The 50 most-cited articles in Neurosurgery, 2022

BACKGROUND: Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) can be catastrophic complications associated with adult spinal deformity (ASD) surgery. These complications are markedly influenced by osteoporosis, leading to additional vertebral fracture and pedicle screw loosening. The MRI-based vertebral bone quality score (VBQ) is a newly developed tool that can be used to assess bone quality. OBJECTIVE: To investigate the utility of the VBQ score in predicting PJK and/or PJF (PJF/PJK) after ASD correction. METHODS: We conducted a retrospective chart review to identify patients age ≥50 years who had received ASD surgery of 5 or more thoracolumbar levels. Demographic, spinopelvic parameters, and procedure-related variables were collected. Each patient's VBQ score was calculated using preoperative T1-weighted MRI. Univariate analysis and multivariate logistic regression were performed to determine potential risk factors of PJK/PJF. Receiver operating characteristic analysis and area-under-the-curve values were generated for prediction of PJK/PJF. RESULTS: A…

BACKGROUND: The mainstay of treatment for symptomatic or large chronic subdural hematoma (CSDH) is surgery, but controversy still exists regarding the best surgical technique. Three different techniques are commonly used: burr hole craniostomy (BHC), minicraniotomy (MC), and twist drill craniostomy (TDC). OBJECTIVE: To determine which surgical technique for drainage of CSDH offers best results. METHODS: We set up a multicenter prospective randomized trial (Comparison of Chronic Subdural Hematoma Treatment [COMPACT] trial) comparing BHC, MC, and TDC for the surgical treatment of CSDH. The primary end point was reoperation rate, and secondary end points included complication rates and clinical outcome. Patients were considered to have good outcome when they did not undergo reoperation, suffered no surgical or medical complication, and had no related mortality. Clinical outcome was also evaluated by evolution of the Markwalder score and the modified Rankin score. RESULTS: Two-hundred forty-five patients were included in the final analysis: 79 BHC, 84 MC, and 82 TDC. Mean duration of…

BACKGROUND: Surgeons can preoperatively assess bone quality using dual-energy X-ray absorptiometry or computed tomography; however, this is not feasible for all patients. Recently, a MRI-based scoring system was used to evaluate the lumbar spine's vertebral bone quality. OBJECTIVE: To create a similar MRI-based scoring system for the cervical spine (C-VBQ), correlate C-VBQ scores with computed tomography-Hounsfield units (HU), and evaluate the utility of this scoring system to independently predict cage subsidence after single-level anterior cervical diskectomy and fusion (ACDF). METHODS: Demographic, procedure-related, and radiographic data were collected for patients. Pearson correlation test was used to determine the correlation between C-VBQ and HU. Cage subsidence was defined as ≥3 mm loss of fusion segmental height. A multivariate logistic regression model was built to determine the correlation between potential risk factors for subsidence. RESULTS: Of 59 patients who underwent single-level ACDF, subsidence was found in 17 (28.8%). Mean C-VBQ scores were 2.22 ± 0.36 for no…

BACKGROUND: Although numerous articles have been published not only on the classification of thoracic outlet syndrome (TOS) but also on diagnostic standards, timing, and type of surgical intervention, there still remains some controversy because of the lack of level 1 evidence. So far, attempts to generate uniform reporting standards have not yielded conclusive results. OBJECTIVE: To systematically review the body of evidence and reach a consensus among neurosurgeons experienced in TOS regarding anatomy, diagnosis, and classification. METHODS: A systematic literature search on PubMed/MEDLINE was performed on February 13, 2021, yielding 2853 results. Abstracts were screened and classified. Recommendations were developed in a meeting held online on February 10, 2021, and refined according to the Delphi consensus method. RESULTS: Six randomized controlled trials (on surgical, conservative, and injection therapies), 4 "guideline" articles (on imaging and reporting standards), 5 observational studies (on diagnostics, hierarchic designs of physiotherapy vs surgery, and quality of life…

BACKGROUND: Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. OBJECTIVE: To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. METHODS: A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. RESULTS: Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P =…

BACKGROUND: Patient satisfaction is an important indicator used to monitor quality of care and outcomes after spine surgery. OBJECTIVE: To examine the complex relationship between preoperative expectations, fulfillment of expectations, postsurgical outcomes, and satisfaction after spine surgery. METHODS: In this national study of patients undergoing elective surgery for degenerative spinal conditions from the Canadian Spine Outcomes and Research Network Registry, we used logistic regression to examine the relationships between patient satisfaction with surgery (1-5 scale), preoperative expectation score (0 = none to 100 = highest), fulfillment of expectations, and disability and pain improvement. RESULTS: Fifty-eight percent of patients were extremely satisfied, and 3% were extremely dissatisfied. Expectations were variable and generally high (mean 79.5 of 100) while 17.3% reported that none of their expectations were met, 49.8% reported that their most important expectation was met, and 32.9% reported that their most important expectation was not met but others were. The results…

To the Editor: Neurological disorders are a leading cause of mortality and disability worldwide.1 Up to 9 million deaths each year are attributable to neurological diseases.1 Surgery plays a major role in managing neurological disorders, especially stroke, which is the single largest contributor of neurological morbidity and mortality1,2 and maybe treated with endovascular or neurosurgical modalities. Unfortunately, the burden of neurological disease is disproportionately distributed, with low- and middle-income countries (LMICs) bearing more than 90% of the global burden.1,3 GLOBAL ACTION PLAN The global health community recognizes the need to reduce the burden of neurological disease. On January 12, 2022, the World Health Organization (WHO) published the final draft of the 2022 to 2031 intersectoral global action plan on epilepsy and other neurological disorders.4 The global action plan has 6 guiding principles, including intersectoral action, which the WHO defines as a “comprehensive and coordinated response to neurological disorders resulting from partnerships and collaboration…

