Carole A. Miller, MD: Matriarch of the Ohio State University's Department of Neurosurgery.

Carole A. Miller, M.D., was born (May 7, 1939) and raised in Kalamazoo, Michigan. She obtained her undergraduate and medical degrees at the Ohio State University. She went on to complete her neurosurgical training at the Ohio State University Medical Center. After her first faculty role at the University of Michigan (1971), she returned to the Ohio State University Medical Center (1975) where she spent nearly 4 decades. She thrived in the specialty, achieving in every facet of academic practice including scientific contributions, graduate medical education, clinical care, and leadership roles within her academic department, locally, and at the national level of organized neurosurgery. Dr. Miller passed away peacefully, on October 28, 2015, after a courageous battle with cancer. Based on her essential programmatic and specialty-related contributions, she is remembered as the 'founding mother' of neurosurgery at the Ohio State University.

Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

IgG4-Related Disease: A New Etiology Underlying Diffuse Intracranial Dilating Vasculopathy.

BACKGROUND: Diffuse intracranial aneurysmal vasculopathy is a rare condition, previously described in patients with human immunodeficiency virus infection. IgG4-related disease (IgG4-RD) is a recognized inflammatory disease of systemic organs, leading to fibrosis of connective tissues. It also has been linked to inflammatory dilating aortic aneurysms, coronary vascular disease, hypophysitis, orbital pseudotumor, and pachymeningitis. It has not yet been described as a cause of diffuse intracranial dilating vasculopathy. Histologically, this disease is characterized by IgG4-plasma cell infiltration, fibrosis, and phlebitis. CASE DESCRIPTION: A 40-year-old woman presented with acute heart failure, valvular insufficiency, and mycotic coronary aneurysms, concerning for endocarditis. Infectious workup was negative. Concurrent neurovascular workup revealed intracranial aneurysms, appearing mycotic in origin. Despite aggressive treatment for more than 5 years, she suffered multiple episodes of subarachnoid hemorrhage from a progressive dilating intracranial vasculopathy. Serum IgG levels and aneurysm wall pathology were consistent with IgG4-RD. CONCLUSIONS: This is the first reported case of a diffuse intracranial dilating vasculopathy secondary to IgG4-RD. Recognition of similar pathologic findings in clinical presentation and radiologic workup should prompt further rheumatologic workup and possible immunosuppressive therapies.

Neuromodulation as a last resort option in the treatment of chronic daily headaches in patients with idiopathic intracranial hypertension.

OBJECTIVE: To determine the feasibility and efficacy of occipital nerve stimulation (ONS) in patients with refractory headaches secondary to idiopathic intracranial hypertension (IIH). BACKGROUND: IIH is a syndrome characterized by elevated intracranial pressures in the absence of a mass lesion. These patients typically present with chronic and intractable headaches. Cerebrospinal fluid (CSF) diversion fails in relieving the headache in a significant proportion of this population. ONS has been shown to be effective in medically refractory headaches and to our knowledge, has not been attempted as a therapeutic modality in this population. METHODS: Four patients with occipital predominant chronic daily headaches and IIH who failed medical management underwent bilateral ONSs. Octopolar percutaneous electrodes were implanted in the defined area of pain. Visual Analog Scale (VAS) was used as an outcome measure. Patient demographics and surgical complications were also reviewed in this retrospective study. Following the trial period, all patients had >50% pain reduction resulting in permanent implantation. RESULTS: All 4 patients had an average improvement of their VAS scores by 75%, with 85% spatial coverage and the remainder of the uncovered region being frontal. Sustained benefits were seen up to 3 years of follow-up. One patient had a lead erosion requiring removal followed by delayed re-implantation and another lost treatment efficacy at 2 years resulting in explantation. One patient required CSF diversion due to visual threat during the follow-up period but maintained sustained benefit from her ONS. CONCLUSIONS: Bilateral ONS may be a useful treatment option in the management of selected patients with IIH, after standard surgical interventions have been attempted. Bilateral ONS may provide therapeutic option for management of residual headaches in these complicated patients.

Endovascular flow diversion therapy for an actively hemorrhaging aneurysm after intraoperative rupture.

We report a 56-year-old woman who had an unruptured posterior communicating artery aneurysm. Given the size and location of the aneurysm, as well as her history of smoking and age, she received endovascular treatment with the pipeline embolization device (PED; ev3 Endovascular, Plymouth, MN, USA), complicated by intraoperative rupture (IOR). Flow diversion therapy with the PED has become an increasingly popular method of aneurysmal embolization and parent vessel remodeling. While its on-label approval is for large unruptured aneurysms of the internal carotid artery, success in off-label scenarios has been reported, including ruptured aneurysms. IOR complicates endovascular aneurysm treatment and can cause devastating morbidity or mortality, necessitating acute embolization of the hemorrhaging aneurysm. This patient illustrates the feasibility of treating an IOR with a stand-alone flow diversion device by using PED.

