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BACKGROUND: Previous data on the prevalence of unruptured intracranial aneurysms (UIAs) vary widely, and studies based on these data are plagued with unintentional bias. Accurate prevalence data are paramount for any physician who counsels patients with intracranial aneurysms on rupture risk and treatment. We therefore sought to determine a more accurate number for the true prevalence of UIAs. METHODS: A retrospective chart review was conducted at a level 1 trauma center and tertiary care hospital in an urban setting between 2019 and 2020. Inclusion criteria included patients admitted with blunt trauma. Exclusion criteria included not having a head and neck CTA performed and read by an attending radiologist. All head and neck CTA radiology reads were reviewed for incidentally discovered UIAs. Subgroup analysis was performed by age group, race, and gender. RESULTS: A total of 5978 out of 8999 patients met the inclusion criteria, and 54 patients with 58 total aneurysms were identified giving an overall prevalence of 0.9%. Subgroup analysis was performed for all age groups, genders, and racial groups. CONCLUSION: The overall aneurysm prevalence was found to be 0.9% in this sample. This rate is lower than rates previously cited in the literature and those quoted in local practice. This finding has significant implications when attempting to understand average rupture risk. Further studies are needed to power more subgroup analyses to use a more personalized approach to understanding an individual's risk of rupture.
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Chordomas can be treated surgically, with radiotherapy, and more recently, chemotherapy.1,2 A 22-year-old female patient presented with recurrence of a clival chordoma, after subtotal resection at an outside institution 3 months prior. MRI showed a predominantly midline lesion at the craniocervical junction with significant lateral extension eccentric to the left. A 3-staged operation was planned. A redo-endoscopic endonasal transclival transodontoid approach3-5 was used to resect the midline component, followed by an extreme lateral transcondylar transodontoid approach with transposition of the ipsilateral vertebral artery followed by drilling of the ipsilateral occipital condyle and C1 lateral mass to resect the lateral component, followed by occiput to C3 fusion given the induced craniocervical instability. Careful subperiosteal dissection with preservation of the periosteal sheath overlying the vertebral artery was performed. There was no overt evidence of vertebral artery injury intraoperatively or on immediate postoperative imaging. However, 3 weeks later, the patient presented with blood from the oral/nasal cavity. Computed tomography angiography showed an unexpected left vertebral artery pseudoaneurysm. Pseudoaneurysms can develop after microtears in the muscularis layer.6-8 Management is based on size, location, and vertebral artery dominance.9,10 This pseudoaneurysm was coiled. Postcoiling, the patient had left hypoglossal palsy. We demonstrate the step-by-step technique of an extreme lateral transcondylar transodontoid approach for a clival chordoma and the unfortunate complication of a vertebral artery pseudoaneurysm with discussion of its etiology and management options for this potentially devastating complication. The patient consented to the procedure/publication. Institutional Review Board approval not obtained as the patient was deidentified, and no additional risk is posed by the publication of this video.
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BACKGROUND AND OBJECTIVES: The management of blunt cerebrovascular injuries (BCVIs) remains an important topic within trauma and neurosurgery today. There remains a lack of consensus within the literature and significant variation across institutions. The purpose of this study was to evaluate management of BCVI at a large, tertiary referral trauma center. METHODS: Institutional Review Board approval was obtained to conduct a retrospective review of patients with BCVI at our Level 1 Trauma Center. Computed tomography angiography was used to identify BCVI for each patient. Patient information was collected, and statistical analysis was performed. With the included risk factors for ischemic complications, a novel scoring system based on ischemic risk, the "Memphis Score," was developed and evaluated to grade BCVI. RESULTS: Two hundred seventeen patients with BCVI from July 2020 to August 2022 were identified. The most common mechanism of injury was motor vehicle collision (141, 65.0%). Vertebral arteries were the most common vessel injured (136, 51.1%) with most injuries occurring at a high cervical location (101, 38.0%). Denver Grade 1 injuries (89, 33.5%) and a Memphis Score of 1 were most frequent (172, 64.6%), and initial anticoagulation with heparin drip was initiated 56.7% of the time (123). Endovascular treatment was required in 24 patients (11.1%) and was usually performed in the first 48 hours (15, 62.5%). While Denver Grade (P = .019) and Memphis Score (P < .00001) were significantly higher in those patients undergoing endovascular treatment, only the Memphis Score demonstrated a significant difference between those patients who had stroke or worsening on follow-up imaging and those who did not (P = .0009). CONCLUSION: Although BCVI management has improved since early investigative efforts, institutions must evaluate and share their data to help clarify outcomes. The novel "Memphis Score" presents a standardized framework to communicate ischemic risk and guide management of BCVI.