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE: To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS: A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS: In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the…

The Women in Neurosurgery (WINS) and the American Association of Neurological Surgeons published a white paper in 2008 setting an ambitious goal for women to comprise 20% of neurosurgery residents by 2012 and 20% of practicing neurosurgeons by 2020. Although there has been steady progress, we have fallen short of these benchmarks. We take this opportunity to look back at the accomplishments made over the past decade and provide an update on our present status. We evaluate current barriers toward progress and propose new goals, highlighting the systemic changes necessary to accomplish them. We propose the following updated recommendations to recruit and retain diverse talent into the neurosurgical workforce. (1) Neurosurgical departments and societies should provide diverse, early formal mentorship opportunities for medical students, residents, and junior faculty members. (2) Parental leave policies must be delineated, promoted, and enforced for all neurosurgeons, with greater awareness of internal discrimination and normalization of the discussion surrounding this topic. (3) We need…

BACKGROUND: Radiation necrosis (RN) after stereotactic radiosurgery (SRS) for brain metastases (BM) can result in significant morbidity, compounded by the effects of extended steroid therapy. Laser interstitial thermal therapy (LITT) is a minimally invasive procedure that can offer definitive treatment for RN while potentially obviating the need for prolonged steroid use. OBJECTIVE: To compare LITT vs medical management (MM) in the treatment of RN. METHODS: A multicenter, retrospective study was performed of SRS-treated patients with BM who developed biopsy-proven RN and were treated with LITT or MM. Clinical outcome data were compared by treatment modality. RESULTS: Seventy-two patients met criteria with a median follow-up of 10.0 months (4.2-25.1), and 57 patients (79%) underwent LITT. Four MM (27%) and 3 LITT patients (5%) demonstrated radiographic progression (P = .031) at a median of 5.3 and 4.0 months (P = .40). There was no significant difference in overall survival (LITT median of 15.2 vs 11.6 months, P = .60) or freedom from local progression (13.6 vs 7.06 months, P = .40).…

BACKGROUND: Screening trials before full implantation of a spinal cord stimulation device are recommended by clinical guidelines and regulators, although there is limited evidence for their use. The TRIAL-STIM study showed that a screening trial strategy does not provide superior patient pain outcome at 6-month follow-up compared with not doing a screening trial and that it was not cost-effective. OBJECTIVE: To report the long-term follow-up results of the TRIAL-STIM study. METHODS: The primary outcome of this pragmatic randomized controlled trial was pain intensity as measured on a numerical rating scale (NRS) and secondary outcomes were the proportion of patients achieving at least 50% and 30% pain relief at 6 months, health-related quality of life, and complication rates. RESULTS: Thirty patients allocated to the "Trial Group" (TG) and 36 patients allocated to the "No Trial Group" (NTG) completed outcome assessment at 36-month follow-up. Although there was a reduction in NRS pain and improvements in utility scores from baseline to 36 months in both groups, there was no difference…

BACKGROUND: Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls. OBJECTIVE: To evaluate outcomes through 24 months postimplantation. METHODS: INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury. RESULTS: Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1…

BACKGROUND: The purpose of transsphenoidal surgery (TSS) for a functioning pituitary tumor (FPT) is to achieve endocrinological remission. The biggest challenge is aggressive tumor resection invading the cavernous sinus (CS). OBJECTIVE: To evaluate the effects of the medial wall of CS (MWCS) resection during FPT surgery. METHODS: Consecutive FPTs were reviewed for CS invasion (CSI) between April 2018 and December 2021. We operated on more than 250 FPTs, including 134 somatotroph tumors, 70 corticotroph tumors, 35 lactotroph tumors, and 9 thyrotroph tumors. RESULTS: The patients were classified into 3 groups based on the relationship between the tumor and the CS: group A (no clear wall invasion), in which MWCS was not removed because of no tumorous direct contact with MWCS (N = 92) and group B (possible wall invasion), where MWCS was removed because we were not confident of MWCS invasion (N = 102). Among these 102 patients, histological tumor invasion was confirmed in 45 of 79 patients (57%) for whom histology findings were available. Tumors invading the CS clearly during surgery…

BACKGROUND: Chronic subdural hematomas (CSDHs) are common in the elderly population and patients taking antiplatelet/anticoagulation medications. Middle meningeal artery (MMA) embolization has become an adjunctive treatment to observation and surgery. Despite many embolization techniques, best practices for optimal CSDH resolution remain unknown. OBJECTIVE: To report a retrospective case series of MMA embolization for CSDHs regarding rate of hematoma improvement and the significance of distal embolic penetration into the falx. METHODS: Retrospective chart review was performed on all patients who underwent MMA embolization for CSDHs between January 2017 and June 2021. Patient demographics, clinical presentation, anticoagulant use, and radiographic features were collected. Pre-embolization and postembolization computed tomography scans were analyzed for volumetric changes and assessed for midline penetration of embolic material in the falx. RESULTS: MMA embolization was performed in 37 patients and 53 hemispheres. Older patients took longer to obtain complete resolution of CSDHs (r =…

