Cervicothoracic epidural hematoma in a toddler with miosis, ptosis, nonspecific symptoms, and no history of major trauma: case report.

INTRODUCTION: Spinal epidural hematomas are uncommon in children. The diagnosis can be elusive as most cases present without a history of trauma, while symptoms can be atypical. CASE REPORT: We encountered a 35-month-old male presenting with nonspecific symptoms and no history of trauma. He later developed unilateral miosis and ptosis; MRI discovered a subacute cervicothoracic epidural which was promptly evacuated. The patient made an excellent recovery. COCLUSIONS: We emphasize the frequent absence of identifiable trauma and the importance of thorough imaging when this entity is suspected. Miosis and ptosis, likely representing a partial Horner syndrome, is an extremely rare presentation, this being one of the only reported cases.

Need for Y-stenting in stent-assisted coiling of wide-neck bifurcation aneurysms.

BACKGROUND AND PURPOSE: Stent-assisted coiling of wide neck bifurcation aneurysms in the anterior communicating segment and basilar tip region can be performed with varying stent configurations, including single stenting or Y-stenting. Y-stenting requires two stents and thus incurs greater cost and procedural complexity than single-stent constructs. The influence of first stent type on the need for Y-stenting remains unknown. MATERIALS AND METHODS: Clinical and angiographic data were retrospectively obtained for patients that underwent stent-assisted coiling for basilar tip or anterior communicating aneurysms at a high-volume center. Patients were included in this study if stent-assisted coiling was performed using Neuroform Atlas or LVIS Jr stents. A multivariate binary logistic regression was performed to measure the influence of first stent type on the need for Y-stenting. RESULTS: Stent-assisted coiling was used to treat 82 aneurysms in 81 patients during the study period, and Y-stenting was performed in 18.3% (15/82) of cases. In multivariate logistic regression analysis, use of LVIS Jr. as the first stent did not significantly influence the need for subsequent Y-stenting after controlling for aneurysm morphology (OR 0.65, 95% CI 0.18-2.43). CONCLUSION: Controlling for aneurysm morphology and location, the use of Y-stenting for stent-assisted coiling was not independently influenced by the choice of LVIS Jr or Neuroform Atlas as the first stent. A larger cohort may reveal differences between these two stents, particularly for aneurysms with large neck sizes.

Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis.

OBJECTIVE: Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS: Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS: In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION: Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.

Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study.

BACKGROUND AND PURPOSE: Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort. MATERIALS AND METHODS: Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications. RESULTS: In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients. CONCLUSION: Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.

Intraoperative neurophysiological monitoring of T9-T10 fracture in a patient with morbid obesity and ankylosing spondylitis: A case report with literature review.

INTRODUCTION: As the prevalence of obesity continues to rise, there is a growing need to identify practices that protect overweight patients from injury during spine surgery. Intraoperative neurophysiological monitoring (IONM) has been recommended for complex spine surgery, but its use in obese and morbidly obese patients is understudied. CASE REPORT: This case report describes a patient with morbid obesity and ankylosing spondylitis who was treated for a T9-T10 3-column fracture with a planned, minimally invasive approach. Forty minutes after positioning the patient to prone, the IONM team identified a positive change in the patient's motor responses in the bilateral lower extremities and alerted the surgical team in a timely manner. It turned out that the pressure exerted by gravity on the patient's large pannus resulted in further dislocation of the fracture and narrowing of the spinal canal. The surgical team acknowledged the serious risk of spinal cord compression and, hence, immediately changed the surgical plan to an urgent, open approach for decompression and reduction of the fracture. The patient's lower extremities' motor responses improved after decompression. The patient was ambulatory on post-operative day 2 and pain-free at six-weeks with no other neurologic symptoms. SIGNIFICANCE: The use of IONM in this planned minimally invasive spine surgery for a patient with morbid obesity prevented potentially serious iatrogenic injury. The authors include a literature review that situates this case study in the existing literature and highlights a gap in current knowledge. There are few studies that have examined the use of IONM during spine surgery for morbidly obese patients. More research is needed to elucidate best practices for the use of IONM in spine surgery for morbidly obese patients.

Pipeline embolization of distal posterior inferior cerebellar artery aneurysms.

