Comparison between endovascular and surgical treatment of spinal dural arteriovenous fistulas: a single-center cohort and systematic review.

OBJECTIVE: With recent advancements in minimally invasive techniques, endovascular embolization has gained popularity as a first-line treatment option for spinal dural arteriovenous fistulas (sDAVFs). The authors present their institution's case series of sDAVFs treated endovascularly and surgically, and they performed a systemic review to assess the outcomes of both modalities of treatment. METHODS: The authors conducted a retrospective observational study of 24 consecutive patients with sDAVFs treated between 2013 and 2023. The primary outcome was the rate of occlusion, which was compared between the surgically and endovascularly treated sDAVFs. They also conducted a systemic review of all the literature comparing outcomes of endovascular and surgical treatment of sDAVFs. RESULTS: A total of 24 patients with 24 sDAVFs were studied. The mean patient age was 63.8 ± 15.5 years, and the majority of patients were male (n = 19, 79.2%). Of the 24 patients, 8 (33.3%) received endovascular treatment, 15 (62.5%) received surgical treatment, and 1 (4.2%) patient received both. Complete occlusion at first follow-up was higher in the surgical cohort but did not achieve statistical significance (66.7% vs 25%, p = 0.52). Recurrence was higher in the endovascular cohort (37.5% vs 13.3%, p = 0.3), while the rate of postprocedural complications was higher in the surgical cohort (13.3% vs 0%, p = 0.52); however, neither of these differences was statistically significant. CONCLUSIONS: Endovascular embolization in the management of sDAVFs is an alternative treatment to surgery, whose long-term efficacy is still under investigation. These findings suggest overall comparable outcomes between endovascular and open surgical treatment of sDAVFs. Future studies are needed to determine the role of endovascular embolization in the overall management of sDAVFs.

Comparison of the transarterial, transvenous, and superior ophthalmic vein approaches in the treatment of indirect carotid-cavernous fistulas.

OBJECTIVE: Indirect carotid-cavernous fistulas (CCFs) are abnormal arteriovenous shunting lesions with a highly variable clinical presentation that depends on the drainage pattern. Based on venous drainage, treatment can be either transarterial (TA) or transvenous (TV). The aim of this study was to compare the outcomes of indirect CCF embolization via the TA, TV, and direct superior ophthalmic vein (SOV) approaches. METHODS: The authors conducted a retrospective analysis of 74 patients admitted to their institution from 2010 to 2023 with the diagnosis of 77 indirect CCFs as confirmed on digital subtraction angiography. RESULTS: A total of 74 patients with 77 indirect CCFs were included in this study. Embolization was performed via the TA approach in 4 cases, the TV approach in 50 cases, and the SOV in 23 cases. At the end of the procedure, complete occlusion was achieved in 76 (98.7%) cases. The rate of complete occlusion at the end of the procedure and at last radiological follow-up was significantly higher in the SOV and TV cohorts than in the TA cohort. The rate of recurrence was highest in the TA cohort (25% for TA vs 5.3% for TV vs 0% for SOV, p = 0.68). CONCLUSIONS: The rate of immediate complete occlusion was higher in the TV and SOV cohorts than in the TA cohort while the rate of complete occlusion at final follow-up was highest in the SOV cohort. The SOV approach was significantly associated with higher rates of postoperative complications. Indirect CCFs require careful examination of the fistulous point and the venous drainage to provide the most effective patient-tailored approach.

General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients.

BACKGROUND AND OBJECTIVES: Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS: The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS: After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION: In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.

A Vascular Quartet: Scalp Arteriovenous Malformation, Sinus Pericranii, Dural Arteriovenous Fistula, and Arteriovenous Brain Malformation in a Single Patient.