BACKGROUND AND IMPORTANCE: Aggressive pituitary adenomas (APAs) are pituitary tumors that are refractory to standard treatments and carry a poor prognosis. Current treatment guidelines are not standardized but combine surgical resection, radiation therapy, and chemotherapy. Temozolomide is the only chemotherapeutic agent with documented effectiveness and is recommended for APA in European Society of Endocrinology clinical guidelines. CLINICAL PRESENTATION: A 57-year-old man presented with visual deterioration and bitemporal hemianopsia. MRI of the brain demonstrated a sellar mass suspected to be pituitary macroadenoma with displacement of the stalk and optic nerve impingement. The patient underwent stereotactic endoscopic transsphenoidal resection of the mass. Postoperative MRI demonstrated gross total resection. Pathology revealed a sparsely granulated corticotroph adenoma with malignant transformation. Immunohistochemistry showed loss of expression of MLH1 and PMS2 in the tumor cells. Proton therapy was recommended given an elevated Ki67 index and p53 positivity. Before…

BACKGROUND: Asleep vs awake surgery for right insula-centered low-grade glioma (LGG) is still debated. OBJECTIVE: To compare neurological outcomes and return to work after resection for right insular/paralimbic LGG performed without vs with awake mapping. METHODS: A personal surgical experience of right insula-centered LGG was analyzed, by comparing 2 consecutive periods. In the first period (group 1), patients underwent asleep surgery with motor mapping. In the second period (group 2), patients underwent intraoperative awake mapping of movement and cognitive functions. RESULTS: This consecutive series included 143 LGGs: 41 in group 1 (1999-2009) and 102 in group 2 (2009-2020). There were no significant difference concerning preoperative clinicoradiological characteristics and histopathology results between both groups. Intraoperative motor mapping was positive in all cases in group 1. In group 2, beyond motor mapping, somatosensory, visuospatial, language, and/or cognitive functions were identified during cortical-subcortical stimulation. Postoperatively, 3 patients experienced a…

BACKGROUND: The Woven EndoBridge (WEB) device (Terumno Corp. [parent company of Microvention]) was approved by the U.S. Food and Drug Administration as the first intrasaccular device for intracranial aneurysm treatment in December 2018. Its use has become more common since then, but both trial results and postmarket experiences have raised questions about the efficacy in achieving complete aneurysm obliteration. Retreatment after WEB embolization has not been extensively discussed. OBJECTIVE: To discuss the incidence and retreatment of aneurysms after initial WEB embolization. METHODS: Retrospective review across 13 institutions identified all occurrences of WEB retreatment within neurovascular databases. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed. RESULTS: Thirty aneurysms were retreated in 30 patients in a cohort of 342 WEB-treated aneurysms. The retreatment rate was 8.8%. Endovascular methods were used for 23 cases, and 7 were treated surgically. Two aneurysms presented…

BACKGROUND: Accurate specimen analysis of skull base tumors is essential for providing personalized surgical treatment strategies. Intraoperative specimen interpretation can be challenging because of the wide range of skull base pathologies and lack of intraoperative pathology resources. OBJECTIVE: To develop an independent and parallel intraoperative workflow that can provide rapid and accurate skull base tumor specimen analysis using label-free optical imaging and artificial intelligence. METHODS: We used a fiber laser-based, label-free, nonconsumptive, high-resolution microscopy method (<60 seconds per 1 × 1 mm2), called stimulated Raman histology (SRH), to image a consecutive, multicenter cohort of patients with skull base tumor. SRH images were then used to train a convolutional neural network model using 3 representation learning strategies: cross-entropy, self-supervised contrastive learning, and supervised contrastive learning. Our trained convolutional neural network models were tested on a held-out, multicenter SRH data set. RESULTS: SRH was able to image the diagnostic…

BACKGROUND: Awake craniotomy (AC) enables real-time monitoring of cortical and subcortical functions when lesions are in eloquent brain areas. AC patients are exposed to various preoperative, intraoperative, and postoperative stressors, which might affect their mental health. OBJECTIVE: To conduct a systematic review to better understand stress, anxiety, and depression in AC patients. METHODS: PubMed, Scopus, and Web of Science databases were searched from January 1, 2000, to April 20, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. RESULTS: Four hundred forty-seven records were identified that fit our inclusion and exclusion criteria for screening. Overall, 24 articles consisting of 1450 patients from 13 countries were included. Sixteen studies (66.7%) were prospective, whereas 8 articles (33.3%) were retrospective. Studies evaluated stress, anxiety, and depression during different phases of AC. Twenty-two studies (91.7%) were conducted on adults, and 2 studies were on pediatrics (8.3 %). Glioma was the most common…

BACKGROUND: Despite an increased understanding of the impact of socioeconomic status on neurosurgical outcomes, the impact of neighborhood-level social determinants on lumbar spine surgery patient-reported outcomes remains unknown. OBJECTIVE: To evaluate the impact of geographic social deprivation on physical and mental health of lumbar surgery patients. METHODS: A single-center retrospective cohort study analyzing patients undergoing lumbar surgery for degenerative disease from 2015 to 2018 was performed. Surgeries were categorized as decompression only or decompression with fusion. The area deprivation index was used to define social deprivation. Study outcomes included preoperative and change in Patient-Reported Outcomes Measurement (PROMIS) physical function (PF), pain interference (PI), depression, and anxiety (mean follow-up: 43.3 weeks). Multivariable imputation was performed for missing data. One-way analysis of variance and multivariable linear regression were used to evaluate the association between area deprivation index and PROMIS scores. RESULTS: In our cohort of 2010…