BACKGROUND AND PURPOSE: Flow diversion is commonly used to treat intracranial aneurysms in various regions of the cerebral vasculature, but is only approved for use in the internal carotid arteries. Treatment of distal PICA aneurysms with PED is sometimes performed but has not been well studied. Here, we report our experience with flow diversion of distal PICA aneurysms with PED. MATERIALS AND METHODS: Clinical and angiographic data of eligible patients was retrospectively obtained and assessed for key demographic characteristics and clinical and angiographic outcomes. Principal outcomes included rates of aneurysm occlusion, ischemic or hemorrhagic complication, technical complication, and in-stent stenosis. RESULTS: Three female and 2 male patients underwent placement of PED in the PICA for treatment of 5 distal PICA aneurysms. Clinical and angiographic follow-up was obtained for all patients. Complete aneurysm occlusion was observed in 100% (5/5) of treated aneurysms at 6 month and longest angiographic follow-up. While there were no ischemic or device-related complications, delayed hemorrhagic complications occurred in 20% (1/5) of patients. CONCLUSION: Pipeline embolization of distal PICA aneurysms can be performed in select patients. Further study is necessary in larger cohorts to better define clinical scenarios in which flow diversion in the distal PICA should be considered.

Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission.

OBJECTIVE: The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome. METHODS: mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3-year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non-displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years. RESULTS: Sixty patients were observed in the EDOU over the 3-year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30-day re-admission, 30-day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow-up in both groups. CONCLUSIONS: Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up.

The combination of the opioid glycopeptide MMP-2200 and a NMDA receptor antagonist reduced l-DOPA-induced dyskinesia and MMP-2200 by itself reduced dopamine receptor 2-like agonist-induced dyskinesia.

Dopamine (DA)-replacement therapy utilizing l-DOPA is the gold standard symptomatic treatment for Parkinson's disease (PD). A critical complication of this therapy is the development of l-DOPA-induced dyskinesia (LID). The endogenous opioid peptides, including enkephalins and dynorphin, are co-transmitters of dopaminergic, GABAergic, and glutamatergic transmission in the direct and indirect striatal output pathways disrupted in PD, and alterations in expression levels of these peptides and their precursors have been implicated in LID genesis and expression. We have previously shown that the opioid glycopeptide drug MMP-2200 (a.k.a. Lactomorphin), a glycosylated derivative of Leu-enkephalin mediates potent behavioral effects in two rodent models of striatal DA depletion. In this study, the mixed mu-delta agonist MMP-2200 was investigated in standard preclinical rodent models of PD and of LID to evaluate its effects on abnormal involuntary movements (AIMs). MMP-2200 showed antiparkinsonian activity, while increasing l-DOPA-induced limb, axial, and oral (LAO) AIMs by ∼10%, and had no effect on dopamine receptor 1 (D1R)-induced LAO AIMs. In contrast, it markedly reduced dopamine receptor 2 (D2R)-like-induced LAO AIMs. The locomotor AIMs were reduced by MMP-2200 in all three conditions. The N-methyl-d-aspartate receptor (NMDAR) antagonist MK-801 has previously been shown to be anti-dyskinetic, but only at doses that induce parkinsonism. When MMP-2200 was co-administered with MK-801, MK-801-induced pro-parkinsonian activity was suppressed, while a robust anti-dyskinetic effect remained. In summary, the opioid glycopeptide MMP-2200 reduced AIMs induced by a D2R-like agonist, and MMP-2200 modified the effect of MK-801 to result in a potent reduction of l-DOPA-induced AIMs without induction of parkinsonism.

Development and Validation of a Mobile Device-based External Ventricular Drain Simulator.

BACKGROUND: Multiple external ventricular drain (EVD) simulators have been created, yet their cost, bulky size, and nonreusable components limit their accessibility to residency programs. OBJECTIVE: To create and validate an animated EVD simulator that is accessible on a mobile device. METHODS: We developed a mobile-based EVD simulator that is compatible with iOS (Apple Inc., Cupertino, California) and Android-based devices (Google, Mountain View, California) and can be downloaded from the Apple App and Google Play Store. Our simulator consists of a learn mode, which teaches users the procedure, and a test mode, which assesses users' procedural knowledge. Twenty-eight participants, who were divided into expert and novice categories, completed the simulator in test mode and answered a postmodule survey. This was graded using a 5-point Likert scale, with 5 representing the highest score. Using the survey results, we assessed the module's face and content validity, whereas construct validity was evaluated by comparing the expert and novice test scores. RESULTS: Participants rated individual survey questions pertaining to face and content validity a median score of 4 out of 5. When comparing test scores, generated by the participants completing the test mode, the experts scored higher than the novices (mean, 71.5; 95% confidence interval, 69.2 to 73.8 vs mean, 48; 95% confidence interval, 44.2 to 51.6; P < .001). CONCLUSION: We created a mobile-based EVD simulator that is inexpensive, reusable, and accessible. Our results demonstrate that this simulator is face, content, and construct valid.

