Treatment of a Pial Arterial Venous Fistula in a Newborn: 2-Dimensional Operative Video.

Pial arterial venous fistulas (PAVFs) are rare vascular entities that occur with direct high-flow connections between pial arterial feeders and large veins without an intervening nidus.1-5 These vascular abnormalities can present in the pediatric population with high output heart failure.1 PAVFs can be treated with endovascular intervention, microvascular ligation, or a combination depending on the clinical scenario.4 Here, we present a case in which a newborn presented in high output heart failure because of a large left-sided middle cerebral artery fed PAVF. We performed a craniotomy for ligation of the PAVF to obliterate the arteriovenous shunting to improve her cardiac status and diminish her intracranial venous hypertension. Throughout the ligation, we used indocyanine green to localize the next appropriate vessels to ligate, allowing us to safely obliterate the anomalous vasculature and improve the patient's cardiac function. Postoperatively, the patient did well neurologically with improvements in cardiac function and near normalization of intracranial vasculature. The patient's guardians consented to the procedure and to the publication of her image.

Cisternostomy as a Surgical Treatment for Traumatic Brain Injury-Related Prolonged and Delayed Intracranial Pressure Elevation: A Case Report.

Traumatic brain injury (TBI) can be classified into primary, due to the effect of the initial trauma, or secondary, due to increased intracranial pressure (ICP). Increased ICP may cause brain herniation and also decreases cerebral blood perfusion leading to ischemia. Recently, a few studies showed that cisternostomy with decompressive craniectomy (DC) has better outcomes than DC alone in patients with TBI. This can be explained by the recent advances indicating that cisternal cerebrospinal fluid (CSF) communicates with cerebral interstitial fluid (IF) through Virchow-Robin spaces. Theoretically, opening cisterns to atmospheric pressure may induce IF drainage and subsequently decrease ICP. A 55-year-old man presented to the emergency department with subdural hematomas, hemorrhagic contusions, and subarachnoid hemorrhage after falling off a moving truck. ICP elevation was refractory despite increased sedation, initiation of paralysis with Cisatracurium, esophageal cooling, multiple doses of 23.4 % saline and mannitol, and DC. Lumbar drain (LD) placement was performed with beneficial results. Unfortunately, the LD stopped functioning multiple times and each time this occurred, he developed increased ventricular size with elevated ICP. The patient underwent cisternostomy and lamina terminalis fenestration. No further increased ICPs were observed after cisternostomy at a one-month follow-up. Cisternostomy is a potential surgical treatment for patients with TBI-related prolonged ICP elevation.

Analysis of reported adverse events of pipeline stents for intracranial aneurysms using the FDA MAUDE database.

OBJECTIVE: Flow diverting stents (FDS) are a validated device in the treatment of intracranial aneurysms, allowing for minimally invasive intervention. However, after its approval for use in the United States in 2011, post-market surveillance of adverse events is limited. This study aims to address this critical knowledge gap by analyzing the FDA Manufacturer and User Facility Device Experience (MAUDE) database for patient and device related (PR and DR) reports of adverse events and malfunctions. METHODS: Using post-market surveillance data from the MAUDE database, PR and DR reports from January 2012-December 2021 were extracted, compiled, and analyzed with R-Studio version 2021.09.2. PR and DR reports with insufficient information were excluded. Raw information was organized, and further author generated classifications were created for both PR and DR reports. RESULTS: A total of 2203 PR and 4017 DR events were recorded. The most frequently reported PR adverse event categories were cerebrovascular (60%), death (11%), and neurological (8%). The most frequent PR adverse event reports were death (11%), thrombosis/thrombus (9%) cerebral infarction (8%), decreased therapeutic response (7%), stroke/cerebrovascular accident (6%), intracranial hemorrhage (5%), aneurysm (4%), occlusion (4%), headache (4%), neurological deficit/dysfunction (3%). The most frequent DR reports were activation/positioning/separation problems (52%), break (9%), device operates differently than expected (4%), difficult to open or close (4%), material deformation (3%), migration or expulsion of device (3%), detachment of device or device component (2%). CONCLUSIONS: Post-market surveillance is important to guide patient counselling and identify adverse events and device problems that were not identified in initial trials. We present frequent reports of several types of cerebrovascular and neurological adverse events as well as the most common device shortcomings that should be explored by manufacturers and future studies. Although inherent limitations to the MAUDE database are present, our results highlight important PR and DR complications that can help optimize patient counseling and device development.