BACKGROUND: Laser interstitial thermal therapy (LITT) for glioblastoma (GBM) has been reserved for poor surgical candidates and deep "inoperable" lesions. We present the first reported series of LITT for surgically accessible recurrent GBM (rGBM) that would otherwise be treated with surgical resection. OBJECTIVE: To evaluate the use of LITT for unifocal, lobar, first-time rGBM compared with a similar surgical cohort. METHODS: A retrospective institutional database was used to identify patients with unifocal, lobar, first-time rGBM who underwent LITT or resection between 2013 and 2020. Clinical and volumetric lesional characteristics were compared between cohorts. Subgroup analysis of patients with lesions ≤20 cm 3 was also completed. Primary outcomes were overall survival and progression-free survival. RESULTS: Of the 744 patients with rGBM treated from 2013 to 2020, a LITT cohort of 17 patients were compared with 23 similar surgical patients. There were no differences in baseline characteristics, although lesions were larger in the surgical cohort (7.54 vs 4.37 cm 3 , P = .017).…

BACKGROUND: Temporal lobe epilepsy (TLE) surgery is associated with the best seizure outcome in adults, although its long-term results remain suboptimal. Retrospective pediatric studies suggest better figures whose determinants are poorly understood. OBJECTIVE: To conduct a systematic review and meta-analysis of studies on the efficacy of TLE surgery in children (age younger than 18 years) and adults. METHODS: We searched MEDLINE, Embase, and Cochrane Library for TLE surgery original research from January 1, 1990, until May 12, 2020. The outcome measures were seizure freedom since surgery and seizure freedom either at last or longest follow-up. We meta-analyzed the proportion of children and adults achieving either Engel I/International League Against Epilepsy (ILAE) 1 or Engel IA/ILAE 1A outcome by follow-up duration, type of surgery, histopathology, neuroimaging, quality of the studies, and publication period. We used a random effects model with Freeman-Tukey double arcsine transformation of proportions. RESULTS: From 40 409 records identified, we included 277 studies (30 848…

BACKGROUND: Despite spinal cord stimulation's (SCS) proven efficacy, failure rates are high with no clear understanding of which patients benefit long term. Currently, patient selection for SCS is based on the subjective experience of the implanting physician. OBJECTIVE: To develop machine learning (ML)-based predictive models of long-term SCS response. METHODS: A combined unsupervised (clustering) and supervised (classification) ML technique was applied on a prospectively collected cohort of 151 patients, which included 31 features. Clusters identified using unsupervised K-means clustering were fitted with individualized predictive models of logistic regression, random forest, and XGBoost. RESULTS: Two distinct clusters were found, and patients in the cohorts significantly differed in age, duration of chronic pain, preoperative numeric rating scale, and preoperative pain catastrophizing scale scores. Using the 10 most influential features, logistic regression predictive models with a nested cross-validation demonstrated the highest overall performance with the area under the curve…

BACKGROUND: Augmented reality (AR) technology is a new and promising option to advance and expand neurosurgical training because of recent advances in computer vision technology, improved AR software and hardware, and growing acceptance of this technology in clinical practice. OBJECTIVE: To analyze the current status of AR use cases with the goal of envisioning future uses of AR in neurosurgical education. METHODS: Articles applying to AR technology use in neurosurgical education were identified using PubMed, Google Scholar, and Web of Science databases following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines. Articles were included for review based on applicable content related to neurosurgical or neuroanatomy training. Assessment of literature quality was completed using standardized MERSQI scoring. RESULTS: The systematic search identified 2648 unique articles. Of these, 12 studies met inclusion criteria after extensive review. The average MERSQI score was 10.2 (SD: 1.7). The most common AR platform identified in this study was the Microsoft…

BACKGROUND: Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized. OBJECTIVE: To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort. METHODS: We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention. RESULTS: A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between…

BACKGROUND: Cerebrospinal fluid (CSF) shunting is widely used in refractory idiopathic intracranial hypotension (IIH). Although multiple reviews have assessed its efficacy compared with other surgical treatments, there is no detailed analysis that evaluates the clinical outcomes after CSF shunting. OBJECTIVE: To conduct a meta-analysis of the clinical impact of CSF shunting for refractory IIH and use this in conjunction with existing information on other treatment modalities to develop a modern management protocol. METHODS: PubMed and Embase were systematically searched for studies describing CSF shunting for medically refractory IIH. Relevant information including study characteristics, patient demographics, clinical outcomes, periprocedural complications, and long-term outcomes were subjected to meta-analysis. RESULTS: Fifteen studies published between 1988 and 2019 met our inclusion and exclusion criteria, providing 372 patients for analysis. The mean age was 31.2 years (range 0.5-71) with 83.6% being female. The average follow-up was 33.9 months (range 0-278 months). The overall…

BACKGROUND: The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke. OBJECTIVE: To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort. METHODS: We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020. RESULTS: The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified…

