Long-term outcomes of hospitalized patients with SARS-CoV-2/COVID-19 with and without neurological involvement: 3-year follow-up assessment.

BACKGROUND: Acute neurological manifestation is a common complication of acute Coronavirus Disease 2019 (COVID-19) disease. This retrospective cohort study investigated the 3-year outcomes of patients with and without significant neurological manifestations during initial COVID-19 hospitalization. METHODS AND FINDINGS: Patients hospitalized for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection between 03/01/2020 and 4/16/2020 in the Montefiore Health System in the Bronx, an epicenter of the early pandemic, were included. Follow-up data was captured up to 01/23/2023 (3 years post-COVID-19). This cohort consisted of 414 patients with COVID-19 with significant neurological manifestations and 1,199 propensity-matched patients (for age and COVID-19 severity score) with COVID-19 without neurological manifestations. Neurological involvement during the acute phase included acute stroke, new or recrudescent seizures, anatomic brain lesions, presence of altered mentation with evidence for impaired cognition or arousal, and neuro-COVID-19 complex (headache, anosmia, ageusia, chemesthesis, vertigo, presyncope, paresthesias, cranial nerve abnormalities, ataxia, dysautonomia, and skeletal muscle injury with normal orientation and arousal signs). There were no significant group differences in female sex composition (44.93% versus 48.21%, p = 0.249), ICU and IMV status, white, not Hispanic (6.52% versus 7.84%, p = 0.380), and Hispanic (33.57% versus 38.20%, p = 0.093), except black non-Hispanic (42.51% versus 36.03%, p = 0.019). Primary outcomes were mortality, stroke, heart attack, major adverse cardiovascular events (MACE), reinfection, and hospital readmission post-discharge. Secondary outcomes were neuroimaging findings (hemorrhage, active and prior stroke, mass effect, microhemorrhages, white matter changes, microvascular disease (MVD), and volume loss). More patients in the neurological cohort were discharged to acute rehabilitation (10.39% versus 3.34%, p < 0.001) or skilled nursing facilities (35.75% versus 25.35%, p < 0.001) and fewer to home (50.24% versus 66.64%, p < 0.001) than matched controls. Incidence of readmission for any reason (65.70% versus 60.72%, p = 0.036), stroke (6.28% versus 2.34%, p < 0.001), and MACE (20.53% versus 16.51%, p = 0.032) was higher in the neurological cohort post-discharge. Per Kaplan-Meier univariate survival curve analysis, such patients in the neurological cohort were more likely to die post-discharge compared to controls (hazard ratio: 2.346, (95% confidence interval (CI) [1.586, 3.470]; p < 0.001)). Across both cohorts, the major causes of death post-discharge were heart disease (13.79% neurological, 15.38% control), sepsis (8.63%, 17.58%), influenza and pneumonia (13.79%, 9.89%), COVID-19 (10.34%, 7.69%), and acute respiratory distress syndrome (ARDS) (10.34%, 6.59%). Factors associated with mortality after leaving the hospital involved the neurological cohort (odds ratio (OR): 1.802 (95% CI [1.237, 2.608]; p = 0.002)), discharge disposition (OR: 1.508 (95% CI [1.276, 1.775]; p < 0.001)), congestive heart failure (OR: 2.281 (95% CI [1.429, 3.593]; p < 0.001)), higher COVID-19 severity score (OR: 1.177 (95% CI [1.062, 1.304]; p = 0.002)), and older age (OR: 1.027 (95% CI [1.010, 1.044]; p = 0.002)). There were no group differences in radiological findings, except that the neurological cohort showed significantly more age-adjusted brain volume loss (p = 0.045) than controls. The study's patient cohort was limited to patients infected with COVID-19 during the first wave of the pandemic, when hospitals were overburdened, vaccines were not yet available, and treatments were limited. Patient profiles might differ when interrogating subsequent waves. CONCLUSIONS: Patients with COVID-19 with neurological manifestations had worse long-term outcomes compared to matched controls. These findings raise awareness and the need for closer monitoring and timely interventions for patients with COVID-19 with neurological manifestations, as their disease course involving initial neurological manifestations is associated with enhanced morbidity and mortality.

Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial. METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data. RESULTS: A total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others. CONCLUSION: VSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.

Prediction of delayed cerebral ischemia followed aneurysmal subarachnoid hemorrhage. A machine-learning based study.

INTRODUCTION: Delayed Cerebral Ischemia (DCI) is a significant complication following aneurysmal subarachnoid hemorrhage (aSAH) that can lead to poor outcomes. Machine learning techniques have shown promise in predicting DCI and improving risk stratification. METHODS: In this study, we aimed to develop machine learning models to predict the occurrence of DCI in patients with aSAH. Patient data, including various clinical variables and co-factors, were collected. Six different machine learning models, including logistic regression, multilayer perceptron, decision tree, random forest, gradient boosting machine, and extreme gradient boosting (XGB), were trained and evaluated using performance metrics such as accuracy, area under the curve (AUC), precision, recall, and F1 score. RESULTS: After data augmentation, the random forest model demonstrated the best performance, with an AUC of 0.85. The multilayer perceptron neural network model achieved an accuracy of 0.93 and an F1 score of 0.85, making it the best performing model. The presence of positive clinical vasospasm was identified as the most important feature for predicting DCI. CONCLUSIONS: Our study highlights the potential of machine learning models in predicting the occurrence of DCI in patients with aSAH. The multilayer perceptron model showed excellent performance, indicating its utility in risk stratification and clinical decision-making. However, further validation and refinement of the models are necessary to ensure their generalizability and applicability in real-world settings. Machine learning techniques have the potential to enhance patient care and improve outcomes in aSAH, but their implementation should be accompanied by careful evaluation and validation.

Metal allergy and neurovascular stenting: A systematic review.

BACKGROUND: Intracranial stents and flow diverters contain significant amounts of metals, notably nickel, which can cause allergic reactions in a considerable portion of the population. These allergic responses may lead to complications like in-stent stenosis (ISS) and TIA/Stroke in patients receiving stents or flow diverters for intracranial aneurysms. METHODS: We conducted a systematic review of studies from inception until July 2023, which reported outcomes of patients with metal allergy undergoing neurovascular stenting. The skin patch test was used to group patients into those with positive, negative, or absent patch test results but with a known history of metal allergy. RESULTS: Our review included seven studies with a total of 39 patients. Among them, 87% had a history of metal allergy before treatment. Most aneurysms (89%) were in the anterior circulation and the rest (11%) were in the posterior circulation. Skin patch tests were performed in 59% of patients, with 24% showing positive results and 33% negative. Incidental ISS was observed in 18% of patients, and the rate of TIA/Stroke was reported in 21%. The pooled rates of ISS and TIA/Stroke were higher in the first group (43% and 38%) compared to the second (18% and 9%) and third groups (15% and 15%), but these differences were not statistically significant. CONCLUSIONS: The current neurosurgical literature does not provide a conclusive association between metal allergy and increased complications among patients undergoing neurovascular stenting. Further studies are necessary to gain a more comprehensive understanding of this topic.

Balloon-assisted U-turn Technique to Access Cortical Vein for Transvenous Embolization of Mixed Dural-pial Arteriovenous Malformation.

Cerebral arteriovenous malformations can be classified into pure pial, mixed dural-pial, and pure dural types. Mixed pial-dural AVMs (DPAVM) are rare and often receive blood supply from dural meningeal arteries, including branches of the internal carotid, external carotid, and vertebral arteries.1- 6 DPAVMs, which are usually large and complex, require delicate endovascular and surgical treatment methods. The cure rate is low, and recurrence is very common, leading to high morbidity and mortality. In this case video, we present a case of PDAVM that recurred after initial endovascular onyx embolization, requiring additional endovascular coiling which resulted in obliteration of the DPAVM.

WEB for recurrent aneurysms: a case series to review technical nuances.

