Improving Access to Extracranial-Intracranial Bypass Surgery in Border Hispanic Communities Utilizing Collaborative Approach Between Plastics and Neurological Surgery

INTRODUCTION: Hispanic patients such as those with Moyamoya disease are less likely to receive surgical revascularization therapy due to inequities in access (1). Our institution is a located in the Southern Texas- Mexico border region serving a largely Hispanic population. We previously referred patients for EC-IC bypass to other quaternary-care centers in Texas. While referrals were already challenging due to distance, mixed immigration status, and poor socioeconomic background of many patients;COVID-19 further exacerbated this problem with restriction of elective surgical volume. METHOD(S): A consecutive series of EC-IC bypasses performed by authors (SKD and MDLG) were retrospectively reviewed. Baseline clinical, perioperative radiographic, and post-operative outcomes were studied. All patients were offered option of a referral to a quaternary-care centers and also given local option for performing bypass surgery. Further, patients met preoperatively with both the plastic and neurological surgeon. Ultimately, decision was made by patient. RESULT(S): A total of 6 craniotomies for EC-IC bypass were performed during the study period. The diagnoses included Moyamoya in 5 cases and symptomatic intracranial atherosclerosis in one. All patients were Hispanic, female, and nonsmokers with mean age of 35.6 years. Mean preoperative HBa1c was 7.9, preoperative LDL was 82, and mean preoperative hemoglobin was 11.3. Direct bypass was performed in 40% of cases. Mean OR time was 3 hours and 7 minutes. CONCLUSION(S): We have found collaboration between plastic and neurological surgery for surgical revascularization is feasible and improved access to care for Hispanic Moyamoya disease patients residing in a border community.

Neuroanesthesia practice during COVID-19: A single-center experience

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.

Transjugular Approach for Recurrent Intracranial Glomus Vagale Tumors: An Ideal Approach to Preserve Hearing and Facial Nerve Function

Lateral skull base paragangliomas (glomus tumors) are rare skull base tumors arising from neuroendocrine cells. These benign tumors can be locally aggressive with potential for intracranial extension and significant morbidity as they compromise cranial nerve structures. Treatment is highly patient dependent. Herein, we present a case of recurrent glomus vagale paraganglioma requiring a multidisciplinary transjugular and transcervical approach for complete resection. A 64-year-old male was referred to the neurotology clinic in 2019 for a left skull base tumor causing progressive dysphonia and dysphagia. Exam revealed left true vocal fold weakness and no other abnormalities. Hearing was normal on the left. Magnetic resonance imaging (MRI) revealed a large hyperintense lesion of the left jugular foramen with intracranial cerebellopontine angle extension and normal flow through the sigmoid sinus and jugular vein. The patient elected for surgical removal and near-total resection was achieved via retrosigmoid craniotomy. A small portion was intentionally left in the jugular foramen to preserve the intact eleventh cranial nerve, internal jugular vein, and sigmoid sinus. Surgical pathology confirmed glomus paraganglioma. Postoperative radiation was strongly recommended, but the patient was lost to follow-up due to the COVID-19 pandemic. The patient re-presented in late 2021 with worsened dysphonia and dysphagia. Exam confirmed left true vocal fold immobility consistent with vagal nerve paralysis and a new finding of left tongue weakness consistent with hypoglossal nerve injury. MRI revealed recurrence of the lesion to dimensions larger than original presentation and complete occlusion of the sigmoid-jugular system. Hearing and facial nerve function remained fully intact, thus a transjugular approach with hearing preservation and complete surgical resection was utilized. After combined retrosigmoid and transcervical incision, the transjugular approach was utilized to resect the sigmoid sinus, the tumor of the jugular foramen, and the intracranial extension. The ear canal and facial nerve canal were preserved. The sigmoid sinus was ligated with surgical clips and the jugular vein was ligated with suture thread. Intracranially, the hypoglossal nerve was identified and preserved, and the vagus nerve was seen eroded by tumor. Pathology confirmed recurrent paraganglioma. Postoperatively, the patient recovered well but continues to endorse persistent dysphonia. His treatment plan includes radiation and thyroplasty. Multiple surgical approaches for the treatment of skull base paragangliomas have been reported including infratemporal types A to D, among others. This report identifies a rare case of recurrent paraganglioma which necessitated removal via transjugular approach. While uncommon in skull base surgery, this approach allowed identification and preservation of important neck and skull base structures (e.g., facial nerve, ear canal, spinal accessory nerve) while achieving complete gross resection. Radiation techniques have become popular alternatives for treatment of glomus tumors of the skull base due to high levels of surgery-related adverse events. Thus, skull base surgeons should be aware of the utility of the transjugular surgical technique for patients with intact hearing and facial nerve function who seek removal of intracranial jugular foramen tumors.