BACKGROUND: Multiple prospective nonrandomized studies have shown 60% to 70% of patients with idiopathic normal pressure hydrocephalus (iNPH) improve with shunt surgery, but multicenter placebo-controlled trial data are necessary to determine its effectiveness. OBJECTIVE: To evaluate the effectiveness of cerebrospinal fluid shunting in iNPH through comparison of open vs placebo shunting groups at 4 months using a pilot study. METHODS: Patients were randomized to a Codman Certas Plus valve (Integra LifeSciences) set at 4 (open shunt group) or 8 ("virtual off"; placebo group). Patients and assessors were blinded to treatment group. The primary outcome measure was 10-m gait velocity. Secondary outcome measures included functional scales for bladder control, activities of daily living, depression, and quality of life. Immediately after 4-month evaluation, all shunts were adjusted in a blinded fashion to an active setting and followed to 12 months after shunting. RESULTS: A total of 18 patients were randomized. At the 4-month evaluation, gait velocity increased by 0.28 ± 0.28 m/s in the…

BACKGROUND: For patients with vestibular schwannoma (VS), stereotactic radiosurgery (SRS) has proven effective in controlling tumor growth while hearing preservation remains a key goal. OBJECTIVE: To evaluate hearing outcomes in the modern era of cochlear dose restriction. METHODS: During the years 2013 to 2018, 353 patients underwent Gamma knife surgery for VS at our institution. We followed 175 patients with pre-SRS serviceable hearing (Gardner-Robertson Score, GR 1 and 2). Volumetric and dosimetry data were collected, including biological effective dose, integral doses of total and intracanalicular tumor components, and hearing outcomes. RESULTS: The mean age was 56 years, 74 patients (42%) had a baseline GR of 2, and the mean cochlear dose was 3.5 Gy. The time to serviceable hearing loss (GR 3-4) was 38 months (95% CI 26-46), with 77% and 62% hearing preservation in the first and second years, respectively. Patients optimal for best hearing outcomes were younger than 58 years with a baseline GR of 1, free canal space ≥0.041 cc (diameter of 4.5 mm), and mean cochlear dose <3.1…

BACKGROUND: The recovery of severe traumatic brain injury (TBI) survivors with long-term favorable outlook is understudied. Time to follow commands varies widely in this patient population but has important clinical implications. OBJECTIVE: To (1) evaluate time to follow commands in severe patients with TBI with favorable outcomes, (2) characterize their trajectory of recovery, and (3) identify predictors associated with delayed cognitive improvement. METHODS: Participants were recruited prospectively at a Level I trauma center through the Brain Trauma Research Center from 2003 to 2018. Inclusion criteria were age 16 to 80 years, Glasgow Coma Scale score ≤8 and motor score <6, and Glasgow Outcome Scale-Extended measure ≥4 at 2 years postinjury. RESULTS: In 580 patients, there were 229 (39.5%) deaths and 140 (24.1%) patients had favorable outcomes at 2 years. The mean age was 33.7 ± 14.5 years, median Glasgow Coma Scale was 7 (IQR 6-7), and median Injury Severity Score was 30 (IQR 26-38). The mean time to follow commands was 12.7 ± 11.8 days. On multivariable linear regression, the…

BACKGROUND: The flow of cerebrospinal fluid (CSF) has been described as a unidirectional system with the choroid plexus serving as the primary secretor of CSF and the arachnoid granulations as primary reabsorption site. This theory of neurosurgical forefathers has been universally adopted and taught as dogma. Many neuroscientists have found difficulty reconciling this theory with common pathologies, and recent studies have found that this "classic" hypothesis may not represent the full picture. OBJECTIVE: To review modern CSF dynamic theories and to call for medical education reform. METHODS: We reviewed the literature from January 1990 to December 2020. We searched the PubMed database using key terms "cerebrospinal fluid circulation," "cerebrospinal fluid dynamics," "cerebrospinal fluid physiology," "glymphatic system," and "glymphatic pathway." We selected articles with a primary aim to discuss either CSF dynamics and/or the glymphatic system. RESULTS: The Bulat-Klarica-Orešković hypothesis purports that CSF is secreted and reabsorbed throughout the craniospinal axis. CSF…

BACKGROUND: Decompression of the injured spinal cord confers neuroprotection. Compared with timing of surgery, verification of surgical decompression is understudied. OBJECTIVE: To compare the judgment of cervical spinal cord decompression using real-time intraoperative ultrasound (IOUS) following laminectomy with postoperative MRI and CT myelography. METHODS: Fifty-one patients were retrospectively reviewed. Completeness of decompression was evaluated by real-time IOUS and compared with postoperative MRI (47 cases) and CT myelography (4 cases). RESULTS: Five cases (9.8%) underwent additional laminectomy after initial IOUS evaluation to yield a final judgment of adequate decompression using IOUS in all 51 cases (100%). Postoperative MRI/CT myelography showed adequate decompression in 43 cases (84.31%). Six cases had insufficient bony decompression, of which 3 (50%) had cerebrospinal fluid effacement at >1 level. Two cases had severe circumferential intradural swelling despite adequate bony decompression. Between groups with and without adequate decompression on postoperative MRI/CT…

