Posterior Interhemispheric-Transtentorial Approach for Resection of an Arteriovenous Malformation of the Superior Medullary Velum and Fourth Ventricle: 2-Dimensional Operative Video.

Brain arteriovenous malformations (AVMs) of the fourth ventricle represent a rare subtype associated with an aggressive natural course.1,2 In this case, a woman in her early 50s presented with dizziness. An AVM was diagnosed in the left superior cerebellar peduncle extending into the fourth ventricle. The AVM was supplied by superior cerebellar artery branches and classified as a Spetzler-Martin grade III and a Lawton-Young grade III, with a supplemented grade of 6.3,4 Being a single case report, institutional review board approval was not needed. Patient consent was obtained. The lesion was accessed through a torcular craniotomy and posterior interhemispheric-transtentorial approach, employing gravity to naturally retract the parietooccipital lobe.5-7 Dissection continued into the quadrigeminal and ambient cisterns, where the tentorium was incised parallelling the straight sinus to reach the superior vermis. Partial resection of the lingual and central lobules of the vermis facilitated access to the superior medullary velum. The superior cerebellar artery feeders were divided and followed to the superior cerebellar peduncle and through the superior medullary vellum. A vertical incision in the superior medullary velum facilitated entry into the fourth ventricle, where the AVM nidus was dissected circumferentially and resected en bloc. Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed complete obliteration of the AVM. After surgery, the patient experienced mild ataxia, but motor symptoms greatly improved during 3-month follow-up. This video illustrates resection of a complex fourth ventricular AVM through a posterior interhemispheric-transtentorial approach, highlighting pivotal considerations of patient positioning and approach selection to optimize treatment outcome for complex posterior fossa AVM resection.

Trends in medical device company payments in neurosurgery: a nationwide, multidatabase, geospatial analysis.

OBJECTIVE: Industry partnerships help advance the field of neurosurgery. Given the nature of the field and its close relationship with innovation, neurosurgeons frequently partner with the medical device industry to advance technology and improve outcomes. However, this can create important ethical concerns for patients. In this paper, the authors sought to comprehensively study how physician payments from medical device companies have changed and what geographic parameters influence the trends observed over the years. METHODS: The authors queried and merged several large databases, including Medicare and Medicaid provider usage data and databases from the Open Payments Program, National Plan and Provider Enumeration System, and US Census Bureau. Geospatial analysis was performed using Moran's I and II clustering. Univariate and multivariable analyses were performed using the Mann-Whitney U-test and geospatially weighted multivariable regression for hot spot and cold spot membership. RESULTS: Data for 952 counties across the continental United States were analyzed. Ninety-seven counties constituted geographic hot spots. These hot spots were primarily concentrated in Florida, the New York-Pennsylvania region, central Colorado, and southwestern United States. Independent predictors of hot spot membership included greater unemployment rates, the percentage of White patients, the presence of mobile homes, and the percentage of county Hispanic and Black populations. Company-based differences were examined. The vast majority of Medtronic's payments were in the form of royalties and licensing (86.6%). Royalties and licensing accounted for the majority of payments for DePuy (69.4%), Globus Medical (62%), and NuVasive (77.1%). In contrast, other companies, such as Boston Scientific, opted to pay physicians in the form of ownership and investment interests (42.1%). The impact of the COVID-19 pandemic was also assessed. During the onset of the pandemic in 2020, physician payments fell or remained the same across all regions with the exception of the South Atlantic region. However, it was observed that nearly all regions rebounded, with stark elevations in physician payments immediately in 2021. CONCLUSIONS: This analysis demonstrates that there are national hot spots and cold spots of physician payments, and offers some social, economic, and company-dependent predictors that may influence the magnitude of payments. Further analysis is needed to better understand this clinical-commercial partnership in healthcare, specifically within neurosurgical practice.

Metastasis of Intracranial Meningioma to the Osseous Spine: Systematic Literature Review and Case Report.

