Neuromodulation: What the neurointerventionalist needs to know.

Neuromodulation is the alteration of neural activity in the central, peripheral, or autonomic nervous systems. Consequently, this term lends itself to a variety of organ systems including but not limited to the cardiac, nervous, and even gastrointestinal systems. In this review, we provide a primer on neuromodulation, examining the various technological systems employed and neurological disorders targeted with this technology. Ultimately, we undergo a historical analysis of the field's development, pivotal discoveries and inventions gearing this review to neuro-adjacent subspecialties with a specific focus on neurointerventionalists.

Safety of the immediate use of nonsteroidal anti-inflammatory drugs after adult craniotomy for tumor.

OBJECTIVE: Poor pain control has a negative impact on postoperative recovery and patient satisfaction. However, overzealous pain management, particularly with opioids, can confound serial neurological assessments, increase morbidity, and predispose patients to long-term dependence. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating postoperative pain and can limit opioid intake, but their use has been limited in patients undergoing craniotomy for brain tumor resection due to concerns of an increased hemorrhage risk. Herein, the authors aim to 1) address the safety of NSAID use in the immediate postoperative setting and 2) determine whether NSAID administration decreases opioid use following craniotomy for tumor resection in adult patients. METHODS: The authors conducted a retrospective cohort study of patients 18 years and older with an estimated glomerular filtration rate ≥ 60 ml/min/body surface area who had undergone craniotomy for tumor resection at their institution between 2019 and 2021. NSAID use in the first 48 hours following surgery was recorded. Primary outcomes were postoperative hemorrhage requiring a return to the operating room before hospital discharge and within 30 days of surgery. Secondary outcomes were more-than-minimal hemorrhage that did not require reoperation, acute kidney injury, and total opioid use within 48 hours after craniotomy. RESULTS: Among 1765 reviewed patient records, 1182 were eligible for inclusion in this analysis. Amid these records were 114 patients (9.6%) who had received at least one dose of an NSAID within 48 hours of their craniotomy. Four (0.3%) patients experienced bleeding requiring a return to operating room, one of whom was from the NSAID-treated group (RR 3.12, 95% CI 0.33-29.77, p = 0.30). No significant difference in nonoperative intracranial hemorrhage (RR 1.34, 95% CI 0.54-3.35, p = 0.53), postoperative acute kidney injury, or clinically significant extracranial bleeding was found between the NSAID and no-NSAID groups. Patients in the NSAID group had significantly higher oral morphine equivalent use (median 68 vs 30, p < 0.001). CONCLUSIONS: Postoperative NSAID use following craniotomy for tumor resection was not associated with an increased risk of hemorrhage requiring a return to the operating room. The authors noted higher opioid use in the patients treated with NSAIDs, which may reflect underlying reasons for the decision to treat patients with NSAIDs in the immediate postoperative period. These data warrant further investigation of NSAIDs as a safe, opioid-sparing postoperative pain management strategy in patients with normal kidney function who are undergoing intracranial tumor resection.

National Institutes of Health grant funding for cerebrovascular diseases.

BACKGROUND: Federal research funding is highly sought after but may be challenging to attain. A clear understanding of funding for specific diseases, such as cerebrovascular disorders, might help researchers regarding which National Institutes of Health (NIH) institutes fund research into specific disorders and grant types. OBJECTIVE: To examine the current scope of NIH grant funding for cerebrovascular conditions. METHODS: The NIH-developed RePORTER was used to extract active NIH-funded studies related to cerebrovascular diseases through January 2023. Duplicate studies were removed, and projects were manually screened and labeled in subcategories as clinical and basic science and as research subcategories. Extracted data included total funding, grant types, institutions that received funding, and diseases studied. Python (version 3.9) and SciPy library were used for statistical analyses. RESULTS: We identified 1232 cerebrovascular projects across seven diseases with US$699 952 926 in total funding. The cerebrovascular diseases with the greatest number of grants were ischemic stroke (705, or 57.2% of all funded projects), carotid disease (193, or 15.7%), and hemorrhagic stroke (163, or 13.2%). R01 grants were the most common mechanism of funding (632 grants, or 51.3%). The National Institute of Neurological Disorders and Stroke (NINDS) funded the most projects (504 projects; US$325 536 405), followed by the National Heart, Lung, and Blood Institute (NHLBI) (376 projects; US$216 784 546). CONCLUSION: Cerebrovascular disease receives roughly US$700 million in NIH funding. Ischemic stroke accounts for the majority of NIH-funded cerebrovascular projects, and R01 grants are the most common funding mechanism. Notably, NHLBI provides a large proportion of funding, in addition to NINDS.