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OBJECTIVE: Congenital anomalies of the atlanto-occipital articulation may be present in patients with Chiari malformation type I (CM-I). However, it is unclear how these anomalies affect the biomechanical stability of the craniovertebral junction (CVJ) and whether they are associated with an increased incidence of occipitocervical fusion (OCF) following posterior fossa decompression (PFD). The objective of this study was to determine the prevalence of condylar hypoplasia and atlas anomalies in children with CM-I and syringomyelia. The authors also investigated the predictive contribution of these anomalies to the occurrence of OCF following PFD (PFD+OCF). METHODS: The authors analyzed the prevalence of condylar hypoplasia and atlas arch anomalies for patients in the Park-Reeves Syringomyelia Research Consortium database who underwent PFD+OCF. Condylar hypoplasia was defined by an atlanto-occipital joint axis angle (AOJAA) ≥ 130°. Atlas assimilation and arch anomalies were identified on presurgical radiographic imaging. This PFD+OCF cohort was compared with a control cohort of patients who underwent PFD alone. The control group was matched to the PFD+OCF cohort according to age, sex, and duration of symptoms at a 2:1 ratio. RESULTS: Clinical features and radiographic atlanto-occipital joint parameters were compared between 19 patients in the PFD+OCF cohort and 38 patients in the PFD-only cohort. Demographic data were not significantly different between cohorts (p > 0.05). The mean AOJAA was significantly higher in the PFD+OCF group than in the PFD group (144° ± 12° vs 127° ± 6°, p < 0.0001). In the PFD+OCF group, atlas assimilation and atlas arch anomalies were identified in 10 (53%) and 5 (26%) patients, respectively. These anomalies were absent (n = 0) in the PFD group (p < 0.001). Multivariate regression analysis identified the following 3 CVJ radiographic variables that were predictive of OCF occurrence after PFD: AOJAA ≥ 130° (p = 0.01), clivoaxial angle < 125° (p = 0.02), and occipital condyle-C2 sagittal vertical alignment (C-C2SVA) ≥ 5 mm (p = 0.01). A predictive model based on these 3 factors accurately predicted OCF following PFD (C-statistic 0.95). CONCLUSIONS: The authors' results indicate that the occipital condyle-atlas joint complex might affect the biomechanical integrity of the CVJ in children with CM-I and syringomyelia. They describe the role of the AOJAA metric as an independent predictive factor for occurrence of OCF following PFD. Preoperative identification of these skeletal abnormalities may be used to guide surgical planning and treatment of patients with complex CM-I and coexistent osseous pathology.
Subject(s)
Arnold-Chiari Malformation , Atlanto-Occipital Joint , Cervical Atlas , Occipital Bone , Spinal Fusion , Syringomyelia , Humans , Arnold-Chiari Malformation/surgery , Arnold-Chiari Malformation/diagnostic imaging , Syringomyelia/surgery , Syringomyelia/diagnostic imaging , Female , Male , Cervical Atlas/abnormalities , Cervical Atlas/surgery , Cervical Atlas/diagnostic imaging , Child , Occipital Bone/surgery , Occipital Bone/diagnostic imaging , Occipital Bone/abnormalities , Spinal Fusion/methods , Adolescent , Atlanto-Occipital Joint/diagnostic imaging , Atlanto-Occipital Joint/surgery , Atlanto-Occipital Joint/abnormalities , Treatment Outcome , Child, Preschool , Decompression, Surgical/methods , Retrospective Studies , Cervical Vertebrae/surgery , Cervical Vertebrae/abnormalities , Cervical Vertebrae/diagnostic imagingABSTRACT
INTRODUCTION: Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH. METHODS: Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality. RESULTS: A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99). CONCLUSIONS: For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events.
