The Utility of Transcranial Electrical Stimulation Motor Evoked Potential Monitoring in Predicting Postoperative Supplementary Motor Area Syndrome and Motor Function Recovery.

BACKGROUND: Postoperative hemiparesis following frontal lobe lesion resection is alarming, and predicting motor function recovery is challenging. Supplementary motor area (SMA) syndrome following resection of frontal lobe lesions is often indistinguishable from postoperative motor deficit due to surgical injury of motor tracts. We aimed to describe the use of intraoperative transcranial electrical stimulation (TES) with motor evoked potential monitoring data as a diagnostic tool to distinguish between SMA syndrome and permanent motor deficit (PMD). METHODS: A retrospective analysis of 235 patients undergoing craniotomy and resection with TES-MEP monitoring for a frontal lobe lesion was performed. Patients who developed immediate postoperative motor deficit were included. Motor deficit and TES-MEP findings were categorized by muscle group as left upper extremity, left lower extremity, right upper extremity, or right lower extremity. Statistical analysis was performed to determine the predictive value of stable TES-MEP for SMA syndrome versus PMD. RESULTS: This study included 20 patients comprising 29 cases of immediate postoperative motor deficit by muscle group. Of these, 27 cases resolved and were diagnosed as SMA syndrome, and 2 cases progressed to PMD. TES-MEP stability was significantly associated with diagnosis of SMA syndrome (P = 0.015). TES-MEP showed excellent diagnostic utility with a sensitivity and positive predictive value of 100% and 92.6%, respectively. Negative predictive value was 100%. CONCLUSIONS: Temporary SMA syndrome is difficult to distinguish from PMD immediately postoperatively. TES-MEP may be a useful intraoperative adjunct that may aid in distinguishing SMA syndrome from PMD secondary to surgical injury.

Balloon-mounted covered stent as endovascular management of a traumatic cervical internal carotid artery pseudoaneurysm in a 23-year-old: a case report.

Background: Distal cervical internal carotid artery (cICA) pseudoaneurysms are uncommon. They may lead to thromboembolic or hemorrhagic complications, especially in young adults. We report one of the first cases in the literature regarding the management via PK Papyrus (Biotronik, Lake Oswego, Oregon, USA) balloon-mounted covered stent of a 23-year-old male with an enlarging cervical carotid artery pseudoaneurysm and progressive internal carotid artery stenosis. Case Description: We report the management of a 23-year-old male with an enlarging cervical carotid artery pseudoaneurysm and progressive internal carotid artery stenosis. Based on clinical judgment and imaging analysis, the best option to seal the aneurysm was a PK Papyrus 5×26 balloon-mounted covered stent. A follow-up angiogram showed no residual filling of the pseudoaneurysm, but there was some contrast stagnation just proximal to the stent, which is consistent with a residual dissection flap. We then deployed another PK Papyrus 5×26 balloon-mounted covered stent, providing some overlap at the proximal end of the stent. An angiogram following this subsequent deployment demonstrated complete reconstruction of the cICA with no residual evidence of pseudoaneurysm or dissection flap. There were no residual in-stent stenosis or vessel stenosis. The patient was discharged the day after the procedure with no complications. Conclusions: These positive outcomes support the use of a balloon-mounted covered stent as a safe and feasible modality with high technical success for endovascular management of pseudoaneurysm.

Transradial or Transulnar Long Sheath Access to the Brachial Artery Allows for Neuroendovascular Procedures in Patients with Radial or Ulnar Artery Occlusion.

BACKGROUND: Transradial access is an important tool for many neuroendovascular procedures. Occlusion of the radial or ulnar artery is not uncommon after transradial or transulnar access and can present a challenge for patients requiring repeat angiography. METHODS: Between March 2022 and June 2023, patients undergoing transradial or transulnar angiography who were found to have a radial artery occlusion or ulnar artery occlusion were identified. Repeat catheterization of the occluded artery was attempted using a 21-gauge single wall puncture needle and a 0.021-inch wire to traverse the occlusion and insert a 23-cm sheath into the brachial artery. RESULTS: A total of 25 patients undergoing 26 angiograms during the study period were found to have a radial artery occlusion or ulnar artery occlusion. Successful repeat catheterization of the occluded artery was achieved in 21 of 26 cases (80.7%). Outer diameter sheath size ranged from 5 Fr (0.0655 inch) to 8 Fr (0.1048 inch). No access complications were encountered. Number of prior angiograms, time since prior angiogram, and prior angiogram procedure time were associated with lower likelihood of successful access. CONCLUSIONS: Transradial or transulnar neuroangiography through an occluded radial or ulnar artery is safe and feasible by traversing the occlusion into the brachial artery with a 23-cm sheath. Repeat catheterization is most successful in patients with an arterial occlusion <6 months old. This technique is important in patients who have limited options for arterial access, avoiding access site complications inherent in transfemoral access, and in patients who specifically require radial or ulnar artery access.