Nonsteroidal Anti-inflammatory Medications in Cranial Neurosurgery: Balancing Opioid-Sparing Analgesia with Bleeding Risk.

Postcraniotomy pain is a common problem frequently encountered by neurosurgeons. This is typically managed with opioids; however, opioids have been shown to increase intracranial pressure by way of hypercapnia and straining from the associated constipation. Additionally, opioids can confound and mask the neurologic examination of postcraniotomy patients, as well as be the nidus for a potential opioid addiction. Thus, alternative solutions for opioids have been a major topic of investigation within the neurosurgical community. Nonsteroidal anti-inflammatory drugs (NSAIDs) present as a potential solution due to their nonaddictive and analgesic properties, but utilization of NSAIDs in neurosurgical patients has been controversial given that NSAIDs alter platelet function. The degree to which NSAIDs alter platelet function and bleeding time to a clinically relevant manner has remained controversial, although several well-designed studies concluded that the utilization of NSAIDs in post-craniotomy patients does not increase the risk of postoperative bleeding. Herein, we review the pharmacology, efficacy, and safety of NSAIDs with a particular emphasis on NSAID use for postintracranial neurosurgical procedure pain management.

Percutaneous transorbital transvenous embolization of a cavernous sinus dural arteriovenous fistula via the superior orbital fissure-technical video.

Carotid-cavernous dural arteriovenous fistulas causing debilitating ocular symptoms and/or retrograde cortical venous drainage necessitate curative treatment, which is achieved by disrupting the proximal draining vein. Transvenous embolization of carotid-cavernous dural arteriovenous fistulas can be achieved through the superior or inferior petrosal sinuses, facial veins, or superior ophthalmic veins.1, 2 However, if these approaches are not feasible, various percutaneous approaches have been described that use the skull base foramina to provide direct access to the cavernous sinus.3, 4 Here we present the case of a 54-year-old male with carotid-cavernous dural arteriovenous fistulas with cortical venous drainage causing diplopia that was cured using a percutaneous transorbital approach. We discuss the alternative endovascular strategies for treating carotid-cavernous dural arteriovenous fistulas and why they were not chosen, the technical nuances of the transorbital approach as well as the pearls and pitfalls of this seldom used technique. A comprehensive understanding of the many approaches for treating carotid-cavernous dural arteriovenous fistulas is important for neurointerventionalists.

Predicting disease progression and the need for tumor-directed treatment in tectal plate gliomas.

OBJECTIVE: Tectal plate gliomas are rare, slow-growing tumors of the midbrain that are discovered predominantly in the pediatric population. Because of their indolent nature, treatment mainly consists of observation and management of hydrocephalus. Unfortunately, a subset of tectal gliomas may exhibit tumor enlargement and disease progression. Currently, there are no established guidelines for predicting future progression of tectal gliomas or the need for tumor-directed treatment. In this paper, the authors present a large case series of tectal plate gliomas with the aim of determining early indicators of tumor progression and the need for tumor-directed treatment in a pediatric population, along with providing their experience in treating progressive tumors. METHODS: A retrospective chart review of 170 patients diagnosed with tectal plate glioma from a single institution, of whom 67 were pediatric patients (≤ 18 years of age), was performed. Univariate analysis was used to determine statistically significant predictors of symptomatic disease progression requiring eventual tumor-directed therapy. RESULTS: The median patient age of the full cohort was 24 years (range 0-73 years). Compared with the pediatric population, the adult population had more instances of incidental lesions (p < 0.001) and lower rates of hydrocephalus (50% vs 84%, p < 0.001). Of the pediatric patients who had ≥ 5 years of follow-up (n = 51), 12 (24%) experienced radiological progression and 13 (25%) required treatment for their tumor. The 1-year, 5-year, and 10-year radiographic progression-free survival (PFS) rates were 98%, 90%, and 86%, respectively. In univariate analysis, lesion involvement of the pons, moderate T1 hypointensity, and moderate contrast enhancement on baseline radiology were significantly associated with worse radiographic PFS. Alternatively, significant predictors of requiring tumor-directed treatment included extraocular eye movement abnormalities at presentation, involvement of the lesion beyond the tectum on baseline radiology, moderate T1 hypointensity, moderate contrast enhancement, and an increase in total lesion size during progression. At the most recent follow-up, 94% of the patients had stable/nonprogressive disease, 2% had progressive disease, and 4% died of tumor progression. CONCLUSIONS: Patients who demonstrate radiographic progression may not necessarily experience clinical/symptomatic progression or require tumor-directed treatment. Certain patient presentation characteristics and baseline radiographic features may be predictive of worse radiographic PFS or the need for future tumor-directed treatment in the pediatric population. Typically, the natural history of these lesions lends to excellent long-term survival, even in patients who experience clinical progression, should appropriate treatment be initiated.