Subject(s)
Autonomic Nervous System Diseases , Subarachnoid Hemorrhage , Vasospasm, Intracranial , Humans , Autonomic Nervous System Diseases/complications , Cerebral Infarction/complications , Cerebrospinal Fluid Leak/complications , Drainage , Subarachnoid Hemorrhage/complications , Subarachnoid Hemorrhage/surgery , Subarachnoid Space , Treatment OutcomeABSTRACT
BACKGROUND AND OBJECTIVES: Competency-based medical education is well established, yet methods to evaluate and document acquisition of surgical skill remain underdeveloped. We describe a novel web-based application for competency-based surgical education at a single neurosurgical department over a 3-year period. METHODS: We used a web-based application to track procedural and cognitive skills acquisition for neurosurgical residents. This process included self-assessment, resident peer evaluations, evaluations from supervising attending physicians, and blinded video reviews. Direct observation by faculty and video recordings were used to evaluate surgical skill. Cases were subdivided into component skills, which were evaluated using a 5-point scale. The learning curve for each skill was continuously updated and compared with expectations. Progress was reviewed at a monthly surgical skills conference that involved discussion and analysis of recorded surgical performances. RESULTS: During an escalating 3-year pilot from 2019 to 2022, a total of 1078 cases in 39 categories were accrued by 17 resident physicians with 10 neurosurgical faculty who participated as evaluators. A total of 16 251 skill performances in 110 categories were evaluated. The most evaluated skills were those that were common to several types of procedures, such as positioning, hemostasis, and wound closure. The concordance between attending evaluations and resident self-evaluations was 76%, with residents underestimating their performance in 17% of evaluations and overestimating in 7%. CONCLUSION: We developed a method for evaluating and tracking surgical resident skill performance with an application that provides timely and actionable feedback. The data collected from this system could allow more accurate assessments of surgical skills and deeper insights into factors influencing surgical skill acquisition.
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INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: The expanded retrosigmoid approach with splitting of the horizontal cerebellar fissure provides a more direct and shorter route for central and dorsolateral pontine lesions while minimizing retraction of tracts, nuclei, and cerebellum. 1-4. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: The middle cerebellar peduncle is partially covered by the petrosal surface of the cerebellum. The horizontal cerebellar fissure (petrosal fissure) divides the petrosal surface of the cerebellar hemisphere into superior and inferior parts. Splitting the petrosal fissure separates the superior and inferior petrosal surfaces and exposes the posterolateral middle cerebellar peduncle (posterior and lateral to the root entry zone of CN5). 1-4. ESSENTIALS STEPS OF THE PROCEDURE: Expanded retrosigmoid craniotomy is performed, including unroofing of the sigmoid sinus; petrosal fissure is split to expose the posterolateral middle cerebellar peduncle; entry point for resection of the cavernoma is identified; nims stimulator stimulator is used to confirm the absence of tracts and nuclei; myelotomy is performed; and cavernoma and its draining vein (but not the developmental venous anomaly) are removed using a combination of traction and countertraction against gliotic plane. PITFALLS/AVOIDANCE OF COMPLICATIONS: Wide splitting of the horizontal cerebellar fissure minimizes retraction or resection of the cerebellum and offers the best angle of attack. Knowledge of brainstem anatomy and use of intraoperative navigation are critical to avoid complications. VARIANTS AND INDICATIONS FOR THEIR USE: Far lateral through the middle cerebellar peduncle is a variant that can be used to resect pontine cavernomas if a caudocranial trajectory is preferred.The patient consented to the procedure and to the publication of her image.