Postoperative course of cerebrospinal fluid diversion in the setting of leptomeningeal disease: a systematic review, meta-analysis, and meta-regression with an illustrative case.

BACKGROUND: Management of hydrocephalus symptoms in the setting of leptomeningeal disease (LMD) includes cerebrospinal fluid (CSF) diversion, which can in the form of ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS). However, the quantifiable postoperative course following this intervention is poorly defined. Correspondingly the aim of our study was to quantitatively define and analyze the pooled metadata regarding this topic. METHODS: Multiple electronic databases from inception to March 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analyses and analyzed by means meta-regression, both utilizing random-effects modeling. Post-hoc bias evaluation was then performed for all outcomes. RESULTS: A total of 12 studies were identified for inclusion, describing 503 LMD patients managed by CSF diversion - 442 (88%) by VPS and 61 (12%) by LPS. Median male percentage and age at diversion were 32% and 58 years respectively, with lung and breast cancer the most common primary diagnoses. Meta-analysis demonstrated pooled incidence of symptom resolution in 79% (95% CI 68-88%) of patients after index shunt surgery, and shunt revision required in 10% (95% CI 6-15%) of cases. Pooled overall survival from index shunt surgery was 3.8 mo (95% CI 2.9-4.6 mo) across all studies. Meta-regression demonstrated that studies published later trended towards significantly shorter overall survival from index shunt surgery (co-efficient=-0.38, P = 0.023), whereas the proportion of VPS to LPS in each study did not impact survival (P = 0.89). When accounting for these biases, overall survival from index shunt surgery was re-estimated to be shorter 3.1 mo (95% CI 1.7-4.4 mo). We present an illustrative case demonstrating the course of symptom improvement, shunt revision and an overall survival of 2 weeks from index CSF diversion. CONCLUSION: Although CSF diversion in the setting of LMD can improve hydrocephalus symptoms in the majority of patients, there is a non-negligible proportion that will require shunt revision. Postoperatively, the prognosis of LMD remains poor irrespective of shunt type, and despite possible biases within the current literature, the expected median overall survival after index surgery is a matter of months. These findings support CSF diversion as an effective palliative procedure when considering symptoms and quality of life. Further research is required to understand how postoperative expectations can be managed to respect the best wishes of patients, their family, and the treating clinical team.

Clinical efficacy of endovascular treatment approach in patients with carotid cavernous fistula: A systematic review and meta-analysis.

Background and objectives: Carotid-cavernous fistulas (CCFs) represent a group of rare, abnormal arteriovenous communications between the carotid arterial system and the cavernous sinuses (CS). CCFs often produce ophthalmologic symptoms related to increased CS pressures and retrograde venous drainage of the eye. Although endovascular occlusion remains the preferred treatment for symptomatic or high-risk CCFs, most of the data for these lesions is limited to small, single-center series. As such, we performed a systematic review and meta-analysis evaluating endovascular occlusions of CCFs to determine any differences in clinical outcomes based on presentation, fistula type, and treatment paradigm. Method: A retrospective review of all studies discussing the endovascular treatment of CCFs published through March 2023 was conducted using PubMed, Scopus, Web of Science, and Embase databases. A total of 36 studies were included in the meta-analysis. Data from the selected articles were extracted and analyzed using Stata software version 14. Results: 1494 patients were included. 55.08% were female and the mean age of the cohort was 48.10 years. A total number of 1516 fistulas underwent endovascular treatment, 48.05% of which were direct and 51.95% of which were indirect. 87.17% of CCFs were secondary to a known trauma while 10.18% were spontaneous. The most common presenting symptoms were 89% exophthalmos (95% CI: 78.0-100.0; I2 = 75.7%), 84% chemosis (95% CI: 79.0-88.0; I2 = 91.6%), 79% proptosis (95% CI: 72.0-86.0; I2 = 91.8%), 75.0% bruits (95% CI: 67.0-82.0; I2 = 90.7%), 56% diplopia (95% CI: 42.0-71.0; I2 = 92.3%), 49% cranial nerve palsy (95% CI: 32.0-66.0; I2 = 95.1%), 39% visual decline (95% CI: 32.0-45.0; I2 = 71.4%), 32% tinnitus (95% CI: 6.0-58.0; I2 = 96.7%), 29% elevated intraocular pain (95% CI: 22.0-36.0; I2 = 0.0%), 31% orbital or pre-orbital pain (95% CI: 14.0-48.0; I2 = 89.9%) and 24% headache (95% CI: 13.0-34.0; I2 = 74.98%). Coils, balloons, and stents were the three most used embolization methods respectively. Immediate complete occlusion of the fistula was seen in 68% of cases and complete remission was seen in 82%. Recurrence of CCF occurred in only 35% of the patients. Cranial nerve paralysis after treatment was observed in 7% of the cases. Conclusions: Exophthalmos, Chemosis, proptosis, bruits, cranial nerve palsy, diplopia, orbital and periorbital pain, tinnitus, elevated intraocular pressure, visual decline and headache are the most common clinical manifestations of CCFs. The majority of endovascular treatments involved coiling, balloons and onyx and a high percentage of CCF patients experienced complete remission with the improvement of their clinical symptoms.

