Spontaneous Intracerebral Hemorrhage Secondary to a Parasagittal Meningioma: A Case Report and Review of the Literature.

Meningiomas are the most prevalent tumors within the central nervous system, with most exhibiting benign characteristics. While they are often discovered incidentally, their growth can lead to symptoms such as headaches, visual changes, dizziness, and seizures. Intratumoral hemorrhage (ITH) within meningiomas is a rare occurrence. This phenomenon carries a poor prognosis, as evidenced by significant rates of morbidity and mortality. This case report describes a unique case of a 52-year-old male who experienced a spontaneous right parietal lobe intracerebral hemorrhage adjacent to the superior sagittal sinus. Subsequent investigations revealed this to be an ITH due to an underlying WHO-grade I meningioma. This case emphasizes that while ITH in meningiomas is rare, prompt recognition and surgical intervention ensure optimal patient outcomes.

Acute Lumbar Schmorl's Node Following Chiropractic Adjustment.

Schmorl's nodes are typically an incidental finding whereby a disc herniates into the vertebral body. The clinical course is rarely symptomatic. Here, we present a 41-year-old male who, following chiropractic manipulation, developed an acute Schmorl's node. The patient was managed successfully with conservative measures. A 41-year-old male with acute on chronic low back pain following a chiropractic adjustment. Imaging demonstrated the development of an acute Schmorl's node of the lumbar four-five disc into the lumbar 4 vertebral body after a chiropractic adjustment. He was treated with conservative measures with over 85% relief of back pain. Acute Schmorl's nodes can develop after the chiropractic adjustment. In the case presented, conservative measures resulted in 85% improvement in pain.

Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies.

Mechanical thrombectomy (MT) for cerebral revascularization in acute stroke is now considered standard of care in select patients. Patients are assessed routinely after MT with CT scanning. The phenomenon of contrast staining is well documented in the literature and is posited to be related to increased blood-brain barrier (BBB) permeability of susceptible and/or infarcting brain tissue allowing angiographic contrast to be visualized outside the normal cerebral vasculature. In some cases, this can progress to include frank blood/contrast extravasation or even more seriously lead to intraparenchymal hemorrhage (IPH) with less favorable clinical outcomes. The relationship of this staining phenomenon and how it may have a cause or effect relationship with progression to hemorrhage is unclear. Many studies have been performed trying to better characterize this radiographic finding in terms of accurate diagnosis and potential for influencing prognosis. A literature review included a glaring lack of standardization in the application of terminology and quantitative/qualitative analysis. Dual energy CT (DECT) appears to be the best imaging modality to differentiate blood from contrast, but its application is limited since it is not as available as conventional CT. The possibility that risk factors are associated with progression of mixed density (blood and contrast) extravasations to frank IPH with resultant poorer outcomes is suggested in some studies. Overall, there remains a lack of consensus on how to best interpret this radiographic finding in altering any future stroke treatment(s). Recommendations of how to overcome this are postulated by the authors, which include standardization of terminology, progression toward more DECT use.

Patient Perspectives on the Participation of Neurosurgery Resident Physicians in Their Care.

Introduction Surgical residents play vital roles in day-to-day patient care as well as in the operating room. However, there is a paucity of literature regarding patients' perspectives on neurosurgical residents and their participation in their care. This current study investigates the knowledge, attitudes, and beliefs of patients regarding neurosurgical residents and their involvement in their healthcare process. Methods Patients older than 18 years who had undergone brain or spine surgery were requested to complete a survey questionnaire. The 7-point Likert scale response ranging from "strongly agree", "agree", "more or less agree", "undecided", more or less disagree", "disagree" to "strongly disagree" was used. The primary objective was to assess patient understanding and attitudes towards resident participation in surgical and medical care within the specialty of neurosurgery. The duration of the study was eight months. Patients having prior exposure to an informed-consent procedure by a neurosurgery team within a year prior to this study were excluded. Data were analyzed using Student's t-test, one-way analysis of variance (ANOVA), and standard averaging of responses. Results Fifty-one patients who had undergone elective surgery participated in the study survey. The majority of these respondents were between the ages of 46 and 60 years. Most of the responses were similar across gender and different age groups for most of the questions on the Likert scale questionnaire. Overall, when asked to assess their comfort level in medical and surgical care participation by residents, patients responded positively (strongly agree: 80.4%; agree: 92.2%). Patients also either disagreed or strongly disagreed (76%) about residents lacking medical knowledge. Patients overwhelmingly disagreed (91.5%) when asked if residents were unprofessional. In addition, 72.5% of the patients were able to accurately define a resident's role. Conclusion Well-formatted surveys can offer a convenient route for patients to provide objective as well as subjective feedback. The results indicate that patients had an overall positive attitude toward having residents involved in their care. These trends also indicate that patients knew the role that residents played in their healthcare process and they were comfortable with them doing so. Further studies may expand the trial to include a larger number of patients, as well as other specialties, to expand the scope of the study. Patient survey questionnaires could be thought of as a useful tool by the Accreditation Council for Graduate Medical Education (ACGME) to incorporate as part of the evaluation process of resident physicians.

The Influence of Intraoperative Technology on Neurosurgery Training.