BACKGROUND: Stereotactic body radiotherapy (SBRT) is used to deliver ablative dose of radiation to spinal metastases. OBJECTIVE: To report the first dedicated series of spine SBRT specific to prostate cancer (PCa) metastases with outcomes reported according to hormone sensitivity status. METHODS: A prospective database was reviewed identifying patients with PCa treated with spine SBRT. This included those with hormone-sensitive PCa (HSPC) and castrate-resistant PCa (CRPC). The primary end point was MRI-based local control (LC). RESULTS: A total of 183 spine segments in 93 patients were identified; 146 segments had no prior radiation and 37 had been previously radiated; 27 segments were postoperative. The median follow-up was 31 months. At the time of SBRT, 50 patients had HSPC and the remaining 43 had CRPC. The most common fractionation scheme was 24-28 Gy in 2 SBRT fractions (76%). LC rates at 1 and 2 years were 99% and 95% and 94% and 78% for the HSPC and CRPC cohorts, respectively. For patients treated with de novo SBRT, a higher risk of local failure was observed in patients…

BACKGROUND: Preoperative embolization has traditionally been regarded as a safe and effective adjunct to microsurgical treatment of brain arteriovenous malformations (bAVM). However, there is currently no high-level evidence to ascertain this presumption. OBJECTIVE: To compare the outcomes of microsurgery (MS) vs microsurgery with preoperative embolization (E + MS) in patients with bAVM through systematic review. METHODS: We searched MEDLINE, PubMed, and Embase. The primary outcome was bAVM obliteration. Secondary outcomes were intraoperative bleeding (mL), complications, worsened modified Rankin Scale (mRS), and mortality. The pooled proportions of outcomes were calculated through the logit transformation method. The odds ratio (OR) of categorical data and mean difference of continuous data were estimated through the Mantel-Haenszel and the inverse variance methods, respectively. RESULTS: Thirty-two studies met the eligibility criteria. One thousand eight hundred twenty-eight patients were treated by microsurgery alone, and 1088 were treated by microsurgery with preoperative…

BACKGROUND: Medically refractory idiopathic intracranial hypertension (IIH) is frequently treated with venous sinus stenosis stenting with high success rates. Patient selection has been driven almost exclusively by identification of supraphysiological venous pressure gradients across stenotic regions based on theoretical assessment of likelihood of response. OBJECTIVE: To explore the possibility of benefit in low venous pressure gradient patients. METHODS: Using a single-center, prospectively maintained registry of patients with IIH undergoing venous stenting, we defined treatment groups by gradient pressures of ≤4, 5 to 8, and >8 mmHg based on the most frequently previously published thresholds for stenting. Baseline demographics, clinical, and neuro-ophthalmological outcomes (including optical coherence tomography and Humphrey visual fields) were compared. RESULTS: Among 53 patients, the mean age was 32 years and 70% female with a mean body mass index was 36 kg/m 2 . Baseline characteristics were similar between groups. The mean change in lumbar puncture opening pressure at 6…

BACKGROUND: Promoting workplace diversity leads to a variety of benefits related to a broader range of perspectives and insights. Underrepresented in medicine (URiM), including African Americans, Latinx, and Natives (Americans/Alaskan/Hawaiians/Pacific Islanders), are currently accounting for approximately 40% of the US population. OBJECTIVE: To establish a snapshot of current URiM representation within academic neurosurgery (NS) programs and trends within NS residency. METHODS: All 115 NS residencies and academic programs accredited by the Accreditation Council for Graduate Medical Education in 2020 were included in this study. The National Residency Matching Program database was reviewed from 2011 to 2020 to analyze URiM representation trends over time within the NS resident workforce. The academic rank, academic and clinical title(s), subspecialty, sex, and race of URiM NS faculty (NSF) were obtained from publicly available data. RESULTS: The Black and Latinx NS resident workforce currently accounts for 4.8% and 5.8% of the total workforce, respectively. URiM NSF are present in…

BACKGROUND: Revascularization surgery for adult patients with ischemic moyamoya disease (MMD) may improve both cognitive function and cerebral perfusion. OBJECTIVE: To determine angiographic, cerebral hemodynamic, and cognitive outcomes of indirect revascularization surgery alone for adult patients with misery perfusion due to ischemic MMD (IDR group) and to test the superiority of indirect revascularization surgery for cognitive improvement by conducting comparisons with historical control patients who had undergone direct revascularization surgery (DR group) through prospective cohort study with historical controls. METHODS: Twenty adult patients with cerebral misery perfusion underwent encephalo-duro-myo-arterio-pericranial-synangiosis alone. Cerebral angiography through arterial catheterization, brain perfusion single-photon emission computed tomography, and neuropsychological testing were performed preoperatively and at 6 months postoperatively. RESULTS: In 17 patients of the IDR group, collateral flows that were newly formed after surgery on angiograms fed more than one-third…

BACKGROUND: Rapid growth in smartphone use has expanded opportunities to use mobile health (mHealth) technology to collect real-time patient-reported and objective biometric data. These data may have important implication for personalized treatments of degenerative spine disease. However, no large-scale study has examined the feasibility and acceptability of these methods in spine surgery patients. OBJECTIVE: To evaluate the feasibility and acceptability of a multimodal preoperative mHealth assessment in patients with degenerative spine disease. METHODS: Adults undergoing elective spine surgery were provided with Fitbit trackers and sent preoperative ecological momentary assessments (EMAs) assessing pain, disability, mood, and catastrophizing 5 times daily for 3 weeks. Objective adherence rates and a subjective acceptability survey were used to evaluate feasibility of these methods. RESULTS: The 77 included participants completed an average of 82 EMAs each, with an average completion rate of 86%. Younger age and chronic pulmonary disease were significantly associated with lower EMA…

BACKGROUND: Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull. OBJECTIVE: To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients. METHODS: Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.…