Radical supramaximal resection for newly diagnosed left-sided eloquent glioblastoma: safety and improved survival over gross-total resection.

OBJECTIVE: Supramaximal resection (SMR) has arisen as a possible surrogate to gross-total resection (GTR) to improve survival in newly diagnosed glioblastoma (nGBM). However, SMR has traditionally been limited to noneloquent regions and its feasibility in eloquent nGBM remains unclear. The authors conducted a retrospective multivariate propensity-matched analysis comparing survival outcomes for patients with left-sided eloquent nGBM undergoing SMR versus GTR. METHODS: A retrospective review was performed of all patients at our institution who underwent SMR or GTR of a left-sided eloquent nGBM during the period from 2011 to 2020. All patients underwent some form of preoperative or intraoperative functional mapping and underwent awake or asleep craniotomy (craniotomy under general anesthesia); however, awake craniotomy was performed in the majority of patients and the focus of the study was SMR achieved via awake craniotomy and functional mapping with lesionectomy and additional peritumoral fluid attenuated inversion recovery (FLAIR) resection. Propensity scores were generated controlling for age, tumor location, and preoperative Karnofsky Performance Status (KPS) score with the nearest-neighbor algorithm. RESULTS: A total of 102 patients (48 SMR, 54 GTR) were included in this study. The median overall survival (OS) and progression-free survival (PFS) for patients receiving SMR were 22.9 and 5.1 months, respectively. Propensity matching resulted in a final cohort of 27 SMR versus 27 GTR patients. SMR conferred improved OS (21.55 vs 15.49 months, p = 0.0098) and PFS (4.51 vs 3.59 months, p = 0.041) compared to GTR. There was no significant difference in postoperative complication rates or KPS score in SMR compared with GTR patients (p = 0.236 and p = 0.736, respectively). In patients receiving SMR, improved OS and PFS showed a dose-dependent relationship with extent of FLAIR resection (EOFR) on log-rank test for trend (p < 0.001). CONCLUSIONS: SMR by means of awake craniotomy with functional mapping for left-sided eloquent nGBM is safe and confers a survival benefit compared to GTR obtained with lesionectomy alone while preserving postoperative neurological integrity. When tolerated, greater EOFR with SMR may be associated with improved survival.

Frameless Robotic-Assisted Biopsy of Pediatric Brainstem Lesions: A Systematic Review and Meta-Analysis of Efficacy and Safety.

BACKGROUND: Pediatric brainstem lesions are diagnoses that require tissue sampling to advance our understanding of them and their management. Frameless, robot-assisted biopsy of these lesions has emerged as a novel, viable biopsy approach. Correspondingly, the aim of this study was to quantitively and qualitatively summarize the contemporary literature regarding the likelihood of achieving tumor diagnosis and experiencing any postoperative complications. METHODS: Searches of 7 electronic databases from inception to September 2022 were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were screened against prespecified criteria. Outcomes were pooled by random-effects meta-analyses of proportions where possible. RESULTS: A total of 8 cohort studies satisfied all criteria. They described 99 pediatric patients with brainstem lesions in whom frameless, robot-assisted biopsy was involved in their work-up. There were 62 (63%) male and 37 (37%) female patients with a median age of 9 years at time of biopsy. Overall, all patients had sufficient tissue obtained by initial biopsy for evaluation. Pooled estimate of achieving tumor diagnosis was 100% (95% confidence interval [CI] 97%-100%) across all studies with a high degree of certainty. Across all studies, there were no cases of procedure-related mortality. The pooled estimates of transient and permanent complications after biopsy were 10% (95% CI 4%-19%) and 0% (95% CI 0%-2%), respectively, of very low and low degrees of certainty each. CONCLUSIONS: The contemporary metadata demonstrates the frameless, robot-assisted biopsy of pediatric brainstem lesions is both effective and safe when performed in an experienced setting. Further research is needed to augment robot and automated technologies into workup algorithms.

