The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas.

Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/µL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).

Combined endovascular and skull base surgical management of pediatric craniocervical pathology: a case series.

OBJECTIVE: Pathological bony abnormalities of the craniocervical region in children sometimes require surgical intervention as part of their management. Rarely, abnormal skeletal or vascular anatomy can render traditional surgical techniques ineffective because of the risk of injury to the vertebral artery. To mitigate these risks, a combined endovascular and skull base approach was devised. The authors describe their experience using vertebral artery sacrifice as an adjunctive surgical method to reduce the risk of inadvertent vertebral artery injury during surgical correction of pediatric craniocervical deformity. METHODS: Three patients underwent vertebral artery sacrifice for structural craniocervical pathologies (1 male, 2 females; ages 12, 14, and 3 years). One patient presented with basilar invagination odontogenic brainstem compression, and the other 2 patients presented with congenital cervical fusion. All patients underwent endovascular left vertebral artery sacrifice after passing balloon test occlusion. RESULTS: No adverse effects from the vertebral artery sacrifice were observed. At the last follow-ups (35, 30, and 32 months), all 3 patients had a satisfactory outcome with no adverse effects as a result of their sacrificed artery. CONCLUSIONS: Endovascular vertebral artery sacrifice followed by skull base approaches can be used to effectively and safely treat craniocervical pathology from a variety of pediatric skeletal abnormalities.

A radiological analysis of pelvic fixation trajectories: patient series.

BACKGROUND: Three well-defined methods for pelvic fixation are used for biomechanical support in spine fusion constructs: iliac, recessed iliac, and S2-alar-iliac (S2AI) screws. The authors compared the maximum screw sizes that could be placed with these techniques by using image-guidance software and high-resolution computed tomography scans from 20 randomly selected patients. Six trajectories were plotted per side, beginning at recognized starting points (standard or recessed posterior superior iliac spine [PSIS] or S2AI screw) and ending at the anterior inferior iliac spine (AIIS) or supra-acetabular notch (SAN). OBSERVATIONS: The mean maximum screw length and width ranged from 80.0 ± 32.2 mm to 140.8 ± 22.6 mm and from 8.25 ± 1.2 mm to 13.0 ± 2.7 mm, respectively, depending on the trajectory. Statistically significant differences in length were found between the standard and recessed PSIS trajectories to the AIIS (p < 0.001) and between the standard PSIS-to-AIIS trajectory and the S2AI-to-AIIS (p = 0.007) or S2AI-to-SAN (p < 0.001) trajectories. The most successful trajectory was the PSIS to SAN (95%, 38/40). LESSONS: The traditional iliac screw trajectory enabled the longest and widest screw trajectories and highest rate of successful screw placement with the fewest theoretical breaches more reliably than recessed and S2AI trajectories. These findings may help surgeons plan for maximum screw purchase for pelvic fixation.

Post-Surgical Cognitive Outcomes of Moyamoya Disease: A Systematic Review.

BACKGROUND: Moyamoya disease (MMD) is an occlusive arteriopathy leading to stroke. Progressive if left untreated, revascularization surgery has become the mainstay of treatment. Although clinical and radiographic outcomes of MMD after intervention are well-characterized, cognitive outcomes in pediatric patients remain unclear. We aimed to examine postoperative cognitive outcomes in children with MMD, examine factors associated with cognitive changes after intervention, and define the effect of revascularization surgery on cognitive outcomes. METHODS: A systematic review was conducted following PRISMA guidelines searching PubMed, Embase, and Scopus databases. Articles met inclusion criteria if they studied pediatric patients undergoing revascularization surgery for MMD and examined cognitive outcomes either qualitatively or quantitatively. All data extracted from included articles was examined descriptively. RESULTS: Of 1091 resultant articles, 12 articles containing 446 patients were included. Surgery was associated with maintained or improved full scale intellectual quotient (IQ), performance IQ, perceptual IQ, memory quotient and verbal memory. However, 70% of patients had impaired cognitive function, with associated poor school performance. Improvements in cognition were associated with increased cerebral blood flow, particularly to the middle cerebral artery, due to the development of collaterals. Female sex, shorter duration from symptom onset to surgery, and surgery after age 7 were predictive of cognitive improvement. Completed ischemic stroke prior to surgery was associated with poorer cognitive outcomes. CONCLUSIONS: Although children with MMD have improved cognitive outcomes following revascularization overall, a distinct subset experience cognitive impairment. Consideration of patient-specific and treatment-related factors is important to enable proper risk stratification and inform management approaches.

Terson syndrome secondary to aneurysmal subarachnoid hemorrhage in a child: illustrative case.

