Ventricular Migration of Vitreous Silicone Oil Masquerading as a Ruptured Colloid Cyst.

The ventricular migration of vitreous silicone oil (SiO) is rare and can easily be mistaken for intraventricular hemorrhage or a ruptured colloid cyst. We report here the case of an adult male who was misdiagnosed with a ruptured colloid cyst and was subsequently found to have ventricular migration of vitreous SiO. A 57-year-old male presented unresponsive following a respiratory arrest and underwent a head computed tomography (CT) scan that demonstrated multiple ovoid hyperdensities in the ventricular system, which was concerning for a ruptured colloid cyst. He was transferred to our institution for neurosurgical evaluation. Magnetic resonance imaging (MRI) was performed and demonstrated widespread abnormal diffusion restriction throughout the cortex and basal ganglia, consistent with anoxic brain injury secondary to hypoxic respiratory arrest. The MRI also demonstrated an abnormal signal in areas corresponding with the previously identified intraventricular lesions, which did not layer posteriorly. Given that the MRI sequence signals of the lesions in the ventricular system matched perfectly with the signals of the somewhat deflated SiO within the globe, these multiple ovoid lesions on imaging were most consistent with the migration of SiO from the vitreous body of the right globe into the ventricular system. This case demonstrates a diagnostic error that can occur in emergent settings because of the broad differential diagnosis for cerebral ventricular hyperdensities. A ruptured colloid cyst was considered the reason for transfer, with the anticipation of neurosurgical intervention, but further imaging demonstrated that this was an incidental finding in this patient who presented in extremis. Awareness of this rare clinical condition can prevent overutilization of resources and unnecessary interventions.

Neurosurgery at Baylor Scott & White Health: Recent History and a Decade of Neurosurgery Residency Training.

Neurosurgery at Baylor Scott & White Memorial Hospital in Temple, Texas began as a division in the Department of Surgery many decades ago. The hospital has long served as the flagship tertiary referral center for the Baylor Scott & White healthcare system, which merged in 2013 with Baylor University Medical Center, a hospital system based in Dallas. It is now the largest non-profit hospital system as well as the most awarded hospital system by the US News and World Report within the state of Texas. The Department of Neurosurgery was established at Baylor Scott & White Memorial Hospital in the 2006-2007 academic year. Between then and 2014, four neurosurgeons served as department chair or interim chair: Dr. Robert Buchanan, Dr. Gerhard Friehs, Dr. Ibrahim El Nihum, and Dr. David Garrett Jr. In 2014, Dr. Jason Huang was appointed chairman after a national search and established the neurosurgery residency program in 2015. The department has undergone tremendous growth under the leadership of Dr. Huang, and the residency program is a priority of the department. Surgical excellence is honed at primarily three campuses: Baylor Scott & White Memorial Hospital, Baylor Scott & White McLane Children's Medical Center, and Baylor Scott & White Medical Center - Hillcrest. In this editorial, we provide a brief history of the institution, a recent history of the neurosurgical presence at Baylor Scott & White Memorial Hospital in Temple, Texas, and briefly describe the program's future directions under the continued leadership of Dr. Jason Huang.

Exploring Spinal Subarachnoid Hemorrhage: A Neurosurgical Case Series.

Spinal subarachnoid hemorrhage (SSAH) is a rare condition that can cause spinal cord or nerve root compression and permanent neurologic damage. The reported etiologies include trauma, vascular malformations or aneurysms, coagulopathies, neoplasms, autoimmune disease, and spontaneous hemorrhage. If there is evidence of neurologic deterioration, it is commonly managed as a surgical emergency, but cases of conservative management have also been reported. In this case series, we present three patients who suffered from SSAH. The first was a spontaneous cervical SSAH that occurred following cardiac catheterization, the second was a spontaneous thoracolumbar SSAH in a patient with a known history of coagulopathy, and the third was a thoracolumbar SSAH that was caused by a dural arteriovenous fistula (dAVF). All three patients exhibited neurologic deficits and thus underwent emergent decompression and hematoma evacuation. The patient with the dAVF also required open ligation of the fistula. Following surgical intervention, all three patients regained at least partial neurologic function, but one patient developed symptomatic arachnoid cysts that required further intervention. The presented case series highlights the importance and time-sensitivity of surgical decompression in patients experiencing neurologic deficits from SSAH. These cases underscore the urgency of timely neurosurgical intervention to mitigate neurologic impairment and add insights to the existing literature on this rare condition.