The composition of landmark vein of Galen malformation research: the emergence of endovascular treatments.

BACKGROUND: Since the advent of endovascular treatment, the long-term prognosis of vein of Galen malformation (VOGM) has markedly improved; however, the nature of research leading to this point is unclear. The objective of this study was to define the composition of VOGM research to date, by means of a bibliometric analysis of the 100 most cited VOGM articles. METHODS: An electronic search of Elsevier's Scopus database was performed to identify the 100 most cited articles on VOGM screened against predetermined criteria. Data were then compared. RESULTS: The 100 most cited VOGM articles were published between 1974 and 2017 in 38 unique journals and originated from 16 unique countries. Mean citation count and rate were 59.4 citations and 2.9 citations/year, respectively. The USA (n = 42); Hôpital de Bicêtre, France (n = 15); and Dr. Pierre Lasjaunias (n = 16) were the largest individual country, institutional, and author contributors. Compared to the older articles (published < 2000), key differences for newer articles were statistically higher citation rates (P < 0.01), more authors (P < 0.01), higher proportion of endovascular treatment descriptions (P = 0.01), and more originating from Asia Pacific (P < 0.01). CONCLUSIONS: From the 100 most cited VOGM articles to date, there has been a noticeable shift from diagnosing VOGM based on the foundational work by Dr. Lasjaunias to understanding how we can model clinical outcomes now that endovascular treatment has become the standard of care. Significant shifts in prognosis are pending, and the current bibliometric data implicate we are on the precipice of more recent works making an impact in the near future.

Effects of Obesity on Cervical Disc Arthroplasty Complications.

OBJECTIVE: High body mass index is a well-established modifiable comorbidity that is known to increase postoperative complications in all types of surgery, including spine surgery. Obesity is increasing in prevalence amongst the general population. As this growing population of obese patients ages, understanding how they faire undergoing cervical disc arthroplasty (CDA) is important for providing safe and effective evidence-based care for cervical degenerative pathology. METHODS: Our study used the Healthcare Cost and Utilization Project's National Inpatient Sample to assess patients undergoing CDA comparing patient characteristics and outcomes in nonobese patients to obese patients from 2004 to 2014. RESULTS: Our study found a significant increase in the overall utilization of CDA as a treatment modality (p = 0.012) and a statistically significant increase in obese patients undergoing CDA (p < 0.0001) from 2004 to 2014. Obesity was identified as an independent risk factor associated with increased rates of inpatient neurologic complications (odds ratio [OR], 6.99; p = 0.03), pulmonary embolus (OR, 5.41; p = 0.05), and wound infection (OR, 6.97; p < 0.001) in patients undergoing CDA from 2004 to 2014. CONCLUSION: In patients undergoing CDA, from 2004 to 2014, obesity was identified as an independent risk factor with significantly increased rates of inpatient neurologic complications, pulmonary embolus and wound infection. Large prospective trials are needed to validate these findings.

Telescoping pipeline vantage embolization devices with shield technology for the treatment of a giant, symptomatic dolichoectatic basilar trunk aneurysm.

Background: Dolichoectatic basilar trunk aneurysms are exceedingly rare and carry a poor prognosis. Treatment strategies are often reserved for patients with severe and progressive symptoms. Case Description: A patient in their 40s with a dolichoectatic basilar trunk aneurysm developed significant progression of the lesion and neurologic decline, necessitating treatment. He underwent flow diversion utilizing multiple telescoping Pipeline Vantage Embolization Devices with Shield Technology for treatment. At 1-year follow-up, the aneurysm was stable in size and the patient remained at his neurologic baseline. Conclusion: This case illustrates the need for continued development of next-generation endovascular devices as these aneurysms have limited management options.

Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR.

OBJECTIVE: Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS: A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS: Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS: Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.