Revisiting destructive operations to prevent second stage caesarean section in COVID times: A case series.

Destructive operations diminish the bulk of the foetus for facilitating vaginal delivery. Procedures such as craniotomy or decapitation can be carried out to deliver a dead baby in appropriately selected cases. Ours is a retrospective case series at a single tertiary facility during the first wave of the COVID pandemic. From July 2020 to January 2021, six destructive operations (five craniotomies and one decapitation) were performed in women who had arrest of descent in the second stage of labour but had intrapartum foetal demise. The average operative time was 30 minutes with a mean hospital stay of 4.3 days, which was significantly less than CS, and with much less morbidity. None of these women had significant post-partum haemorrhage or sepsis. Destructive procedures should be considered for better obstetric future of the patient, and a lesser burden on the health facility. What was practiced in COVID times should be extended beyond.

The impact of COVID-19 on neurosurgical theatre activity in the National Neurosurgical Centre of Ireland.

BACKGROUND: The global healthcare activity including neurosurgical services has been significantly impacted by the COVID-19 pandemic. AIM: Compare neurosurgical theatre activity from 2019 (pre-pandemic) to that of the subsequent pandemic years (2020-2021) and explore how each wave of COVID-19 infection impacted activity levels. METHODS: A retrospective analysis of neurosurgical theatre activity at the National Neurosurgical Centre of Ireland was performed from 1 January 2019 till 31 December 2021. The extracted data included date, surgical procedure, demographics of the patient and case scheduling (elective or emergency). RESULTS: In total, 6139 neurosurgical procedures were recorded throughout the study period. Two thousand one hundred forty-four neurosurgical procedures were recorded in 2019, 2052 in 2020 and 1943 in 2021 corresponding to a reduction in theatre activity by 4.3% and 9.4% in 2020 and 2021 respectively. The lowest number of monthly caseloads was recorded in April 2020 during the first wave of the pandemic. The first quarter of 2021 recorded the lowest number of quarterly surgical procedures over the entire 3-year period contributing to just 19.4% of 2021 caseload. Subgroup analysis showed a significant reduction in trans-sphenoidal pituitary surgeries post-pandemic by 36% and 44% in 2020 and 2021 respectively. CONCLUSIONS: Despite the exceptional stress imposed on our institution by COVID-19, the neurosurgical service managed to maintain comparable activity levels to 2019. The 2021 activity levels were more significantly impacted with 9.4% reduction when compared with pre-pandemic figures in 2019. Institutions need to develop a robust emergency plan to reduce the impact of any subsequent pandemics on healthcare delivery.

Trends in Emergency Department Visits and Surgeries due to Traumatic Brain Injury During the COVID-19 Pandemic in Finland.

We aim to evaluate the changes in the incidence of TBI, trauma craniotomies, and craniectomies during the COVID-19 pandemic in Finland. This retrospective register study was conducted at three Finnish hospitals. We retrieved the numbers of emergency department (ED) visits, inpatient admissions, and trauma craniotomies and craniectomies due to TBI in the adult population from 2017 to 2020.We calculated the incidences per 100 000 inhabitants and compared the year 2020 to the reference years (2017-2019) by incidence rate ratios (IRR) with 95% confidence intervals. The incidence of TBI-related ED visits during the study period compared to the reference years started to decrease in March 2020 (IRR 0.86, CI: 0.73-1.02), and the lowest incidence was seen in April 2020 (IRR 0.83, CI: 0.68-1.01). The incidence of ED visits showed a second decrease in December (IRR 0.80, CI: 0.67-0.96). The incidence of concussion decreased during the national lockdown in March (IRR 0.80, CI 0.66-0.97). The incidence of ED visits due to TBI decreased after the declaration of national lockdown in spring 2020 and showed a second decrease during regional restrictions in December. In addition, the incidence of neurosurgically treated TBI decreased during restaurant restrictions in the spring.