Cerebral Fat Embolism Syndrome in a Patient With an Aortic Dissection and Orthopedic Injuries: A Case Report.

Traumatic brain injury is a significant cause of morbidity and mortality in adults and can be associated with severe secondary complications, including post-traumatic cerebral infarction. One potential cause of post-traumatic cerebral infarction is cerebral fat embolism syndrome (FES). We present a case in which a male in his twenties was involved in a motorcycle collision with a truck. He sustained numerous injuries, including bilateral femur fractures, left acetabular, open left tibial and fibular fractures, and a type A aortic dissection. Before orthopedic fixation, his Glasgow Coma Score (GCS) was 10. Following open reduction and internal fixation, his GCS was noted to be 4, with a stable computed tomography scan of the head. The differential included embolic strokes related to his dissection, an unrecognized cervical spine injury, and cerebral FES. Stat magnetic resonance imaging of the head demonstrated a starfield pattern of restricted diffusion consistent with cerebral FES. An intracranial pressure (ICP) monitor was placed, and his ICP acutely spiked to over 100 mmHg despite maximal medical management. This case highlights several key learning points, namely, that cerebral FES should remain in the mind of any physician treating high-energy multisystem traumas. While it is a rare syndrome, its effects can lead to significant morbidity and mortality as treatment is controversial and can conflict with the treatment of other systemic injuries. Further research into prevention and treatment is warranted to continue optimizing outcomes following cerebral FES.

The effects of aneurysmal subarachnoid hemorrhage on cerebral vessel diameter and flow velocity.

BACKGROUND: Transcranial Doppler flow velocity is used to monitor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Generally, blood flow velocities appear inversely related to the square of vessel diameter representing local fluid dynamics. However, studies of flow velocity-diameter relationships are few, and may identify vessels for which diameter changes are better correlated with Doppler velocity. We therefore studied a large retrospective cohort with concurrent transcranial Doppler velocities and angiographic vessel diameters. METHODS: This is a single-site, retrospective, cohort study of adult patients with aneurysmal subarachnoid hemorrhage, approved by the UT Southwestern Medical Center Institutional Review Board. Study inclusion required transcranial Doppler measurements within 1.1, R2>0.9). Furthermore, velocity and diameter changed (P<0.033) consistent with the signature time course of cerebral vasospasm. CONCLUSIONS: These results suggest that middle cerebral artery velocity-diameter relationships are most influenced by local fluid dynamics, which supports these vessels as preferred endpoints in Doppler detection of cerebral vasospasm. Other vessels showed less influence of local fluid dynamics, pointing to greater role of factors outside the local vessel segment in determining flow velocity.

Delayed Symptomatic Entrapment and Herniation of Lumbar Nerve Root Due to a Prior Durotomy Defect Initially Misdiagnosed As Arachnoiditis: A Case Report.

Incidental durotomies are well-known complications of spine surgery. They are often identified and repaired intraoperatively, with a preference for primary rather than secondary repair. We present the case of a middle-aged male with worsening radicular pain six months after spinal surgery complicated by a durotomy defect. His pain was worse with coughing or standing. Magnetic resonance imaging identified an L3-L5 extradural fluid collection in the lumbar spinal canal and an empty sac sign. Computed tomography lumbar myelogram identified clumping of the cauda equina nerve roots at L2-L3 and an empty sac sign at L4-L5 and L5-S1, concerning adhesions and arachnoiditis. The patient's unusual worsening of symptoms and a history of a durotomy defect with secondary repair led to suspicion of an alternative cause. Surgical exploration identified the left L5 nerve root herniated through the durotomy defect. Reduction of the nerve root herniation with primary repair of the durotomy was performed, and the patient experienced immediate relief that was stable at his one-month follow-up. This case features an unusual presentation of a delayed herniated nerve root through a prior durotomy defect with entrapment. We highlight the importance of a high degree of caution in cases of increased radicular pain following spinal surgery with a known durotomy, particularly when symptoms do not support the clinical presentation of arachnoiditis. Additionally, primary repair of durotomies should be undertaken whenever possible to avoid this potential complication.

