Spontaneous regression of an interhemispheric arachnoid cyst: illustrative case.

BACKGROUND: Intracranial arachnoid cysts are benign collections of cerebrospinal fluid that are often asymptomatic and discovered incidentally. An interhemispheric location of these lesions is rare, with only a few such cases reported in the literature. Though spontaneous regression of arachnoid cysts has been described in other locations, to date this phenomenon has not been reported in interhemispheric fissure cysts. OBSERVATIONS: In this report, we describe a patient with a large, multiloculated interhemispheric arachnoid cyst diagnosed on prenatal ultrasound. She did not exhibit neurologic deficits or signs of increased intracranial pressure and was observed with serial imaging. After several years of observation, imaging revealed spontaneous and progressive decrease in the cyst size. LESSONS: We illustrate a case of regression of an interhemispheric arachnoid cyst in a pediatric patient. To our knowledge, this is the first reported case of spontaneous shrinkage of an arachnoid cyst in this location. Although the current presentation is rare, this reporting adds to the current understanding of natural history of arachnoid cysts and provides an example of radiographical improvement without intervention of a cyst located within the interhemispheric fissure.

Nontraumatic symptomatic de novo arachnoid cyst in an adolescent patient treated with cystoperitoneal shunting: illustrative case.

BACKGROUND: Arachnoid cysts are often congenital, asymptomatic lesions detected in the pediatric population. When seen in adults, they usually occur following trauma. De novo formation of arachnoid cysts is uncommon, with only a few instances cited in the literature and most of which occurred in the pediatric population. Treatment options for these lesions include observation, craniotomy for cyst resection, microsurgical/endoscopic fenestration, or shunting. OBSERVATIONS: In this report, the authors describe a female patient with a de novo, symptomatic, enlarging middle cranial fossa arachnoid cyst detected at age 16 years. She was treated with the placement of a cystoperitoneal shunt. After surgery, she experienced clinical and radiological improvement. LESSONS: We illustrate successful shunting of a de novo arachnoid cyst in a symptomatic teen patient. Although arachnoid cysts in certain intracranial locations are more likely to produce symptoms, those in the middle cranial fossa tend to be asymptomatic. To our knowledge, this is the first reported case of a symptomatic de novo arachnoid cyst located in the middle cranial fossa in a postpubertal patient. Although the current presentation is rare, the authors demonstrate an effective surgical treatment of a symptomatic, large, de novo arachnoid cyst in a postpubertal pediatric patient.

Neurosurgery Influences and X: A Social Media Analysis.

BACKGROUND: There exists a complex and ever-evolving relationship between social media and medicine. This study investigates the usage of X (formerly Twitter) among neurosurgeons and explores how virtual engagement potentially impacts this specialty. METHODS: The researchers examined X posts from the top fifty influential neurosurgeons over 6 months. Demographics and practice information were collected. Posts were categorized into 9 predetermined coding definitions. Descriptive statistics were used to summarize user characteristics. χ2 tests and two-tailed T-tests were employed to examine patterns of posting behavior. RESULTS: Most influencers practiced in an academic setting (89%) and 43% of them were age fifty or older. Only 15% identified as female. Cerebrovascular subspecialists accounted for 39% of the cohort. Reposting was the most popular type of posting, constituting 61% of all posts. The most common postcategory observed was "Professional Events" (31%), while "Patient Education" was the least common (0.8%). Private practice and general neurosurgeons infrequently posted about "Professional Events" (5.1%, P < 0.01 and 3.2%, P < 0.01, respectively). "Personal Thoughts" constituted the second most common category, with a notable increase among users younger than 50 (25%, P < 0.01), individuals who identified as female (62%, P < 0.01), those in private practice (69%, P < 0.01), and general neurosurgeons (86%, P < 0.01). CONCLUSIONS: Neurosurgeons of all ages use X to advance their careers and stay updated. However, the utilization of this influential platform likely varies depending on the current practice setting and individual career goals. Neurosurgeons on X appear to have the greatest influence within an academic context, particularly when promoting professional events.

Predictors of Subsequent Intervention After Middle Meningeal Artery Embolization for Treatment of Subdural Hematoma: A Nationwide Analysis.