Recurrent intracranial aneurysms (IAs) often present with more complex morphology such as irregular shape, shallow height, and wide neck, which can make for challenging endovascular treatments.1 Initial rupture and interventions are associated with fibrotic changes and considerable alteration in the aneurysm configuration, which limits retreatment options and increases the risk of complications during retreatment.2 The Woven Endobridge (WEB) embolization device has demonstrated high efficacy, flexibility, and safety for the treatment of wide-neck bifurcation IAs, including ruptured and recurrent IAs, as shown in multiple retrospective studies and meta-analyses.3-8 Due to its optimal barrel shape, the WEB device is useful in the setting of previously treated aneurysms, particularly with wide-neck previously coiled aneurysms.1 9 10 In this technical video of four cases (video 1), we describe the technical nuances of WEB embolization for recurrent IAs, which were initially either coiled or clipped and demonstrated progressive growth with a wide-neck presentation on follow-up. neurintsurg;16/3/226/V1F1V1Video 1Management of recurrent intracranial aneurysms via WEB: This video describes four recurrent intracranial aneurysms, which were initially either coiled or clipped but demonstrated progressive growth with a wide-neck presentation on follow-up. All cases were successfully treated via WEB.

Exploring the Validity and Reliability of Neurosurgery Residency Program Rankings: A Quantitative Analysis.

OBJECTIVE: To evaluate the relationships between Doximity rankings (Doximity, Inc.) of residency programs and 2 new ranking systems based on publication rates and academic pursuits. METHODS: We collected data on 550 neurosurgery graduates over 3 years. We analyzed the median number of published manuscripts per resident and the percentage of residents pursuing academic careers and compared them across the Doximity Research Productivity and Reputation Rankings. We used logistic regression to evaluate the relationships among the rankings, publication rates, and academic pursuits. RESULTS: Neurosurgery residents published a median of 10 manuscripts per person (IQR: 6-17), and 50% (IQR: 33%-67%) of residents in a given program pursued an academic career. The distributions of the median number of published manuscripts across the Doximity Research Productivity Ranking and the Doximity Reputation Ranking tiers differed significantly (all P < 0.001). Similarly, the distribution of the percentage of residents pursuing an academic career across both published Doximity ranking systems' tiers differed significantly (all P = 0.02). Moreover, we found moderate agreement between the 2 Doximity rankings, fair agreement between the publication and the other 3 rankings, and slight agreement between the academic pursuit and the Doximity rankings. CONCLUSIONS: We introduced 2 new methods to rank residency programs based on the number of graduates pursuing an academic position and the median number of published manuscripts per resident. By taking a comprehensive approach, neurosurgery applicants can ensure that they select a residency program that meets their needs and offers them the best opportunity for success.

Current Understanding of Moyamoya Disease (MMD) and Associated Neuropsychiatric Outcomes.

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by the progressive narrowing and occlusion of the intracranial internal carotid arteries, leading to the formation of abnormal collateral vessels. MMD primarily affects the cerebrovascular system, and evidence suggests it is associated with various neuropsychiatric outcomes. This manuscript aims to provide an overview of the current understanding of MMD, including its epidemiology, pathophysiology, clinical manifestations, and diagnosis. Furthermore, it explores the emerging research on the neuropsychiatric sequelae of MMD, such as cognitive impairment, psychiatric disorders, and quality of life. The manuscript concludes with the challenges in managing MMD-related neuropsychiatric outcomes and potential avenues for future research.

Is perioperative blood transfusion associated with postoperative thromboembolism or infection after metastatic spinal tumor surgery?