BACKGROUND: Terson syndrome is the phenomenon of intraocular hemorrhage in the setting of subarachnoid hemorrhage (SAH). Vision loss can lead to morbidity for the affected individual. Aneurysmal SAH related to intracranial aneurysms is rare in children. Studies have shown the incidence of Terson syndrome in adults with aneurysmal SAH to be over 40%; however, few cases of Terson syndrome in pediatric aneurysmal SAH have been reported. OBSERVATIONS: A 9-year-old male presented with altered mental status and seizures. Computed tomographic angiography showed aneurysmal SAH from a ruptured, left-sided posterior inferior cerebellar artery aneurysm. The patient underwent endovascular treatment with coiling and external ventricular drainage for SAH. Ophthalmological consultation for blurry vision revealed the diagnosis of Terson syndrome with decreased vision in the left eye, which was managed conservatively. LESSONS: Terson syndrome after SAH can occur in children. Prompt ophthalmological evaluation in pediatric patients with aneurysmal SAH is vital for recognition and management to decrease overall morbidity.

Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series.

OBJECTIVE: Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS: The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS: Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0-2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS: PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Postischemic Trigeminal Neuropathy Treated With Radiofrequency Ablation.

Trigeminal neuralgia is a pain syndrome that is defined by sharp electrical shock-like pain that radiates in the sensory distribution of the trigeminal nerve. The classical cause of this syndrome is vascular compression, but other causes, such as stroke, have also been described. Instances of post-ischemic trigeminal pain have been described as meeting the classic description, and are termed trigeminal neuropathy. The treatment paradigms for trigeminal neuralgia versus neuropathy differ significantly, especially with the consideration of surgical management.We present a case of a 78-year-old man with post-ischemic trigeminal neuropathy that was successfully treated with radiofrequency ablation after failure of conservative management.We also summarize three previous cases of post-ischemic trigeminal neuropathy that were also successfully treated with percutaneous surgical treatment, showing that percutaneous surgical management should be considered in patients with post-ischemic trigeminal neuropathy that fail conservative management.

Middle meningeal artery embolization as a perioperative adjunct to surgical evacuation of nonacute subdural hematomas: An multicenter analysis of safety and efficacy.

BACKGROUND: By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort. METHODS: Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected. RESULTS: Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%. CONCLUSION: This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.

Radiographic and clinical outcomes with particle or liquid embolic agents for middle meningeal artery embolization of nonacute subdural hematomas.

BACKGROUND: Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization. METHODS: Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic). RESULTS: The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00). CONCLUSIONS: MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days.

Acute Mirror M1 Occlusions Treated With Endovascular First-Pass Contact Aspiration Technique.

Patients with acute bilateral M1 occlusion are usually comatose at presentation and have a grave prognosis. There have been few reports of emergent treatment using endovascular reperfusion therapy (ERT). We describe a patient treated with simultaneous first-pass contact aspiration and review the literature for cases describing the successful use of ERT in patients with bilateral anterior circulation proximal large-vessel occlusion (LVO). A functionally independent 95-year-old woman with history of atrial fibrillation (AF) presented with altered mentation, aphasia, and weakness in all extremities. Her National Institutes of Health Stroke Scale (NIHSS) score was 13. CT angiogram and perfusion demonstrated acute mirror M1 occlusions with extensive bilateral middle cerebral artery (MCA) territory penumbra, respectively. Emergent ERT was performed with simultaneous contact aspiration within the bilateral M1s under concomitant flow arrest with a balloon guide catheter. Modified Thrombolysis in Cerebral Infarction (mTICI) grades 3 and 2c were achieved on the left and right, respectively. By postoperative day 1 (POD1), the patient had improved motor function, mentation, and communication.The technical feasibility of simultaneous contact aspiration thrombectomies for acute bilateral M1 occlusions was demonstrated with successful reperfusion of both vascular territories in a single pass lasting 28 minutes. Simultaneous thrombectomies yielded rapid recanalization and reperfusion and minimized radiation exposure. Previous cases demonstrating this technique utilized stent-retriever techniques in successive fashion, with a consequent increase in the patient's total ischemic time. The technical success of our aggressive approach suggests it may have utility in the treatment of acute multivessel occlusions (MVOs).

Stereotactic electroencephalography is associated with reduced opioid and nonsteroidal anti-inflammatory drug use when compared with subdural grids: a pediatric case series.

