Periprocedural management of ruptured blister aneurysms treated with pipeline flow diversion.

Background: Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation. Methods: A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado. Results: In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement. Conclusion: Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications.

Rapidly Progressive Contralateral Internal Carotid Artery Stenosis After COVID-19 Infection in a Down Syndrome Patient With Unilateral Moyamoya Arteriopathy.

Moyamoya arteriopathy is a condition where chronic, progressive stenosis of large intracranial arteries, primarily of the anterior circulation, results in ischemia and the growth of small, abnormal collateral vessels. There is increasing evidence that infectious pathologies, such as COVID-19, may serve as a sort of trigger, or "second hit," for the development of moyamoya arteriopathy. In this article, we present the case of a 13-year-old female with Down syndrome and unilateral moyamoya arteriopathy who developed contralateral internal carotid artery (ICA) dissection and thrombus in the setting of a positive COVID-19 test and subsequently developed rapidly progressive contralateral ICA and bilateral anterior cerebral artery (ACA) moyamoya-like stenosis. The rapidly progressive contralateral ICA and bilateral ACA moyamoya-like stenosis are likely multifactorial in nature. The contralateral ICA may have had a predisposition for injury and stenosis due to the preexisting moyamoya arteriopathy, making stenosis more likely after COVID-19-induced vascular inflammation and injury as well as after a possible thrombectomy-associated injury. Based on this presentation, patients with moyamoya arteriopathy may be at risk for rapid progression of their moyamoya pathology when exposed to catalysts, including infection, such as COVID-19, and vascular injury, such as thrombectomy-induced injury. In these circumstances, high suspicion and close monitoring are essential for addressing ischemia related to the stenosis before permanent injury.

Untangling the Modern Treatment Paradigm for Unruptured Brain Arteriovenous Malformations.

Brain arteriovenous malformations (AVMs) often present treatment challenges. Patients with unruptured AVMs must consider not only whether they want to be treated, but what treatment modality they would prefer. Vascular neurosurgeons, neurointerventional surgeons, and stereotactic radiosurgeons must in turn guide their patients through the most appropriate treatment course considering the risk of AVM rupture, an individual AVM's characteristics, and patient preferences. In this review we will look at how the clinical trial "A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)" has influenced the approach to unruptured brain AVMs and the treatment modalities available to clinicians to deal with these formidable lesions.

Tailored Treatment Options for Cerebral Cavernous Malformations.

The diagnosis and treatment of cerebral cavernous malformations (CCMs), or cavernomas, continues to evolve as more data and treatment modalities become available. Intervention is necessary when a lesion causes symptomatic neurologic deficits, seizures, or has high risk of continued hemorrhage. Future medical treatment directions may specifically target the pathogenesis of these lesions. This review highlights the importance of individualized treatment plans based on specific CCM characteristics.

A Retrospective Review of the Timing of Glasgow Coma Scale Documentation in a Trauma Database: Implications for Patient Care, Research, and Performance Metrics.

BACKGROUND: The Glasgow Coma Scale (GCS) is intended to be an objective, reliable measure of a patient's mental status. It is included as a metric for trauma registries, having implications for performance metrics and research. Our study compared the GCS recorded in the trauma registry (GCS-1) with that recorded in the neurosurgery consultation (GCS-2). METHODS: This retrospective review compared GCS-1 with GCS-2. The Trauma Injury Severity Score (TRISS) method was used to calculate probability of survival (POS) for patients using both GCS-1 and GCS-2. RESULTS: GCS-1 score significantly differed from GCS-2 score (6.69 vs. 7.84, ± 2.553; P < 0.001). There were 172 patients (37.55%) with a GCS-1 score of 3 and 87 (19.00%) with a GCS-2 score of 3 (χ2P < 0.001). The POS calculated using TRISS methodology with GCS-1 (POS-1) was 74.7% ± 26.6% compared with GCS-2 (POS-2), which was 79.3% ± 24.4%. There was a statistically significant difference in the means of POS-2 and POS-2 (P < 0.001). The actual observed survival for the cohort was 71.0% (325/458). CONCLUSIONS: The immediate GCS score recorded on patient arrival after trauma differs significantly from the GCS score recorded at later times. This finding significantly altered the probability of survival as calculated by the TRISS methodology. This situation could have profound effects on risk-adjusted benchmarking, assessments of quality of care, and injury severity stratification for research. More studies into the optimal timing of GCS score recording or changes in GCS score and their impact on survival are warranted.