Central Nervous System Metastases from Exocrine Glands Carcinoma: Case Management in Low Resource Setting and Review of Literature

INTRODUCTION: Head and neck exocrine gland tumors metastases to central nervous system (CNS) account for less than 1% with median survival of less than 6 months. Unlike brain metastases from lung, breast, melanoma, and colon, there is no established consensus or published clinical guidelines in the management from excorine glands. Filipino patients are manage individually but experienced delays due to limited access to a tertiary level health care and with scarcity of treatment protocols. Methods and RESULTS: We present two cases with exocrine glands carcinoma with CNS metastases. First case is a 51/F with a known case of left parotid cystic adenocarcinoma s/p parotidectomy and radiation therapy 2 years prior to the development of neurological deficits and COVID-19 infection, neuroimaging noted extra-axial 7.5 x 5 x 4.5 cm contrast enhancing tumor at bilateral frontal convexity. She underwent bifrontal craniotomy, gross total excision of tumor and anterior sagittal sinus, histopathology results cystic adenocarcinoma. She was discharged GOS 2, planned for chemoradiotherapy but lost to follow up and expired after 2 months post op. Second case is a 28/M known case of lacrimal gland pleomorphic adenocarcinoma OD s/p excision biopsy 2 years prior to the development of multiple right frontal lobe, right orbital wall and right pterion metastases. He underwent gross excision of extracranial and intracranial tumors and a right orbital exenteration. He was discharged GOS 2 and underwent chemoradiation as outpatient with good tumor control and no tumor recurrence after 1 year of treatment. DISCUSSION: CNS metastases from exocrine glands are rare and difficult to manage since no approved protocol was established. Patients in low resource setting were then manage on individual basis since molecular and genomic studies are not available. The delays in the management are multifactorial such as geographic disadvantages, COVID-19 pandemic, and government's inadequate support for health system.

Awake Craniotomy for Cerebral Abscess with Pulmonary Arteriovenous Malformation

A cerebral abscess can be a life-threatening complication of pulmonary arteriovenous malformations (PAVM), thus posing significant morbidity if left untreated. We report a case of an incidental finding of a PAVM in a patient diagnosed with cerebral abscess. A 22-year-old male presented to the emergency department with acute onset right-sided weakness in both upper and lower limbs for 1 week. Magnetic resonance imaging showed a ring-enhancing lesion within the left parasagittal frontoparietal region s/o intracerebral abscess. High-resolution computed tomography was done as a protocol in patients posted for surgery due to coronavirus disease 2019 and coincidentally, it showed a single well-defined parenchymal nodule, 4 x 3.4 cm in the lateral basal segment of the left lower lobe. The knowledge of the pathophysiology of PAVM and expected complications during general anesthesia (GA) and positive pressure mechanical ventilation is essential. In such conditions, awake craniotomy under conscious sedation and scalp block may be considered as an alternative to GA.

Trepanation revisited in COVID-19 era: A perspective on craniotomy during current pandemic, surgical technique, and complications avoidance.

Background: Craniotomy creates maximum aerosols threatening the health care workers (HCWs) of operation room. The technique of trepanation and measures to avoid complications has never been described in the literature. The time taken for craniotomy by different instruments has also never been compared. Methods: The study included only COVID-positive patients who underwent surgery. Craniotomy was performed using trephine, pneumatic/power drill (PD), and Hudson brace-Gigli saw (HB-GS). Trepanation as done in 32 patients. The generation of aerosols and time taken for craniotomy by these instruments was observed. The droplet spread over a waterproof graph paper of 10 × 10 sq. cm was calculated in 13 cases of all the three craniotomy methods. The technique of trepanation and maneuvers to overcome complications was discussed. Results: There was a gross difference in aerosol production and soiling of the surgical drapes, floor, surgeon's glove, gowns, face shield, goggles, etc. The average number of droplet aerosol in trepanation group was 4.76, 23.6 in drill and 21.3 in Gigli saw method. The average time taken for trepanation, PD, and HB-GS craniotomy was 4.8, 22.8, and 24.4 min, respectively. One mortality secondary to COVID was noted. All the HCWs assisting trepanation were negative for COVID-19 during postoperative follow-up of 7 days. However, 13 members of the surgical team which assisted in electric drill and HB-GS methods were COVID-positive. Conclusion: Trepanation should be the preferred method of craniotomy during COVID-19 pandemic as it is associated with the least aerosolization and is the most time efficient.

