (95% confidence interval, 28.6%-37.7%). High grit was associated with U.S. graduates (P = 0.006), married residents (P = 0.025), and fewer social/personal stressors (P = 0.003). Lower resilience was associated with female sex (P = 0.006), whereas higher resilience was associated with international medical graduates (P = 0.017) and fewer social/personal stressors (P = 0.005). High burnout was associated with greater social/personal stressors (P = 0.002), clinical rotations (P = 0.001), and lack of children (P = 0.016). There were positive correlations between EE and DP and among PA, grit, and resilience. There were negative correlations for EE and DP with PA, grit, and resilience and between grit/resilience and burnout. CONCLUSIONS: There is an inverse relationship between grit/resilience and burnout. Increased social/personal stressors are associated with increased levels of burnout and decreased grit and resilience. Grit and resilience are higher when social and personal stressors are decreased, indicating that these characteristics may fluctuate over time.

Accredited Endovascular Surgical Neuroradiology Programs: Current Specialty Composition and Academic Impact Using the h Index.

BACKGROUND: Concerns exist that neurosurgery might fail to lead the field of endovascular surgical neuroradiology (ESN), as other specialties are allowed to train and practice ESN. This study aimed to assess the current breakdown of specialties and their relative academic productivity in accredited ESN fellowship programs. METHODS: A list of fellowship programs was obtained from the Accreditation Council for Graduate Medical Education and Committee on Advanced Subspecialty Training directories. Primary specialty (i.e., residency) training for each faculty member in these programs was determined using information provided by the programs. A bibliometric search was performed for each member using Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA). Cumulative and ESN-specific h indices were calculated; h indices were compared between each specialty group and between international medical graduates and US medical graduates, regardless of specialty training. RESULTS: Thirty-one ESN fellowship programs with 88 faculty members were included. Neurosurgeons constituted 61.4% (n = 54) of the total ESN faculty, followed by radiologists with 30.7% (n = 27), and neurologists with 7.9% (n = 7). The mean ESN-specific h index for neurosurgery-trained ESN faculty was 16.2 ± 14.6 compared with 14.4 ± 10.9 for radiologists and 13.0 ± 12.6 for neurologists (P = 0.76). There were 12 IMGs and 76 USMGs. The mean ESN-specific h index was greater for IMGs than USMGs, 24.7 ± 14.3 versus 14.0 ± 12.7 (P = 0.008), respectively. CONCLUSIONS: Neurosurgery is leading the ESN field in numbers; however, the h index is not significantly different among ESN faculty based on primary training. The number of IMGs is relatively small, yet IMGs have significantly higher mean h indices.

Computer-Assisted Three-Dimensional Morphology Evaluation of Intracranial Aneurysms.

OBJECTIVE: Precise morphologic evaluation is important for intracranial aneurysm (IA) management. At present, clinicians manually measure the IA size and neck diameter on 2-dimensional (2D) digital subtraction angiographic (DSA) images and categorize the IA shape as regular or irregular on 3-dimensional (3D)-DSA images, which could result in inconsistency and bias. We investigated whether a computer-assisted 3D analytical approach could improve IA morphology assessment. METHODS: Five neurointerventionists evaluated the size, neck diameter, and shape of 39 IAs using current and computer-assisted 3D approaches. In the computer-assisted 3D approach, the size, neck diameter, and undulation index (UI, a shape irregularity metric) were extracted using semiautomated reconstruction of aneurysm geometry using 3D-DSA, followed by IA neck identification and computerized geometry assessment. RESULTS: The size and neck diameter measured using the manual 2D approach were smaller than computer-assisted 3D measurements by 2.01 mm (P < 0.001) and 1.85 mm (P < 0.001), respectively. Applying the definitions of small IAs (<7 mm) and narrow-necked IAs (<4 mm) from the reported data, interrater variation in manual 2D measurements resulted in inconsistent classification of the size of 14 IAs and the necks of 19 IAs. Visual inspection resulted in an inconsistent shape classification for 23 IAs among the raters. Greater consistency was achieved using the computer-assisted 3D approach for size (intraclass correlation coefficient [ICC], 1.00), neck measurements (ICC, 0.96), and shape quantification (UI; ICC, 0.94). CONCLUSIONS: Computer-assisted 3D morphology analysis can improve accuracy and consistency in measurements compared with manual 2D measurements. It can also more reliably quantify shape irregularity using the UI. Future application of computer-assisted analysis tools could help clinicians standardize morphology evaluations, leading to more consistent IA evaluations.

Pipeline embolization of posterior circulation aneurysms: a multicenter study of 131 aneurysms.

OBJECTIVE: Flow diversion for posterior circulation aneurysms performed using the Pipeline embolization device (PED) constitutes an increasingly common off-label use for otherwise untreatable aneurysms. The safety and efficacy of this treatment modality has not been assessed in a multicenter study. METHODS: A retrospective review of prospectively maintained databases at 8 academic institutions was performed for the years 2009 to 2016 to identify patients with posterior circulation aneurysms treated with PED placement. RESULTS: A total of 129 consecutive patients underwent 129 procedures to treat 131 aneurysms; 29 dissecting, 53 fusiform, and 49 saccular lesions were included. At a median follow-up of 11 months, complete and near-complete occlusion was recorded in 78.1%. Dissecting aneurysms had the highest occlusion rate and fusiform the lowest. Major complications were most frequent in fusiform aneurysms, whereas minor complications occurred most commonly in saccular aneurysms. In patients with saccular aneurysms, clopidogrel responders had a lower complication rate than did clopidogrel nonresponders. The majority of dissecting aneurysms were treated in the immediate or acute phase following subarachnoid hemorrhage, a circumstance that contributed to the highest mortality rate in those aneurysms. CONCLUSIONS: In the largest series to date, fusiform aneurysms were found to have the lowest occlusion rate and the highest frequency of major complications. Dissecting aneurysms, frequently treated in the setting of subarachnoid hemorrhage, occluded most often and had a low complication rate. Saccular aneurysms were associated with predominantly minor complications, particularly in clopidogrel nonresponders.