Long-term outcomes following pipeline embolization of unruptured aneurysms.

BACKGROUND: Flow diversion using the pipeline embolization device (PED) for unruptured aneurysms is associated with high occlusion and low morbidity and mortality. However, most reports have limited follow-up of 1-2 years. Therefore, we sought to report our outcomes after PED for unruptured aneurysms in patients with at least 5-years of follow-up. METHODS: Review of patients undergoing PED for unruptured aneurysms from 2009 to 2016. RESULTS: Overall, 135 patients with 138 aneurysms were included for analysis. Seventy-eight percent of aneurysms (n=107) over a median radiographic follow-up of 5.0 years underwent complete occlusion. Among aneurysms with at least 5-years of radiographic follow-up (n=71), 79% (n=56) achieved complete obliteration. No aneurysm recanalized after radiographic obliteration. Furthermore, over a median clinical follow-up period of 4.9 years, 84% of patients (n=115) self-reported mRS scores between 0 and 2. For patients with at least 5-years of clinical follow-up, 88% (n=61) reported mRS between 0 and 2. In total, 3% (n=4) of patients experienced a major, non-fatal neurologic complication related to the PED, 5% (n=7) of patients experienced a minor neurologic complication related to PED placement, and 2% (n=3) died from either delayed aneurysm rupture, delayed ipsilateral hemorrhage after PED placement, or delayed (9 months after treatment) neural compression after progressive thrombosis of a PED-treated dolichoectactic vertebrobasilar aneurysm. CONCLUSIONS: Treatment of unruptured aneurysms with the PED is associated with high rates of long-term angiographic occlusion and low, albeit clinically important, rates of major neurologic morbidity and mortality. Thus, flow diversion via PED placement is safe, effective, and durable.

Sagittal Spinal Deformity in Patients with Idiopathic Normal Pressure Hydrocephalus.

AIM: To measure the baseline spinopelvic parameters and characterize the sagittal, and coronal plane deformities in patients with idiopathic normal pressure hydrocephalus (iNPH). MATERIAL AND METHODS: We analyzed a series of patients at one academic institution who underwent ventriculoperitoneal shunting for iNPH with pre-shunt standing full length x-rays. The series of patients was enrolled consecutively to minimize selection bias. We quantified comorbid sagittal plane spinal deformity based on the Scoliosis Research Society-Schwab classification system by assessing pelvic incidence and lumbar lordosis mismatch (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA). RESULTS: Seventeen patients (59% male) were included in this study. Mean (± standard deviation) age was 74 ± 5.3 years with a body mass index (BMI) of 30 ± 4.5 kg/m < sup > 2< sup > . Six patients (35%) had marked sagittal plane spinal deformity by at least one parameter: five (29%) had greater than 20˚ PI-LL mismatch, three (18%) had > 9.5 cm SVA, and one (6%) had PT greater than 30˚. Additionally, the thoracic kyphosis exceeded the lumbar lordosis in nine patients (53%). CONCLUSION: Positive sagittal balance, with thoracic kyphosis exceeding lumbar lordosis, is common in iNPH patients. This may lead to postural instability, especially in patients whose gait does not improve following shunting. These patients may warrant further investigation and workup, including full length standing x-rays. Future studies should assess for improvement in the sagittal plane parameters following shunt placement.