Anesthetic Considerations for Chiari I Malformation in a BMI 62 Patient

Patients with Chiari I malformations present with tonsillar herniation below the foramen magnum causing abnormal spinal anatomy. Anesthesia challenges in this population include difficult airway management, monitoring intraoperative autonomic dysfunction, avoiding increased intracranial pressure, and accommodating sensitivity to neuromuscular blockade. We present a case with an additional airway management challenge due to morbid obesity with a BMI of 62. A 23 year old female with a history of Covid pneumonia and morbid obesity who presented with syringomyelia and Chiari I malformation. She initially presented with bilateral numbness, tingling, weakness, and pain in her hands. Imaging with MRI at the time showed downward displacement of the cerebellar tonsils with the tips reaching the lower portion of C1 and overall 10-12 mm displacement below the level of the foramen magnum. Syrinx was also visualized from the level of C1-C2 extending down to the level of T5-T6. Repeat MRI a year later showed no significant changes. However, she has worsening symptoms of pain in her right arm preventing her from working. She is agreeable to surgical decompression of the posterior fossa through a suboccipital craniotomy with resection of the posterior arch of C1 with duraplasty. Significant findings on the physical exam include Mallampati III, shorter thyromental distance, and limited range of motion of her cervical spine due to pain in her arms. We chose awake fiberoptic intubation due to difficult airway from morbid obesity and limited cervical spine range of motion and the consideration of hypercapnia induced from brief apnea the patient may not tolerate. She was premedicated with versed, glycopyrrolate, and dexmedetomidine, and given a 5% lidocaine paste lollipop to topicalize oropharynx. She was also started on a low dose remifentanil infusion for sedation during the awake fiberoptic approach. Blood pressure, heart rate, respiratory rate with continuous end-tidal capnography, and pulse oximetry were monitored during the awake fiberoptic intubation. A 7.0 endotracheal tube was lubricated with viscous lidocaine and placed over a fiberoptic scope. Once there was visualization of the vocal cords, additional 2% lidocaine was administered directly at the vocal cords. She was intubated smoothly on the first attempt. She was then immediately induced to general anesthesia with propofol and non-depolarizing muscle relaxant to avoid using succinylcholine due to the possible hypersensitivity caused by denervation. Intraoperatively, a conventional air warmer was used to prevent hypothermia. Invasive arterial blood pressure monitoring was applied. Normotensive blood pressure and normocapnia were maintained throughout the surgery. Muscular blockade was reversed with sugammadex at the end of surgery to ensure adequate ventilation especially with the patient's body habitus. Upon extubation, the patient had acute hypertension which was managed by nicardipine infusion and hydralazine boluses. Patient was taken to a neurosurgical intensive unit and monitored for two days. She was discharged home without any complication. In conclusion, anesthetic considerations for patients with Chiari I malformation include airway management, monitoring for autonomic dysfunction, avoiding increase in ICP, and optimizing postoperative neurological status with balanced anesthetic management.