BACKGROUND: Osseous spinal metastases from intracranial meningiomas are rare but represent a serious disease progression. A literature review was performed on this topic to understand the clinical course of patients with this disease entity. We also present a case of spinal metastasis in a patient with a World Health Organization grade III meningioma. METHODS: The PubMed/MEDLINE database was queried on August 15, 2021, using the keywords (meningioma) AND (metastasis) AND (vertebra∗ OR spin∗). All publications reporting outcomes of patients with meningioma metastatic to the spine were included. Disease characteristics, treatment modality, and outcomes were extracted from each study. Because data availability varied widely between studies, no meta-analysis was performed. RESULTS: A total of 30 articles with 33 cases were included. Outcome data varied greatly in terms of quality and length of follow-up. Of 28 cases with reported outcomes data, 20 resulted in patient mortality ranging from a few weeks to 5 years after spinal metastasis. Mean (standard deviation) survival time was 5.8 (6.4) years following initial diagnosis, but only 1.4 (3.2) years from spinal metastasis. The longest survivor was noted to have no recurrence of disease 4 years after spinal metastasis. CONCLUSIONS: Bony spinal metastasis from intracranial meningioma is an extremely rare occurrence. Within the limits of the available literature, outcomes of patients with this disease appear to be poor. However, data reporting is inconsistent, and several articles did not report any outcome data. Further study is needed to better clarify the course and prognosis of this disease.

Radiographic and Clinical Outcomes After Stand-Alone Anterior Lumbar Interbody Fusion for Symptomatic L5-S1 Retrolisthesis.

BACKGROUND AND OBJECTIVES: Degenerative lumbar spondylolisthesis is associated with significant pain and disability. The literature on the treatment options and clinical outcomes for lumbar anterolisthesis is robust, but very few reports specifically evaluate lumbar retrolisthesis. This study investigated surgical outcomes for symptomatic L5-S1 retrolisthesis treated with stand-alone L5-S1 anterior lumbar interbody fusion (ALIF). METHODS: All patients with symptomatic L5-S1 retrolisthesis treated with stand-alone L5-S1 ALIF at a single institution over a 7-year period were identified. Exhaustive nonoperative management had failed for all patients. Patients with previous lumbar fusion were excluded. Preoperative and postoperative radiographic images and patient-reported outcome measures for 20 patients (14 males and 6 females; mean [SD] age, 50.3 [13.7] years) were analyzed. RESULTS: The mean (SD) follow-up was 43.0 (23.7) months (range, 12.1-102.5 months). Patients experienced postoperative improvements in L5-S1 retrolisthesis (P = .048), L5-S1 disk height and angle (P < .001), L5 foraminal height (P < .001), L5-S1 lordosis (P < .001), and lumbar lordosis (P = .01). There were no significant changes in spinopelvic parameters. At the most recent follow-up, minimal clinically important differences in Oswestry Disability Index score, 36-Item Short-Form Survey (SF-36), and numerical rating scale score for leg pain were achieved in 11 of 20 (55%), 7 of 14 (50%), and 7 of 13 (54%) patients, respectively. All patients demonstrated fusion with no graft subsidence at up to 32 months. No patient experienced intraoperative complications, was readmitted, or required a subsequent posterior decompression or fusion because of refractory symptoms. CONCLUSION: In our cohort, stand-alone L5-S1 ALIF was associated with radiographic and clinical improvement in patients with symptomatic L5-S1 retrolisthesis.

Bilateral sacroiliac joint fusion in long constructs using self-harvesting porous S2-alar iliac screws with an integrated tulip: technical considerations and early clinical and radiographic experience.