Ad26.COV2.S Vaccine-Induced Thrombocytopenia Leading to Dural Sinus Thrombosis and Intracranial Hemorrhage Requiring Hemicraniectomy: A Case Report and Systematic Review.

The coronavirus disease 2019 (COVID-19) pandemic has claimed nearly 5.5 million lives worldwide. Adenovirus-based vaccines are safe and effective, but they are rarely associated with vaccine-induced thrombosis and thrombocytopenia (VITT) as well as cerebral venous sinus thrombosis (CVST). We conducted a systematic literature search of intracerebral hemorrhage (ICH) secondary to CVST associated with VITT from the Ad26.COV2.S vaccine, and we present the first case of this pathology in the reviewed literature of a patient who required neurosurgical decompression. The systematic literature review was completed on December 19, 2021, by searching PubMed and Ovid for articles with primary data on CVST associated with VITT following the Ad26.COV2.S vaccine. We also specifically searched for cases that required neurosurgical intervention. Articles were independently screened by two authors, and both secondary and tertiary searches were done as well. Descriptive statistics were collected and presented in table form. Nine studies were identified that met inclusion criteria. There were no cases identified of patients who underwent neurosurgical decompression after developing this pathology. We thus present the first case in the reviewed literature of a patient who developed ICH after receiving the Ad26.COV2.S vaccine and underwent decompressive hemicraniectomy. Despite severe thrombocytopenia and prolonged intensive care, the patient was discharged to neurorehabilitation. There is a much greater risk of CVST and ICH during COVID-19 infections than from the vaccines. However, as booster vaccines are approved and widely distributed, it is critical to make prompt, accurate diagnoses of this vaccine-related complication and consider neurosurgical decompression.

Endoscopic Endonasal versus Transcranial Optic Canal Decompression: A Morphometric, Cadaveric Study.

Introduction Decompression of the optic nerve within the optic canal is indicated for compressive visual decline. The two most common approaches utilized for optic canal decompression are a medial approach with an endoscopic endonasal approach and a lateral approach with a craniotomy. Our study is a cadaveric anatomical study comparing the length and circumference of the orbit decompressed via an endoscopic endonasal approach versus a frontotemporal craniotomy. Methods Five cadaveric specimens were utilized. Predissection computed tomography (CT) scans were performed on each specimen. On each specimen, a standard frontotemporal craniotomy with anterior clinoidectomy and superolateral orbital decompression was performed on one side and an endoscopic endonasal approach with medial wall decompression was performed on the contralateral side. Post-dissection CT scans were performed. An independent radiologist provided measurements of the length (mm) and circumference (degrees) of optic canal decompression bilaterally. Results The mean length of optic canal decompression for open and endoscopic approach was 13 mm (range 12-15 mm) and 12.4 mm (range 10-16 mm), respectively. The mean circumference of decompression for open and endoscopic approaches was 252.8 degrees (range 205-280 degrees) and 124.6 degrees (range 100-163 degrees), respectively. Conclusion The endoscopic endonasal and the transcranial approaches provide a similar length of optic canal decompression, but the transcranial approach leads to greater circumferential decompression. The endoscopic endonasal approach has the benefit of being minimally invasive, though. Ultimately, the surgical approach decision should be based on the location of the pathology and the surgeon's comfort.

Safety of Contemporary Carotid Artery Stenting and Associated Risk Factors for Treatment of Carotid Artery Stenosis.