Awake Craniotomy in the MRI Suite - a review of local practice

Introduction: Modern awake craniotomy (AC) has been performed since the 1980s, initially for epilepsy surgery but expanding to surgery for intracranial tumours (1). Intra-operative magnetic resonance imaging (ioMRI) was first utilised in 1994 in Boston (2), to overcome the issue of intra-operative brain shift during craniotomy, and permit the surgical team to check the extent of resection before closing. The techniques have been more recently combined, aiming to remove as much tumour from eloquent areas as possible. The interventional MRI (iMRI) suite at the National Hospital for Neurology and Neurosurgery (NHNN) consists of a 1.5 Tesla MRI scanner with an MR-conditional anaesthetic machine and operating table just outside the 5 Gauss line. This can be rotated to connect to the MRI table, and the patient is transferred into the bore of the scanner. There have been very few studies looking at iMRI and awake craniotomies, however there has been a suggestion that the addition of the MRI scan to awake craniotomy may reduce the requirement for redo surgery (3), and that awake craniotomies in iMRI may reduce the incidence of neurological impairment compared to surgery under general anaesthesia in iMRI. As the number of iMRI theatre suites increases across the UK, increasingly AC is being performed in this environment. In our study, we looked at these patients and their various pathologies, undergoing awake tumour resections in our iMRI suite, and their clinical management. Method(s): The theatre log book in MRI was reviewed for all awake cases, a longer time window was selected due to the impact of covid. Records reviewed to exclude procedures other than awake tumour resections with intraoperative MRI scanning. Identified total of 43 cases, a number grossly affected by covid interruptions. Post operative notes and discharge letters were reviewed to ascertain Clavien-Dindo scoring for postop complications. Result(s): 43 cases, with an average patient age of 36 years (spanning 19 y to 72 y), gender ratio M:F=16:5. Mode ASA 2 (1-3), mean weight 78 kg (55-114 kg) and mean BMI 25.6 kg/m2 (20.2-35.6). * Most had a single ioMRI except three cases which had 2 scans, and 40% of cases had further resection after the ioMRI. * 44% noted complete resection on the post-operative MRI * Anaesthetic technique varied but asleep-awake-asleep/sedation comprised 88% of cases, with iGel used in 74% and classical LMA in 23%, and propofol/remifentanil used in 81%. * All patients had urinary catheters and arterial lines, no patients had central venous catheters. * Anaesthetic time (WHO sign-in to WHO time-out) ranged from 5 hours to 13 hours10 minutes with an average of 8 hours 54 minutes. * Postoperative destination was overnight recovery in 76%, HDU in 14%, and the remainder direct to the ward, where length of stay mean was 10.5 days (though mode was 4 d). * Clavien-Dindo score on discharge was 0 in 40%, 1 in 50%, 2 in 4.6% and 3b and 4 in 2.3%. * 44% were discharged with no new neurological deficit. Conclusion(s): We interpret the outcomes here as very positive, with a high proportion of patients leaving hospital with low Clavien-Dindo scores or with no new deficits identified post-operatively. It is clear that awake craniotomy is safely performed in the iMRI suite. As is often the case in anaesthesia, whilst we saw some absolute consistencies (such as 100% rate of urinary catheters and arterial lines), we saw here that the anaesthetic approaches were as varied as the anaesthetists themselves. Anaesthetists should be prepared for prolonged surgical time to ensure satisfactory surgical resection.

Experience in Neuroanesthesia Practice from Indonesia Tertiary Hospital during COVID-19 Pandemic Era: A Descriptive Study

Background: Severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) or COVID-19 pandemic was a highly contagious virus that was first reported in the city of Wuhan, China in December 2019. COVID-19 pandemic has been a challenge to the global healthcare system and healthcare professionals including Indonesia. The first case found in Indonesia was in March 2020 and there were three peaks of the case, which were in January 2021, July 2021, and February 2022. Cipto Mangunkusumo Hospital, as a tertiary level and national referral hospital, was assigned as one of the biggest COVID-19 center hospitals in Indonesia. Throughout the pandemic, several policies regarding anesthesia practice were made, including the COVID-19 screening system and surgical patient pathway. Thus, there were two exclusive negative pressure operating rooms located in a centralized COVID-19 building and an emergency unit. Many surgical procedures were performed during the pandemic, including neurosurgical cases which involved neuro anesthesia practices that needed some adjustment due to the pandemic. There are two main questions that will be addressed in this research. First, Of all patients that undergo neurosurgery procedures how many have COVID-19. Second, Of all COVID- 19 patients that undergo surgery how many of them are neurosurgery. Method(s): This study was descriptive and involved a retrospective review of data collected from patients who underwent neurosurgeries between March 2020 and March 2022. Analyzes were performed according to COVID-19 status, age, classification case, type of surgery, and type of anesthesia. Result(s): A total of 933 neurosurgery cases and 488 COVID-19 surgery cases were identified. There were 26 neurosurgery cases with COVID 19. It was about 2.7% relative to all neurosurgery cases and about 5.3% relative to all COVID 19 surgery cases. General anesthesia was conducted in all of the cases. Fifty percent of the surgery was performed in centralized COVID-19 building operating room with elective setting, following 46% of cases was performed in emergency unit. There was one case was performed in catheterization lab. The population of cases was 65.3% in adult patients and 34.7% in pediatric population, consisted of eight vascular cases, seven oncology cases, seven infection cases, three trauma cases, and one congenital case. The procedure performed were 57.6% cerebrospinal fluid diversion, 34.6% craniotomy and 7,6% debridement.We followed our hospital established local COVID-19 guideline for surgical procedures, international guidelines, and recommendations, such as SNACC, to help deciding the risk stratification and time to perform the procedures. However, we have not performed transnasal procedure, awake craniotomy, and intraoperative neuromonitoring. All safety measures and infection control protocols were implemented. Conclusion(s): Neurosurgical procedures for patient with COVID-19 are considered uncommon with respect to all COVID-19 surgery cases and all neurosurgery cases. This information can be taken into consideration when making guidelines in the pandemic era. Further research are needed to explore impact of COVID-19 to neurosurgery patients.