STUDY DESIGN: Retrospective cohort. SUMMARY OF BACKGROUND DATA: Patients with metastatic spine disease who undergo surgical intervention have a high risk of requiring red blood cell (RBC) transfusion. Perioperative transfusion has been independently associated with increased risk of venous thromboembolic (VTE) and infectious complications following orthopedic procedures and degenerative spinal intervention; however, literature within spine oncology is limited. OBJECTIVE: To determine the association between perioperative RBC transfusion and postoperative VTE or infection following spinal tumor surgery. METHODS: A total of 153 patients who underwent surgery for spinal metastases between April 2012 and April 2022 were included. Medical records were reviewed to identify RBC transfusion administered either intraoperatively or within 96 h following surgery. The primary endpoints were: 1) development of any VTE or 2) development of any infection within 30 days following surgery. Any VTE was defined as deep vein thrombosis or pulmonary embolism, and any infection was defined as pneumonia, meningitis, Clostridium difficile infection, urinary tract infection, surgical site infection, or sepsis. Logistic regression analyses were performed. RESULTS: Of the 153 patients included in the study, 43 % received a perioperative RBC transfusion. The overall incidence of postoperative VTE and infection was 15 % and 22 %, respectively. In univariate analysis, perioperative transfusion was not associated with postoperative VTE (odds ratio [OR] 2.41; 95 % confidence interval [CI] 0.97-6.00; p = 0.058) but was associated with infection (OR 3.02; 95 % CI 1.36-6.73; p = 0.007). After adjusting for confounders such as performance status, operative time, and surgical extent, transfusion was not associated with both VTE (OR 1.25; 95 % CI 0.36-4.32; p = 0.727) or infection (OR 1.86; 95 % CI 0.70-4.92; p = 0.210). While not statistically significant, sub-analyses demonstrated a trend towards increased VTE incidence in patients requiring transfusion earlier (within 24 h) as opposed to later postoperatively. CONCLUSIONS: We found that perioperative transfusion was not an independent predictor of 30-day postoperative VTE or infection in patients undergoing metastatic spinal surgery. Further exploration of time-dependent transfusion outcomes is warranted.

Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage.

Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.

Endovascular Embolization of Basilar Artery Fenestration Aneurysms: A 21-Year Institutional Case Series.

BACKGROUND AND OBJECTIVES: Basilar artery fenestration is a rare phenomenon sometimes associated with basilar artery fenestration aneurysms (BAFAs). This review investigates the natural history and management outcomes of BAFAs and describes the outcomes of BAFAs treated with embolization. METHODS: A single-center database was queried for all cases of endovascular BAFA treatment. Data on complications, clinical and angiographic outcomes, and retreatment rates were collected. RESULTS: Seventeen aneurysms across 17 patients were treated. The mean (SD) age was 56 (13) years, and 15 (88%) patients were women. Among 15 aneurysms with data available, 2 arose from the fenestration limbs and 13 from both limbs and the vertebral artery. Of 16 aneurysmal projections available, 7 projected anteriorly, 7 posteriorly, and 2 superiorly. Among 17 patients, balloon-assisted coiling was the most common treatment (n = 10), followed by primary coiling (n = 3), stent-assisted coiling (n = 2), coiling with flow diversion (n = 1), and balloon-assisted coiling and flow diversion (n = 1). Complications noted in 5 patients included hemorrhage, thromboembolism, paresthesias, vasospasm, and transient hemiparesis. Among 16 patients with postoperative results available, 12 showed favorable clinical outcomes, 3 were disabled, and 1 died. The rates of postoperative complete (Raymond-Roy Occlusion Classification 1) and incomplete (Raymond-Roy Occlusion Classification 2 and 3) occlusion among 15 patients with available data were 6 and 9, respectively. CONCLUSION: Endovascular management of these rare aneurysms is feasible and safe, with high rates of favorable radiographic and clinical outcomes. This series reflects a general preference toward coiling and stent-assisted coiling, although flow diversion may be considered in select cases.

Morphological characteristics of brain aneurysms among age groups.