OBJECTIVE: The incidence of sacroiliac joint (SIJ) dysfunction after lumbosacral fusion is high. Upfront bilateral SIJ fusion using novel fenestrated self-harvesting porous S2-alar iliac (S2AI) screws could reduce the incidence of SIJ dysfunction and need for subsequent SIJ fusion. In this study, the authors report their early clinical and radiographic results of SIJ fusion using this novel screw. METHODS: The authors began using self-harvesting porous screws in July 2022. This is a retrospective review of consecutive patients at a single institution who underwent long thoracolumbar surgery with extension to the pelvis using this porous screw. Radiographic parameters of regional and global alignment were collected preoperatively and at the time of last follow-up. The incidence of intraoperative complications and need for revision were collected. The incidences of mechanical complications, including screw breakage, implant loosening/pullout, and screw cap dislocation at the time of last follow-up were also collected. RESULTS: Ten patients with a mean age of 67 years were included, 6 of whom were male. Seven patients had a thoracolumbar construct with extension to the pelvis. Three patients had upper instrumented vertebrae at the proximal lumbar spine. Intraoperative breach was not encountered in any of the patients (0%). Postoperatively, 1 patient (10%) had screw breakage at the neck of the tulip of the modified iliac screw discovered at routine follow-up without clinical sequalae. CONCLUSIONS: Use of self-harvesting porous S2AI screws incorporated into long thoracolumbar constructs was safe and feasible, demanding unique technical considerations. Long-term clinical and radiographic follow-up with a large patient cohort is necessary to determine their durability and efficacy to achieve SIJ arthrodesis and prevent SIJ dysfunction.

Complications associated with single-position prone lateral lumbar interbody fusion: a systematic review and pooled analysis.

OBJECTIVE: Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term follow-up; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF. METHODS: A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded. RESULTS: Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]). CONCLUSIONS: Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.

Back to basal: contemporary cerebrovascular cohort study of the supratentorial-infraoccipital approach.

OBJECTIVE: The objective of this paper was to assess applications of the supratentorial-infraoccipital (STIO) approach for cerebrovascular neurosurgery. METHODS: The authors conducted a cohort study of all consecutive cases in which the STIO approach was used during the study period, December 1995 to January 2021, as well as a systematic review of the literature. RESULTS: Twenty-five cerebrovascular cases were identified in which the STIO approach was used. Diagnoses included arteriovenous malformation (n = 15), cerebral cavernous malformation (n = 5), arteriovenous fistula (n = 4), and aneurysm (n = 1). The arteriovenous malformations consisted of Spetzler-Martin grade II (n = 3), grade III (n = 8), and grade IV (n = 4) lesions. Lesion locations included the occipital lobe (n = 15), followed by the tentorial dural (n = 4), temporal-occipital (n = 3), temporal (n = 1), thalamic (n = 1), and quadrigeminal cistern (n = 1) regions. Many patients (75%) experienced transient visual deficits attributable to retraction of the occipital lobe, all of which resolved. As of last follow-up (n = 12), modified Rankin Scale scores had improved for 6 patients and were unchanged for 6 patients compared with the preoperative baseline. CONCLUSIONS: The STIO approach is a safe and effective skull base approach that provides a specialized access corridor for appropriately selected cerebrovascular lesions.

Ketogenic Metabolic Therapy for Glioma.

PURPOSE: This study describes a retrospective case series of patients with glioma who received ketogenic metabolic therapy through dietary adherence and intermittent fasting. METHODS: A retrospective chart review of a single surgeon's clinic records was performed to identify patients who maintained nutritional ketosis for at least four months between January 2015 and October 2020. RESULTS: Sixteen patients who met the inclusion criteria constituted a heterogeneous population of patients with diagnoses including eight World Health Organization (WHO) grade IV gliomas (seven glioblastoma, one gliosarcoma), seven WHO grade III gliomas (three oligodendroglioma, four astrocytoma), and one WHO grade II oligodendroglioma. IDH1 mutation status was present for 12 patients, and MGMT methylation status was present for eight patients. The mean (standard deviation [SD]) duration of ketogenic metabolic therapy was 20.6 (13.8) months. The Response Assessment in Neuro-oncology Criteria was applied during the ketogenic metabolic therapy interval, indicating a complete response in eight patients and partial response in eight patients. The mean (SD) progression-free survival while patients maintained ketogenic metabolic therapy was 20.0 (14.4) months. CONCLUSION: Ketogenic metabolic therapy appears to convey a survival advantage within this patient series, which highlights the possibility that this therapy, when strictly applied, can augment the standard of care. Further exploration of this modality in a prospective series is warranted to formally explore this therapy.