BACKGROUND: Glioblastoma (GBM) is a rapidly growing and most life-threatening malignant brain tumor. The significance of early treatment to the clinical outcomes of patients with GBM is unclear. OBJECTIVE: To determine whether early diagnosis and surgery improve the preoperative and postoperative Karnofsky performance status (KPS) and prognosis of patients with GBM. METHODS: Data of isocitrate dehydrogenase-wildtype patients with GBM treated at our institution between January 2010 and December 2019 were reviewed. Patients were classified into early or late diagnosis groups with a threshold of 14 days from initial symptoms. In addition, patients were divided into early, intermediate, and late surgery groups with thresholds of 21 and 35 days. Representative symptoms and patient prognoses were examined. RESULTS: Of 153 patients, 72 and 81 were classified into the early and late diagnosis groups. The median tumor volume was significantly smaller in the former group. The proportion of patients with preoperative KPS scores 90 was 48.6% and 29.6% in the early and late diagnosis groups ( P…

BACKGROUND: Current traumatic brain injury (TBI) prognostic calculators are commonly used to predict the mortality and Glasgow Outcome Scale, but these outcomes are most relevant for severe TBI. Because mild and moderate TBI rarely reaches severe outcomes, there is a need for novel prognostic endpoints. OBJECTIVE: To generate machine learning (ML) models with a strong predictive capacity for trichotomized discharge disposition, an outcome not previously used in TBI prognostic models. The outcome can serve as a proxy for patients' functional status, even in mild and moderate patients with TBI. METHODS: Using a large data set (n = 5292) of patients with TBI from a quaternary care center and 84 predictors, including vitals, demographics, mechanism of injury, initial Glasgow Coma Scale, and comorbidities, we trained 6 different ML algorithms using a nested-stratified-cross-validation protocol. After optimizing hyperparameters and performing model selection, isotonic regression was applied to calibrate models. RESULTS: When maximizing the microaveraged area under the receiver operating…

BACKGROUND: Machine learning (ML) holds promise as a tool to guide clinical decision making by predicting in-hospital mortality for patients with traumatic brain injury (TBI). Previous models such as the international mission for prognosis and clinical trials in TBI (IMPACT) and the corticosteroid randomization after significant head injury (CRASH) prognosis calculators can potentially be improved with expanded clinical features and newer ML approaches. OBJECTIVE: To develop ML models to predict in-hospital mortality for both the high-income country (HIC) and the low- and middle-income country (LMIC) settings. METHODS: We used the Duke University Medical Center National Trauma Data Bank and Mulago National Referral Hospital (MNRH) registry to predict in-hospital mortality for the HIC and LMIC settings, respectively. Six ML models were built on each data set, and the best model was chosen through nested cross-validation. The CRASH and IMPACT models were externally validated on the MNRH database. RESULTS: ML models built on National Trauma Data Bank (n = 5393, 84 predictors)…

BACKGROUND: There is evidence that macrophage infiltration in the tumor microenvironment promotes vestibular schwannoma (VS) growth. Efficacy of bevacizumab in NF2-associated VS demonstrates the value of therapies targeting the microvascular tumor microenvironment, and tumor-associated macrophages (TAMs) may represent another druggable target. OBJECTIVE: To characterize the relationship between growth, TAM infiltration, and circulating monocyte chemokines in a large cohort of patients with VS. METHODS: Immunostaining for Iba1 (macrophages), CD31 (endothelium), and fibrinogen (permeability) was performed on 101 growing and 19 static sporadic VS. The concentrations of monocyte-specific chemokines were measured in the plasma of 50 patients with growing VS and 25 patients with static VS. RESULTS: The Iba1 + cell count was significantly higher in growing as compared with static VS (592 vs 226/×20 HPF, P =<0.001). Similarly, the CD31 + % surface area was higher in growing VS (2.19% vs 1.32%, P = .01). There was a positive correlation between TAM infiltration and VS growth rate, which…

BACKGROUND: The most extensively validated prognostic models for traumatic brain injury (TBI) are the Corticoid Randomization after Significant Head Injury (CRASH) and International Mission on Prognosis and Analysis of Clinical Trials (IMPACT). Model characteristics outside of area under the curve (AUC) are rarely reported. OBJECTIVE: To report the discriminative validity and overall model performance of the CRASH and IMPACT models for prognosticating death at 14 days (CRASH) and 6 months (IMPACT) and unfavorable outcomes at 6 months after TBI. METHODS: This retrospective cohort study included prospectively collected patients with severe TBI treated at a single level I trauma center (n = 467). CRASH and IMPACT percent risk values for the given outcome were computed. Unfavorable outcome was defined as a Glasgow Outcome Scale-Extended score of 1 to 4 at 6 months. Binary logistic regressions and receiver operating characteristic analyses were used to differentiate patients from the CRASH and IMPACT prognostic models. RESULTS: All models had low R 2 values (0.17-0.23) with AUC values…

BACKGROUND: Middle meningeal artery (MMA) embolization has been recognized as a promising treatment for patients with subdural hematoma (SDH). OBJECTIVE: To present the technical feasibility and efficacy of n-butyl cyanoacrylate (n-BCA) embolization in the largest consecutive cohort to date. METHODS: We retrospectively reviewed our consecutive cases of recurrent SDH treated with MMA embolization using diluted n-BCA with the "sugar rush" technique. In brief, a 2.1-Fr microcatheter was used to selectively catheterize the frontal and posterior branches of the MMA. 5% dextrose in water (D5W) was injected through an intermediate catheter while injecting n-BCA through the microcatheter. Complete obliteration of MMA and lack of SDH recurrence in a 3-6 months follow-up computed tomography scan were defined as efficacy outcomes. Cranial nerve palsy, vision loss, transient neurological deficit, and stroke were defined as safety outcomes. RESULTS: A total of 61 patients were identified with a mean (±standard deviation) age of 62.5 ± 9 years. In 6 patients (10%), coil embolization of the origin…