Patients undergoing surgical intervention for epilepsy mapping are typically administered opioids for pain control. The use of opioids is demonstrably lower after other procedures when a minimally invasive surgery (MIS) technique is used. Our objective was to determine whether using MIS for stereoelectroencephalography (SEEG) resulted in lower opioid requirement by pediatric patients when compared with subdural grid placement after craniotomy (ECoG). A retrospective chart review was conducted to identify patients < 18 years who underwent epilepsy mapping surgery using SEEG or ECoG in 2015-2019. The hospital stay was divided into four time periods, and the total amounts of opioids (converted into morphine milligram equivalents (MMEs)) and nonsteroidal anti-inflammatory drugs (NSAIDs) and pain scores (on numerical rating scale (NRS)) were calculated for each time interval. The two groups were then compared statistically. The study included 31 patients in the SEEG group and 9 in the ECoG group. The SEEG group consumed significantly fewer opioids during the hospital stay than the ECoG group (23.6 vs. 61.7 MMEs; p = 0.041). There were also significant differences in the length of stay (6.9 vs. 12.2 days; p = 0.002), rate of complications (0% vs. 20%; p = 0.006), and total NSAIDs consumed (3,264.8 vs. 12,730.2 mg; p = 0.002). Opioid and NSAID consumption were significantly lower and hospital stays were shorter in pediatric patients who underwent epilepsy mapping via SEEG compared with ECoG. These results suggest that MIS for epilepsy mapping may decrease the overall pain medication use and expedite patient discharge.

Postoperative bowel complications after non-shunt-related neurosurgical procedures: case series and review of the literature.

Postoperative bowel complications after non-shunt-related neurosurgical procedures are relatively rare. In an effort to identify the primary risk factors, we evaluated postoperative bowel complications in cranial, endovascular, and spinal procedures in neurosurgery patients using our own institutional case series along with a literature review.We identified severe postoperative bowel complications that occurred at our institution after non-shunt-related neurosurgical procedures between July 2016 and December 2018. We also completed a systematic review of PubMed/MEDLINE using search terms related to bowel complications.At our institution, 7 patients (average age 49.7 ± 9.5 years, range 34-60; no apparent sex predilection) had severe postoperative bowel complications after undergoing a total of 10 neurosurgical procedures. Diagnosis was on average 1 week postoperatively (range 5-13 days), and the time between radiographic/clinical diagnosis and either surgery or death was 1.3 ± 1.4 days (range 0-4 days). Bowel perforation occurred in 4 patients. Five of the patients died, 3 as a direct result of the bowel complication. In the literature review, we identified 6487 spine and 66 cranial and/or endovascular bowel complications after neurosurgical procedures.Our case series and literature review demonstrate that severe postoperative bowel complications after non-shunt-related neurosurgical procedures, while rare, carry significant morbidity/mortality despite prompt and aggressive management. These can also happen without direct injury to bowel tissue, instead occurring as sequelae of inflammatory processes, as well as from delayed mobility, extended use of opiate narcotics, and lack of standardized protocols to ensure early bowel movements that likely stems from unfamiliarity with this potentially devastating complication.

Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery.

The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0-30.83 (4664 patients), 30.84-34.58 (2548 patients), 34.59-38.04 (3147 patients), 38.05-45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity.

Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series.

BACKGROUND: Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE: To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS: Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS: The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION: Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke: A Multi-Institutional Experience of Technical and Clinical Outcomes.

BACKGROUND: Endovascular thrombectomy is a promising treatment for acute ischemic stroke in children, but outcome and technical data in pediatric patients with large-vessel occlusions are lacking. OBJECTIVE: To assess technical and clinical outcomes of thrombectomy in pediatric patients. METHODS: We undertook a retrospective cohort study of pediatric patients who experienced acute ischemic stroke from April 2017 to April 2019 who had immediate, 30-, and 90-d follow-up. Patients were treated with endovascular thrombectomy at 5 US pediatric tertiary care facilities. We recorded initial and postprocedural modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b, initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and pediatric modified Rankin scale (mRS) score 0 to 2 at 90 d. RESULTS: There were 23 thrombectomies in 21 patients (mean age 11.6 ± 4.9 yr, median 11.5, range 2.1-19; 52% female). A total of 19 (83%) thrombectomies resulted in mTICI grade ≥ 2b recanalization. The median PedNIHSS score was 13 on presentation (range 4-33) and 2 (range 0-26) at discharge (mean reduction 11.3 ± 6.1). A total of 14 (66%) patients had a mRS score of 0 to 2 at 30-d follow-up; 18/21 (86%) achieved that by 90 d. The median mRS was 1 (range 0-4) at 30 d and 1 (range 0-5) at 90 d. One patient required a blood transfusion after thrombectomy. CONCLUSION: In this large series of pediatric patients treated with endovascular thrombectomy, successful recanalization was accomplished via a variety of approaches with excellent clinical outcomes; further prospective longitudinal study is needed.

Defining a new neurosurgical complication classification: lessons learned from a monthly Morbidity and Mortality conference.