Cisternotomy and Liliequist's Membrane Fenestration as a Surgical Treatment for Idiopathic Intracranial Hypertension (Pseudotumor Cerebri): A Case Report.

Subarachnoid basal cistern opening (cisternotomy) is used during many microsurgical operations to relax the brain by removing or diverting cerebrospinal fluid (CSF). Recently, cisternotomy has been used in patients with traumatic brain injury to improve outcomes due to its ability to decrease intracranial pressure (ICP) and brain edema by diverting CSF. Theoretically, another condition that can benefit from cisternotomy is idiopathic intracranial hypertension (IIH) as it presents with manifestations of increased ICP, such as headache, vomiting, and papilledema. Here, we discuss the case of a 39-year-old woman with IIH who presented with headache, nausea, and papilledema in the setting of maximally tolerated medical management after five months of shunt removal due to infection. The patient did not want to proceed with the replacement of her shunt and therefore underwent a right eyebrow craniotomy for cisternotomy, lamina terminals fenestration, and Liliequist's membrane opening. Postoperatively, her symptoms improved completely. She was off acetazolamide altogether at the three-month follow-up and no longer had pseudotumor cerebri headaches. This case report demonstrates the use of cisternotomy to relieve the manifestations of increased ICP and its potential as a surgical option for patients with IIH.

Lead toxicity due to retained intracranial bullet fragments: illustrative case.

BACKGROUND: Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments. OBSERVATIONS: The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms. LESSONS: Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

Basilar artery incarceration secondary to a longitudinal clivus fracture: A rare and favorable outcome of an often devastating injury.

Background: Clival fractures are a rare traumatic finding and are often the result of high-impact craniofacial trauma. Rarely, longitudinal clival fractures can be associated with incarceration of the basilar artery within the fracture and/or the sphenoid sinus. Of the 12 reported cases of basilar incarceration, 11 of these injuries have proved to be fatal due to pontine infarction. We present a patient with basilar artery incarceration without any neurologic deficits. Case Description: The case reported is a 17-year-old male who presented after a motor vehicle collision with a linear and longitudinal clival fracture with entrapment of the basilar artery within the sphenoid sinus. Diagnostic subtraction angiography showed a small intimal tear with possible intraluminal thrombus. The patient was started on aspirin and at 3-month post injury had no neurologic deficits. Conclusion: Basilar artery incarceration is an injury often associated with pontine infarction secondary to basilar artery dissection and/or thrombus developing at the site of entrapment. Our case illustrates a favorable outcome after this injury. Based on these results, antiplatelet therapy may be a viable option for prevention of brainstem infarcts in patients with this injury; however, further prospective studies must be done to assess the overall efficacy and validity of this treatment. There are no established treatment guidelines for this condition. Further research on this topic should also be tailored toward early identification of this pathology and prevention of thromboembolic sequelae of this injury.

Reversal of cognitive, behavioral, and language impairments after the left frontal arachnoid cyst fenestration in a pediatric patient.

BACKGROUND: Arachnoid cysts (ACs) are cerebrospinal fluid-containing cysts located between the surface of the brain or spinal cord and arachnoid layer of the leptomeninges. ACs have been known to cause cognitive, language, and behavioral deficits and currently there is no standard treatment paradigm. Surgical indications include papilledema, increasing growth with mass effect causing neurological deficit, or rapid head growth, however, cognitive symptoms related to mass effect may not always be considered. CASE DESCRIPTION: We present a 3-year-old male with an AC of the left anterior fossa causing frontal lobe compression with resultant behavioral, language, and cognitive deficits. CONCLUSION: Surgical intervention for AC decompression may be indicated when there are cognitive, behavioral, or language delays related to the mass effect and location of the AC. Neuropsychiatric testing or more advanced imaging studies may further support surgical treatment. After craniotomy for fenestration of the left frontal AC, there was drastic improvement in cognitive, language, and behavioral symptoms in our pediatric patient.