BACKGROUND: Patient's age is an important factor in determining the risk of aneurysm rupture. However, there is limited data on how aneurysm morphology differs among age groups. We studied morphological characteristics of brain aneurysms among age groups in a large cohort. METHODS: Aneurysms from the Stroke Thrombectomy and Aneurysm Registry (STAR) were analyzed. The following parameters were included: location, size, neck, width, height, aspect ratio, and regular versus irregular morphology. The risk of rupture presentation was estimated using logistic regression. RESULTS: A total of 1407 unruptured and 607 ruptured saccular aneurysms were included. The most common locations of ruptured aneurysms in patients younger than 70 years-old were the middle cerebral artery (MCA) and the anterior communicating artery (ACOM). The most common location of ruptured aneurysms in patients older than 70 years-old were the posterior communicating artery (PCOM) and ACOM. The size of unruptured aneurysms increased with age (p < .001). Conversely, the size of ruptured aneurysms was similar among age groups (p = .142). Unruptured and ruptured aneurysms became more irregular at presentation with older age (p < .001 and p .025, respectively). Irregular morphology and location were associated with rupture status across all age groups in multivariate regression. CONCLUSIONS: Younger patients have small unruptured and ruptured aneurysms, and ruptured aneurysms are mostly located in the MCA and ACOM. Older patients have larger and more irregular unruptured aneurysms, and ruptured aneurysms are mostly located in the PCOM and ACOM. An irregular morphology increases the risk of rupture in all age groups.

The impact of interaction between verteporfin and yes-associated protein 1/transcriptional coactivator with PDZ-binding motif-TEA domain pathway on the progression of isocitrate dehydrogenase wild-type glioblastoma.

Verteporfin and 5-ALA are used for visualizing malignant tissue components in different body tumors and as photodynamic therapy in treating isocitrate dehydrogenase (IDH) wild-type glioblastoma (GBM). Additionally, verteporfin interferes with Yes-associated protein 1 (YAP)/Transcriptional coactivator with PDZ-binding motif - TEA domain (TAZ-TEAD) pathway, thus inhibiting the downstream effect of these oncogenes and reducing the malignant properties of GBM. Animal studies have shown verteporfin to be successful in increasing survival rates, which have led to the conduction of phase 1 and 2 clinical trials to further investigate its efficacy in treating GBM. In this article, we aimed to review the novel mechanism of verteporfin's action, the impact of its interaction with YAP/TAZ-TEAD, its effect on glioblastoma stem cells, and its role in inducing ferroptosis.

Competitive neurosurgery residency programs: Predictors of matching outcome and research productivity.

OBJECTIVE: The aim of this study was to provide a comprehensive assessment of preresidency research and school as predictors of competitive neurosurgery matching and to assess for any correlations between preresidency and intraresidency research productivity. METHODS: Individuals who graduated from US neurosurgery programs from 2018 through 2020 were assessed for medical school, degree (MD, DO, or PhD), preresidency versus intraresidency publications, author order, article type, and neurosurgery matching outcomes. RESULTS: Medical school ranking (top 50) and the number of published papers (≥3) before intern year were predictors for matching to a top-25 residency program after adjusting for other covariates (p < 0.001, p = 0.002, respectively). On average, individuals who published more papers before residency published more papers during residency. For the comprehensive clinical papers category, there was a significant difference between individuals from the top 25 residency programs and others, with a stronger correlation between the number of preresidency publications and intraresidency publications for neurosurgeons who attended a top-25 residency program (r = 0.378 and r = 0.179, respectively; p = 0.02). CONCLUSION: Medical school ranking and research productivity as measured by the number of published papers were independently associated with matching to the top 25 residency programs. In addition, high research productivity in the preresidency years was associated with continued productivity during residency, especially in the category of comprehensive clinical papers.

Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours.

BACKGROUND AND PURPOSE: Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). METHODS: This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). RESULTS: Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0-2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence. CONCLUSION: In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients' age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.

Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry.

BACKGROUND: Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE: To investigate factors that predict MTF. METHODS: This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF (

Spinal Dorsal Intradural Arteriovenous Fistulas: Natural History, Imaging, and Management.