Flow Diversion for the Treatment of Basilar Apex Aneurysms.

BACKGROUND: Flow diversion for basilar apex aneurysms has rarely been reported. OBJECTIVE: To assess flow diversion for basilar apex aneurysms in a multicenter cohort. METHODS: Retrospective review of prospectively maintained databases at 8 academic institutions was performed from 2009 to 2016 to identify patients with basilar apex aneurysms treated with flow diversion. Clinical and radiographic data were analyzed. RESULTS: Sixteen consecutive patients (median age 54.5 yr) underwent 18 procedures to treat 16 basilar apex aneurysms with either the Pipeline Embolization Device (Medtronic Inc, Dublin, Ireland) or Flow Redirection Endoluminal Device (Microvention, Tustin, California). Five aneurysms (31.3%) were treated in the setting of subarachnoid hemorrhage. Seven aneurysms (43.8%) were treated with flow diversion alone, while 9 (56.2%) underwent flow diversion and adjunctive coiling. At a median follow-up of 6 mo, complete (100%) and near-complete (90%-99%) occlusion was noted in 11 (68.8%) aneurysms. Incomplete occlusion occurred more commonly in patients treated with flow diversion alone compared to those with adjunctive coiling. Patients with partial occlusion were significantly younger. Retreatment with an additional flow diverter and adjunctive coiling occurred in 2 aneurysms with wide necks. There was 1 mortality in a patient (6.3%) who experienced posterior cerebral artery and cerebellar strokes as well as subarachnoid hemorrhage after the placement of a flow diverter. Minor complications occurred in 2 patients (12.5%). CONCLUSION: Flow diversion for the treatment of basilar apex aneurysms results in acceptable occlusion rates in highly selected cases. Both primary flow diversion and rescue after failed clipping or coiling resulted in a modified Rankin Scale score that was either equal or better than at presentation and the technology represents a viable alternative or adjunctive option.

Mandatory Change From Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases: A Single-Center Experience With More Than 15 000 Patients.

BACKGROUND: Surgical site infections (SSIs) are noteworthy and costly complications. New recommendations from a national organization have urged the elimination of traditional surgeon's caps (surgical skull caps) and mandated the use of bouffant caps to prevent SSIs. OBJECTIVE: To report SSI rates for >15 000 class I (clean) surgical procedures 13 mo before and 13 mo after surgical skull caps were banned at a single site with 25 operating rooms. METHODS: SSI data were acquired from hospital infection control monthly summary reports from January 2014 to March 2016. Based on a change in hospital policy mandating obligatory use of bouffant caps since February 2015, data were categorized into nonbouffant and bouffant groups. Monthly and cumulative infection rates for 13 mo before (7513 patients) and 13 mo after (8446 patients) the policy implementation were collected and analyzed for the groups, respectively. RESULTS: An overall increase of 0.07% (0.77%-0.84%) in the cumulative rate of SSI in all class I operating room cases and of 0.03% (0.79%-0.82%) in the cumulative rate of SSI in all spinal procedures was noted. However, neither increase reached statistical significance (P > .05). The cumulative rate of SSI in neurosurgery craniotomy/craniectomy cases decreased from 0.95% to 0.75%; this was also not statistically significant (P = 1.00). CONCLUSION: National efforts at improving healthcare performance are laudable but need to be evidence based. Guidelines, especially when applied in a mandatory fashion, should be assessed for effectiveness. In this large, single-center series of patients undergoing class I surgical procedures, elimination of the traditional surgeon's cap did not reduce infection rates.

Neuroendovascular Fellowship Training: Self-Assessment of a Program Accredited by the Committee on Advanced Subspecialty Training.

The University at Buffalo's neuroendovascular fellowship is one of the longest running fellowship programs in North America. The burgeoning neurointerventional workforce and the rapid growth in the neurointerventional space on the heels of groundbreaking clinical trials prompted us to assess the fellowship's academic impact and its graduates' perceptions and productivity. An anonymized web-based survey was sent to all former neuroendovascular fellows with specific questions pertaining to current practice, research and funding, and perceptions about the fellowship's impact on their skills, competitiveness, and compensation. Additionally, the h-index was calculated to assess the academic productivity of each graduated fellow. Among 50 former fellows, 42 (84%) completed the survey. The fellows came from various countries, ethnic backgrounds, and specialties including neurosurgery (n = 39, 93%), neurology (n = 2, 5%), and neuroradiology (n = 1, 2%). Twenty (48%) respondents were currently chairs or directors of their practice. Most (n = 30, 71%) spent at least 10% of their time on research activities, with 27 (64%) receiving research funding. The median h-index of all 50 former fellows was 14. The biggest gains from the fellowship were reported to be improvement in endovascular skills (median = 10 on a scale of 0-10 [highest]) and increase in competitiveness for jobs in vascular neurosurgery (median = 10), followed by increase in academic productivity (median = 8), and knowledge of vascular disease (median = 8). In an era with open calls for moratoriums on endovascular fellowships, concerns over market saturation, and pleas to improve training, fellowship programs perhaps merit a more objective assessment. The effectiveness of a fellowship program may best be measured by the academic impact and leadership roles of former fellows.