Antibiotic Impregnated External Ventricular Drains: Meta and Cost Analysis.

OBJECTIVE: To determine whether antibiotic impregnated external ventricular drains (AI-EVDs) are effective in preventing ventriculostomy associated infection (VAI), and to examine their cost effectiveness. METHODS: A comprehensive literature search was performed for published data through May 2014, including randomized controlled trials and observational cohort studies comparing AI-EVDs with nonimpregnated controls. A meta-analysis of included studies was performed using a random effects model. Historical data at the authors' institution were used to estimate both the incremental price of AI-EVDs and the hospital expenses associated with VAI. RESULTS: Three randomized controlled trials and 5 observational studies met inclusion criteria. The analysis demonstrated a statistically significant protective effect of AI-EVDs against VAI (risk ratio = 0.31 [0.15-0.64]; P = 0.002), although there was significant heterogeneity (χ(2) = 18.08; P = 0.01; I(2) = 61%). The number of AI-EVDs needed to prevent one infection (Number needed to treat [NNT]) was 19. Based on $100 as the incremental price, and $30,000 as the estimated expense of one episode of VAI, AI-EVDs would result in an overall savings estimate of $28,100 (range, $26,400-$28,500) per NNT. If a hospital places 150 AI-EVDs annually, savings could range from $109,292 to $278,577 per year. CONCLUSIONS: Meta-analysis demonstrated a significant protective benefit of AI-EVDs against VAI, and this benefit is likely associated with cost savings. However, current data on AI-EVDs are limited, and overall hospital costs will vary among institutions. Although both the efficacy and cost effectiveness of AI-EVDs are supported by this analysis, further study of AI-EVDs is clearly warranted.

Point-of-View Recording Devices for Intraoperative Neurosurgical Video Capture.

INTRODUCTION: The ability to record and stream neurosurgery is an unprecedented opportunity to further research, medical education, and quality improvement. Here, we appraise the ease of implementation of existing point-of-view devices when capturing and sharing procedures from the neurosurgical operating room and detail their potential utility in this context. METHODS: Our neurosurgical team tested and critically evaluated features of the Google Glass and Panasonic HX-A500 cameras, including ergonomics, media quality, and media sharing in both the operating theater and the angiography suite. RESULTS: Existing devices boast several features that facilitate live recording and streaming of neurosurgical procedures. Given that their primary application is not intended for the surgical environment, we identified a number of concrete, yet improvable, limitations. CONCLUSION: The present study suggests that neurosurgical video capture and live streaming represents an opportunity to contribute to research, education, and quality improvement. Despite this promise, shortcomings render existing devices impractical for serious consideration. We describe the features that future recording platforms should possess to improve upon existing technology.

Long-term hypoxia modulates expression of key genes regulating adrenomedullary function in the late gestation ovine fetus.

We previously communicated that long-term hypoxia (LTH) resulted in a selective reduction in plasma epinephrine following acute stress in fetal sheep. The present study tested the hypothesis that LTH selectively reduces adrenomedullary expression of phenylethanolamine-N-methyltransferase (PNMT), the rate-limiting enzyme for epinephrine synthesis. We also examined the effect of LTH on adrenomedullary nicotinic, muscarinic, and glucocorticoid receptor (GR) expression. Ewes were maintained at high altitude (3,820 m) from 30 to 138 days gestation (dGA); adrenomedullary tissue was collected from LTH and age-matched, normoxic control fetuses at 139-141 dGA. Contrary to our hypothesis, in addition to PNMT, adrenomedullary expression (mRNA, protein) of tyrosine hydroxylase (TH) and dopamine beta-hydroxylase (DBH) were reduced in the LTH fetus. Immunocytochemistry indicated that TH and DBH expression was lower throughout the medulla, while PNMT appeared to reflect a reduction in PNMT-expressing cells. Nicotinic receptor alpha 1, 2, 3, 5, 6, 7, beta 1, 2, and 4 subunits were expressed in the medulla of LTH and control fetuses. Messenger RNA for alpha 1 and 7 and beta 1 and 2 subunits was lower in LTH fetuses. Muscarinic receptors M1, M2, and M3 as well as the GR were also expressed, and no differences were noted between groups. In summary, LTH in fetal sheep has a profound effect on expression of key enzymes mediating adrenomedullary catecholamine synthesis. Further, LTH impacts nicotinic receptor subunit expression potentially altering cholinergic neurotransmission within the medulla. These findings have important implications regarding fetal cardiovascular and metabolic responses to stress in the LTH fetus.