Pediatric middle meningeal artery embolization for chronic subdural hematoma: A case report.

BACKGROUND: The most common neuroradiological finding in pediatric nonaccidental trauma (NAT) is subdural hematoma (SDH). Management options for pediatric SDH range from conservative clinical surveillance to craniotomy or decompressive craniectomy. The middle meningeal artery (MMA) indirectly feeds the hematoma; thus, MMA embolization is an alternative or adjunct to current surgical treatments in adults. Herein, we present, to the best of our knowledge, the first reported case of successful MMA embolization in a pediatric patient as an adjunct to current standard treatment for chronic SDH (cSDH). CASE DESCRIPTION: An 18-month-old male with a history of NAT presented at 5 months of age with an acute right parietal skull fracture and bilateral SDH treated with burr hole drainage. He was lost to follow-up until 15 months of age with an increased head circumference and new dysconjugate gaze. Imaging revealed a right-sided cSDH and underwent craniotomy. Six-week follow-up revealed significant improvement in the SDH but cSDH remained at the periphery of the craniotomy's reach. The patient symptoms continued. The right-sided MMA embolization was offered as option to avoid repeat craniotomy. Follow-up CTs at 2 weeks, 3 months, and 6 months postprocedure revealed decrease of cSDH size and density. At 8-month follow-up, the patient continued to meet developmental milestones with near resolution of his dysconjugate gaze. CONCLUSION: This case report details the first successful use of MMA embolization in the treatment of pediatric cSDH as an adjunct to standard treatment. Further investigation of MMA embolization in pediatrics should be made to expand options available for cSDH in this patient population.

Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room.

Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.

Intrawound Vancomycin Decreases the Risk of Surgical Site Infection After Posterior Spine Surgery: A Multicenter Analysis.

STUDY DESIGN: Secondary analysis of data from a prospective multicenter observational study. OBJECTIVE: The aim of this study was to evaluate the occurrence of surgical site infection (SSI) in patients with and without intrawound vancomycin application controlling for confounding factors associated with higher SSI after elective spine surgery. SUMMARY OF BACKGROUND DATA: SSI is a morbid and expensive complication associated with spine surgery. The application of intrawound vancomycin is rapidly emerging as a solution to reduce SSI following spine surgery. The impact of intrawound vancomycin has not been systematically studied in a well-designed multicenter study. METHODS: Patients undergoing elective spine surgery over a period of 4 years at seven spine surgery centers across the United States were included in the study. Patients were dichotomized on the basis of whether intrawound vancomycin was applied. Outcomes were occurrence of SSI within postoperative 30 days and SSI that required return to the operating room (OR). Multivariable random-effect log-binomial regression analyses were conducted to determine the relative risk of having an SSI and an SSI with return to OR. RESULTS: .: A total of 2056 patients were included in the analysis. Intrawound vancomycin was utilized in 47% (n = 966) of patients. The prevalence of SSI was higher in patients with no vancomycin use (5.1%) than those with use of intrawound vancomycin (2.2%). The risk of SSI was higher in patients in whom intrawound vancomycin was not used (relative risk (RR) -2.5, P < 0.001), increased number of levels exposed (RR -1.1, P = 0.01), and those admitted postoperatively to intensive care unit (ICU) (RR -2.1, P = 0.005). Patients in whom intrawound vancomycin was not used (RR -5.9, P < 0.001), increased number of levels were exposed (RR-1.1, P = 0.001), and postoperative ICU admission (RR -3.3, P < 0.001) were significant risk factors for SSI requiring a return to the OR. CONCLUSION: The intrawound application of vancomycin after posterior approach spine surgery was associated with a reduced risk of SSI and return to OR associated with SSI. LEVEL OF EVIDENCE: 2.