Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

BACKGROUND AND OBJECTIVES: Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era. METHODS: This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis. RESULTS: Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction. CONCLUSION: These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

Corrigendum: Grade 3 Meningioma Survival and Recurrence Outcomes in an International Multicenter Cohort.

[This corrects the article DOI: 10.1055/s-0044-1779888.].

Grade 3 meningioma survival and recurrence outcomes in an international multicenter cohort.

OBJECTIVE: Grade 3 meningioma represents a rare meningioma subtype, for which limited natural history data are available. The objective of this study was to identify demographics and pathologic characteristics, clinical and functional status outcomes, and prognostic factors in an international cohort of grade 3 meningioma patients. METHODS: Clinical and histopathological data were collected for patients treated at 7 sites across North America and Europe between 1991 and 2022. RESULTS: A total of 103 patients (54% female, median age 65 [IQR 52, 72] years) were included. Sixty-seven (65%) patients had de novo grade 3 lesions, whereas 29 (28%) had malignant transformations of lower-grade meningiomas. All patients underwent initial resection of their tumor. Patients were followed for a median of 46 (IQR 24, 108) months, during which time there were 65 (73%) recurrences and 50 (49%) deaths. The 5-year overall survival (OS) and progression-free survival (PFS) rates were 66% (95% CI 56%-77%) and 37% (95% CI 28%-48%), respectively. Age ≥ 65 years and male sex were independent predictors of worse OS and PFS in multivariate regression analysis, while postoperative radiotherapy was independently associated with improved OS. Karnofsky Performance Status (KPS) remained stable relative to baseline over 5 years postdiagnosis among participants who were alive at the end of the follow-up period. CONCLUSIONS: This large multicenter study provides insight into the longitudinal outcomes of grade 3 meningioma, with respect to recurrence, survival, and functional status. This study affirms the survival benefit conferred by radiotherapy in this population and suggests good functional status outcomes for patients surviving to 5 years postoperatively.

Cranial vault suspension for basilar invagination in patients with open cranial sutures: technique and long-term follow-up. Illustrative case.

BACKGROUND: Hajdu-Cheney syndrome (HCS) is an extremely rare genetic disorder characterized by severe osteoporosis, scoliosis, and persistent open cranial sutures (POCSs). Neurological complications include hydrocephalus, Chiari I malformations, and basilar invagination (BI). Surgical intervention in HCS is challenging due to severe osteoporosis, ligamentous laxity, POCSs, and extreme skeletal deformities. Herein, the authors present a case of BI repair in a patient with HCS and POCSs, requiring a novel technique of cranial vault suspension, with long-term follow-up. OBSERVATIONS: A 20-year-old female with HCS and progressive symptomatic BI, initially managed with posterior fossa decompression and occipital to cervical fusion, subsequently required cranial vault expansion due to symptomatic shifting of her cranium secondary to POCS. This custom construct provided long-term stabilization and neurological improvement over a follow-up duration of 9.5 years. A literature review performed revealed three other cases of surgical intervention for BI in patients with HCS and clinicopathological characteristics of each case was compared to the present illustrative case. LESSONS: POCSs in patients with BI complicate traditional surgical approaches, necessitating more invasive techniques to secure all mobile cranial parts for optimal outcomes. Using this cranial vault suspension and fusion technique results in lasting neurological improvement and construct stability.

Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries.

BACKGROUND: Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. OBJECTIVE: To compare care patterns and outcomes between homeless and nonhomeless individuals with acute neurotraumatic injuries. METHODS: Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, in-hospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. RESULTS: Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger ( P = .004), predominantly male ( P = .003), and less frail ( P = .003) but had similar presenting Glasgow Coma Scale scores ( P = .85), neurointensive care unit stay time ( P = .15), neurosurgical interventions ( P = .27), and in-hospital mortality ( P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). CONCLUSION: Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

How I Do It: Endonasal transethmoidal, transcribriform approach for resection of giant olfactory groove meningioma.

BACKGROUND: Olfactory groove meningiomas (OGMs) arise from the cribriform plate of the anterior fossa and account for 9-12% of all meningiomas. Giant OGMs are those larger than 6 cm and are technically challenging to resect. METHOD: Here we present the surgical decision-making and intraoperative details regarding the endonasal endoscopic resection of an OGM using a minimally invasive, endonasal approach in a 68-year-old female patient. CONCLUSION: Giant OGMs can be safely and effectively removed using an endonasal, transcribriform approach.

Innovation in Neurosurgery: Lessons Learned, Obstacles, and Potential Funding Sources.

Innovation is central to neurosurgery and has dramatically increased over the last twenty years. Although the specialty innovates as a whole, only 3-4.7% of practicing neurosurgeons hold patents. Various roadblocks to innovation impede this process such as lack of understanding, increasing regulatory complexity, and lack of funding. Newly emerging technologies allow us to understand how to innovate and how to learn from other medical specialties. By further understanding the process of innovation, and the funding that supports it, Neurosurgery can continue to hold innovation as one of its's central tenets.