Pharmacological neuroprotection and clinical trials of novel therapies for neonatal peri-intraventricular hemorrhage: a comprehensive review.

Peri-intraventricular hemorrhage (PIVH) is a serious condition for preterm infants, caused by traumatic or spontaneous rupture of the germinal matrix (GM) capillary network in the cerebral ventricles. It is a common source of morbidity and mortality in neonates, and risk correlates with earlier delivery, low birth weight, maternal-fetal infection, and vital sign derangements, among others. PIVH typically occurs in the first 72 h of life, and symptoms, when present, manifest most commonly within the first week of life. Prevention remains the primary goal in management, predominantly via prolonging of gestation. Current therapy protocols are center-dependent without consistent consensus guidelines, but infant positioning, homeostatic stabilization, and neuroprotection offer potential options. In this update of pharmacologic neuroprotective therapies for PIVH, we highlight commonly utilized therapies and review the investigative literature. Further multi-institutional clinical trials and basic research studies are required.

Vascularized Pericranial Flap as a Method to Prevent Persistent Skull Defects After Craniectomy for Sagittal Synostosis.

ABSTRACT: Some cranial defects resulting from sagittal craniectomy for craniosynostosis never completely close and require cranioplasty. This study evaluates the results of 2 methods to minimize such defects: (1) trapezoidal craniectomy that is narrower posteriorly (2) vascularized pericranial flap that is sewn to the dura under a rectangular craniectomy.Children who underwent primary open sagittal craniectomy with biparietal morcellation (with/without frontal cranioplasty) for single-suture nonsyndromic sagittal synostosis from 2013 through 2018 were included. Children were excluded if there was a dural tear, if they had no 1-year follow-up, or if they had unmeasured and/or uncounted skull defects. Surgeries were divided into (1) standard craniectomy, (2) trapezoidal craniectomy, or (3) craniectomy with pericranial flap. Differences in percentage of children with defects and mean total defect area 1 year postsurgery were compared between the 3 groups.We reviewed 148 cases. After exclusions, 34 of 53 children (64%) who underwent standard craniectomy, 6 of 17 children (35%) who had pericranial flaps, and 5 of 11 children (46%) who underwent trapezoidal craniectomy had defects 1 year postsurgery. The percentage of children with defects (P = 0.0364) but not the defect area was significantly higher in the standard craniectomy than in the pericranial flap group. The percentage of subjects with defects was not significantly different between the standard and the trapezoidal craniectomy groups.Sewing a vascularized pericranial flap to the dura at the craniectomy site may protect against persistent bony defects after sagittal craniectomy for craniosynostosis. Longer follow-up is needed to determine if this technique leads to lower rates of cranioplasty.

Development of a Technical Skills Test to Improve Assessment and Evaluation in Neuroendoscopic Education.

BACKGROUND: Endoscopy requires a unique set of skills that are difficult to acquire in most training programs. A method to test technical skills, in a validated manner, has rarely been attempted. The purpose of this study was to develop a technical skills examination for objective assessment in neuroendoscopic education. METHODS: Twenty-nine participants were included for analysis and divided by seniority level into 2 groups defined as before or upon postgraduation year (PGY) 5 (n = 18, junior surgeons) or after PGY5 (n = 11, senior surgeons). Study participants were assessed for baseline performance and then again following a 4-hour neuroendoscopy course. Wilcoxon test was used to evaluate for performance differences between cohorts. Correlation analyses were performed using the Pearson or Spearman coefficient. RESULTS: Increasing PGY level was correlated with a decreased average time to complete all 3 tasks (r = -0.44, P = 0.03) at baseline. Overall performance improved in both cohorts following the course (P < 0.001). When comparing junior surgeons after endoscopy training (posttest) to senior surgeons at their baseline (pretest), the junior surgeons were faster after endoscopic training than the senior surgeons were before training (P < 0.001). CONCLUSIONS: A neuroendoscopic skills test can distinguish between more or less experienced surgeons. Significant overall performance improvement, regardless of seniority level, following neuroendoscopic training demonstrates the accuracy of the test at detecting operating improvement in all stages of learning.