BACKGROUND: It is estimated that >50% of acute basilar artery occlusion (ABAO) patients with successful reperfusion after endovascular treatment (EVT) have futile recanalization. However, few studies investigated the reasons behind this. OBJECTIVE: To identify the factors associated with futile recanalization in ABAO after successful reperfusion. METHODS: We recruited patients with successful reperfusion (expanded Thrombolysis In Cerebral Infarction score of ≥2b) after EVT from the Basilar Artery Occlusion Study registry. Patients were divided into meaningful recanalization (90-day modified Rankin Scale 0-3) and futile recanalization (90-day modified Rankin Scale 4-6) groups. Multivariable logistic regression analyses were used to identify the predictors of futile recanalization. RESULTS: A total of 522 patients with successful reperfusion were selected. Of these, 328 patients had futile recanalization and 194 had meaningful recanalization. Multivariable logistic regression shows that higher neutrophil-to-lymphocyte ratio ( P = .01), higher baseline National Institutes of Health…

BACKGROUND: Chronic subdural hematoma (CSDH) is an increasingly prevalent disease in the aging population. Patients with CSDH frequently suffer from concurrent vascular disease or develop secondary thrombotic complications requiring antithrombotic treatment. OBJECTIVE: To determine the safety and impact of early reinitiation of antithrombotics after middle meningeal artery embolization for chronic subdural hematoma. METHODS: This is a single-institution, retrospective study of patients who underwent middle meningeal artery (MMA) embolizations for CSDH. Patient with or without antithrombotic initiation within 5 days postembolization were compared. Primary outcome was the rate of recurrence within 60 days. Secondary outcomes included rate of reoperation, reduction in CSDH thickness, and midline shift. RESULTS: Fifty-seven patients met inclusion criteria. The median age was 66 years (IQR 58-76) with 21.1% females. Sixty-six embolizations were performed. The median length to follow-up was 20 days (IQR 14-44). Nineteen patients (33.3%) had rapid reinitiation of antithrombotics (5…

BACKGROUND: Low-grade cerebral neoplasms are commonly associated with medically intractable epilepsy. Despite increasing evidence that epileptogenic brain regions commonly extend beyond visible tumor margins, the utility of extended surgical resections leveraging intraoperative electrocorticography (ECoG) remains unclear. OBJECTIVE: To determine whether ECoG-guided surgery is associated with improved postoperative seizure control. METHODS: We performed a systematic review and meta-analysis encompassing both adult and pediatric populations. The primary outcome measure was postoperative seizure freedom as defined by Engel class I outcome. Class I/II outcome served as a secondary measure. Relevant clinical and operative data were recorded. A random-effects meta-analysis based on the pooled odds ratio (OR) of seizure freedom was performed on studies that reported comparative data between ECoG-guided surgery and lesionectomy. RESULTS: A total of 31 studies encompassing 1115 patients with medically refractory epilepsy met inclusion criteria. Seven studies reported comparative data between…

BACKGROUND: In-stent stenosis (ISS) is a delayed complication that can occur after pipeline embolization device use when treating intracranial aneurysms (IAs). OBJECTIVE: To assess the incidence, predictors, and outcomes of ISS. METHODS: This was a retrospective, multicenter, observational study. All patient data were collected from a PLUS registry study. We collected data from patients with IA who completed digital subtraction angiography at follow-up and divided patients into "non-ISS," "mild ISS," or "severe ISS" groups. Multivariate logistic regression analysis was conducted to determine predictors of ISS. RESULTS: A total of 1171 consecutive patients with 1322 IAs participated in this study. Angiographic follow-up was available for 662 patients with 728 IAs, and the mean follow-up time was 9 months. ISS was detected in 73 cases (10.03%), including 61 mild ISS cases and 12 severe ISS cases. Univariate and multivariable analysis demonstrated that current smoking history (mild ISS: OR 2.15, 95% CI 1.122-4.118, P = .021; severe ISS: OR 5.858, 95% CI 1.186-28.93, P = .030) and…

BACKGROUND: Endovascular treatment (EVT) for cerebral vein thrombosis (CVT) has not been proven to be more effective than anticoagulation based on recent results of the Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TO-ACT) randomized clinical trial. OBJECTIVE: To compare outcomes of EVT vs medical management in CVT. METHODS: We compared EVT vs medical management in a retrospective multinational cohort of consecutive patients with CVT across 4 countries (USA, Italy, Switzerland, and New Zealand) and 27 sites (2015-2020), using propensity score matching (PSM) and inverse probability treatment weighting (IPTW), and meta-analyzed these results with the TO-ACT trial. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0-1) at 90 days. RESULTS: Of the 987 patients, the mean age was 45.7 ± 16.9 years and 79 (8%) underwent EVT. With PSM (n = 124), there were no major differences in clinical or imaging features between groups other than a higher proportion of female patients receiving EVT (81% vs 65%, P = .04). There was no difference in the…