BACKGROUND: Middle meningeal artery (MMA) embolization has recently emerged as an effective technique to treat subdural hematomas (SDHs). Studies to date have been limited, largely, to single-center studies with limited follow-up and have not assessed subsequent surgical interventions and factors associated with these interventions. OBJECTIVE: To evaluate rates of retreatment for SDH after MMA embolization and patient-specific factors that may be important predictors for these interventions. METHODS: Using an all-payer claims database, Mariner, patients who underwent MMA embolization between January 2010 and October 2020 after the diagnosis of SDH were identified. Rates of post-MMA embolization surgical interventions, including craniotomy and burr hole drainage, were accessed within 5 years following. Patient-specific contributors to the rates of these interventions were studied using Gaussian logistic regression models. RESULTS: A total of 322 patients were included. Of this cohort, 55 (17.1%) required subsequent intervention within 5 years, with 36 (11.2%) receiving burr hole evacuation and 19 (5.9%) receiving craniotomy. Factor Xa inhibitor use was independently associated with subsequent interventions after MMA embolization procedures (odds ratio: 1.20 [95% CI: 1.02-1.40]). Of the other patient factors evaluated, including age, sex, comorbidity status, and use of vitamin K antagonists, antiplatelets, and factor Xa inhibitors, none were found to be significantly associated with future interventions. CONCLUSION: Although previous literature has shown MMA embolization to be safe and successful in preventing recurrent SDH, patients undergoing this procedure still carry a risk of future interventions. Patients taking factor Xa inhibitors are at especially high risk of subsequent intervention after MMA embolization.

Extensive Symptomatic Thoracolumbar Epidural Lipomatosis Treated With Minimally Invasive Hemilaminectomies: Technical Case Report.

BACKGROUND AND IMPORTANCE: Spinal epidural lipomatosis is a rare condition commonly associated with chronic corticosteroid use and obesity that involves deposition of adipose tissue in the epidural space of the spinal canal. This accumulation of adipose tissue may cause compression of the spinal cord and/or nerve roots and result in compressive symptoms such as myelopathy or radiculopathy. Spinal involvement is usually confined to either the thoracic or lumbar spine but can infrequently affect both regions. Depending on pre-existing conditions, treatment options include weight loss and discontinuation of exogenous steroid use, both of which have been shown to be effective therapeutic methods. Surgical decompression may be useful for appropriately selected patients in whom conservative therapy has failed or who experience acute neurological deterioration, although this is rarely indicated. CLINICAL PRESENTATION: In this study, we describe a patient receiving long-term corticosteroid therapy who presented with symptomatic epidural lipomatosis that involved the thoracic and lumbar spine. She was treated with decompression by continuous T3-L5 hemilaminectomies performed through 5 small incisions of alternating laterality. After surgery, the patient experienced clinical improvement and was able to return to her baseline. CONCLUSION: We illustrate a successful spinal decompression of extensive epidural lipomatosis through a less-invasive surgical approach using several small incisions to accomplish uninterrupted hemilaminectomies. This alternative approach to a standard continuous incision can be considered in cases of extensive spinal epidural lipomatosis in patients with multiple medical comorbidities in whom wound healing is believed to be an issue and for whom minimizing blood loss is crucial.

Use of intraoperative MRI for resection of intracranial tumors: A nationwide analysis of short-term outcomes.

OBJECTIVE: Recent evidence supports the use of intraoperative MRI (iMRI) during resection of intracranial tumors due to its demonstrated efficacy and clinical benefit. Though many single-center investigations have been conducted, larger nationwide outcomes have yet to be characterized. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database to examine baseline characteristics and 30-day postoperative outcomes among patients undergoing craniotomy for tumor resection with and without iMRI. Comparisons between outcomes were accomplished after propensity matching using chi-square tests for categorical variables and Welch two-sample t-tests for continuous variables. RESULTS: A total of 38,003 patients met inclusion criteria. Of this population, 54 (0.1%) received iMRI, while 37,949 (99.9%) did not receive iMRI. After propensity score matching, the resulting groups consisted of an iMRI group (n = 54) and a matched non-iMRI group (n = 54). Procedures involving iMRI were associated with significantly increased operation length compared to those without (p < 0.01). Length of hospital stay was higher in patients without iMRI, with this difference trending towards significance (p = 0.05) in the unmatched comparison. Patients undergoing craniotomy without iMRI had a higher rate of readmission (p = 0.04). There was no significant difference in occurrence of other adverse events between the two patient groups. CONCLUSION: Despite increasing operative length, iMRI is not associated with higher infection rate and may have a clinical benefit associated with reducing readmissions and a trend towards reducing inpatient length of stay. Additional nationwide analyses including more iMRI patients would provide further insight into the strength of these findings.