Small symptomatic anterior communicating artery aneurysms: report of three cases and literature review.

PURPOSE: Given the anatomical relationship between the ACom complex and the optic nerve, small aneurysms of the ACom can present with visual symptoms. CASE REPORTS: We summarize and illustrate the clinical course of three patients with symptomatic small ACom aneurysms and collect similar other cases reported. RESULTS: Ten patients with small unruptured visually symptomatic anterior communicating artery aneurysms were found in the literature. Including three patients herein reported, the mean age at presentation was 56. The most common visual symptoms were bitemporal vision loss and/or a decrease in visual acuity. CONCLUSION: Unruptured aneurysms of the anterior communicating artery can present with visual symptoms due to compression of optic pathways, even at a small size. Prompt recognition and treatment of such a condition are paramount as new onset of visual symptoms can signify impending rupture akin to small PCom aneurysms compressing the third nerve. We discuss a few pitfalls of clipping small ACom aneurysms compressing the optic nerve.

Weathering the storm: a single-institution experience with paroxysmal sympathetic hyperactivity after brain tumor resection in pediatric patients.

OBJECTIVE: Paroxysmal sympathetic hyperactivity (PSH) is a complication of severe traumatic or hypoxic brain injury characterized by transient episodes of tachycardia, tachypnea, hypertension, hyperthermia, diaphoresis, and/or dystonic posturing. Posttraumatic "sympathetic storms" are associated with poor outcomes. PSH rarely occurs after brain tumor resection in pediatric patients; only 4 cases have been published since 1929. Thus, the authors sought to report their experience with postcraniotomy PSH in pediatric brain tumor patients. METHODS: A retrospective study of patients younger than 18 years of age who underwent craniotomy for brain tumor resection at a single center by a single surgeon over a 7-year period was performed. A clinical diagnosis of postoperative PSH was recorded. Recorded outcomes included the interval between surgery and initiation of cytotoxic therapy, need for long-term CSF diversion, length of hospital stay, and survival. RESULTS: Of the 150 patients who were included for analysis, 4 patients were diagnosed with postoperative PSH for an overall occurrence of 2.7%. PSH patients were younger than non-PSH patients (1.8 ± 0.4 years vs 9.2 ± 5.3 years, p = 0.010) and tended to have intraventricular tumors close to the thalamus, basal ganglia, and/or brainstem. PSH patients experienced longer hospital admissions (44.3 ± 23.4 days vs 6.8 ± 9.4 days, p = 0.001), a shorter interval between surgery and initiation of cytotoxic cancer-directed therapy (14.3 ± 8.0 days vs 90.7 days ± 232.9 days, p = 0.011), and increased need for long-term CSF diversion compared with non-PSH patients (75% vs 25%, p = 0.005). At the last follow-up, 50% of PSH patients had died compared with 13% of non-PSH patients (p = 0.094). CONCLUSIONS: PSH is a rare postoperative complication that may affect young children with periventricular tumors and is associated with poorer clinical outcomes. Increasing awareness of this condition is vital to improving patient outcomes.

Above-The-Hairline Suboccipital Transverse Approach for the Treatment of Chiari I Malformation.

BACKGROUND: Chiari I malformation is a common pediatric neurosurgical disorder with an established treatment paradigm. Posterior fossa decompression and duraplasty (PFDD) is associated with symptom improvement but it carries postoperative risk, particularly cerebrospinal fluid (CSF) leak and wound complications. In addition, the cosmetic outcomes of PFDD have been overlooked in the literature. OBJECTIVE: To describe a novel approach for PFDD in which the transverse surgical incision is completely hidden above the hairline and to report early outcomes in a prospective patient cohort. METHODS: Clinical and cosmetic outcomes were recorded for 15 consecutive pediatric patients who underwent PFDD for Chiari I malformation via the above-the-hairline transverse suboccipital approach. RESULTS: The median clinical follow-up time was 6 months (range 1-12 months), and the majority of patients experienced significant improvement of their preoperative symptoms. Three patients (20%) experienced complications associated with surgery, which included injury to the greater occipital nerve, CSF hypotension and subfascial pseudomeningocele, and superficial wound dehiscence that resolved spontaneously with oral antibiotics. Zero patients (0%) returned to the operating room for persistent CSF leak, deep wound infection, or revision decompression. An excellent cosmetic outcome was achieved in 12 patients (80%). No patient had a poor cosmetic outcome. CONCLUSION: The above-the-hairline transverse suboccipital approach for PFDD in patients with Chiari I malformation offers favorable cosmetic outcomes and fascial closure while permitting adequate decompression.