Adolescent subdural empyema in setting of COVID-19 infection: illustrative case.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an ongoing viral pandemic that has affected modern medical practice and can complicate known pathology. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes symptoms that may mimic a viral pneumonia, with potential for serious sequelae, including acute respiratory distress syndrome, coagulopathy, multiorgan dysfunction, systemic vascular abnormalities, and secondary infection. OBSERVATIONS: The authors describe a case of a 15-year-old boy who presented with a right subdural empyema and sinusitis while having active COVID-19 infection. The patient initially presented with left-sided weakness, frontal sinusitis, and subdural empyema. Emergent surgery was performed for evacuation of empyema and sinus debridement. Samples of purulent material within the subdural space were tested for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. The patient had a successful recovery and regained the use of his right side after combined treatment. To our knowledge, this is the first reported case of a bacterial subdural empyema associated with frontal sinusitis in a coinfected patient with COVID-19 without evidence of COVID-19 intracranial infection. LESSONS: A subdural empyema, which is a surgical emergency, was likely a superinfection caused by COVID-19. This, along with the coagulopathy caused by the virus, introduced unique challenges to the treatment of a known pathology.

45th Annual Meeting of the American Society of Neuroimaging

The proceedings contain 31 papers. The topics discussed include: brain abscess appearing 20 years post craniotomy;postoperative diffusion restriction in the proximal optic nerve: optic neuropathy or central retinal artery occlusion?;magnetic resonance imaging as a prognostic disability marker in clinically isolated syndrome: a systematic review;bilateral internuclear ophthalmoplegia caused by unilateral infarction;neuroaspergillosis in a patient with chronic lymphocytic leukemia as progressively worsening ischemic infarct;neuroimaging in mitochondrial short-chain enoyl-coa hydratase 1 deficiency: a progressive encephalomyelopathy starting in utero;childhood-onset neurodegeneration with brain atrophy: imaging findings of a rare diagnosis;multiple sclerosis associated with Balo-like lesions post-coronavirus disease 2019;and within-subject reproducibility of quantitative proton density mapping.

Implementation of the "No ICU - Unless" approach in postoperative neurosurgical management in times of COVID-19.

Following elective craniotomy, patients routinely receive 24-h monitoring in an intensive care unit (ICU). However, the benefit of intensive care monitoring and treatment in these patients is discussed controversially. This study aimed to evaluate the complication profile of a "No ICU - Unless" strategy and to compare this strategy with the standardized management of post-craniotomy patients in the ICU. Two postoperative management strategies were compared in a matched-pair analysis: The first cohort included patients who were managed in the normal ward postoperatively ("No ICU - Unless" group). The second cohort contained patients routinely admitted to the ICU (control group). Outcome parameters contained detailed complication profile, length of hospital and ICU stay, duration to first postoperative mobilization, number of unplanned imaging before scheduled postoperative imaging, number and type of intensive care interventions, as well as pre- and postoperative modified Rankin scale (mRS). Patient characteristics and clinical course were analyzed using electronic medical records. The No ICU - Unless (NIU) group consisted of 96 patients, and the control group consisted of 75 patients. Complication rates were comparable in both cohorts (16% in the NIU group vs. 17% in the control group; p = 0.123). Groups did not differ significantly in any of the outcome parameters examined. The length of hospital stay was shorter in the NIU group but did not reach statistical significance (average 5.8 vs. 6.8 days; p = 0.481). There was no significant change in the distribution of preoperative (p = 0.960) and postoperative (p = 0.425) mRS scores in the NIU and control groups. Routine postoperative ICU management does not reduce postoperative complications and does not affect the surgical outcome of patients after elective craniotomies. Most postoperative complications are detected after a 24-h observation period. This approach may represent a potential strategy to prevent the overutilization of ICU capacities while maintaining sufficient postoperative care for neurosurgical patients.