Positive predictive value and trends of inferior petrosal sinus sampling (IPSS) in diagnosing cushing disease and ectopic ACTH secretion: A systematic review and meta-analysis.

BACKGROUND: Inferior petrosal sinus sampling (IPSS) offers a means of differentiating between Cushing disease and Cushing syndrome with lower false-positive and false-negative rates relative to traditional techniques. However, consolidated data on efficiency reflecting contemporary use is lacking. We present a comprehensive meta-analysis of IPSS as a means of diagnosing ACTH-cortisol axis derangements via both CRH and desmopressin-stimulated techniques. METHODS: Searches of 7 electronic databases from inception to December 2020 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes were pooled by random-effects meta-analyses of proportions where possible. We performed a meta-analysis of sixty-eight unique publications, assessing each technique for positive predictive value (PPV), false positive rates, and overall changes in practice patterns over time. RESULTS: A total of 68 studies satisfied all criteria, with 3685 (3471, 94.2% confirmed) and 332 (285, 85.8% confirmed) patients tested for Cushing's disease and syndrome, respectively. Pooled analyses demonstrated an overall PPV of 89.3% (95%CI[83.6%, 94.0%]) in CRH stimulation diagnosis of Cushing disease. In desmopressin stimulation, our analyses demonstrated an overall PPV of 96.5% (95%CI[94.5%, 98.1%]) in diagnosis of Cushing disease. There was a significant decline in the use of CRH-stimulation IPSS in diagnosis of both Cushing disease (p = 0.0055) and Cushing syndrome (p = 0.013). Concurrently, there was a significant increase in the use of desmopressin-stimulation IPSS in diagnosis of both pathologies (p < 0.0001). CONCLUSION: Our findings demonstrate significant changes in practice patterns with respect to IPSS stimulation technique. Our pooled analyses demonstrate improved diagnostic performance in desmopressin stimulation procedures relative to CRH stimulation procedures. Further multi-institutional studies with special attention to acquiring quality data for sensitivity, specificity, and other critical analyses are necessary to truly evaluate this promising technique.

Contemporary outcomes of diffuse leptomeningeal glioneuronal tumor in pediatric patients: A case series and literature review.

BACKGROUND: Diffuse leptomeningeal glioneuronal tumor (DLGNT), also known as oligodendrogliomatosis, is a rare neuro-oncologic condition along the neuraxis that remains poorly understood in children. We sought to describe our institutional experience and quantitively summarize the clinical survival and prognostic features of DLGNT in the pediatric population across the contemporary literature. METHODS: We report four institutional cases of pediatric DLGNT diagnosed between 2000 and 2020 based on retrospective review of our records, and performed a comprehensive literature search for published cases from 2000 onwards to create an integrated cohort for analysis. Kaplan-Meier estimations, Fisher's exact test, and logistic regression were utilized to interrogate the data. RESULTS: Of our four cases, three females aged 2-, 3- and 13-years old at diagnosis survived 6-years, 3-years and 14-months respectively, and one male aged 5-years old at diagnosis was still alive 5 years later. Our overall integrated cohort consisted of 54 pediatric DLGNT patients, with 19 (35%) female and 35 (65%) male patients diagnosed at an average age of 6.4 years (range, 1.3-17 years) by means of surgical biopsy. Chemotherapy was used in 45 cases (83%), and mean follow-up time of 54 months (range, 3-204). Across the entire cohort, overall survival 1 month after diagnosis was 96% (95% CI 86-99%), and by 10 years was 69% (95% CI 49-82%). On multivariate analysis of complete data, chemotherapy treatment (HR=0.23, P = 0.04) was statistically predictive of longer overall survival. CONCLUSIONS: More than 2-out-of-3 pediatric DLGNT patients survive beyond one decade. Chemotherapy is statistically associated with longer survival in DLGNT pediatric patients and should form the core of any treatment regimen in this setting. Early detection by means of judicious imaging and surgical biopsy for tissue diagnosis can lead to earlier treatment and likely superior outcomes.

The Emerging Relevance of H3K27 Trimethylation Loss in Meningioma: A Systematic Review of Recurrence and Overall Survival with Meta-Analysis.