Stereotactic radiosurgery for intermediate- and high-grade arteriovenous malformations: outcomes stratified by the supplemented Spetzler-Martin grading system.

OBJECTIVE: The supplemented Spetzler-Martin (Supp-SM) grading system was developed to improve the predictive accuracy of surgical risk for patients with brain arteriovenous malformations (AVMs). The aim of this study was to apply the Supp-SM grading system to patients having stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) intermediate- (grade III) or high-grade (grade IV-V) AVMs to enable comparison with published microsurgical series. METHODS: In 219 patients who underwent SRS during the period from 1990 to 2016, the Supp-SM grade was calculated for SM grade III (n = 154) or SM grade IV-V (n = 65) AVMs. The Supp-SM grades in these patients were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). Sixty patients (27%) had deep AVMs (basal ganglia, thalamus, or brainstem). Thirty-nine patients (18%) had volume-staged SRS; 41 patients (19%) underwent repeat SRS. The median follow-up period was 69 months for SM grade III AVMs and 113 months for SM grade IV-V AVMs. RESULTS: AVM obliteration was confirmed in 163 patients (74%) at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. Thirty-one patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). Six patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurological decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of nonobliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurological decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading score did not correlate with either obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurological decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38). CONCLUSIONS: The Supp-SM grading system was not predictive of outcomes after SRS of intermediate- or high-grade AVM. In a cohort that included a high percentage (47%) of "inoperable" AVMs according to Supp-SM grade (≥ 7), most patients had obliteration after SRS, although there was a high risk of neurological decline.

Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience.

BACKGROUND: Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE: To report a multicenter experience assessing microsurgery safety/efficacy. METHODS: Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS: Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION: Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

Iatrogenic vertebral artery injury with concomitant contralateral idiopathic vertebral artery dissection managed with intravascular intervention: a case report.

Background: Vertebral artery injury (VAI) is a known potential complication of posterior cervical fusion surgery. Pre-operative imaging is used to determine the patency of bilateral vertebral arteries during the planning and execution of surgery. This case illustrates an example of a staged anterior/posterior cervical reconstruction in which an iatrogenic VAI combined with a contralateral idiopathic vertebral artery dissection not identified on pre-operative imaging resulted in absent basilar artery anterograde flow. Case Description: A 61-year-old female underwent planned staged anterior cervical decompression C4-T1 with posterior cervical fusion C2-T4 for the treatment of degenerative cervical myeloradiculopathy. During the second stage posterior fusion, iatrogenic VAI occurred during drilling for placement of the right C2 pars screw. Upon post-operative angiography, in addition to the known right VAI, there was a new left vertebral artery dissection that occurred during/after the anterior stage. The basilar artery was only filled in retrograde fashion from the right internal carotid artery across the right posterior communicating artery. The left vertebral artery dissection was treated with telescoping flow diverting stents to restore flow to the basilar artery and the right VAI was treated with coiling. Conclusions: Surgeons should be aware of the possibility, while rare, that an occult injury to the non-injured artery is always a possibility if significant deformity correction or alignment change has occurred during cervical spine surgery. Working closely with neurointerventional colleagues can be invaluable to quickly assess and if necessary, restore blood flow to the brain through these life saving techniques.

Right posterior petrosectomy for resection of petroclival meningioma.

Petroclival meningiomas, which arise from the upper two-thirds of the clivus and are medial to the trigeminal nerve, carry significant surgical risk. Patients whose operations are tailored to maximize tumor resection while minimizing neurological morbidity have favorable outcomes. Subtotally resected tumors can be subsequently considered for radiosurgery in an attempt to limit recurrence. Here the authors report the case of a 40-year-old woman with postpartum trigeminal neuropathy secondary to a petroclival meningioma. The patient underwent an aggressive subtotal resection via a posterior petrosal approach with preservation of neurological function followed by adjuvant radiosurgery. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21227.