Comparison of Intraoperative Indocyanine Green Videoangiography vs Postoperative Catheter Angiography to Confirm Microsurgical Occlusion of Spinal Dorsal Intradural Arteriovenous Fistulas.

BACKGROUND: Dorsal intradural arteriovenous fistulas (DI-AVFs) represent 80% of spinal AVFs. Microsurgical clip occlusion is a durable treatment that uses preoperative and postoperative digital subtraction angiography (DSA) as standard practice. Intraoperative indocyanine green videoangiography (ICG-VA) is a valuable intraoperative adjunct in these cases. Intraoperative ICG-VA findings have not been compared with postoperative DSA findings. OBJECTIVE: To assess the diagnostic value of intraoperative ICG-VA vs postoperative DSA for spinal DI-AVFs. METHODS: A multi-institutional database of vascular malformations was queried for all surgically managed cases of DI-AVF. Patients with both intraoperative ICG-VA and postoperative DSA were included. Demographic and radiologic data, intraoperative findings, and surgical outcomes data were retrospectively analyzed. RESULTS: Forty-five patients with DI-AVF were identified (male sex, 32; mean age, 61.9 [range, 26-85] years). All DI-AVFs were treated with interruption of the fistula with clip occlusion of the draining vein. Intraoperative ICG-VA showed complete obliteration in all patients. Postoperative DSA was performed for 40 patients and confirmed complete obliteration in all patients. The negative predictive value of ICG-VA confirming complete occlusion of the DI-AVFs was 100%. Eighteen patients (47%) experienced clinical improvement, and 16 (42%) experienced no change in condition. CONCLUSION: ICG-VA is useful for intraoperative identification of DI-AVFs and confirmation of complete microsurgical occlusion. Correlation between intraoperative ICG-VA and postoperative DSA findings demonstrates the diagnostic power of ICG-VA. This finding suggests that postoperative DSA is unnecessary when intraoperative ICG-VA confirms complete occlusion of the DI-AVF, which will spare patients the procedural risk and cost of this invasive procedure.

Unique Presentation and Novel Surgical Approach to a Transcribriform Penetrating Head Injury Caused by a Nail Gun.

A penetrating head injury caused by a nail gun is an infrequent clinically diverse condition that varies in severity by the neurovascular structures involved. The authors present the case of a patient whose frontal lobe was pierced by a nail that entered via a transnasal transcribriform trajectory without causing vascular injury or intracranial hemorrhage; the man was unaware of the nail's presence and presented with headache five days after the incident. The nail was extracted using a bifrontal craniotomy for direct visualization and for defect repair of the skull base combined with endoscopic endonasal extraction of the nail.

Residual Tumor Volume and Tumor Progression after Subtotal Resection and Observation of WHO Grade I Skull Base Meningiomas.