Subject(s)
Hemangioma, Cavernous , Middle Cerebellar Peduncle , Humans , Female , Middle Cerebellar Peduncle/surgery , Pons/diagnostic imaging , Pons/surgery , Cerebellum/surgery , Cerebellum/pathology , Craniotomy/methods , Brain Stem/surgery , Hemangioma, Cavernous/surgerySubject(s)
Aneurysm , Carotid Artery Diseases , Humans , Middle Cerebral Artery/diagnostic imaging , Middle Cerebral Artery/surgery , Carotid Artery, Internal/diagnostic imaging , Carotid Artery, Internal/surgery , Aneurysm/surgery , Carotid Artery, Common , Carotid Artery Diseases/diagnostic imaging , Carotid Artery Diseases/surgery , StentsABSTRACT
Facial nerve hemangiomas are a rare entity of skull base lesions that arise within the temporal bone and affect the seventh cranial nerve.1 They are vascular malformations arising from the vascular plexuses surrounding the nerve. Although slow growing and overall benign in nature, they can cause significant facial nerve dysfunction even at small sizes.2 Facial nerve hemangiomas can arise within different segments of the facial nerve within the temporal bone, but most commonly arise near the geniculate ganglion.3 We describe the case of a 34-year-old female who presented with progressive right facial palsy (House-Brackmann 4) and a calcified lesion arising from the petrous temporal bone. Resection of the lesion was performed with a posterior to anterior middle fossa approach, with identification of the greater superficial petrosal nerve and geniculate ganglion, sectioning of the middle meningeal artery, and identification of V2 and V3 segments of the trigeminal nerve (Video 1). The bony mass was peeled off the petrous temporal bone and the geniculate ganglion without sacrifice of the facial nerve. Postoperative imaging showed gross total resection, and the patient's facial palsy improved to House-Brackmann 1. A comprehensive literature review on surgical approaches and outcomes for the resection of hemangiomas involving the geniculate ganglion or the facial nerve is also provided.2,4-18 The case presentation, surgical anatomy, operative nuances with technical considerations, and postoperative course with imaging are reviewed. The patient and family provided informed consent for the procedure and publication of patient images.
Subject(s)
Aneurysm , Carotid Artery Diseases , Humans , Middle Cerebral Artery/diagnostic imaging , Middle Cerebral Artery/surgery , Carotid Artery, Internal/diagnostic imaging , Carotid Artery, Internal/surgery , Aneurysm/surgery , Carotid Artery, Common , Carotid Artery Diseases/diagnostic imaging , Carotid Artery Diseases/surgery , StentsSubject(s)
Hemifacial Spasm , Microvascular Decompression Surgery , Humans , Hemifacial Spasm/diagnostic imaging , Hemifacial Spasm/etiology , Hemifacial Spasm/surgery , Basilar Artery/diagnostic imaging , Basilar Artery/surgery , Polytetrafluoroethylene , Microvascular Decompression Surgery/methods , DecompressionABSTRACT
Simple clip trapping may not adequately decompress giant paraclinoidal or ophthalmic artery aneurysms for safe permanent clipping.1-10 Full temporary interruption of the local circulation via clipping of the intracranial carotid artery with concomitant suction decompression via an angiocatheter placed in the cervical internal carotid artery as originally described by Batjer et al3 allows the primary surgeon to use both hands to clip the target aneurysm. Detailed understanding of skull base and distal dural ring anatomy is critical for microsurgical clipping of giant paraclinoid and ophthalmic artery aneurysms.2-4 Microsurgical approaches allow for direct decompression of the optic apparatus as opposed to endovascular coiling or flow diversion that may contribute to increased mass effect.11 We describe the case of a 60-year-old woman who presented with left-sided visual loss, a family history of aneurysmal subarachnoid hemorrhage, and a giant unruptured clinoidal-ophthalmic segment aneurysm with both extradural and intradural components.2 The patient underwent an orbitopterional craniotomy, Hakuba "peeling" of the temporal dura propria from the lateral wall of the cavernous sinus, and anterior clinoidectomy (Video 1). The proximal sylvian fissure was split, the distal dural ring was completely dissected, and the optic canal and falciform ligament were opened. The aneurysm was trapped, and retrograde suction decompression via the "Dallas Technique" was employed for safe clip reconstruction of the aneurysm.3,4 Postoperative imaging showed complete obliteration of the aneurysm, and the patient remained at her neurologic baseline. The technical considerations and literature regarding the suction decompression technique to treat giant paraclinoid aneurysms are reviewed.2-4 The patient and family provided informed consent for the procedure and consented to the publication of her images.
Subject(s)
Intracranial Aneurysm , Humans , Female , Middle Aged , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/surgery , Suction/methods , Craniotomy , Carotid Artery, Internal/diagnostic imaging , Carotid Artery, Internal/surgery , DecompressionABSTRACT
BACKGROUND: Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era. METHODS: Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales. RESULTS: A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio [OR], 0.65 [0.48-0.87]; P = 0.004), long-term ischemia (OR, 0.32 [0.23-0.44]; P < 0.0001), overall ischemia (OR, 0.36 [0.28-0.44]; P < 0.0001), and favorable outcomes (OR, 3.63 [2.84-4.64]; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS. CONCLUSIONS: Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.