MIDDLE MENINGEAL ARTERY EMBOLIZATION AS A SAME-DAY DISCHARGE PROCEDURE

Introduction Middle meningeal artery embolization (MMAE) is a fundamental piece in the management of Chronic Subdural Hematoma (cSDH) that prevents recurrence and can serve as primary treatment for nonoperative candidates. MMAE offers time-effectiveness, since it may be performed in less than one hour under minimal sedation. As the COVID-19 pandemic makes inpatient beds scarce, MMAE could potentially become a same-day procedure which poses a potential economic benefit for both patients and health institutions alike. We reviewed MMAEs performed at our institution and measured the complication rates in an effort to determine if hospital admission after the procedure is necessary. Methods A retrospective analysis of patients who underwent MMAE for cSDH at the University of California, San Diego was performed. Data collected included post-procedural complications such as focal neurologic deficit, cognitive decline, and groin access-point hemorrhage identified within the first 4 hours, 24 hours, and delayed manner respectively. Success of treatment was defined as patient stability and return to baseline following the post-procedure assessment protocol performed routinely at our institution. We further characterized patients with the Charlson Comorbidity Index (CCI) to identify higher risk populations that would require increased observation. The CCI was also used to determine a cut-off point for same-day discharge eligibility. Results We analyzed data from 95 patients that had 143 subdural hematomas treated at our institution. Of the 95 patients, 93 patients (98%) had no complications following our institution's standardized assessments after MMAE or at discharge the following day. Average SDH size was 12.9mm. Twenty-one patients underwent surgical drainage after MMAE. Following MMAE, two patients presented complications;one patient, an 83-year-old female, developed transient headache and blurry vision one day after MMAE and was discharged uneventfully;this patient had a CCI of 4 points. The other patient was a 77-year-old male with metastatic prostate carcinoma and had an SDH volume expansion one day after the procedure which required operative intervention with burr-hole craniotomy and drainage;this patient had a CCI of 9 points (0% estimated 10-year survival). The remaining 93 patients suffered no complications after MMAE. Conclusion Time-effectiveness and low complication rates make MMAE an ideal same-day procedure for patients with cSDH and a low CCI score. The grand majority of patients had no complications following MMAE, suggesting a large patient population that may benefit from the same-day procedure aspect of intervention. Although some patients underwent planned surgical drainage, the embolization component of management was uneventful. Our analysis provides evidence that MMAE could develop into an ambulatory procedure in patients with cSDH and a low comorbidity profile;this could have economic benefits for both the patients requiring and the institutions offering the procedure. Further prospective studies are needed to strengthen these findings.

Documented growth of a de novo intracranial capillary hemangioma: a case report

Background: Intracranial capillary hemangiomas are rare, particularly in adults, and diagnosis can be challenging. The literature lacks visualization of intracranial capillary hemangioma growth over time. Here we document growth of a de novo intracranial capillary hemangioma, initially interpreted radiologically as a glioma. Methods: We report a case of a 64 year old male with history of HIV, recent Lyme disease and unconfirmed prior COVID-19 infection, who presented with exhaustion and confusion. Imaging demonstrated an intra-axial high T2/FLAIR signal lesion centred in the subcortical white matter of the posterior right temporal lobe. There was faint enhancement, and a few mildly prominent vessels were seen along its anterior aspect. Imaging 2 years prior had not shown the lesion. Stereotactic biopsy was nondiagnostic. Craniotomy and resection was carried out. Results: Pathological examination and immunohistochemistry returned the diagnosis of capillary hemangioma. We review how this case adds to proposed theories of de novo intracranial capillary hemangioma growth. Our patient's co-morbidities support possible inflammation related triggers for symptomatic progression of these uncommon lesions. Conclusions: This unusual case documents the radiological appearance and progression of a de novo intracranial capillary hemangioma. It represents the first time such growth has been visualized in an adult male.

Enterogenous Cyst and Glioblastoma: A Brief Histopathological Review of Two Uncommon Cystic Lesions of the Central Nervous System

Intracranial cystic lesions are common findings in cerebral imaging and might represent a broad spectrum of conditions. These entities can be divided into nonneoplastic lesions, comprising Rathke cleft cyst, arachnoid cyst, and colloid cyst, as well as neoplastic lesions, including benign and malignant components of neoplasms such as pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. Surgical resection and histological evaluation are currently the most effective methods to classify cysts of the central nervous system. The authors report two uncommon cases presenting as cystic lesions of the encephalic parenchyma-a enterogenous cyst and a glioblastoma-and discuss typical histological findings and differential diagnosis.