In this review, we describe the pathophysiology, diagnosis, and treatment of spinal dorsal intradural arteriovenous fistulas (DI-AVFs), focusing on novel research areas. DI-AVFs compose the most common subgroup of spinal arteriovenous lesions and most commonly involve the thoracic spine, followed by lumbar and sacral segments. The pathogenesis underlying DI-AVFs is an area of emerging understanding, thought to be attributable to venous congestion and hypertension that precipitate ascending myelopathy. Patients with DI-AVFs typically present with motor, sensory, or urinary dysfunction, although a wide swath of other less common symptoms has been reported. DI-AVFs can be subdivided by spinal region, which in turn is associated with 4 distinct clinical phenotypes: craniocervical junction (CCJ), subaxial cervical, thoracic, and lumbosacral. Patients with CCJ and lumbosacral DI-AVFs have particularly interesting presentations and treatment considerations. High-value diagnostic findings on MRI include flow voids, missing-piece sign, and T2-weighted intramedullary hyperintensity. However, digital subtraction angiography is the gold standard for diagnosis and localization of DI-AVFs and for definitive treatment planning. Surgical disconnection of DI-AVFs is almost universally curative and frontline treatment, especially for CCJ and lumbosacral DI-AVFs. Endovascular techniques evolve in promising ways, such as improved visualization, distal access, and liquid embolic techniques. The pathophysiology of DI-AVFs is better understood using newly identified radiologic diagnostic markers. Despite new techniques and devices introduced in the endovascular field, surgery remains the gold-standard treatment for DI-AVFs.

Novel Immunotherapeutic Approaches for the Treatment of Glioblastoma.

Glioblastoma is highly aggressive and remains difficult to treat despite being the most common malignant primary brain tumor in adults. Current standard-of-care treatment calls for maximum resection of the tumor mass followed by concurrent chemotherapy and radiotherapy and further adjuvant chemotherapy if necessary. Despite this regimen, prognosis remains grim. Immunotherapy has shown promising success in a variety of solid tumor types, but efficacy in glioblastoma is yet to be demonstrated. Barriers to the success of immunotherapy in glioblastoma include: a heterogeneous tumor cell population, a highly immunosuppressive microenvironment, and the blood-brain barrier, to name a few. Several immunotherapeutic approaches are actively being investigated and developed to overcome these limitations. In this review, we present different classes of immunotherapy targeting glioblastoma, their most recent results, and potential future directions.

Heart rate and heart rate variability during diagnostic and interventional neuroendovascular procedures.

INTRODUCTION: Heart rate variability (HRV) reflects the activity of the autonomic nervous system (ANS) and can be used as a potential predictor of stress-related cardiovascular diseases. This study aimed to assess whether physical and mental strain during the performance of cerebral endovascular procedure influence time-domain HRV parameters in operating surgeon. MATERIALS AND METHODS: Heart rate (HR) and HRV metrics were measured using a HR sensor chest strap before, during, and after neuroendovascular interventions performed by a single neurosurgeon. Three consecutive data series were reported by recording time domain: before procedure, during and after performing endovascular procedures. HR and HRV parameters were recorded during diagnostic and interventional neuroendovascular procedures. HR and HRV measures were analyzed by procedure type and recording time domain. RESULTS: HRV measures of a single endovascular neurosurgeon were recorded during 50 procedures. The median intraprocedural HRV score was the lowest and the median HR was the highest (HRV: 52, HR: 89 bpm) compared to preprocedural (HRV: 59, HR: 70 bpm) and postprocedural cardiovascular measures (HRV: 53, HR: 79, bpm, p < 0.001). On univariate linear regression, a negative association of interventional procedures with lower intraprocedural (ß = -0.905, p = 0.001) and postprocedural (ß = -1.12, p < 0.001) HRV scores compared to the diagnostic procedures was noted. CONCLUSIONS: HRV is a reliable tool to measure cardiovascular and mental stress. Interventional neuro-endovascular procedures seem to negatively impact the cardiovascular measures of neurointerventionalists. Further longitudinal studies utilizing HRV are warranted to address their long-term effects on the mental health of physicians.