OBJECTIVEThe absence of a commonly accepted standardized classification system for complication reporting confounds the recognition, objective reporting, management, and avoidance of perioperative adverse events. In the past decade, several classification systems have been proposed for use in neurosurgery, but these generally focus on tallying specific complications and grading their effect on patient morbidity. Herein, the authors propose and prospectively validate a new neurosurgical complication classification based on understanding the underlying causes of the adverse events.METHODSA new complication classification system was devised based on the authors' previous work on morbidity in endovascular surgery. Adverse events were prospectively compiled for all neurosurgical procedures performed at their tertiary care academic medical center over the course of 1 year into 5 subgroups: 1) indication errors; 2) procedural errors; 3) technical errors; 4) judgment errors; and 5) critical events. The complications were presented at the monthly institutional Morbidity and Mortality conference where, following extensive discussion, they were assigned to one of the 5 subgroups. Additional subgroup analyses by neurosurgical subspecialty were also performed.RESULTSA total of 115 neurosurgical complications were observed and analyzed during the study period. Of these, nearly half were critical events, while technical errors accounted for approximately one-third of all complications. Within neurosurgical subspecialties, vascular neurosurgery (36.5%) had the most complications, followed by spine & peripheral nerve (21.7%), neuro-oncology (14.8%), cranial trauma (13.9%), general neurosurgery (12.2%), and functional neurosurgery (0.9%).CONCLUSIONSThe authors' novel neurosurgical complication classification system was successfully implemented in a prospective manner at their high-volume tertiary medical center. By employing the well-established Morbidity and Mortality conference mechanism, this simple system may be easily applied at other neurosurgical centers and may allow for uniform analyses of perioperative morbidity and the introduction of corrective initiatives.

Delayed Occipitocervical Instability With Cranial Settling After Far-Lateral Transcondylar Surgery for Invasive Skull Base Tumor.

BACKGROUND: Occipitocervical instability is a rare but potentially severe complication of a far-lateral transcondylar surgical approach to the skull base. OBJECTIVE: To investigate the incidence of clinically significant occipitocervical instability after transcondylar surgery via a far-lateral approach and to determine whether the extent of occipital condyle resection relative to the hypoglossal canal was associated with the development of occipitocervical instability. METHODS: A retrospective review of patients undergoing far-lateral transcondylar surgery was performed at our institution to identify patients who developed postoperative occipitocervical instability. RESULTS: Of the 61 far-lateral transcondylar operations performed, the authors identified 2 cases of delayed occipitocervical instability after surgery. In each case, the patient had tumor invading into the occipital condyle and supracondylar region and a resection extending anterior to the hypoglossal canal was performed. Both patients presented with pathological fractures and a severe occipitocervical deformity. CONCLUSION: Patients who have tumor involvement of the occipital condyle and supracondylar region and undergo partial unilateral condylar resection are at risk for occipitocervical instability and should be considered for occipitocervical fusion.

Moderate Sedation for Pipeline Embolization of Posterior Circulation Disease: Technical Note from a Single Center.

OBJECTIVE: Flow diversion has been an important addition to endovascular neurosurgery, but its use in the posterior circulation remains controversial. Our goal is to describe the safety and efficacy of moderate sedation during flow diversion for posterior circulation lesions (aneurysms or dissecting pseudoaneurysms). METHODS: The authors retrospectively reviewed the medical records of all patients who underwent placement of a Pipeline embolization device for a posterior circulation lesion using moderate sedation at a single institution from August 2012 through November 2017. Clinical data and outcomes were evaluated. RESULTS: Fifteen consecutive patients were identified: 8 female, 7 male (mean age 52.2 ± 16.3 years, range 15-81). Eleven lesions were located in the vertebral artery, 1 in the posterior inferior cerebellar artery, 2 in the posterior cerebral artery, and 1 in the basilar artery. All patients underwent flow diversion with Pipeline embolization devices. One patient experienced an acute occlusion of the basilar artery during the procedure that required revascularization. Mean fluoroscopy time was 35.6 ± 16.5 minutes (range 15.5-75). Mean follow-up time was 12.7 ± 8.8 months (range 3-36). No patient had new neurologic deficits in the perioperative or postoperative period. Conversion to general anesthesia was not required in any case. CONCLUSIONS: Moderate sedation is safe and feasible in patients undergoing flow diversion for posterior circulation lesions. In addition, its use may allow for more rapid identification of procedural complications, facilitating emergent treatment and decreasing procedure-related morbidity.

Adenosine-induced cardiac standstill for endovascular treatment of pediatric vein of Galen malformations.

Vein of Galen malformations are congenital high-flow vascular malformations that often present with heart failure, hydrocephalus, developmental delay, and intracranial hemorrhage. Because open surgical treatment is associated with high morbidity and mortality, endovascular embolization is increasingly becoming the preferred method of intervention. However, embolization of these lesions can be difficult because of their high-flow nature. The use of adenosine-induced cardiac standstill for treatment of vein of Galen malformations has not been previously described in neonates. The authors describe 3 treatments in 2 patients that demonstrate that the use of adenosine is well tolerated and allows safe transarterial embolization of high-flow vein of Galen malformations in the pediatric population.