Awake craniotomy for glioblastoma in COVID-19-positive patients and delivering the standard of care: illustrative case.

BACKGROUND: Providing the standard of care to patients with glioblastoma (GBM) during the novel coronavirus of 2019 (COVID-19) pandemic is a challenge, particularly if a patient tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Further difficulties occur in eloquent cortex tumors because awake speech mapping can theoretically aerosolize viral particles and expose staff. Moreover, microscopic neurosurgery has become difficult because the use of airborne-level personal protective equipment (PPE) crowds the space between the surgeon and the eyepiece. However, delivering substandard care will inevitably lead to disease progression and poor outcomes. OBSERVATIONS: A 60-year-old man with a left insular and frontal operculum GBM was found to be COVID-19 positive. Treatment was postponed pending a negative SARS-CoV-2 result, but in the interim, he developed intratumoral hemorrhage with progressive expressive aphasia. Because the tumor was causing dominant hemisphere language symptomatology, an awake craniotomy was the recommended surgical approach. With the use of airborne-level PPE and a surgical drape to protect the surgeon from the direction of potential aerosolization, near-total gross resection was achieved. LESSONS: Delaying the treatment of patients with GBM who test positive for COVID-19 will lead to further neurological deterioration. Optimal and timely treatment such as awake speech mapping for COVID-19-positive patients with GBM can be provided safely.

INTRACRANIAL COMPLICATIONS OF STREPTOCOCCUS INTERMEDIUS DURING COVID-19 PANDEMIC

Purpose of Study Streptococcus intermedius is a Gram-positive bacterium that is part of normal oropharyngeal flora but can cause serious infections such as brain and liver abscesses. An increase of brain abscess cases related to sinusitis were recognized during the coronavirus disease 2019(COVID-19) pandemic. We present three cases of brain abscess related to sinusitis in pediatric patients. S. intermedius was isolated in all cases. Methods Used A retrospective chart review was performed in patients with brain abscess whose cultures grew S. intermedius during the COVID-19 pandemic. Summary of Results Case 1: A 6-year-old male with 4-day history of headaches, diagnosed with viral infection by his pediatrician. He was also seen at an Urgent Care facility for fevers and managed supportively. He then developed a seizure- like episode which prompted an emergency room (ED) visit. Head computerized tomography (CT) revealed bifrontal epidural abscess and pansinusitis. He underwent bifrontal craniotomy with evacuation of epidural abscess and maxillary antrostomy. He was treated with a prolonged course of IV antibiotics with good response to treatment and resolution of seizures. Case 2: A 9-year-old female with left eye pain and swelling for six days associated with headaches and emesis. She was diagnosed with a hordeolum at an ED. Worsening of symptoms prompted a second ED visit where a CT revealed preseptal cellulitis and abscess. Further imaging showed left orbital abscess with epidural abscess. She underwent bicoronal craniotomy with evacuation of abscess and maxillary antrostomy. Treatment also included a prolonged course of IV antibiotics. She was discharged at neurologic baseline. Case 3: A 14-year-old male with fever, left eye and forehead swelling for two weeks. At the initial ED visit, he was diagnosed with a 'boil' and prescribed antibiotics and steroids. He had interval improvement of swelling but continued with daily fevers and developed vomiting prompting another ED visit. He was admitted to the pediatric intensive care unit (PICU) due to hypertension and vision changes. Upon arrival to the PICU, he required immediate cardiopulmonary resuscitation due to pulseless ventricular tachycardia. Further workup demonstrated extensive subdural empyema and partial venous sinus thrombosis. Left decompressive hemicraniectomy and maxillary antrostomy was done emergently. He received a prolonged course of IV antibiotics. He developed right sided weakness, required nutritional and ventilatory support despite appropriate treatment. Conclusions S. intermedius can cause life threatening intracranial infections which may have increased during the COVID- 19 pandemic for reasons unknown. The diagnosis is often delayed as patients present with nonspecific symptoms. Prompt neurosurgical intervention and administration of prolonged antibiotics improve outcomes.