Successful treatment of hemorrhagic brainstem cavernous malformation with hematoma evacuation and postoperative propranolol.

In this case, we describe an evident hemorrhagic brainstem cavernous malformation successfully treated with a planned sequence of surgical evacuation of the hematoma followed by postoperative propranolol therapy. In contrast to common practice, the cavernoma itself was not resected. A nearly 3-year-old male presented with altered mental status, gait disturbance, and facial palsy. CT and MRI demonstrated a large acute pontine hematoma. A large nearby vein suggested cavernous malformation. He was initially treated conservatively but a repeat CT scan demonstrated further expansion of hematoma and he was taken emergently to the OR. Due to the sensitive location of the hematoma in the pons, we planned to evacuate the hematoma without resecting any of the presumed cavernoma. Instead, we planned to treat the cavernoma with propranolol. Postoperatively, the patient's condition improved and was still improving at hospital discharge 2 weeks later. Six-month follow-up MRI showed no cavernoma with only hemosiderin at the site of the evacuated hematoma. This is the first reported case of a hemorrhagic brainstem cavernous malformation treated with a planned sequence of hematoma evacuation followed by propranolol without an attempt to resect the cavernoma.

The Impact of Drug and Alcohol Intoxication on Glasgow Coma Scale Assessment in Patients with Traumatic Brain Injury.

BACKGROUND: The effect of intoxicating substances on assessment of Glasgow Coma Scale (GCS) in the trauma setting has not been completely elucidated. METHODS: A trauma registry was queried for patients with blunt head trauma in 2013-2017. Initial GCS score and toxicology screening from the database were reviewed. Next recorded GCS score from the neurosurgery evaluation and change in GCS score (ΔGCS) were compared. RESULTS: We reviewed 468 patients. In 217 (46.4%) patients, no toxic substances were found, whereas >1 toxic substance was found in 104 (22.2%) patients. Alcohol level above the legal limit was found in 109 (23.3%) patients, marijuana was found in 105 (22.4%) patients, benzodiazepines were found in 94 (20.1%) patients, opiates were found in 48 (10.3%) patients, and cocaine was found in 41 (8.8%) patients. Mean change in GCS score was significantly higher in impaired patients compared with patients with a negative screening test (1.74 ± 2.4 vs. 0.75 ± 2.7, P < 0.001); this is despite both groups having a similar initial GCS score (6.23 ± 3.86 in impaired group vs. 6.47 ± 3.52 in sober group, P = 0.677). Initial GCS score was 3 in 187 patients, of whom 150 had a positive toxicology screen. Change in GCS score was significantly higher in the impaired group (2.75 ± 2.7 vs. 1.19 ± 1.8, P < 0.001). CONCLUSIONS: Intoxicating substances can confound GCS assessment in trauma patients. This can have effects on patient care as well as performance metrics and predictive analytics. These patients should be screened, and intoxicating substances should be reversed or allowed to wear off before GCS score is recorded for benchmarking or quality reporting.

Diplopia With Dural Fibrotic Thickening.

Idiopathic hypertrophic pachymeningitis (HP) is a rare disorder of diffuse thickening of the cranial or spinal dura mater without an identifiable cause. Most common in adult males, idiopathic HP typically presents with headache with or without varied associated focal neurologic deficits and findings of dural enhancement on magnetic resonance imaging in a linear, nodular, or combined pattern. As it is felt to be an autoimmune disorder, treatment with high-dose corticosteroids is typically recommended, and without intervention, the course is usually progressive. The disease can commonly progress with a relapsing remitting course requiring other immune modulators such as methotrexate, azathioprine, or cyclophosphamide for control. Here, we describe a unique case of idiopathic HP as it presented in a pediatric patient and resolved without immunomodulatory therapy.