BACKGROUND: The prevalence of carotid artery atherosclerosis and stroke is increasing. Carotid artery stenting (CAS), which treats carotid artery stenosis and prevents strokes, has benefited from advances in techniques and technology. In this study, we aimed to identify significant risk factors for major complications following contemporary CAS. METHODS: Utilizing the National Surgical Quality Improvement Program registry, we investigated individuals who underwent CAS between the years 2015-2018. Multivariable logistic regression was performed to identify risk factors associated with stroke, myocardial infarction (MI), and death within 30 days of CAS. RESULTS: Of the 770 patients within the National Surgical Quality Improvement Program registry who met study criteria, 3.2% experienced strokes, 1.6% experienced MIs, and 2.2% died within 30 days of CAS. A total of 6.1% of patients experienced any of these major complications. Of the 395 asymptomatic patients, 3.5% suffered a stroke, 1.5% experienced an MI, and 1.0% died for a total of 5.6% patients suffering from any event. Of the 375 symptomatic patients, there were 2.9% strokes, 1.6% MIs, and 3.5% deaths with 6.7% suffering any event. Age, race, and hyponatremia were significantly associated with stroke, and hyponatremia was associated with MI. Age, anemia, hypoalbuminemia, international normalized ratio, and emergency case were associated with death. CONCLUSIONS: These results suggest that preoperative risk stratification of CAS patients may not be straightforward as each adverse event has its own risk factors, precluding a generalized CAS risk stratification scoring system from being created. This paper can aid in patient selection for CAS by highlighting risk factors in modern CAS.

Lateral Ventricle Solitary Fibrous Tumor: A Case Report and Review of the Literature.

Solitary fibrous tumors (SFTs) are rare tumors thought to be of mesenchymal origin. Even though intracranial, especially intraventricular, SFTs are rare, this diagnosis should be considered in the differential for intraventricular lesions. Here, report the case of a female in her 60s who underwent a non-contrast-enhanced magnetic resonance imaging scan of the brain for new-onset memory issues and headache which revealed a well-circumscribed intraventricular lesion in the right lateral ventricle with vasogenic edema, trapping of the temporal horn, and subfalcine herniation. She was admitted and started on dexamethasone prior to surgical treatment of the tumor. A right-sided superior parietal lobule approach was utilized to reach and resect the lesion. Histopathology was consistent with World Health Organization grade I SFT. Only 10 other cases of lateral ventricular SFTs have been reported in the literature. Intraventricular SFT is a rare diagnosis, and, as such, the literature on this topic mostly consists of case reports. Although the lesion is benign, metastases have been reported, and thus, gross total resection remains the standard of care. This case adds to the paucity of SFTs reported in the literature.

Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers.

OBJECT: Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI). METHODS: A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05. RESULTS: A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate. CONCLUSIONS: The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

Does endovascular therapy change outcomes in nonagenarians with acute ischemic stroke?

BACKGROUND: Ischemic strokes can be devastating for elderly patients, and randomized control trials of mechanical thrombectomy have shown encouraging results. We present the first analysis of clinical outcomes in nonagenarians with acute ischemic stroke treated with best medical therapy compared to endovascular revascularization therapy. METHODS: A retrospective analysis was performed on 42 patients 90 years or older who were treated for acute ischemic stroke. Modified Rankin scores were calculated immediately post-injury, at discharge, and at 30 days and 90 days following discharge. Student's t-test and Wald tests were performed to evaluate whether endovascular treatment was associated with modified Rankin Score improvement at discharge, 30 days, or 90 days after discharge. RESULTS: Follow-up data were available for 32/42 (76%) and 20/42 (48%) patients at 30 and 90 days after discharge, respectively. 8/9 (89%) patients who underwent endovascular treatment reached Thrombolysis in Cerebral Infarction scale 2b or better with no procedural complications. 12/42 (29%) patients, including four who underwent endovascular treatment, were discharged to hospice or deceased. No significant differences in modified Rankin Score improvement were observed between the endovascular and medical management groups at discharge (p = 0.96), at 30 days (p = 0.63), or at 90 days (p = 0.96). CONCLUSIONS: Our analysis shows that revascularization therapy is a safe treatment, but it was not associated with improved functional status in nonagenarians with acute ischemic stroke. Endovascular therapy shows promise, and larger prospective studies are necessary to assess the benefits of revascularization therapy in the elderly population.

Biplane Fluoroscopic-Guided Percutaneous Thoracic Instrumentation: A Technical Note.