High Long-Term Mortality Rate in Elderly Patients with Mild Traumatic Brain Injury and Subdural Hematoma due to Ground-Level Fall: Neurosurgery's Hip Fracture?

BACKGROUND: Moderate-to-severe traumatic brain injury (TBI) is a major source of morbidity and mortality in elderly patients. Little is known about long-term mortality in elderly patients following mild, nonfatal TBI and how the injury mechanism predicts survival. This study aimed to compare long-term mortality in elderly patients with mild TBI and traumatic subdural hematoma (tSDH) due to ground-level fall (GLF) versus those with TBI and tSDH due to another cause (i.e., non-ground-level fall [nGLF]). METHODS: This retrospective study comprised 288 patients ≥60 years old from a single Level I trauma center with tSDH and Glasgow Coma Scale scores 13-15. RESULTS: Median follow-up after initial TBI presentation was 2.9 years for the GLF group and 2.4 years for the nGLF group. During follow-up, 98 patients died, and median survival for all elderly patients with mild TBI and tSDH was 4.6 years. The GLF group had a higher mortality rate than the nGLF group, with 93 patients in GLF group dying during follow-up compared with 5 in nGLF group (P < 0.0001). The annual death rate for patients in the GLF group was 12.5% per year. For patients 60-69 years old, 39% in GLF group died compared with 4% in nGLF group during follow-up (P = 0.0002). Likewise, for patients 70-79 years old, 29% in GLF group died compared with 7% in nGLF group (P = 0.021). Finally, 56% of patients >80 years old in GLF group compared with 18% in nGLF group (P = 0.11). CONCLUSIONS: Elderly patients with mild TBI and tSDH due to GLF have significantly higher long-term mortality than patients with injuries due to nGLF.

Outcomes and Principles of Patient Selection for Laser Interstitial Thermal Therapy for Metastatic Brain Tumor Management: A Multisite Institutional Case Series.

BACKGROUND: Laser interstitial thermal therapy (LITT) is an emerging treatment modality for both primary brain tumors and metastases. We report initial outcomes after LITT for metastatic brain tumors across 3 sites at our institution and discuss potential strategies for optimal patient selection and outcomes. METHODS: International Classification of Diseases, Ninth Revision and Tenth Revision codes were used to identify patients with malignant brain tumors treated via LITT across all 3 Mayo Clinic sites with at least 6 months follow-up. Local control was based on radiologic and clinical evidence. Overall survival was measured from time of receiving LITT until death or end of the study period. RESULTS: Twenty-three patients were treated for progression of a single (n = 21) or multiple (n = 2) previously radiated metastatic lesions and/or radiation necrosis. Median age was 56 years (interquartile range, 47-66.5 years). LITT achieved local control of the lesion in most patients with metastatic tumors or radiation necrosis (n = 18; 81.8%) for the duration of follow-up. One patient did not have local control data available. Thirteen (56.5%) patients remained alive at the end of the study period. No other patients died of their treated disease during the study period; 5 of 10 deaths were attributable to central nervous system progression outside the treated lesion. Although median survival for this cohort has not yet been reached, the current median survival is 16 months (interquartile range, 12-48.5 months) after LITT for metastatic/radiation necrosis lesions. CONCLUSIONS: LITT was associated with sustained local control in 81.8% of patients treated for radiographic progression of metastatic central nervous system disease.

Ultra-early therapeutic anticoagulation after craniotomy - A single institution experience.