Objective This study investigated the impact of residual tumor volume (RTV) on tumor progression after subtotal resection and observation of WHO grade I skull base meningiomas. Study Design This study is a retrospective volumetric analysis. Setting This study was conducted at a single institution. Participants Patients who underwent subtotal resection of a WHO grade I skull base meningioma and postsurgical observation (July 1, 2007-July 1, 2017). Main Outcome Measure The main outcome was radiographic tumor progression. Results Sixty patients with residual skull base meningiomas were analyzed. The median (interquartile range) RTV was 1.3 (5.3) cm 3 . Tumor progression occurred in 23 patients (38.3%) at a mean duration of 28.6 months postsurgery. The 1-, 3-, and 5-year actuarial progression-free survival (PFS) rates were 98.3, 58.6, and 48.7%, respectively. The Cox multivariate analysis identified increasing RTV ( p = 0.01) and history of more than 1 previous surgery ( p = 0.03) as independent predictors of tumor progression. In a Kaplan-Meier analysis for PFS, the RTV threshold of 3 cm 3 maximized log-rank testing significance between groups of patients dichotomized at 0.5 cm 3 thresholds ( p < 0.01). The 3-year actuarial PFS rates for meningiomas with RTV ≤3 cm 3 and >3 cm 3 were 76.2 and 32.1%, respectively. When RTV >3 cm 3 was entered as a covariate in the Cox model, it was the only factor independently associated with tumor progression ( p < 0.01). Conclusion RTV was associated with tumor progression after subtotal resection of WHO grade I skull base meningioma in this cohort. An RTV threshold of 3 cm 3 was identified that minimized progression of the residual tumor when gross total resection was not safe or feasible.

ZAP-X Gyroscopic Radiosurgery System: A Preliminary Analysis of Clinical Applications within a Retrospective Case Series.

INTRODUCTION: The ZAP-X Gyroscopic Radiosurgery system (ZAP Surgical Systems, Inc., San Carlos, CA, USA) is a novel high-dose targeted stereotactic radiosurgery platform for outpatient use that includes self-shielding, X-ray image guidance, and the capacity to aim the radiation beam gyroscopically at an intracranial lesion using 5 independent degrees of freedom. The ZAP-X Gyroscopic Radiosurgery system accomplishes these actions while meeting widely accepted standards for dose gradient and accuracy. This retrospective study examined data of patients treated with gyroscopic radiosurgery (GRS) to document clinical outcomes. METHODS: Medical records of all outpatients treated with GRS over a 20-month period from January 2019 to August 2020 were searched to extract relevant details, including follow-up data until August 2021 (32-month study interval). Patients with <6 months of radiographical follow-up data were excluded unless death occurred. Data collection included pretreatment clinical history, pathological diagnosis, radiographical features, treatment parameters, and long-term clinical and radiographical follow-up. RESULTS: Sixty-eight patients received outpatient treatment with GRS during the 20-month treatment interval, with 59 patients remaining after exclusion for the minimum follow-up threshold, with a mean (standard deviation [SD]) fractionation of 1.85 (1.63). Eighty-two lesions were treated across a very heterogeneous patient population, including meningiomas (42.4%), metastases (39.0%), gliomas (6.8%), schwannomas (1.7%), and pituitary tumor (1.7%). Mean (SD) radiographical follow-up data (14.7 [6.60] months) were available for 56 patients. During that interval, 13 treated lesions in 13 patients (15.9%) demonstrated progression, 9 of which were stable during the initial posttreatment imaging surveillance period. Mean lesion volume was stable from pretreatment (2.54 cm3 [4.37 cm3]) to most recent follow-up (2.80 cm3 [8.20 cm3]) (t [79] = -0.310; p = 0.76). Minor adverse clinical events were noted in 3 (5.1%) of the 59 patients during the posttreatment phase that may have been related to the treatment. Ten (16.9%) patients died within the 32-month study interval. DISCUSSION/CONCLUSION: This preliminary assessment of the first series of patients treated with the Zap-X Gyroscopic Radiosurgery system documents its overall feasibility in clinical applications. Although the duration of follow-up was brief, GRS appeared to be both safe and effective. Additional analysis, with an ongoing prospective registry, is underway.

Bone grafting and biologics for spinal fusion in the pediatric population: current understanding and future perspective.

Pediatric spinal fusions have been associated with nonunion rates of approximately 25%, putting patients at risk for neurological complications while simultaneously incurring significant costs for revision surgery. In an effort to decrease nonunion rates, various bone grafts and biologics have been developed to increase osseous formation and arthrosis. The current gold-standard bone graft is autologous bone taken from the iliac crest or ribs, but this procedure is associated with significant morbidity and postoperative pain due to an additional graft harvesting procedure. Other bone graft substitutes and biologics include allografts, demineralized bone matrix, bone morphogenetic protein, and bioactive glass. Ultimately, these substitutes have been studied more extensively in the adult population, and there is a paucity of strong evidence for the use of these agents within the pediatric population. In this review, the authors will discuss in detail the characteristics of the various bone graft substitutes, their fusion efficacy, and their safety profile in this subpopulation.