Biplane fluoroscopy in a hybrid operating room (OR) is commonly used for neuroendovascular and hybrid open/endovascular cases. The image quality is far superior to most C-arm fluoroscopy machines in the regular OR. This advantage can be particularly useful for upper and mid-thoracic percutaneous screw placement because the C-arm visualization in the regular OR is suboptimal due to shoulders absorbing the majority of the photons on lateral fluoroscopy. A 31-year-old man was ejected following a motor vehicle accident and sustained a T7 burst fracture with anterior translation on T8 and spinal cord transection. Following stabilization in the intensive care unit, the patient was taken to the biplane hybrid OR for percutaneous pedicle screw fixation. The patient had percutaneous instrumentation and fixation of T5-T10, and sequential reducers were also used to re-align T7 and T8. The use of biplane fluoroscopy enhanced safety and visualization. The patient tolerated the procedure well without complication. We believe this is an unrealized and underutilized function of a biplane hybrid OR that bears further investigation and study.

Tumoral Mimics of Subdural Hematomas: Case Report and Review of Diagnostic and Management Strategies in Primary B-Cell Lymphoma of the Subdural Space.

BACKGROUND: Subdural lymphomas are a rare subtype of primary central nervous system lymphomas that can radiographically mimic epidural blood and pose a diagnostic challenge. They can complicate treatment if not preemptively identified. METHODS: We present a case report of a subdural lymphoma that mimicked a compressive subdural hematoma, and we review the PubMed database for similar cases. RESULTS: A 77-year-old woman presented with a transient left facial droop and what appeared to be a subdural hematoma on computed tomography scan. The patient underwent surgery, during which grossly abnormal solid epicortical adherent tissue was noted instead of the expected appearance of a subdural hematoma. An intraoperative biopsy was suggestive of lymphoma, and the surgery was converted to a craniectomy. Pathology confirmed the diagnosis of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. The patient underwent radiotherapy with no complications or recurrence. Magnetic resonance imaging demonstrated complete resolution of the mass at 3 months after treatment, at which time the patient underwent a synthetic cranioplasty. Seven case reports of primary dural lymphomas mimicking subdural blood were found, with variable pathologic subclassifications. CONCLUSIONS: Although rare, a primary dural lymphoma can be mistaken for a subdural hematoma on computed tomography scan. The most common subtype is low-grade extranodal marginal zone lymphomas. It is important to keep these diseases in the differential diagnosis, especially when there is incongruence between imaging and the clinical picture, as earlier detection correlates to a stronger therapeutic response.

Biplane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note.

BACKGROUND: The classic percutaneous technique used to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomic structures, such as the distal cervical internal carotid artery, at risk. OBJECTIVE: To use fixed anatomic landmarks to safely and reliably locate the foramen ovale on anteroposterior (AP) fluoroscopy. METHODS: Locating the foramen ovale was initially tested using AP fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures in patients with trigeminal neuralgia. This technique has been successfully used in multiple patients. In this report, we describe our technique in detail. RESULTS: The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided. CONCLUSION: Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.

Retrieval of an Intracranially Migrated Dental Injection Needle Through the Foramen Ovale: 2-Dimensional Operative Video.

Dental injection needle migration is a rare complication of orthodontal procedures. When these needles fracture, they typically dislodge into the cervical space or the facial musculature. Migration into the cranial vault is difficult because of the obstacle created by the skull base. We report a rare case of intracranial migration of an anesthetic injection needle through the foramen ovale. A 59-yr-old man underwent the extraction of a right maxillary molar. The distal end of a 25-gauge injection needle broke into his pterygoid musculature, causing him pain while chewing. Vascular imaging obtained after a computed tomography scan of his face showed that the needle had migrated, potentially because of his efforts of mastication, and had traversed the foramen ovale into the middle cranial fossa. The patient started experiencing intermittent right facial numbness, likely due to compression or injury to the right trigeminal nerve. Our oral and maxillofacial colleagues did not believe that the needle could be retrieved from its facial end. The patient elected to undergo the recovery of the needle through a craniotomy given the fact that the object was contaminated and because he was becoming increasingly symptomatic. A right pterional craniotomy was planned. Extradural dissection was performed until the dura going into the foramen ovale was revealed. We could feel the metallic needle under the dural sheath of the trigeminal nerve. The dura was opened sharply directly over the needle. We then proceeded to mobilize the needle into the face, and then pulled it out completely through the craniotomy to avoid injury to the temporal lobe. The patient recovered well and was asymptomatic at the time of discharge. This case report was written in compliance with our institutional ethical review board. Institutional review board (IRB) approval and patient consent were waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern (UTSW) IRB.