We present a case of a 51-year-old female who presented for evaluation of a large scalp mass found to have a different quartet of vascular malformations- a persistent scalp arteriovenous malformation (sAVM) with sinus pericranii, an inoperable intracranial SM-V brain arteriovenous malformation (bAVM), and a Cognard I dural arteriovenous fistula (dAVF). This is the first reported instance with four distinct vascular pathologies. We review the etiologies of multiple vascular abnormalities in the cerebral circulation that could contribute to this patient's findings and review strategies for treatment. We conducted a retrospective review of the clinical and angiographic records for a single adult female patient, including a management approach and an in-depth literature review. Given the high baseline vascularity of these complex lesions, surgery was not considered the initial therapy. We focused primarily on the sAVM with a staged embolization involving both transarterial and transvenous approaches. Transarterial coil embolizes 5 feeding artery branches of the right external carotid artery, followed by transvenous coil embolization into the common venous pouch accessed through the transosseous sinus pericranii via the SSS, dramatically reduced the size and filling of the large sAVM and eliminated a significant source of hypertensive venous outflow. Serial endovascular treatments of her sAVM led to a significant reduction in size and pulsatility, and the pain from tenderness to palpation was concurrently decreased. Despite multiple treatments, serial angiographic evaluations of her scalp lesion showed continued new development of collaterals. Ultimately the patient elected to forego further treatment for her sAVM. To our knowledge, there has not been another report of a single adult patient with a quartet of vascular malformations in the literature. Treatment paradigms for sAVMs are limited to case reports and small series; however, we purport that the most successful therapeutic approaches are multimodal and likely should incorporate surgical resection when feasible. We emphasize the caution required for patients with multiple other underlying intracranial vascular malformations. The altered intracranial flow dynamics can drastically hinder the success of a unimodal approach involving endovascular therapy alone.

Spinal epidural tuberculoma with osseous involvement: illustrative case.

BACKGROUND: A tuberculosis infection of the central nervous system can present as a localized, intraspinal tuberculoma. These lesions may cause spinal cord compression requiring early identification and surgical decompression to limit deleterious neurological sequelae. OBSERVATIONS: A 28-year-old female with a history of opioid use disorder presented with low-back pain in the setting of trauma with progressive bilateral lower extremity radiculopathy and paraparesis. T1- and T2-weighted magnetic resonance imaging sequences of the spine demonstrated a heterogeneously hyperintense extra-axial epidural mass at T11 with mass effect. Biopsy of the lesion revealed benign soft tissue with necrosis and caseating granulomatous inflammation consistent with tuberculoma. The patient underwent laminectomy and debulking of mass for decompression and was subsequently began antitubercular treatment with good neurological outcome. LESSONS: To the best of the authors' knowledge, there are only a handful of microbiologically and radiographically confirmed cases of spinal epidural tuberculoma in English literature. These lesions are rare and difficult to clinically and radiographically characterize in the absence of systemic pulmonary TB symptoms. Tuberculoma is an important differential for a spinal epidural mass, particularly because resection with systemic antitubercular treatment results in symptom resolution.

Surgical Treatment of Upper Extremity Segmental Myoclonus in an Adolescent with Chiari Malformation and Cervicothoracic Syrinx.

BACKGROUND: Myoclonus is an involuntary movement disorder characterized by semirhythmic jerking movements of muscle groups but is rarely seen in association with Chiari malformation type I (CM-1). CM-1 is a frequently encountered clinical entity in pediatric neurosurgery characterized by caudal displacement of the cerebellar tonsils with or without syringomyelia. We report a pediatric patient who presented with upper extremity myoclonus and was found to have CM-1 and a complex septated cervicothoracic syrinx eccentric to the left. CASE PRESENTATION: A 12-year-old female presented with 6 months of headaches and upper extremity paresthesias who subsequently developed a left upper extremity segmental myoclonus after a fall. MRI demonstrated a CM-1 and a large complex cervicothoracic syrinx with a midline and left paracentral cavities. Her myoclonus was nonepileptic and refractory to clonazepam, cyclobenzaprine, and gabapentin. She underwent an intradural Chiari decompression and duraplasty. Postoperatively, she had complete resolution of her segmental myoclonus. DISCUSSION: This case demonstrates a durable resolution of posttraumatic upper extremity segmental myoclonus after surgical decompression of a CM-1 with syringomyelia. Thus, Chiari decompression should be considered in cases of myoclonus with CM-1 and syringomyelia.

Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience.

BACKGROUND: Neurosurgical complications from epidural injections have rarely been reported. OBJECTIVE: To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention. METHODS: A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed. RESULTS: Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1). CONCLUSION: A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.

Natural history of cerebral cavernous malformations.

Cerebral cavernous malformations (CCM) are vascular abnormalities of the central nervous system with an incidence of 0.4-0.5% and an annual rate of hemorrhage ranging from 0.7% to 1%. Most lesions are located in the cerebral hemisphere but some occur in deeper locations such as the basal ganglia and pons. The most common symptoms during presentation are headache, seizures, and focal neurologic deficits. Surgery remains the most effective treatment modality for symptomatic CCM, while the management of incidental CCM remains controversial. Factors associated with increased risk of hemorrhage include being female and less than 40 years old. This finding, however, is not consistent in all natural history studies evaluated. During follow-up, the most important and consistent risk factor for rebleed was a prior hemorrhage. Here, we provide an indepth but concise review of the literature regarding the natural history of CCMs.

Beyond the Cyst: The Many Contributions of Isadore Tarlov (1905-1977) to Contemporary Neurosurgical Practice.

: Isadore Max Tarlov (1905-1977) is primarily remembered for his 1938 description of the eponymous perineural "Tarlov cyst." However, during his long career as a neurosurgeon and researcher, he was responsible for many other observations and inventions that influenced the development of neurosurgery in the 20th century. While studying at Johns Hopkins Medical School he was acquainted with Walter Dandy, and he became the first resident to study under Wilder Penfield at the newly formed Montreal Neurological Institute. He made many novel observations about peripheral and cranial nerve anatomy, pioneered nerve anastomosis and grafting techniques, and introduced the concept of fibrin glue. He developed an animal model of spinal cord injury and used it to establish for the first time that functional neurological reserve is proportional to rapidity of injury, because gradual onset of compression is better tolerated by neural tissue than acute compression. He was the first to describe the use of the knee-chest position for lumbar spine surgery to minimize increases in epidural venous pressure due to abdominal compression. Finally, near the end of his career, he published a collection of thoughtful, philosophical essays entitled The Principle of Parsimony in Medicine and Other Essays, in which he advocated for a humanistic and restrained approach to medical practice. In this article, we discuss the contributions of Tarlov to the field of neurosurgery, including many of his lesser-known accomplishments that have become part of neurosurgery's collective legacy.

A revolution in preventing fatal craniovertebral junction injuries: lessons learned from the Head and Neck Support device in professional auto racing.

Fatal craniovertebral junction (CVJ) injuries were the most common cause of death in high-speed motor sports prior to 2001. Following the death of a mutual friend and race car driver, Patrick Jacquemart (1946-1981), biomechanical engineer Dr. Robert Hubbard, along with race car driver and brother-in-law Jim Downing, developed the concept for the Head and Neck Support (HANS) device to prevent flexion-distraction injuries during high-velocity impact. Biomechanical testing showed that neck shear and loading forces experienced during collisions were 3 times the required amount for a catastrophic injury. Crash sled testing with and without the HANS device elucidated reductions in neck tension, neck compression, head acceleration, and chest acceleration experienced by dummies during high-energy crashes. Simultaneously, motor sports accidents such as Dale Earnhardt Sr.'s fatal crash in 2001 galvanized public opinion in favor of serious safety reform. Analysis of Earnhardt's accident demonstrated that his car's velocity parallel to the barrier was more than 150 miles per hour (mph), with deceleration upon impact of roughly 43 mph in a total of 0.08 seconds. After careful review, several major racing series such as the National Association for Stock Car Auto Racing (NASCAR) and Championship Auto Racing Team (CART) made major changes to ensure the safety of drivers at the turn of the 21st century. Since the rule requiring the HANS device in professional auto racing series was put in place, there has not been a single reported case of a fatal CVJ injury.