Sex Differences in Cerebral Aneurysms and Subarachnoid Hemorrhage.

Sex differences in cerebral aneurysm occurrence and characteristics have been well described. Although sex differences in outcomes following ischemic stroke have been identified, the effect of sex on outcomes following hemorrhagic stroke, and in particular, aneurysm treatment has been less studied. We describe the current state of knowledge regarding the impact of sex on treatment and outcomes of cerebral aneurysms. Although prior studies suggest that aneurysm prevalence and progression may be related to sex, we did not find clear evidence that outcomes following subarachnoid hemorrhage vary based on sex. Last, we identify areas for future research that could enhance understanding of the role sex plays in this context.

Cannabis Abuse and Perioperative Complications After Treatment of Intracranial Aneurysms: A Nationwide Analysis.

OBJECTIVE: In the present retrospective cohort analysis, we examined the differences in baseline characteristics and peri- and postoperative outcomes stratified by 3 groups: cannabis abuse or dependence versus none, surgical versus endovascular treatment, and unruptured and ruptured intracranial aneurysms. METHODS: A study population of 26,868 patients was defined using the 2009-2016 National Inpatient Sample database. The baseline characteristics were compared between the cannabis and no-cannabis groups, and the traits that differed significantly were factored into the multivariate analysis using 1:1 propensity score matching. The matched groups were analyzed to compare the cannabis and no-cannabis cohorts for the following endpoints: mortality, length of stay, discharge disposition, total hospital charges, and several peri- and postoperative outcomes. RESULTS: In the surgically and endovascularly treated groups for unruptured intracranial aneurysms, those in the cannabis group were more likely to be male and younger and to smoke tobacco than were those in the no-cannabis group. After matching, no significant endpoint differences were noted. Similarly, in the surgically and endovascularly treated ruptured aneurysm groups, those in the cannabis group were more likely to be male and younger and to smoke tobacco. After matching, the cannabis group within the endovascular treatment group had had a longer length of stay and were more likely to have developed any hydrocephalus, obstructive hydrocephalus, sepsis, and acute kidney injury. Those in the cannabis group who had undergone surgery were more likely to have developed any hydrocephalus, specifically, communicating hydrocephalus. CONCLUSIONS: The cannabis group with ruptured intracranial aneurysms was more likely to experience certain adverse outcomes after surgical or endovascular treatment compared with the no-cannabis group. However, such was not the case for cannabis abusers treated for unruptured aneurysms.

Inpatient outcomes of posterior fossa decompression with or without duraplasty for Chiari malformation type I.

OBJECTIVE: Chiari malformation type 1 (CM-1) is a congenital neurologic condition in which the cerebellar tonsils herniate below the foramen magnum, resulting in symptoms such as headache and neck pain. Two common surgical treatment approaches are posterior fossa decompression with (PFDD) and without duraplasty (PFD). Previous single-center studies have demonstrated increased neurologic complications after PFDD compared to PFD. The goal of this study is to determine differences in inpatient complications and hospitalization data among patients treated with these surgical techniques using a nationwide sample. METHODS: The National Inpatient Sample (NIS) was queried for years 2012-2015 for all patients with a primary diagnosis of CM-1 who underwent PFD or PFDD. Differences in baseline demographics and comorbidities were accounted for in subsequent analysis using propensity score matching. Hospitalization measures and inpatient complications of the two cohorts were compared using Chi-squared tests and t-tests when appropriate. RESULTS: A total of 2395 patients with CM-1 were included in this study, with 750 (31.3%) undergoing PFD and 1645 (68.7%) undergoing PFDD. PFDD was associated with higher total hospital costs than PFD. There were no significant differences in other hospitalization or discharge data, non-neurologic complications, or CNS complications (CSF leak, pseudomeningocele, abscess, meningitis, stroke) between the two surgical groups. CONCLUSIONS: This study represents the largest national analysis to date of adult CM-1 patients undergoing PFD or PFDD. Our findings suggest that whether the decision is made to perform the less invasive PFD or more invasive PFDD, inpatient complications and hospitalization data will not significantly differ.

Disparities in the symptomatic presentation of Moyamoya disease in the United States: A nationwide all-payer analysis.