There is a paucity of information regarding the optimal timing of initiation or re-initiation of therapeutic anticoagulation after intracranial surgery. Anticoagulation that is started too soon after surgery may increase the risk of catastrophic intracranial bleeding. However, there are scenarios that necessitate the use of anticoagulation in the immediate post-operative period despite the increased risk of hemorrhage. Therefore, we sought to report our experience with ultra-early therapeutic anticoagulation after craniotomy. Retrospective chart review of patients from a single institution between 1/1/2010 and 10/1/2021 who were treated with therapeutic anticoagulation for venous thromboembolism on or before 7-days after a craniotomy or craniectomy. The primary endpoint was intracranial hemorrhage resulting in death or return to the operating room for hematoma evacuation. Secondary endpoints included extra-cranial hemorrhage, length of hospital stay, and 90-day readmission rate. Eighteen patients were included for analysis. The median time that therapeutic anticoagulation was started was post-operative day 5 (range 1-7 days). One patient (5.6%) met the primary endpoint as they experienced an intracranial hemorrhage 5 days after starting anticoagulation, which required surgical evacuation. No patients experienced an extra-cranial hemorrhage. The median length of hospitalization was 13 days (range 4-89 days). No patients were readmitted within 90 days. The 90-day survival rate was 100%. Ultra-early anticoagulation after craniotomy resulted in a 5.6% risk of intracranial hemorrhage. Thus, ultra-early anticoagulation can be performed safely but it does carry a substantial risk of intracranial bleeding that may require emergent hematoma evacuation or result in permeant neurologic deficits or death.

Delayed-Onset Heparin-Induced Thrombocytopenia With Cerebral Venous Sinus Thrombosis Following Total Knee Arthroplasty: Case Report.

Heparin-induced thrombocytopenia (HIT) is a prothrombotic state caused by autoantibodies against platelet factor 4 (PF4)-heparin complexes. Although HIT typically presents 5-10 days after the initiation of heparin, thrombosis and thrombocytopenia may occur up to several weeks following heparin withdrawal, so-called delayed-onset HIT. Although rare, there have been isolated reports of HIT-induced cerebral venous sinus thrombosis (CVST), which carry high rates of morbidity and mortality. There is a need to further characterize the etiology, clinical presentation, treatment paradigms, and outcomes of patients with HIT-induced CVST. Here, we present the case of a 57-year old female who presented to the emergency department with a headache and seizure 11 days following a right total knee arthroplasty for which she received 3 post-operative doses of enoxaparin. Work-up demonstrated acute intracerebral hemorrhage (ICH), CVST, and thrombocytopenia. Intravenous heparin resulted in rapidly deteriorating platelet count and subsequent serologic testing confirmed the diagnosis of HIT. Treatment with bivalirudin was initiated, the HIT resolved, and the patient was discharged home on hospital day 19 with long-term anticoagulation mediated by warfarin. At 3-month follow up, the patient had mild upper motor neuron pattern weakness and was living independently. This case depicts a rare case of delayed-onset HIT and CVST, highlights the importance of establishing a fluid treatment plan for managing HIT-induced CVST, and illustrates the importance of employing rapid anticoagulation despite acute ICH to achieve a desirable clinical outcome.

Beware: Sialadenitis as a Rare Post Neurosurgical Complication: A Single-Institution Clinical Case Series.

OBJECTIVE: Acute postoperative sialadenitis is a potentially life-threatening complication of cranial neurosurgery characterized by swelling of the face and neck due to obstruction of salivary ducts by either mechanical obstruction or, potentially, pharmacologic stasis or gland obstruction. Given the paucity of literature surrounding this rare phenomenon, we sought to report our experience with acute sialadenitis after cranial neurosurgery. METHODS: Retrospective review of patients with acute sialadenitis after neurosurgical craniotomy or craniectomy from a single institution from January 1, 2011, through December 31, 2021. RESULTS: Seven patients (median age: 27 years; 6 female) identified meeting our inclusion criteria out of 10,014 patients who underwent craniotomy and/or craniectomy procedures during last 11 years (∼0.006%), 5 of these cases were considered skull base procedures. Five (71%) patients required emergent airway management either via intubation or tracheostomy and 5 (71%) were treated with steroids. Additional supportive care included sialagogues, warm compress, massage, analgesics, and intravenous hydration for all 7 patients. Three patients (43%) developed concomitant transient focal neurologic deficits attributable to the sialadenitis. No mortalities occurred as a result of this complication. CONCLUSIONS: Acute post-neurosurgical sialadenitis spans a range of severity, with some patients requiring emergent airway management and prolonged ventilator support whereas other patients only require conservative supportive care. Early recognition of acute sialadenitis after cranial neurosurgery can prevent fatal outcomes and provide complete recovery from this condition. Therefore, all neurosurgeons, anesthesiologists, and intensivists should be aware of this rare, but potentially life-threatening, complication.