Bevacizumab as a surgery-sparing agent for spinal ependymoma in patients with neurofibromatosis type II: Systematic review and case.

Neurofibromatosis type 2 (NF2) is a rare, hereditary tumor syndrome, often requiring repeated surgeries for multiple lesions with significant cumulative morbidity. As such, non-operative management should be considered when possible for this patient population. The aim of this study is to provide a systematic review of the literature regarding this treatment strategy. A descriptive case of a patient in whom bevacizumab treatments enabled over 15 years of surgical postponement for a symptomatic spinal cord ependymoma is also provided. Evidence suggests that bevacizumab is a reasonable surgery-deferring option for cystic lesions, and it may be especially useful in NF2 patients to reduce cumulative morbidity.

Coccidioidal meningitis with multiple aneurysms presenting with pseudo-subarachnoid hemorrhage: illustrative case.

BACKGROUND: Coccidioidomycosis is a primarily self-limiting fungal disease endemic to the western United States and South America. However, severe disseminated infection can occur. The authors report a severe case of coccidioidal meningitis that appeared to be a subarachnoid hemorrhage (SAH) on initial inspection. OBSERVATIONS: A man in his early 40s was diagnosed with coccidioidal pneumonia after presenting with pulmonary symptoms. After meningeal spread characterized by declining mental status and hydrocephalus, coccidioidal meningitis was diagnosed. The uniquely difficult aspect of this case was the deceptive appearance of SAH due to the presence of multiple aneurysms and blood draining from the patient's external ventricular drain. LESSONS: Coccidioidal infection likely led to the formation of multiple intracranial aneurysms in this patient. Although few reports exist of coccidioidal meningitis progressing to aneurysm formation, patients should be closely monitored for this complication because outcomes are poor. The presence of basal cistern hyperdensities from a coccidioidal infection mimicking SAH makes interpreting imaging difficult. Surgical management of SAH can be considered safe and viable, especially when the index of suspicion is high, such as in the presence of multiple aneurysms. Even if it is unclear whether aneurysmal rupture has occurred, prompt treatment is advisable.

Outcomes in a Case Series of Elderly Patients with Aneurysmal Subarachnoid Hemorrhages in the Barrow Ruptured Aneurysm Trial (BRAT).

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is debilitating in elderly patients, but literature regarding this population is scarce, and clinical decision-making remains debated. Outcomes of elderly patients with aSAH stratified by age and clinical presentation were analyzed. METHODS: Patients treated for aSAH were retrospectively analyzed. Patients were trichotomized into a young cohort (aged <60 years [n = 268]) and 2 elderly cohorts (aged 60-65 years [n = 60] and ≥65 years [n = 77]). The elderly cohorts were analyzed by poor or good scores at presentation (Hunt and Hess [HH] score >3 vs. ≤3, respectively) and poor functional outcome (modified Rankin Scale score >2). RESULTS: Of 137 elderly patients, 121 had a 6-year follow-up. The >65-year-olds (75% [52/69]) were more likely to have poor functional outcomes than the 60 to 65-year-olds (48% [25/52]) (odds ratio, 3.3; 95% confidence interval, 1.5-7.1; P = 0.002). Among those with an HH score ≤3 at presentation (n = 90), the >65-year-old cohort had poorer outcomes than the 60 to 65-year-old cohort at 6-year follow-up (69% [35/51] vs. 36% [14/39], respectively; odds ratio, 3.9; 95% confidence interval, 1.6-9.4; P = 0.003). Among patients with an HH score >3, no statistically significant differences in functional outcome were observed between the >65-year-old (n = 18) and 60 to 65-year-old (n = 13) cohorts. CONCLUSIONS: Elderly patients with aSAH are at high risk for poor functional outcomes. However, among those presenting with good HH scores, younger-elderly patients (aged 60-65 years) tend to fare better than older-elderly patients (aged >65 years). Elderly patients presenting with high-grade aSAH fare poorly regardless of age, which can inform clinical decision-making and prognostication.

Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement and Reduction in Operative Time and Total Hospital Charges.

OBJECTIVE: In ventriculoperitoneal shunt (VPS) placement, distal placement of the peritoneal catheter will typically be performed by a neurosurgeon. More recently, laparoscopic-assisted (LA) placement of the distal peritoneal catheter by general surgeons has become common. The present study examined whether LA placement of a VPS (LAVPS) is associated with a reduced operative time, lower hospital costs, and fewer distal revisions. METHODS: A retrospective review was performed of the data from all patients who had received a new VPS at our institution from 2013 to 2016. Age, sex, diagnosis, previous abdominal surgery, operative time, anesthesia grade, incidence of 30-day shunt failure, and total hospital charges were analyzed. RESULTS: A total of 680 patients had undergone first-time VPS placement, including 199 with LAVPS and 481 with non-LAVPS placement (non-LAVPS). The mean age of the LAVPS patients was significantly older than that of the non-LAVPS patients (64.1 vs. 59.3 years; P = 0.002). The mean operative time was shorter in the LAVPS group than in the non-LAVPS group (55 vs. 75 minutes; P < 0.001). Distal shunt revision within 30 days occurred more often for the non-LAVPS patients (6 of 481 [1.2%]) than for the LAVPS patients (0 of 199 [0%]). A subset analysis of patients with normal-pressure hydrocephalus found decreased total hospital charges in the LAVPS group ($67,124 vs. $80,890; P = 0.009). CONCLUSIONS: Compared with non-LAVPS, LAVPS was associated with significantly shorter operative times and fewer distal shunt revisions within 30 days. The findings from a subset analysis supported a decrease in total hospital charges. Additional studies are needed; however, these data suggest that LAVPS is a safer, less-expensive alternative to non-LAVPS.

Digital subtraction cerebral angiography after negative computed tomography angiography findings in non-traumatic subarachnoid hemorrhage.

BACKGROUND: CT angiography (CTA) is widely used for the detection of vascular lesions in patients with non-traumatic subarachnoid hemorrhage (ntSAH); however, digital subtraction angiography (DSA) remains the gold standard for diagnosis. Our aim was to analyze the diagnostic yield of DSA after negative high-resolution CTA findings. METHODS: Records of patients with a CTA-negative ntSAH at a single institution from 2014 to 2018 were retrospectively analyzed. ntSAH patterns were categorized as cortical, perimesencephalic, or diffuse. Subsequent DSA findings were compared across the three cohorts. RESULTS: A total of 186 patients had CTA-negative ntSAH. The ntSAH pattern was identified as cortical (n=77, 41.4%), diffuse (n=60, 32.3%), or perimesencephalic (n=49, 26.3%). In eight patients (4%), DSA revealed a vascular lesion (one cervical arteriovenous fistula and seven atypical aneurysms) after negative CTA findings. All eight patients with positive DSA findings had diffuse SAH (13% of patients with a diffuse pattern). The seven aneurysms included four blister or dissecting (two basilar artery, one superior cerebellar artery, and one dorsal wall internal carotid artery), two fusiform (one posterior communicating artery and one anterior spinal artery), and one saccular aneurysm (middle cerebral artery). CONCLUSION: DSA identified a causative lesion in 4% of patients with CTA-negative ntSAH, but only in patients with diffuse ntSAH. Most of the lesions detected were atypical aneurysms and were found on delayed angiograms. These results suggest that DSA can help to diagnose CTA-negative ntSAH caused by unusual aneurysms, and repeat DSA may be needed only for patients with diffuse ntSAH.