BACKGROUND: Moyamoya disease is a chronic occlusive cerebrovascular disease that can present with either hemorrhagic or ischemic symptoms. The objective of this study was to evaluate whether the symptomatology of Moyamoya disease differs according to patient demographic groups. METHODS: In this study, we used the Nationwide Inpatient Sample (NIS) to investigate differences in the presentation of Moyamoya disease by age group, gender, and ethnicity from 2012 to 2016. After propensity score matching was utilized to control for overall comorbidity, the matched cohorts for each symptomatology were compared using a Chi-square test with respect to the potential risk factors of interest (i.e. age, sex, ethnicity) in order to generate multivariate reported P-values. RESULTS: A total of 4,474 patients met inclusion criteria. Patients presenting with ischemic stroke were more likely to be 65 years and older (p < 0.001); patients presenting with intracranial hemorrhage (ICH) were more likely to be 65 years and older (p < 0.001), male (p = 0.027), and Asian (p = 0.007); those presenting with seizure were more likely to be less than 10 years old (p = 0.002) and African American (p < 0.001); and those presenting with headache were more likely to be between 10 and 19 years old (p = 0.008). CONCLUSIONS: Our findings demonstrate that the distinct presentations of Moyamoya are associated with patient age, gender, and race. This is the largest study of its kind and adds to the collective understanding of this rare but life-threatening condition.

Revision Discectomy with or without Fusion for the Treatment of Recurrent Lumbar Disc Herniation: A Nationwide Analysis of Risk Profiles and Short-Term Outcomes.

OBJECTIVE: We compared the demographics, risk factors, and complications for adult patients with recurrent lumbar disc herniation (RLDH) undergoing revision discectomy with or without concurrent fusion. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who had undergone revision discectomy with or without simultaneous fusion. The demographic variables and various peri- and postoperative complications were compared between these 2 patient groups. RESULTS: A total of 6901 discectomy patients were included in the present study, of whom 2996 (43.4%) had undergone revision discectomy with fusion and 3905 (56.6%) had undergone revision discectomy alone. The revision discectomy with fusion group was significantly more likely to be older, female, and White or Black and to have a higher average body mass index than was the revision discectomy alone group. The discectomy with fusion group had longer hospital lengths of stay and was more likely to have a diagnosis of hypertension, insulin-dependent and non-insulin-dependent diabetes, and chronic obstructive pulmonary disease. In addition, the patients who had undergone discectomy with fusion were significantly more likely to develop pneumonia, require ventilation for >48 hours, require a blood transfusion, and to develop urinary tract infection, myocardial infarction, deep vein thrombosis, or pulmonary embolism compared with the patients who had undergone revision discectomy only. CONCLUSIONS: Our findings reveal that older patients with more comorbidities were more likely to undergo revision discectomy with fusion. Also, this surgical group experienced more adverse events after their procedure compared with the revision discectomy only group.

Gunshot wounds to the head: racial disparities in inpatient management and outcomes.

OBJECTIVE: Several studies have indicated that racial disparities may exist in the management and outcomes of acute trauma care. One segment of trauma care that has not been as extensively investigated, however, is that of cranial trauma care. The goal of this study was to determine whether significant differences exist among racial and ethnic groups in various measures of inpatient management and outcomes after gunshot wounds to the head (GWH). METHODS: In this study, the authors used the Nationwide (National) Inpatient Sample (NIS) to investigate all-cause mortality, receipt of surgery, days from admission to initial intervention, discharge disposition, length of hospital stay, and total hospital charges of those with GWH from 2012 to 2016. A 1:1 propensity score-matched analysis was conducted to evaluate the effect of race on these endpoints, while controlling for baseline demographics and comorbidities. RESULTS: A total of 333 patients met the inclusion and exclusion criteria: 148 (44.44%) white/Caucasian, 123 (36.94%) black/African American, 54 (16.22%) Hispanic/Latinx, and 8 (2.40%) Asian. African American patients were sent to immediate care and rehabilitation significantly less often than Caucasian patients (RR 0.17 [95% CI 0.04-0.71]). There were no significant differences in mortality, length of stay, rates of surgical intervention, or total hospital charges among any of the racial groups. CONCLUSIONS: The authors' findings suggest that racial disparities in inpatient cranial trauma care and outcomes may not be as prevalent as previously thought. In fact, the disparities seen were only in disposition. More research is needed to further elucidate and address disparities within this population, particularly those that may exist prior to, and after, hospitalization.