Successful endovascular reconstruction of a recurrent giant middle cerebral artery aneurysm with multiple telescoping flow diverters in a pediatric patient.

Intracranial aneurysms of the pediatric population are rare, but giant fusiform aneurysms (GFAs) of the middle cerebral artery (MCA) are common within this cohort of patients. These aneurysms are difficult to treat and often require advanced microsurgical skills, as they are usually not amenable to direct clipping. Here, we report the successful treatment of a recurrent GFA of the MCA with three telescoping Pipeline Embolization Devices 6 months after attempted clip reconstruction in a pediatric patient.

Endovascular management of anterior communicating artery aneurysms.

The management of intracranial aneurysms has evolved significantly over the past 2 decades. Anterior communicating artery aneurysms (AComAAs) represent a common and often challenging problem for physicians and patients. Experience and technological advances have broadened the indications for endovascular treatment of all aneurysms. Balloon-mounted catheters and intracranial stents are 2 technological advancements that have made the treatment of previously uncoilable aneurysms feasible. As with all intracranial aneurysms, complete angiographic occlusion remains the goal of care. Balancing the risks of thromboembolic complications with decreasing the risk of hemorrhage, especially in acutely ruptured aneurysms, represents an objective for vascular neurosurgeons.

Endovascular treatment of basilar aneurysms.

Basilar artery aneurysms account for a small percentage of intracranial aneurysms; however, they are a diverse group of lesions necessitating different treatment techniques for those that are ruptured and unruptured. Basilar apex aneurysms are the most common type and are frequently wide-necked, necessitating stent-assisted coiling or balloon remodeling. Other techniques have evolved to forego stenting in acutely ruptured wide-necked aneurysms. The prevention of delayed thromboembolic complications with dual antiplatelet therapy in patients with stents is critical. After treatment, basilar aneurysms require close follow-up to ensure complete occlusion. Basilar apex aneurysms often require delayed re-treatment, especially when previously ruptured.

Thoracolumbar spinal vascular malformation as a rare cause of isolated intraventricular hemorrhage.

Spinal vascular malformations are rare vascular lesions that most frequently present with back pain, radiculopathy, and/or myelopathy. Neurological decline is typically secondary to progressive radiculopathy, myelopathy, venous thrombosis, and stroke. Few case reports have described thoracolumbar spinal vascular malformations that present with both subarachnoid and intraventricular hemorrhage. This is the first reported case of a thoracolumbar spinal vascular malformation presenting with isolated intraventricular hemorrhage on initial imaging followed by acute and fatal rehemorrhage.

Ventriculoperitoneal shunt infection following uterine instrumentation for dysfunctional uterine bleeding.

Shunt infections are most common within the first 6 months following implantation. A shunt infection 19 years after implantation secondary to uterine ablation has not been reported to our knowledge. Office hysteroscopic procedures have become commonplace in gynecologic practice. Infectious complication rates are low, but peritonitis has been described. We present a patient with a ventriculoperitoneal shunt infection following a uterine ablation for dysfunctional uterine bleeding. Three days following the ablation she developed abdominal pain. CT scan of the abdomen 5 months after the procedure revealed a pseudocyst. She then underwent removal of her shunt with intra-operative cultures revealing Streptococcus agalactiae. Definitive treatment consisted of shunt explantation and antibiotic treatment with complete resolution of her pain and pseudocyst. Consideration for prophylactic antibiotics should be made when a patient with a ventriculoperitoneal shunt undergoes any transvaginal procedure.

Metastatic esophageal adenocarcinoma to the prostate presenting with bilateral ureteral obstruction.

Carcinoma metastatic to the prostate occurs rarely and is most commonly associated with malignant bladder neoplasms. We present the case of a 73-year-old male with a history of gastroesophageal adenocarcinoma and clinically symptomatic benign prostatic hyperplasia who underwent photoselective vaporization of the prostate and presented several months later with gross hematuria, intermittent urinary retention and bilateral ureteral obstruction causing acute renal failure. After relieving the ureteral obstruction, subsequent transurethral resection of the prostate revealed locally invasive metastatic esophageal adenocarcinoma. To our knowledge, this is the first reported case of metastatic gastroesophageal carcinoma to the prostate.