BACKGROUND: It has been proposed in the most recent 2021 World Health Organization classification of brain tumors that the loss of trimethylation at histone 3 lysine site 27 (H3K27me3) might prognosticate meningioma outcomes. However, to date, the emerging literature has remained diffuse in its stance. Thus, the aim of the present study was to determine the prognostic relevance of H3K27me3 loss in meningioma. METHODS: Searches of 7 electronic databases from inception to October 2021 were conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. Articles were screened against prespecified criteria. Outcomes were pooled by random effects meta-analyses of proportions, where possible. RESULTS: A total of 7 retrospective cohort studies satisfied all the criteria, with a total of 2180 meningioma patients overall (1291 male patients [59%]; mean age, 56 years). Across all 7 studies, the pooled incidence of H3K27me3 loss was estimated at 15% (95% confidence interval, 8%-24%). Across 6 studies, the pooled multivariate-derived hazard ratio estimate for recurrence was 1.77 (95% confidence interval, 1.23-2.31; P < 0.01). Overall survival on univariate analysis was significantly shorter with H3K27me3 loss in 2 of 4 studies (50%), and 2 studies had described a significant association between H3K27me3 loss and shorter overall survival on multivariate analysis. CONCLUSIONS: The contemporary metadata favor a greater incidence of meningioma recurrence based independently on H3K27me3 loss, with a statistically significant difference. It is possible that these effects are more pronounced for grade 2 meningiomas; however, more robust data and analysis are needed to augment this position.

The utility of congenital cardiac status to predict endoscopic third ventriculostomy and ventriculoperitoneal shunt failure in hydrocephalic infants.

OBJECTIVE: The effect of congenital cardiac status on endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) failure in hydrocephalic infants is unknown. Because cardiac status in infants can impact central venous pressure (CVP), it is possible that congenital heart disease (CHD) and congenital cardiac anomalies may render these cerebrospinal fluid diversion interventions more susceptible to failure. Correspondingly, the aim of this study was to determine how CHD and congenital cardiac anomalies may impact the failure of these initial interventions. METHODS: A retrospective review of the Nationwide Inpatient Sample (NIS) database was conducted. Infants (aged < 1 year) with known congenital cardiac status managed with either ETV or VPS were included. Quantitative data were compared using either parametric or nonparametric methods, and failure rates were modeled using univariable and multivariable regression analyses. RESULTS: A total of 18,763 infants treated with ETV or VPS for hydrocephalus were identified in our search, with ETV used to treat 7657 (41%) patients and VPS used to treat 11,106 (59%). There were 6722 (36%) patients who presented with CHD at admission, and a total of 25 unique congenital cardiac anomalies were detected across the cohort. Overall, the most common anomaly was patent ductus arteriosus (PDA) in 4990 (27%) patients, followed by atrial septal defect (ASD) in 2437 (13%) patients and pulmonary hypertension in 810 (4%) patients. With respect to initial intervention failure, 3869 (21%) patients required repeat surgical intervention during admission. This was significantly more common in the ETV group than the VPS group (36% vs 10%, p < 0.01). In both the ETV and VPS groups, CHD (p < 0.01), including all congenital cardiac anomalies, was an independent and significant predictor of failure. ASD (p < 0.01) and PDA (p < 0.01) both significantly predicted ETV failure, and PDA (p < 0.01) and pulmonary hypertension (p = 0.02) both significantly predicted VPS failure. CONCLUSIONS: These results indicate that congenital cardiac status predicts ETV and VPS failure in patients with infantile hydrocephalus. The authors hypothesized that this finding was primarily due to changes in CVP; however, this may not be completely universal across both interventions and all congenital cardiac anomalies. Future studies about optimization of congenital cardiac status with ETV and VPS are required to understand the practical significance of these findings.

Iatrogenic radial arteriovenous fistula closure via intraluminal compression in a patient with fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is an arteriopathy of medium-sized vessels causing pathological arterial wall fragility. However, only minimal data exist on evaluating the risk of transradial access (TRA) in these patients. We describe the case of a woman in her 70s who underwent left middle meningeal artery embolisation for an acute-on-chronic subdural haematoma via right TRA. Radial angiography demonstrated significant FMD throughout the entire right upper extremity. To prevent radial spasm, a 23 cm sheath was placed without difficulty. However, follow-up angiography demonstrated the presence of a new radial arteriovenous fistula (AVF) just distal to the brachial bifurcation. Since no forearm haematoma or limb ischaemia developed, the procedure was continued transradially. After embolisation, the guide catheter was removed and follow-up angiography demonstrated resolution of the fistula. This case illustrates that, in the absence of concerning clinical signs, compression from the guide catheter alone may facilitate thrombosis of an acutely identified iatrogenic radial AVF.