The Use of Prone Magnetic Resonance Imaging to Rule Out Tethered Cord in Patients With Structural Spine Anomalies: A Diagnostic Technical Note for Surgical Decision-making.

Tethered cord syndrome (TCS) is a clinical diagnosis that can be difficult to establish, as symptoms do not always match classic radiological findings, such as a low-lying conus. Surgery for spinal detethering is not without risk and does not always result in clinical improvement. Prone magnetic resonance imaging (MRI) has been described as a tool to assess the mobility of the spine. This is a technical imaging report where prone imaging was a factor that influenced the decision to defer surgery in favor of conservative management. T1 and T2 sagittal and T1 axial MRI imaging were obtained with the patient supine, and then repeated in the prone position. An anteroposterior conus movement of >10% of the canal width was considered normal. There was significant anterior movement of the conus when switching to the prone position. Surgery was deferred, and the patient improved after a regimen of intensive physical therapy. Prone MRI can be a useful tool to have in our neurosurgical armamentarium when assessing spinal cord tethering. Surgery is not recommended when normal anteroposterior movement of the conus is present.

Intradural Juvenile Xanthogranuloma with Involvement of Multiple Nerve Roots: A Case Report and Review of the Literature.

BACKGROUND: Juvenile xanthogranuloma (JXG) is a rare, non-Langerhans cell histiocytic disorder that primarily presents as multiple cutaneous lesions in young males. Solitary lesions in the spinal column are an especially rare presentation of this disease, and central nervous system involvement can portend a poor prognosis. We report an unusual case of an adult woman with an unresectable JXG of the lumbar spine. A review of the reported cases of thoracolumbar JXG and the current data regarding diagnosis and treatment are presented. CASE DESCRIPTION: A 28-year-old woman presented with back pain and worsening lower extremity pain, numbness, and weakness. Magnetic resonance imaging demonstrated an enhancing lumbar mass. However, at surgery, no discrete mass was identified. Multiple roots were grossly enlarged, and electrical stimulation identified the L4 root with the most abnormal findings. Despite an attempt at debulking, most of the mass could not be safely removed. The patient experienced incomplete improvement of the symptoms postoperatively but elected to forgo chemotherapy. The 3-month follow-up imaging study showed active lumbar spinal disease, and imaging and follow-up examinations at 27 months revealed no changes. Her symptoms were satisfactorily controlled with conservative therapy. CONCLUSIONS: JXG of the spine is a rare disease with nonspecific clinical and radiographic findings that can make it difficult to diagnose and dictates the use of immunohistochemical staining. If possible, total surgical resection will offer the best outcomes; however, other modalities such as chemotherapy can be viable alternatives or adjuvant modalities.

Delayed treatment of ruptured brain AVMs: is it ok to wait?

OBJECTIVE Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.

The utility of bioactive coils in the embolization of aneurysms.

There has been an exponential growth in the endovascular treatment of intracranial aneurysms over the past three decades and it is now the primary mode of treatment in the cerebrovascular community. Despite the proven safety and efficacy of bare platinum coils, criticism of the durability of endovascular coiling with respect to traditional open surgical clipping persists. In order to overcome this criticism, several newer generations of coils have been introduced with the purpose of enhancing the durability of the initial endovascular treatment. These 'bioactive' coils have an additional material [polyglycolic acid (PGA), polyglycolic/polylactic acid (PGLA), or hydrogel)] added to the bare platinum coil in order to induce an inflammatory response and/or increase packing density within the aneurysm. While comparable safety profiles have been proven, a review of the multiple trials and clinical series published on this topic provides no clear evidence to suggest that the current bioactive coil iterations provide any sustained benefit over bare platinum coils.