Background Intraoperative technology (IOT) is an expanding field designed to produce better patient outcomes and decrease iatrogenic injury. Neurosurgical residents often encounter these machines in the operating room. Therefore, our primary objective was to assess the influence of IOT on neurosurgery residents' surgical skills and training. Methods An electronic survey was created and sent to the neurosurgical residency programs in the state of California. The data were collected and analyzed. Results A majority of residents agreed that IOT helps in learning new concepts important for patient safety. 38% agreed that IOT helps to improve the motivation level of residents. 35% agreed that IOT makes the resident more productive. 31% felt that IOT helped them refine their surgical skills. 54% did not find IOT too stressful. 34% said that IOT helps in learning new concepts important for patient safety. 50% agree that IOT is a valuable tool in training. 42% affirmed that IOT provides good learning experience for clinical skills and knowledge. Conclusion Surgical training and IOT have evolved substantially over the last decade and resulted in increased intraoperative accuracy. Residents agreed that evolving technology improves surgical skills. Further studies elucidating patient outcomes are warranted.

The 100 Most Cited vs. Most Relevant Articles in the Journal of Neurosurgery: A Bibliometric Analysis.

Introduction The Journal of Neurosurgery (JNS) published its first volume in 1944 and has evolved into the top cited journal in the field of neurosurgery. The aim of this study was to determine and characterize the 100 most cited (based on the total number of citations) vs. most relevant (based on the number of citations per year) articles originating in JNS. Methods The top 100 most cited articles in JNS were determined by searching the Web of Science database. Citations per year were additionally calculated for the top 1000 articles by total citations to rank the 100 most relevant articles. Results The median number of total citations for the 100 most cited articles in JNS was 505 (range 383-2200), and the median number of citations per year for the 100 most relevant articles was 21.88 (range 17.31-82.61). The median year of publication for the 100 most cited and most relevant articles was 1990 and 1999, respectively (P < 0.0001). Most articles originated in the United States in both categories (72% and 71%, respectively). The most common topic of study was cerebrovascular on both lists, followed by trauma on the most cited list vs. tumor on the most relevant list. The most relevant list also contained considerably more articles with a higher level of evidence such as systemic reviews/meta-analyses and prospective studies. Conclusions This study highlights the key contributing factors to the growth and flourishing of JNS. It also reveals several discrepancies between the most cited and most relevant articles, with the latter including more recently published articles, more studies addressing tumor, and more level I/1 (NHMRC/CEBM) evidence. Bibliometric analysis serves as a useful tool for clinicians and researchers to appraise published literature and understand the scientific foundation of modern neurosurgery.

A patient with multiple synchronous gliomas of distinctly different grades and correlative radiographic findings.

BACKGROUND: Multiple gliomas represent approximately 2 to 5% of all high-grade gliomas which are categorized as multifocal or multicentric depending on the timing, location and pattern of spread. We present a patient with bi-hemispheric, noncontiguous, low- and high-grade gliomas proven by biopsy. She underwent surgical excision and radiotherapy, but unfortunately succumbed to her disease shortly thereafter. CASE DESCRIPTION: A 64-year-old female presented to the hospital with confusion, disorientation and retrograde amnesia after an unwitnessed fall. There were no symptoms of headaches or visual disturbances before presentation. Magnetic resonance imaging (MRI) with and without gadolinium revealed a nonenhancing left temporal lobe mass without surrounding edema, an enhancing left frontal lobe mass with surrounding edema, and an enhancing right parietal lobe mass with surrounding edema. The patient underwent a left frontal craniotomy with gross total resection of the left frontal mass and a left temporal craniotomy, anterior temporal lobectomy and sub-total resection of the temporal lobe mass. Intraoperative Brainlab® image-guided navigation was used. Postoperative treatment consisted of radiotherapy. CONCLUSION: This is the first reported case of multiple separate glial tumors, each with differing grades in which an MRI can be correlated with the tissue diagnoses. This case also highlights the possible mechanisms of transformation of glial tumors in the continuum from benign to malignant forms, lending insight to the possibility of using advanced genetic analysis in the treatment and diagnosis of these entities.

Proximal intracranial internal carotid artery branches: prevalence and importance for balloon occlusion test.

OBJECT: The aim of this study was to determine the prevalence of angiographically identifiable skull base arterial branches that potentially serve as collateral conduits during a balloon occlusion test (BOT) of the internal carotid artery (ICA). The authors posited that neurological deficits in patients who had previously tolerated the occlusion test may be attributable to an unrecognized collateral support through these channels (operant during proximal ICA BOT) when permanent ICA occlusion was performed more distally. METHODS: In 481 cases (962 ICAs), cerebral angiograms obtained during routine Wada testing were retrospectively reviewed. Two hundred sixty-one patients had at least one angiographically identifiable ICA branch; 109 patients had two or more branches. A meningohypophyseal branch of the cavernous ICA was identified on the right side in 108 patients and on the left in 122. A vidian artery originated from the petrous portion of the ICA on the right side in 58 patients and on the left in 85. The inferolateral trunk revealed itself as a branch of the cavernous ICA on the right side in 17 patients and on the left in 33. A caroticotympanic artery arose from a left cavernous ICA. A persistent trigeminal artery was situated on the right side in two patients and on the left in three. More than half of the patients had angiographically identifiable and perhaps hemodynamically significant skull base branches of the ICA, and approximately one quarter had more than one identifiable branch. CONCLUSIONS: The authors recommend that patients be screened during angiography studies performed prior to BOT in branches of the proximal intracranial ICA and that the site of BOT be moved distally if such branches are identified.

Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: indications, endovascular technique, and outcome in 21 patients.

OBJECT: The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes. METHODS: Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavrnous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2-46 months). CONCLUSIONS: Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.